Every finding on record at St John specialty Care Center

Based on clinical records and staff interview, it was determined that the facility failed to update a care plan for one of six residents (Resident R1) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (declining cognitive abilities of remembering, thinking, or making decisions), chronic pain and diabetes mellitus. Review of Resident R1's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 3/18/26, indicated the diagnoses remain current. Review of physician orders dated 3/14/26, Resident R1 is to get showers and skin assessment weekly on evening shift. Per St [NAME] Skin Issues Identification Form (form used to document assessment of skin and refusal of showers), Resident R1 refused showers eight times. 3/16/26, 4/11/26, 4/14/26, 4/18/26, 4/28/26, 5/5/26, 5/6/26, 5/16/26. Review of Resident R1's most recent Resident Care Plan Report, indicated no revision of care refusals. During an interview on 6/23/26, at 1:30 p.m. Nursing Home Administrator confirmed the facility failed to revise care plan for Resident R1 as required. 28 Pa. Code: 211.11(d) Resident Care Plan

Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect which resulted in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital.Findings include:Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, and Misappropriation of Property dated 8/18/25, indicated the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, and misappropriation of resident property.Review of the facility policy Transportation-Competencies and Monitoring dated 8/18/25, indicated all drivers will perform and pass competencies in the following areas: Q-Straint Wheelchair Securement (straps and buckle system that secures wheelchair in wheelchair van), van lift operation, driver responsibilities while escorting a resident, and safe operation of vehicle.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/15/26, indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section C0500 Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.Review of Resident R1's progress note dated 1/20/26, at 2:37 p.m. indicated resident was on the way to an appointment in the wheelchair van. Per resident's statement the van was taking a left-hand turn when the wheelchair tipped over and resident landed on their right side. Resident believes they hit their head on the door of the wheelchair van. Resident was assisted out of the van and back to the bed. Resident complained of significant pain to the right shoulder, right hip, had a small hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, caused by damaged vessel walls from trauma) above the right ear, and hematoma on the right ear. Unable to assess right hip and right shoulder for bruising while in bed due to pain with movement trying to remove clothing. Resident is on Lovenox (blood thinner). Orders received to transfer to the emergency room. Brother present and made aware of transfer orders.Review of the hospital documentation dated 1/20/26, indicated resident was in a wheelchair van and resident stated they were not secure in the chair. The chair was secure in the van. The wheelchair went around the bend, and it tipped and collapsed on the resident making the resident fall. Complaints of right shoulder and right hip pain that struck the side of the van. Resident also struck their head.Injuries: 1. Non-displaced right transverse process fracture of the seventh cervical vertebra of the spine (C7). 2. Acute right transverse process fracture of the second thoracic vertebra of the spine (T2). 3. Fractures of the first, second, third, and fourth right ribs. 4. Fracture of right clavicle (collar bone) with questionable extension into the joint. 5. Non-displaced fracture of the posterior inferior right pubic ramus (part of lower pelvic bone). 6. Acute comminuted (severe injury where a bone breaks into three or more pieces) fracture of the anterior right hip acetabulum (socket of hip). 7. Questionable fracture of right lateral sacrum (base of the spine that forms the back wall of the pelvis).emergency room physician at local hospital discussed resident's case with Trauma Hospital physician at another hospital reporting multi-system trauma from fall in a wheelchair van while going around a bend. The trauma level hospital accepted the care of resident and ordered transfer for further treatment.Review of facility provided documentation dated 1/20/26, indicated Incident: resident fall with injury during wheelchair van transport due to failure to apply passenger seatbelt.Review of Driver Employee E1's orientation and competency documentation dated 9/2/25, indicated the Q-straint securement system training was provided and Driver Employee E1's signature and date of 9/2/25, was on the document.Review of Driver Employee E1's signed witness statement dated 1/20/26, indicated they turned left in a wide and slow turn, the wheelchair collapsed and went to the right. The resident fell off wheelchair onto the floor of the van. The wheelchair seemed flimsy when the driver strapped the lower bars in at all four points.Review of Resident R1's signed witness statement dated 1/20/26, indicated the driver did not fasten a belt around their chest.Interview with Maintenance Manager Employee E2, on 2/11/26, at 11:31 a.m. indicated the Q-Straint system is a five-point system, four connect to the actual wheelchair and then there is a chest lap harness almost like a regular seat belt, as the fifth point. The following day I examined the van and all the parts and belts were intact and functioning. The resident said that the final seatbelt strap was not connected correctly, and if it had been resident would not have suffered a fall. Interview on 2/11/26, at 1:45 p.m. Resident R1 indicated the wheelchair was strapped into the floor but Driver Employee E1 never put the chest lap harness on. When we went around the bend in the van, the chair tipped over and resident fell to the wheelchair van's floor on the right side.Interview on 2/11/26, at 11:45 a.m. the Nursing Home Administrator indicated the Driver Employee E1 was terminated for neglecting to use the Q-Straint appropriately at all five points as required.During an interview on 2/11/26, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to protect Resident R1 from neglect when staff failed to properly secure resident in wheelchair van resulting in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital.28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to make certain that each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital. Findings include: Review of the facility policy Resident Accidents/Incidents dated 8/18/25, indicated the facility will provide a safe and secure environment for residents and will be proactive in the prevention of accidents and incidents.Review of the facility policy Reporting a Resident Incident During Transport dated 1/2026, indicated all drivers operating company vehicles will do so in a cautious and careful manner with the safety and well-being of the residents in mind at all times.Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/15/26, indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section C0500 Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 15, cognitively intact.Review of Resident R1's progress note dated 1/20/26, at 2:37 p.m. indicated resident was on the way to an appointment in the wheelchair van. Per resident's statement the van was taking a left-hand turn when the wheelchair tipped over and resident landed on their right side. Resident believes they hit their head on the door of the wheelchair van. Resident was assisted out of the van and back to the bed. Resident complained of significant pain to the right shoulder, right hip, had a small hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, caused by damaged vessel walls from trauma) above the right ear, and hematoma on the right ear. Unable to assess right hip and right shoulder for bruising while in bed due to pain with movement trying to remove clothing. Resident is on Lovenox (blood thinner). Orders received to transfer to the emergency room. Brother present and made aware of transfer orders.Review of the hospital documentation dated 1/20/26, indicated resident was in a wheelchair van and resident stated they were not secure in the chair. The chair was secure in the van. The wheelchair went around the bend, and it tipped and collapsed on the resident making the resident fall. Complaints of right shoulder and right hip pain that struck the side of the van. Resident also struck their head.Injuries: 1. Non-displaced right transverse process fracture of the seventh cervical vertebra of the spine (C7). 2. Acute right transverse process fracture of the second thoracic vertebra of the spine (T2). 3. Fractures of the first, second, third, and fourth right ribs. 4. Fracture of right clavicle (collar bone) with questionable extension into the joint. 5. Non-displaced fracture of the posterior inferior right pubic ramus (part of lower pelvic bone). 6. Acute comminuted (severe injury where a bone breaks into three or more pieces) fracture of the anterior right hip acetabulum (socket of hip). 7. Questionable fracture of right lateral sacrum (base of the spine that forms the back wall of the pelvis).emergency room physician at local hospital discussed resident's case with Trauma Hospital physician at another hospital reporting multi-system trauma from fall in a wheelchair van while going around a bend. The trauma level hospital accepted the care of resident and ordered transfer for further treatment.Review of facility provided documentation dated 1/20/26, indicated Incident: resident fall with injury during wheelchair van transport due to failure to apply passenger seatbelt.Review of Resident R1's signed witness statement dated 1/20/26, indicated the driver did not fasten a belt around their chest.Interview with Maintenance Manager Employee E2, on 2/11/26, at 11:31 a.m. indicated the Q-Straint system is a five-point system, four connect to the actual wheelchair and then there is a chest lap harness almost like a regular seat belt, as the fifth point. The following day the van was examined, and all the parts and belts were intact and functioning. The resident said that the final seatbelt strap was not connected correctly, and if it had been resident would not have suffered a fall. Interview on 2/11/26, at 1:45 p.m. Resident R1 indicated the wheelchair was strapped into the floor but Driver Employee E1 never put the chest lap harness on. When we went around the bend in the van, the chair tipped over and resident fell to the wheelchair van's floor on the right side.During an interview on 2/11/26, at 3:00 p.m. the Nursing Home Administrator confirmed at the facility failed to make certain that each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital. 28 Pa. Code 201.14 Responsibility of Licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.29 Responsibility of Licensee.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.28 Pa. Code 211.10(d) Resident care policies.

Based on review of facility policy, resident clinical records, facility provided documents, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R2).Findings include:Review of facility policy Abuse, Neglect, Misappropriation, and Exploitation Reporting dated 8/18/25, indicated all incidents of actual, alleged, or suspected abuse, neglect, theft, misappropriation of residents' property or injury of unknown origin will be promptly reported and thoroughly investigated.Review of the admission record indicated Resident R4 was admitted to the facility on [DATE].Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/1/26, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section C0500 Brief Interview for Mental Status (BIMS - is a screening test that aids in detecting cognitive impairment) indicated a score of 99 resident was unable to complete the interview.Review of facility provided documents dated 12/30/35, indicated two staff members reported to the Director of Nursing that they overheard Nurse Aide (NA) Employee E3 yelling at Resident R2. Two statements indicated NA Employee 3 was yelling and swearing at Resident R2. NA Employee E5 indicated they informed NA Employee E3 that they could not speak to the resident like that.Review of Licensed Practical Nurse (LPN) Employee E4's signed witness statement dated 12/30/25, indicated they were getting ready to enter Resident R2's room when they heard NA Employee E3 say to Resident R2 I can't stand you f*cking yelling like that. NA Employee E5 said to NA Employee E3 you can't speak to the resident like that. NA Employee E3 kept responding I don't care, I can't f*cking stand you yelling like that.Review of NA Employee E5's signed witness statement dated 12/30/25, indicated they were assisting NA Employee E3 with taking Resident R2 off the toilet, NA Employee E3 kept saying I don't care, I can't f*cking stand you yelling like that.Interview on 2/11/26, at 1:57 p.m. LPN Employee E4 indicated I remember NA Employee E3 was getting Resident R2 up and ready for the day, as I was entering the room NA Employee E3 verbalized I can't f*cking stand you yelling. NA Employee E5 told NA Employee E3 not to talk to the residents like that and NA Employee E3 walked away scoffing. We both reported it to the Director of Nursing.Interview on 2/11/26, at 2:10 p.m. NA Employee E5 indicated NA Employee E3 yelled at Resident R2 saying I can't stand you f*cking yelling like that. I told NA Employee E3 you can't talk to the residents like that and NA Employee E3 kept saying I don't care. We both reported it to the Director of Nursing. Administration called up to the unit to remove NA Employee E3 from the unit.Interview on 2/11/26, at 2:30 p.m. the Director of Nursing indicated the facility had an investigation; however, chose not to report it to the Department of Health as required because she didn't feel it was threatening in nature.Interview on 2/11/26, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to report an allegation of abuse for one of three residents (Resident R2).28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management28 Pa Code: 201.18 (b)(1) (e)(1) Management.

Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Resident R1).Findings include: Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property dated 8/18/25, indicated the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, exploitation or misappropriation of resident property. Review of the facility policy Falls, Resident Treatment of dated 8/18/25, indicated all residents who fall will be evaluated immediately for injury. When a resident is found on the floor do not move resident until a licensed nurse examines the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's physician orders revealed an order dated 8/5/25, that indicated resident may transfer and ambulate (move about) with supervision. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/24/25, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), depression, and difficulty swallowing. Review of Resident R1's progress note dated 8/24/25, at 10:35 a.m. stated the following: Called to evaluate resident. History of fall on 8/19/25 with no apparent injury. Resident found in bed, appeared to be in pain. On evaluation, left leg had very significant swelling along entire femur (upper leg) area, ecchymosis (bruise) along entire posterior (back) hip and upper femur area that extended into groin, external rotation, and shortening. Positive pain response (yell out and grimace) to palpation (touching) of femur and hip, and with attempts to log roll. Resident unable to do any bed mobility on his own. Resident medicated for pain with Tylenol ( a pain reliever) and call placed to doctor. Resident to have hospice evaluation tomorrow for general decline. Per staff, he was able to stand and pivot on both [NAME] (lower extremities- legs) yesterday. Review of Resident R1's progress note dated 8/24/25, at 7:37 p.m. stated Call placed to hospital, patient was admitted with left hip fracture. Review of a written statement from Licensed Practical Nurse (LPN) Employee E1 dated 8/24/25, stated This LPN removed resident's BLE (bilateral lower extremities (both legs) ACE wraps (an elastic compression bandage) around 7:00- 7:15 p.m. [on 8/23/25] while resident's family was visiting. BLE were at baseline for resident. No pain noted. After family left Nurse Aide (NA) Employee E2, and NA Employee E3 put resident in bed. This LPN was not made aware of any falls or anything. Review of a written statement from NA Employee E4 dated 8/24/25, stated While providing morning care, I noticed his [Resident R1] leg was turned out and seemingly shorter than the right leg. I began providing peri care (washing anal, and genital areas) and while removing his brief I noticed his left thigh and groin was swollen with bruising to the outer hip, inner thigh, and groin. This occurred at approximately 10:00 a.m. on 8/24/25, and I immediately alerted his nurse. Review of a written statement from Registered Nurse (RN) Supervisor Employee E5 dated 8/24/25, stated This nurse asked Nurse Aide (NA) Employee E2 about the incident that occurred on 3 pm to 11 pm shift on 8/23/25. At that time NA Employee E2 stated 'I need to tell you the truth'. NA Employee E2 stated that she, and NA Employee E3 were transferring Resident R1 into bed [from the wheelchair], and they had to lower him to the ground. I asked how hard he hit the ground and she said it was a little harder on NA Employee E2's side than her side. I asked if she notified the nurse. She said they talked and decided not to let the nurse know. When I asked how the resident got up, she said that NA Employee E2 went and got NA Employee E6 to help. When I asked NA Employee E2 if NA Employee E6 was aware that the nurse didn't know about the incident, she told me he was not aware. When I asked if she noticed any bruising or anything after, she said she did not. Educated her that any change of plane for a resident is an incident that the nurse needs to be aware of. Review of a written statement form NA Employee E2 dated 8/24/25, stated on 8/22/25, Resident R1 displayed signs of unable to stand steadily. On 8/23/25, prior to 8:00 p.m. I asked NA Employee E3 to help me assist resident into bed. NA Employee E2 was unable to hold resident's weight on her side, and the resident began to drop towards the floor. I still had a hold of resident under his right arm, his pants, and resident was resting on my right leg. NA Employee E3 was unable to pick him up from the position. I was holding his weight and was unable to lift up. I told her to lower him to the floor since we were unable to place him back into his chair and unable to pivot and place him in the bed. We lowered him to the floor. NA Employee E3 left to get someone to assist us to pick him up and returned with NA Employee E6, who helped me pick the resident up from a sitting position on the floor. I asked that we not mention we lowered the resident to the floor because it wasn't a fall. During an interview on 10/1/25, at 11:36 a.m. the Director of Nursing stated that Resident R1 fell on 8/23/25, on evening shift when staff lowered resident to the floor during a transfer, and that this event was not reported by the nurse aides involved in the transfer. Injury was not suspected until 8/24/25, when daylight shift noticed bruising, and outward turning of his leg. This is when the facility began an investigation. During an interview on 10/1/25, at 12:51 p.m. RN Employee E7 stated that Resident R1 had a Recent change in function. He was able to walk independently just prior to the fall. During an interview on 10/2/25, at 12:59 p.m. NA Employee E4 stated that she takes care of Resident R1 often and resident had been able to ambulate and transfer with only one person assisting him before the recent decline. NA Employee E4 stated that she was aware of the recent fall, and stated that staff was educated on falls, and reporting falls. NA Employee E4 added I'm surprised they didn't report [the incident] as a fall, because we all know that it's a fall. During an interview on 10/1/25, at 1:13 p.m. the Nursing Home Administrator confirmed that the facility failed to protect Resident R1 from neglect when staff failed to report the fall and assess resident for injuries. 28 Pa. Code: 201.14(a) Responsibility of licensee28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1). Findings include: A review of the facility Resident Rights last reviewed 8/30/24, indicates the resident or representative have the right to be fully informed of your medical condition. A review of Resident R1's clinical record indicates an admitted [DATE], with the diagnosis of traumatic brain injury (TBI), urinary tract infection (UTI) and dysphagia (difficult swallowing). A review of Resident R1's physician progress notes dated 12/3/24, follow up for hospitalization indicate Resident R1 was treated for chronic outlet obstruction and had a foley catheter (tube inserted into the bladder to drain urine) placed which should stay in place and follow up with urology. A review of Resident R1's care plan on 1/15/25, indicated Resident R1 had a 14 french (size) with 10cc balloon (holds catheter in place in the bladder) foley catheter. Review of nursing progress note dated 11/15/24, at 9:00 p.m. indicates received notification from Nurse Aid (NA) and daughter that resident was having blood in urine. Also, brown discharge noted in resident ' s brief. No lesions or open areas noted in genital areas that could be causing brown discharge. Call placed to physician and made aware of information, stated to obtain urinalysis testing and lab work. Stated ok to straight catheterize resident if necessary. During an interview completed on 1/15/25, at 3:26 p.m. the Director of Nursing confirmed that the resident ' s representative was not notified of the new orders received on 11/15/24, for urinalysis testing, lab work and straight catheterization if necessary. Review of nursing progress note dated 12/23/24, at 2:28 p.m. indicates this morning the NA was giving the patient a shower when the patient pulled out his foley. NA immediately notified the nurse for assessment. Nurse entered the shower room and assessed the patient. Patient siting in shower chair with blood dripping from his penis that became to clot. Nurse cleaned the area. The patient stopped bleeding. Patient at the time, is not screaming or crying. The NA finished cleaning the patient and got him dressed. I notified the nurse supervisor and physician for further guidance and direction. During an interview completed on 1/15/25, at 12:48 p.m. the Director of Nursing confirmed that the resident ' s representative was not notified of Resident R1's catheter dislodgement and the facility failed to notify a family representative of a change in condition for one of three residents. (Resident R1). 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on a review of facility policy, observation, and staff interview, it was determined that the facility failed to properly maintain kitchen equipment and unit pantries in a sanitary condition creating the potential for cross contamination and food-borne illness (Main Kitchen, [NAME] Court, and [NAME] Court). Findings include: A review of facility policy Food Storage dated 8/30/24, indicated that food storage areas shall be maintained in a clean, safe, and sanitary manner. During an observation on 10/7/24, at 10:11 a.m., of the walk-in dairy cooler in the main kitchen, conducted with Dining Services Director (DSD) Employee E1, revealed that the cold air condenser fan covers (6 total) and the ceiling immediately forward of these cooler fans had a build-up of dust, grime, and debris. DSD Employee E1 confirmed observation by surveyor when viewed. During an observation on 10/8/24, at 10:20 a.m., on the [NAME] Court Nursing Unit, revealed 3 blue gel cold therapy ice packs were found in the Resident Food Pantry area freezer. During an interview on 10/8/24, at 10:23 a.m., Licensed Practical Nurse (LPN) Employee E2 confirmed that blue gel cold therapy ice packs should not be stored with food in the Resident Food Pantry freezer. During an observation on 10/9/24, at 11:35 a.m., on the [NAME] Court Nursing Unit, revealed 2 blue gel cold therapy ice packs were found in the Resident Food Pantry area freezer. During an observation and interview on 10/9/24, at 11:40 a.m., with the Assistant Director of Nursing (ADON) Employee E3, who confirmed that ice packs should not be stored in Resident Food Pantry freezers, creating the potential for cross-contamination and food-borne illness. During an interview on 10/11/24, at 1:15 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to properly maintain kitchen equipment and unit pantries in a sanitary condition creating the potential for cross contamination and food-borne illness (Main Kitchen, [NAME] Court, and [NAME] Court). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for two of ten months (September and October 2024). Findings include: Review of facility policy Infection Control Program dated 8/30/24, indicated the program, surveillance, and prevention for infection control practices are the responsibility of the Infection Preventionist and the Committee. Review of the Center for Disease Control and Prevention How to Safely Remove Personal Protective Equipment (PPE) dated 10/3/22, indicated all PPE is removed before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. It was indicated gloves, goggles or face shield, and gown must be removed and discarded in a waste container. During an observation on of a dressing change on 10/8/24, at 10:41 a.m. Registered Nurse, Employee E21 exited Resident R16's room, who was in isolation for COVID, with her gloves and gown. Review of infection control documentation for the previous ten months (January - October 2024) failed to reveal surveillance for tracking infections for residents and staff for two of ten months (September and October 2024). During an interview on 10/9/24, at 1:33 p.m. the Director of Nursing confirmed the facility failed to implement an effective infection control plan as required for the months of September and October 2024 and was unable to produce the documents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on facility policy, clinical record review, and staff interviews, it was determined the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with an indwelling urinary catheter and bladder needs (Resident R39, R44, R63, R122, and R236). Findings include: A review of facility policy Catheter Care dated 8/30/24, indicated the facility will provide catheter care, consistent with the resident's comprehensive assessment and plan of care to prevent infection of the resident's urinary tract. Be sure the catheter tubing and drainage bag are kept off the floor and below the level of the bladder. Catheter bags should be maintained in a dignity bag at all times except when care is being provided. Review of Resident R39's clinical admission record indicated that resident was admitted to the facility 8/26/24, with diagnoses chronic kidney disease (gradual loss of kidney function that can lead to kidney failure), bladder cancer, and atrophy of kidney (a condition where one or both kidneys shrink and loss function due to various reasons). Review of Resident R39's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/2/24, indicated that diagnoses remain current upon review. Section H, Bladder and Bowel, indicated that an indwelling catheter was present. During an observation on 10/7/24, at 11:30 a.m., Resident R39 was in bed with his urinary drainage bag uncovered and laying on the floor. During an interview on 10/7/24, at 11:33 a.m., Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R39's urinary drainage bag was uncovered and laying on the floor. Review of Resident R39's physician order dated 8/27/24, indicated foley catheter (document FR size and balloon in Notes) change PRN [as needed] clogging/dislodgement. Further review of physician orders failed to indicate a diagnosis for indwelling catheter use, failed to include physician orders for care to indwelling catheter site, and failed to include the size tubing and balloon used for Resident R39's indwelling catheter. Review of Resident R39's current plan of care failed to indicate diagnosis for indwelling catheter use and failed to include the size tubing and balloon used for Resident R39's indwelling catheter. Review of Resident R44's clinical admission record indicated that resident was admitted to the facility 8/10/23, with diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R44's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R44's physician order dated 10/8/24, indicated bladder scan (a device that uses sound waves to create a picture of the inside of the bladder) every eight hours for three days. Review of physician progress note dated 10/9/24, indicated urinary stent (thin, flexible tubes that hold open the ureters, allowing urine to flow from the kidneys to the bladder) and urine infection/stones. Review of Resident R44's care plan failed to indicate problems or interventions for urinary retention, urinary infection, or the bladder scans. Interview of 10/10/24, at 11:10 a.m. Assistant Director of Nursing (ADON) Employee E3 confirmed the urinary retention and bladder scans were not included in the care plan as required for Resident R44. Review of Resident R63's clinical admission record indicated that resident was admitted to the facility 4/22/23, with diagnoses of high blood pressure, anxiety, and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R63's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R63's physician orders dated 9/27/24, indicated to apply an external female urinary catheter. Change daily for non-healing wound and incontinence (inability to control bladder). Review of Resident R63's Treatment Administration Record (TAR) failed to include the orders for external female catheter. Observation of Resident R63 on 10/10/24, at 10:00 a.m. failed to include the use of an external female catheter as ordered. Interview on 10/10/24, at 10:14 a.m. the Director of Nursing indicated We don't have the supplies yet fifteen days after the order was written. Interview on 10/10/24, at 11:00 a.m. the Director of Nursing indicated The supplies arrived the other day and somebody put them straight in the closet and staff were unaware they arrived. Review of Resident R122's clinical admission record indicated that resident was admitted to the facility 8/8/24, with diagnoses of anoxic brain damage (injury to the brain due to a lack of oxygen), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and viral hepatitis (disease of the liver caused by a virus). Review of Resident R122's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R122's physician orders dated 10/4/24, indicated to irrigate (flush) catheter with Renacidin (a sterile irrigating solution used to treat kidney and bladder stones and prevent clogs in bladder catheters and tubes) once daily. Observation on 10/8/24, at 10:00 a.m. Resident R122's bedside stand had a bladder irrigation bottle filled with a clear liquid with a syringe lying in it. The irrigation bottle was dated 10/7/24. Interview on 10/8/24, at 10:10 a.m. LPN Employee E17 confirmed the clear irrigation liquid in the bottle should not have been left in the bottle, nor the syringe, and that it was dated from the day prior. Review of Resident R236's clinical admission record indicated that resident was admitted [DATE], with diagnoses benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of the prostate gland), chronic kidney disease, and surgical aftercare for genitourinary (urinary and reproductive) system. During an observation on 10/7/24, at 1:43 p.m., Resident R236 was in bed with his urinary drainage bag uncovered, hanging from the frame of his bed. During an interview on 10/7/24, at 1:45 p.m., Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R236's urinary drainage bag was uncovered. Review of Resident R236' physician order dated 10/8/24, indicated foley catheter (document FR size and balloon in Notes) change PRN [as needed] for clogging/dislodgement. Further review of physician orders failed to indicate a diagnosis for indwelling catheter use, failed to include physician orders for care to indwelling catheter site, and failed to include the size tubing and balloon used for Resident R236's indwelling catheter. Review of Resident R236's current plan of care failed to indicate diagnosis for indwelling catheter use and failed to include the size tubing and balloon used for Resident R39's indwelling catheter. During an interview of 10/22/24, at 11:15 a.m., the Director of Nursing (DON) the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with an indwelling urinary catheter and bladder needs (Resident R39, R44, R63, R122, and R236). 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for three of four residents (Resident R55, R84, and R119). Findings include: Review of the facility policy Hospice Communication dated 8/30/24, indicated the facility will communicate with hospice providers throughout the course of a resident's care. Communication will be done quarterly in conjunction with the care plan and PRN (as needed) based upon resident specific issues. Documentation of stated communication will be reflected in the resident medical record. Review of Resident R55's clinical admission record indicated that he was admitted to the facility 6/11/24, with diagnoses of vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), respiratory failure, and benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of the prostate gland). Review of Resident R55's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/26/24, indicated diagnoses remain current upon review. Section O-0110 Special treatments indicated an x for hospice services. Review of Resident R55's physician order dated 6/27/24, indicated hospice services were to be provided as of this date. Further review of Resident R55's current physician orders failed to indicate which hospice provider was providing this service and this hospice providers contact information. Review of Resident R55's current plan of care on 10/10/24, failed to indicate diagnosis for hospice care, which hospice provider was providing services, and providers contact information. During an interview of 10/10/24, at 12:20 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed that Resident R55's current physician orders for hospice did not indicate which hospice provider was selected and providers contact information, and that Resident R55's care plan did not include hospice diagnosis and provider information as required. Review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease (a movement disorder of the nervous system that worsens over time), depression, and intellectual disabilities. Review of Resident R84's MDS assessment dated [DATE], indicated diagnoses were current. Review of a physician order dated 12/6/23, indicated to refer Resident R84 to hospice for Parkinson's Disease. Review of Resident R84's care plan on 10/9/24, indicated the resident has a terminal condition. Interventions indicated to refer to hospice agency and/or pastoral care interventions for end-of-life preparation. Review of Resident R84's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 10/9/24, at 10:15 a.m. Unit Manager, Registered Nurse, Employee E16 confirmed Resident R84 did not have a hospice name or contact information located in the resident's care plan or order. Review of Resident R119's clinical admission record indicated that she was admitted [DATE], with diagnoses of dementia and cachexia (complex syndrome associated with underlying illness, causing on going muscle loss). Review of Resident R119's MDS assessment dated [DATE], indicated diagnoses remain current upon review. Section O-0110 Special treatments indicated an x for hospice services. Review of Resident R119's current active physician orders as of 10/11/24, failed to indicate an order for hospice services to include diagnosis for hospice care, hospice provider, and contact information for provider. Review of Resident R119's current plan of care on 10/10/24, failed to indicate diagnosis for hospice care, which hospice provider was providing services, and providers contact information. During an interview on 10/11/24, at 10:34 a.m., RNAC Employee E4 confirmed that Resident R119's current physician orders did not include an order for hospice care, and that Resident 119's care plan did not include hospice diagnosis and provided information as required. During an interview on 10/11/24, at 1:15 p.m., the Nursing Home Administrator confirmed the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of- life care for three of four residents (Resident R55, R84, and R119). 28 Pa Code: 211.12 (d)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for communication for one of six residents (Resident R1). Findings include: Review of the facility policy Maintaining Respect and Dignity of the Resident dated 8/30/24, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. It was indicated residents shall be treated with dignity and respect at all times. Review of the facility policy Clinical Procedure Augmentative Communication Device dated 8/30/24, indicated communication boards and/or augmentative devices may be provided to individuals who are limited in their ability to communicate verbally but are able to communicate by using a device with pictures and/or words. The individual, speech therapist, or physician will identify a need for augmentative communication, and a screen or order may be requested from physician or licensed independent provider. Evaluation, treatment, and progress are documented. Review of the admission record indicated Resident R1 admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R1's MDS dated [DATE], indicated the diagnoses of encephalopathy (a disease that affects brain structure or function), aphasia (a disorder that affects language and communication), and epilepsy (a brain condition that causes recurring seizures). Review of Resident R1's Speech Language Pathology Comprehensive Evaluation dated 2/23/24, indicated the resident uses a communication device at baseline function. Review of Resident R1's physician order dated 4/16/24, indicated nurse to ensure that Dynavox (a device that assists individuals who are unable to communicate reliably with their own voices due to cognitive, language and physical impairments) is charging while the resident sleeps every day at bedtime. Review of Resident R1's care plan dated 7/20/16, last revised 6/12/24, indicated the resident has conditions that impair his ability to communicate his wants and/or needs. Interventions included to use his Dynavox to communicate. During an observation on 10/7/24, at 11:04 a.m. Resident R1's Dynavox was observed sitting on a table and not in reach to Resident R1. Resident R1 was unable to communicate. During an interview on 10/07/24, at 11:07 a.m. Licensed Practical Nurse, Employee E9 stated Resident R1 communicates with hand gestures, sign language, and a speech board. LPN, Employee E9 confirmed Resident R1's Dynavox was not in reach. During an interview on 10/08/24, at 12:18 p.m. Nurse Aide, Employee E10 indicated Resident R1 uses his Dynavox to communicate. During an interview on 10/9/24 10:07 a.m. Resident R1 Indicated he prefers to use Dynavox for communication. Review of Resident R1's clinical record on 10/10/24, at 10:10 a.m. failed to include an order for the use of a Dynavox communication device. During an interview on 10/10/24, at 9:20 a.m. the Director of Nursing confirmed the facility failed to provide appropriate care and services to maintain activities of daily living (ADLs) for communication for one of six residents. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, Resident Group interviews, Resident Council meeting minutes, grievances, and staff interview it was determined the facility failed to consider the views of a resident and/or family and act promptly on grievances and recommendations concerning issues of resident care and life in the facility for three of four months (July, August, September 2024). Findings include: Review of facility policy titled Grievance Policy, last reviewed 8/30/24, indicated facility will have a procedure on how to file a grievance or complaint available to the resident and will ensure a prompt resolution of all grievance including the residents' right. During a Resident Group meeting held on 10/8/24, six of six members voiced concerns over food quality, and five of six residents voiced concerns over call bells. Resident R503 reported pasta is hard, carrots aren't cooked and has complained to management for the last 3-4 months with no resolve, also staff come in when calls bells are on, shuts them off and doesn't attend to their needs. Resident R504 voiced concerns that pasta is undercooked, lunch time tray times vary widely, and nothing is done about their concerns. Resident 505 voiced concerns on call bells, not tending to residents. Review of Resident Council meeting minutes revealed food quality and call bell concerns as follows: 7/10/24, Prior meeting concerns, Pasta is too hard, grilled cheese not cooked, meals are late, call bells are turned off before need is met -New: Meat is dry, staff talk to each other during care 8/14/24, Prior concerns: Some food, nursing concerns continue. -New: Pasta not cooked/noodles dry, carrots. 1 shower room is not enough. Staff turn off call bells before doing care. Staff talk to each other during care. 9/11/24 Prior concerns: Pasta not cooked/noodles dry, carrots. 1 shower room is not enough. Staff turn off call bells before doing care. Staff talk to each other during care. -New: Meat is too hard, can't eat, grilled cheese is not grilled, staff talking to each other during care, call bells turn lights off without addressing needs The facility could not provide documentation that the facility investigated and provided a resolution of the Resident Council concerns. During an interview on 10/10/24, at 10:00 a.m. the Director of Activities Employee E6 confirmed the facility did not resolve the above concerns. 28 Pa. Code: 201.18(e)(4) Management 28 Pa. Code: 201.29(i) Resident Rights

Based on facility policy, resident record review, review of facility documents, and staff interview, the facility failed to provide an environment free from verbal abuse for one of three residents (Resident R400). Findings include: Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property dated 8/30/24, indicated that the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, exploitation or misappropriation of property. Review of the clinical record revealed that Resident R400 was admitted to the facility on [DATE]. Review of Resident 400's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), unspecified visual loss, and muscle weakness. Review of documentation provided by the facility revealed that on 7 /13/24, Speech Therapist (ST) Employee E14 witnessed Nurse Aide (NA) Employee E15 yell at Resident R400 in the dining room. Allegedly NA Employee E15 ripped the pillow out of Resident R400's hands because she was getting the pillow in her food and yelled at her Why don't you go the fuck to sleep?. Resident R400 sat quietly in her chair with her eyes closed. Review of a written statement from ST Employee E14 dated 7/12/24, stated that Resident R 400 was placed at dining room table and had a pillow on her lap. She placed the pillow on top of her tray of food and NA Employee E15 then went over to Resident R400 and ripped the pillow out of her hands and said, 'Why don't you go the fuck to sleep?'. Incident was reported to Director of Nursing. Review of a written statement from NA Employee E15 dated 7/12/24, stated Raised my voice to Resident R400. It was uncalled for and I am ashamed of my actions. During an interview on 10/10/24, at 9:35 a.m. Nursing Home Administrator confirmed that the facility failed to provide an environment free from verbal abuse for Resident R400. 28 Pa. Code: 201.18(b)(1)(2) 28 Pa. Code 201.29(a)(c)(d)(j)(m)

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of four residents sampled with facility-initiated transfer (Residents R16 and R37). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on [DATE]. Review of Resident R16's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R37's admission record indicated she was originally admitted on [DATE], with diagnoses that included venous insufficiency, retention of urine and colostomy (procedure that creates an opening in the abdominal wall to divert the large intestine to an external pouch). Review of Resident R37's clinical record revealed that the resident was transferred to the hospital on 6/9/24, and returned to the facility on [DATE]. Review of Resident R37's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 10/9/24 at 1:15 p.m. the Assistant Director of Nursing (ADON) confirmed that the facility failed to provide the necessary information for Resident R16 and R37. 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of four residents (Residents R16). Findings include: Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 9/3/24, indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on [DATE]. Review of Resident R16's clinical record indicated the facility failed to include documented evidence that the facility provided a written transportation notification to the Office of the Long-Term Care Ombudsman for the hospitalization on [DATE]. During an interview on 8/15/24 at 11:05 a.m. the Director of Nursing (DON) confirmed the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for one of four residents (Residents R16). 28 Pa. Code 201.29(a)(c.3)(2) Resident rights

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) for one of four resident hospital transfers (Resident R16). Review of the clinical record indicated Resident R16 was admitted to the facility on [DATE]. Review of Resident R16's MDS dated [DATE], indicated diagnoses of aftercare following joint replacement, urinary tract infection and hyperlipidemia (abnormally high levels of lipids or fats in the blood). Review of the clinical record indicated Resident R16 was transferred to hospital on 8/6/24 and returned to the facility on [DATE]. Review of Resident R16's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 8/6/24. During an interview on 10/9/24, at 1:15 p.m. Assistant Director of Nursing Employee E3 confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for one of four resident hospital transfers as required. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

Based on a review of the RAI (Resident Assessment Instrument), clinical records, and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R1, and R128). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated the following: Section A2105 Discharge Status: This item documents the location to which the resident is being discharged at the time of discharge. Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person. Section P0100 Physical Restraints: Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Code 1 if a restraint is used less than daily during a seven day look back period. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's MDS dated [DATE], indicated the diagnoses of anxiety, depression, and epilepsy (a brain condition that causes recurring seizures.) Section P0100. Physical Restraints indicated the resident uses a limb restraint in bed. During an observation and interview on 10/9/24, at 10:10 a.m. no restraints were observed on Resident R1. Resident R1 indicated he does not utilize any limb restraints. Review of the admission record indicated Resident R128 was admitted to the facility on [DATE]. Review of Resident R128's MDS dated [DATE], indicated the diagnoses of anemia (too little iron in the body causing fatigue), urinary tract infection (infection in any part of the kidneys, bladder, or urethra), and cardiomyopathy (disease of the heart muscle). Section A2105 was entered as 04, which indicated that resident R128 was discharged to a Short-Term General Hospital. Review of progress notes dated 7/12/24, indicated that Resident R128 was discharged to Personal Care. During an interview on 10/9/24, at 1:25 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed the facility failed to make certain that resident assessments were accurate for two of twelve residents (Residents R1, and R128). 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing Services.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of five residents (Resident R29) to accurately reflect the current status of the resident and care needs. Findings include: Review of the facility policy Comprehensive Plan of Care dated 8/30/24 indicated specific individualized steps or approaches that staff will take to assist the resident to achieve the goals will be identified. These approaches serve as instructions for resident care and provide for continuity of care by all staff. Short and concise instructions should be written. Review of the admission record indicated Resident R29 admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/2/24, indicated the diagnoses of anemia (the blood doesn't have enough healthy red blood cells), coronary artery disease (narrow arteries decreasing blood flow to heart), and heart failure (heart doesn't pump blood as well as it should). Review of Resident R29's physician order dated 10/8/24, indicated to give Eliquis (a medication that thins the blood) daily. Review of Resident R29's care plan on 10/10/24, at 12:19 p.m. failed to identify the use of the blood thinner and the monitoring/management of its use. Interview on 10/10/24, at 12:20 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed the facility failed to identify the blood thinner for Resident R29's care plan and the facility failed to update a care plan for one of five residents (Resident R29) to accurately reflect the current status of the resident and care needs. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to provide a dignified dining experience by failing to provide meals timely for one of six residents (Resident R1). Findings include: Review of the facility policy Maintaining Respect and Dignity of the Resident dated 8/30/24, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. It was indicated residents shall be treated with dignity and respect at all times. Review of the facility policy Resident Rights dated 8/30/24, indicated the facility will inform a resident at the time of admission, and periodically throughout his/her stay, of the rights afforded to all residents. Review of the admission record indicated Resident R1 admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R1's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 8/29/24, indicated the diagnoses of anxiety, depression, and epilepsy (a brain condition that causes recurring seizures). During an observation on 10/8/24, at 11:31 a.m. Resident R1's roommate lunch tray was dropped off in his room. Resident R1 did not receive his meal. During an interview and observation on 10/8/24, at 11:54 a.m. Resident R1 was observed with no meal and indicated he is hungry. Resident R1 indicated it bothers him that his roommate gets food before him. During an interview on 10/8/24, at 11:55 a.m. Resident R1's roommate was observed finished with his meal sleeping in bed. During an observation on 10/8/24, at 12:17 p.m. Nurse Aide, Employee E10 was observed entering Resident R1's room with his meal. A total of 46 minutes since Resident R1's roommate received his meal. During an interview on 10/8/24, at 12:18 p.m. Nurse Aide, Employee E10 confirmed Resident R1's roommate got his meal prior to Resident R1. During an interview on 10/9/24, at 12:24 p.m. the Director of Nursing confirmed the facility failed to provide a dignified experience by failing to provide meals timely for one of six residents (Resident R1). 28 Pa Code: 201.29 (i) Resident rights.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident had a physician order for care and management of an invasive catheter for one of one resident formerly on dialysis (Resident R122). Findings include: Review of facility policy Standards of Care dated 8/30/24, indicated a detailed care plan based on the resident's assessment, including specific interventions, goals, and responsible staff members. Ensure that all staff members are adequately trained in providing quality care, including specific skills needed for resident needs. Review of the admission record indicated Resident R122 was admitted to the facility on [DATE]. Review of Resident R122's Minimum Data Set (MDS- a periodic assessment of care needs) dated 8/8/24, indicated the diagnosis of anoxic brain damage (injury to the brain due to a lack of oxygen), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and viral hepatitis (disease of the liver caused by a virus). Review of Resident R122's current physician orders on 10/9/24, at 1:45 p.m. failed to include orders for care and management of the Tesio catheter (a long-term vascular access device for hemodialysis - a treatment for kidney failure that rids your body of unwanted toxins, waste products, and excess fluids by filtering your blood). Review of the Resident R122's current care plan on 10/9/24, at 2:00 p.m. indicated I will remain free from infection related to my dialysis catheter. The care plan failed to identify care and management of the Tesio catheter and site. Observation of Resident R122 on 10/10/24, at 2:05 p.m. indicated two Tesio catheter ports sticking out from under the resident's shirt on the left upper arm. Interview with Resident R122 on 10/10/24, at 2:05 p.m. indicated she last had dialysis over a month ago and they haven't done anything with the Tesio catheter since. Observation with Licensed Practical Nurse (LPN) Employee E5 on 10/10/24, at 2:10 p.m. indicated a Tesio catheter in the left upper chest with dark dried blood at the insertion site under a clear, crumpled dressing. There was not a readable date on the dressing. Interview with LPN Employee E5 confirmed the appearance of the Tesio site, dressing, and that Resident R122 hasn't had dialysis in over a month. LPN Employee E5 further indicated staff of the facility do not handle the Tesio catheters. Interview with the Director of Nursing on 10/10/24, at 2:25 p.m. confirmed the facility failed to ensure a resident had a physician order for care and management of an invasive catheter for one of one resident formerly on dialysis (Resident R122). 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility documentation, clinical record, and staff interviews it was determined that the facility failed to provide adequate supervision and effective safety measures to prevent elopement (unauthorized leave from a safe area) of residents with wandering behaviors and/or history of elopement behaviors and failed to ensure resident safety with a staff breakroom left open behind a nurses station. This allowed for Resident R1 and Resident R2 to elope out of the facility without staff knowledge. The facility failed to ensure safety when Resident R1 found a cigarette and lighter in an unlocked staff break room visible behind the nurses station, and was found smoking at the nurses station. The two elopement incidents and the resident smoking at the nursing station resulted in an immediate jeopardy situation for two of three residents (Residents R1 and R2). Findings include: Review of facility policy Missing Resident, dated 8/31/22, indicated: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing to the charge nurse of the neighborhood immediately. Should an employee observe a resident leaving the premises, attempt to prevent the departure, obtain assistance from other staff, instruct another staff member to inform the charge nurse. Should an employee discover that a resident is missing from the facility , they should alert the charge nurse immediately. A search for the resident is to begin immediately. Maintenance is to be contacted to review security camera footage to see if resident is able to be seen on the cameras. Review of facility policy Elopement Risk assessment dated [DATE], indicated that it is the policy of the facility that residents will be assessed for elopement risk on admission, quarterly and prn with significant changes. Interventions will be developed and entered on the interim plan of care for all residents identified as being an elopement risk at time of admission. Review of facility policy Smoking, Tobacco, and Electronic Cigarette Use dated 8/31/22, indicated that the community is a smoke-free and tobacco free facility except for the designated employee smoking shelter at the facility. Resident R1 was admitted to the facility on [DATE], with the following diagnoses, dementia ( a group of thinking and social symptoms that interferes with daily functioning), traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the brain usually due to a Traumatic brain injury), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), unspecified intellectual disabilities ( a broad category of diseases characterized by an impairment to the intelligence an individual possesses), and wandering in disease (It's common for a person living with dementia to wander or become lost or confused about their location and it can happen at any stage of the disease), all of which remained current as of the Minimum Data Sets (MDS - a periodic assessment of resident needs) dated 11/26/22 and 3/2/23. Review of clinical documentation elopement assessment dated [DATE], indicated that Resident R1 was a risk for elopement. Review of physician orders showed Resident R1 was given a Wanderguard. Review of the clinical documentation progress notes indicated the following: Resident R1 attempted to elope from the secured nursing unit three times in August 2022, attempting to run down the back stairwell, exit out the door from the back stairwell and go outside. Resident R1 had on-going behaviors of wandering up and down the hall going by each exit door and setting off the alarm - waiting for staff to re-set the alarm and try to get to the doorway prior to the alarm setting. Facility staff on multiple days and multiple shifts in August of 2022, had staff assigned to the doorways to ensure that Resident R1 did not get out of the secured unit. Resident R1 had 1:1 assigned twice during that time frame due to wandering behaviors. Resident R1 had behaviors in September 2022, of wandering, impulsiveness, and exit seeking. Resident R1 was found eating and drinking food off of other resident's trays, attempting to eat or drink off of resident food trays in the dirty food cart and taking beverages off of the nurses cart. Resident R1 required re-orientation throughout those days. Resident R1 had behaviors of wandering, exit seeking in December 2022, and continued to need re-orientation throughout the day. Resident R1 had behaviors in February 2023, of wandering in and out of other resident rooms and sleeping in their beds or on the floor. Resident R1 continued to need re-orientation throughout the day, continued to wander, exit seek and require supervision due to elopement risk. To include the following: 2/9/23: Resident observed lying on the fall mat beside bed in room (that was not Resident R1's), covered with a sheet. Staff redirected resident from this room several times. Resident observed getting in to bed in same room at this time. Staff providing 1:1 to keep resident from entering this room. 2/21/23: Restorative note . Resident continues to walk on the unit with no assistive device. Resident R1 does wander in and out of other rooms. Resident R1 does know where their room is, also has name posted on the door for recall. Resident able to follow instructions with continuous verbal and visual cueing. 2/22/23: Resident R1 moved has been extremely difficult to keep from going into that room, verbal and physical redirection are not effective, stop signs, room name signs and the simulation of a hole in front of the door have been effective. When others are placed in that room. Resident R1 will is intrusive even if they are in there, looking out their window, laying in the bed or standing on the bed and pulling out the ceiling tiles. Peers are sometimes verbally threatening or fearful of him. 2/22/23: Restorative note . Resident walked in the hallway today with no assistive device. Resident R1 does receive supervision from the staff due to being an elopement risk. Resident does have on a wonder guard device. Resident does have a behavior of wondering into other resident's rooms. Resident does have behavior of walking on the white tiles on the floor. 2/24/23: Restorative note . Resident continues to walk on the unit with no assistive device. Resident R1 does require supervision due to elopement risk. 2/27/23: Resident R1 was moved to the room that he/she frequents, but continues to walk into all rooms and lay in the beds. Review of facility clinical documentation indicated that on 3/3/23: At shortly after 5:30 this morning this writer was notified by Nurse Aide that the resident could not be found and believed to have left the unit. All nursing units, PC, Dietary staff and housekeeper were immediately notified to begin a building wide search. This writer went outside and walked the perimeter of the building. At that point a call was made to notify the administrator and 911 was called to assist. Staff continued to search until the police arrived and informed this writer that they had found Resident R1. That Resident R1 walked to the convenience store down the street and they had given him/her a banana and appeared unharmed. This writer attempted to coerce the resident into getting out the police car but he/she just kept giggling and counting. The LPN who was working Resident R1 unit arrived at that point and also attempted to convince Resident R1 to come out of the police car. Resident R1 just kept giggling. When the police officer said, Come on buddy, let's go inside Resident R1 hopped right out. This writer and LPN along with the 2 state police officers walked the resident up to the unit. The resident was wearing a hospital gown and non-skid socks. Nurse aide assisted resident back to room to get dressed and to warm up. Clinical notes from 3/3/23, included that Resident R1 was attempting to get off the the unit from after 4:15 a.m. (when nurse took break) and when nurse came back from break was observed aggresively shaking on door trying to elope. Around 5:05 a.m. writer was able to get back onto unit (Resident R1 was refusing to move away from doorway) - Resident R1 was redirected and given some tea and taken back to the nurses station at this time. Clinical notes included the following: 3/3/23: Resident R1 eloped from unit/building this AM. Around 5:25a.m., this writer was attempting to administer resident's AM medication, while walking down the hall to locate resident, when asked oncoming Nurse Aide, Nurse Aide stated she had not seen him when she arrived inside the door on unit. Alarm was not sounding at that time. Front lounge/conference room was noted to vacant. This writer began looking in every room on way back up east hall d/t (due to) resident having history of being in other resident's room. Upon not finding Resident R1 this writer notified Nurse Aide's on unit to do thorough look again into every resident's room and bathroom. RN supervisor notifying other nursing units to look for Resident R1. Staff looked throughout facility, parking lot, behind building, front. RN supervisor notified police of resident being missed. Police brought resident back to facility after finding Resident R1 on road and the gas station where Resident R1 at a banana. Resident R1 did not want to get out of the police car for RN, this writer offered an ice tea Resident R1 said yes but then said close the door. Officer told Resident R1 it was time that he/she had to get out of the car, this writer offered resident a blanket and warm clothes that were upstairs and resident climbed out of the car and took this writer and RN by our arms and walked with us back into the facility escorted by the two police officers. Resident came back unto unit, holding mine and RN supervisor's hand. Sat into chair by nurse's desk, this writer ave resident blanket to cover up with. Prior to elopement, this writer left unit around 4:15 a.m., Resident R1 was still in bed. Nurse Aide stated while this writer had been off unit, Resident R1 made several attempts at exit seeking at the front doors and when the Nurse Aide would put in the code to reset the alarm resident would rush the doors and attempt to get out. Nurse Aide stated Resident R1 made it a step or two out of door able to redirect resident and bring back into doors. This writer arrived back onto floor around 4:35-4:40 a.m. to enter into unit. Alarm was sounding at time and this writer was able to see resident behind doors where he was aggressively shaking doors and peering out frosted design windows. This writer would wait until resident seemed to move away from doors and approach, hesitate a few seconds to see if resident was still waiting infront of doors and resident would quickly start shaking doors again. Resident R1 would move from side to side to violently shake doors and then peer out windows to see if anyone was going got open doors. This writer did hear female aide attempt to redirect resident, however resident refused and remained by door. Resident R1 seemed to hide in conference room or off to side where this writer was unable to see Resident from small windows in door as soon as Resident R1 would see this writer would violently shake doors again. Around 5:05 a.m., Nurse Aide was able to open door and allow this LPN entry, this writer and the Nurse Aide awaited inside doors for lock to reset and click then this nurse walked Resident R1 back to nurses desk for cup of iced tea. Resident obtained cup of tea and began walking away again. This nurse began getting ready for med pass, prepared Resident R1's medications and began to try to find him up front. Review of facility documentation incident report documentation dated 3/3/23, indicated the following: This writer could not find resident when attempted to administer AM medications around 5:30 a.m. Searched all rooms, no alarms were noted to be alarming. Oncoming Nurse Aide stated she did not see resident she entered unit. Supervisor notified. Other staff members from other units searching units and floors. This writer searched dietary old PC unit on three. Searched rooms on this unit multiple times. Supervisor notified police department. Police found resident on road at convenience store and returned Resident R1. Additional documentation review indicated, prior to incident around 4:45 a.m., this writer was attempting to go back onto unit and resident was up front at door shaking the doors aggressively. Nurse Aide attempted to redirect, resident was noted to rush the door when Nurse Aide reset alarm and attempt to get out. Nurse Aide was able to keep Resident R1 from getting too far and back into unit. Resident R1 continued this behavior of shaking the doors for approximately 20 minutes. Review of the facility video documentation for the day of 3/3/23, showed Resident R1 dressed in a hospital gown and non-skid socks leaving the nursing care unit by himself at approximately 5:14/5:15 a.m. Observation of the video documentation was confirmed with the Corporate Employee E2. Review of the facility investigation incident statements indicated the following: -Employee E4: prior to incident Nurse Aide stated Resident R1 had been exit seeking and rushing to the door as soon as Nurse Aide put code into reset alarm. Got a step or two out of door and Nurse Aide got Resident R1 back into Nursing unit. Alarm bracelet on and functioning. -Employee E5: Resident R1 was standing by front door around 4:30 a.m. I tried to redirect Resident R1 away from door. Resident R1 was so close to door and would not move away from door. The last time I saw Resident R1 was around 5:15 a.m. The front door alarm was blaring for at least 35 minutes Resident R1 would not go way from the front door. Resident R2 was admitted to the facility on [DATE], with the following diagnoses major depressive disorder (a mental health disorder characterized by persistently depressed moods), other mixed anxiety disorders (people who suffer from both anxiety and depressive disorder), and cirrhosis of liver (chronic liver damage). All of which remained current as of the MDS dated [DATE]. Review of Resident R2 elopement risk evaluation dated 1/9/23, indicated that Resident R2 was a high risk for elopement - no wander guard, or care plan was initiated. Review of Resident R2 clinical record clinical notes report dated 1/9-1/10/23, indicated the following: Resident R2 was confused upon admit, and had several attempts of trying to going outside even after staff attempted to orient resident to rooms. Resident R2 called family members and police to pick him up. Staff spoke with Resident again to reorient to room and facility. Resident had very poor insight and staff informed family Resident R2 may be transferred to the secured unit for safety concerns. Resident R2 was brought back to nursing unit due to being found outside. Review of facility documentation submitted to the state survey agency revealed the following: On 1/14/23, Employee E3 was leaving at end of shift (12:30 am) and heard knocking on the facility front door on the patio leading to the parking lot. Resident R2 asked Employee E3 how to get back inside the building after having used the stairwell from the unsecured unit to the ground floor and outside to the parking lot. Employee E3 escorted Resident R2 back into the building and called the night shift supervisor. Resident R2 stated that he/she went to take a walk, went down the stairs and outside the building only to find the door locked. Review of the documentation included that the temperature on that day was 27 degrees and Resident R2 was wearing a t - shirt and shorts with grip sock. Review of the facility investigation incident statements indicated the following: -Employee E5: Resident R2 was seen walking back to his/her room around 12:10 a.m. -Employee E6: Resident R2 was seen at 12 am walking into room. Resident R2 was walking around unit myself and other Employee kept an eye on the Resident until he/she walked into their room. Resident R2 must have went down back stairwell as we could see unit main doors. Fire stairwell is unlocked with no alarm. During an interview on 3/21/2023, at 12:30 p.m. the Assistant Nursing Home Administrator (NHA)and the Director of Nursing (DON) confirmed that Resident R1 and Resident R2 eloped from the facility, with Resident R1 going to a convenience store and Resident R2 eloping to the front of the building without staff awareness. Review of Resident R1 clinical record progress notes revealed the following: 8/27/2022, while this writer was helping an aid with a transfer, another resident yelled for me that this resident was smoking a cigarette. This writer ran to the front of the nurses (station) and found this resident sitting in a chair smoking a cigarette. Resident R1 had taken the nurses station gate down and gone into the nurses break room and had taken an employee's cigarettes and started smoking it. During an interview on 3/21/2023, at 12:40 p.m. NHA (over the phone), Assistant Nursing Home Administrator (ANHA), DON and Assistant Director of Nursing (ADON) confirmed that Resident R1 and Resident R2 did leave the Nursing Care Home without staff knowledge. During the interview they confirmed that Resident R1 did smoke a cigarette at the nurses station on the secured unit. During the interview administrative staff agreed that residents should not be able to elope from the facility and that staff should be aware of where the residents are in the facility and nursing unit. Administration also acknowledged that the facility is nonsmoking for residents. Resident R1 should not have had access to the employee break room and employee cigarettes, and should not have been smoking in the facility. The facility did not agree that the elopements and smoking incident raised to the level of immediate jeopardy. The DON and NHA were made aware that an Immediate Jeopardy situation existed for residents on 3/21/2023, at 12:30 p.m. and an immediate action plan was requested. On 3/21/2023, at 12:37 p.m. the Immediate Jeopardy template was provided to the facility. On 3/21/2023, at 6:27 p.m. An acceptable Corrective Action Plan was received which included the following interventions: 1. Maintenance if verifying the functionality of all wander guard alarm equipment 2. The facility will do a head-count of all residents 3. The facility will check each wander guard bracelet 4. Notices will be placed on and off the secure unit with reminders not to allow others off of the unit. 5. Elopement assessments will be completed on all residents. 6. Education will be provided all employees regarding elopement/exit seeking behaviors including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. 7. A facility audit to identify potential risk/hazards in the environment. 8. Residents will be monitored for elopement risk/exit seeking behavior on admission, quarterly, significant change. 9. Nurses notes will be monitored each day during clinical report. 10. Resident at risk for elopement/exit seeking will be audited twice weekly x2 weeks, then weekly x2 weeks, then monthly x 2 months. 11. Environmental audits Q shift for 2 weeks, then twice weekly x2 weeks, then weekly x2 weeks, then monthly x2 months to check for resident safety concerns. 12. Education and audits will be reviewed at the quarterly Quality Assurance and Performance Improvement meetings. During an interview on 3/22/23, at 5:57 p.m. Nurse Aide (NA) (3:00-10:00 pm shift) Employee E10 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possessions inaccessible to residents during the interview. During an interview on 3/22/23, at 6:15 p.m. Registered Nurse (RN) Employee E11 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. During an interview on 3/22/23, at 6:21 p.m. NA Employee E12 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 7:15 a.m. Nurse Aide (NA) Employee E13 (11pm-730 am shift)confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 7:19 a.m. Licensed Practical Nurse (LPN) Employee E14 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 7:30 a.m. RN Employee E15 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 7:40 a.m Unit Secretary Employee E16 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 7:59 a.m. Speech Therapist Employee E17 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 8:08 a.m. Dietary Technician Employee E18 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 8:18 a.m. Receptionist Employee E19 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. During an interview on 3/23/23, at 8:28 a.m. Driver/Central Supply Employee E20 confirmed that they received education on elopement exit seeking behaviors, including assessing, identifying, prevention and procedures for elopement. Staff will be educated on keeping personal possessions inaccessible to residents. Staff were able to verbalize the education on elopement and keeping personal possession inaccessible to residents during the interview. The review of the documentation received from the facility 3/23/2023, at 1:00 p.m. revealed all elements of the Corrective action Plan were substantially completed per the facility action plan. Verification of the facility's plan was completed, and the Immediate Jeopardy was lifted on March 23, 2023, at 1:06 p.m. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 207.2(a)Administrators Responsibility 28 Pa. Code 211.12(a)(c)(d)(3)(5)Nursing services.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs for two of three residents (Resident R36 and R50), which resulted in actual harm of Resident R50 causing a fractured humerus(arm bone) and fractured shin(leg bone) and no injury for Resident R36. Facility failed to provide assistance without causing an injury for one of six residents (Resident R65), which resulted in a hand injury. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. The RAI further indicated that How a resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of Toileting. Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of facility policy Resident Accidents/Incidents dated November 2021, indicated the facility will provide a safe and secure environment for residents and will be proactive in the prevention of accidents and incidents. Review of Resident R36's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R36's MDS (Minimum Data Set- a periodic assessment of care needs) dated 5/12/22, indicated diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior and coronary artery disease (damage or disease in the heart's major blood vessels). Review of Resident R36's MDS assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, dated 2/15/19, 5/18/19, 7/14/19, 10/9/19, 1/9/20, 1/21/20, 5/2/20, 8/2/20, 8/28/20, 11/28/20, 2/8/21, 5/11/21, 8/11/21, 11/9/21, 2/19/22, 5/12/22, and 5/17/22, all indicated that Resident R36 required extensive assistance of two or more staff members. Review of Resident R36's plan of care for Fall Risk and for ADLs (activities of daily living) initiated 2/11/19, and reviewed on 2/22/22, and 5/31/22, failed to reveal the bed mobility assistance level for Resident R36. Review of a progress note written by Registered Nurse (RN) Employee E14 dated 7/4/21, at 4:25 p.m. indicated, Staff alerted this writer that resident had a fall in her room. Upon entering room, the resident was observed lying, on her back, on the floor between the wall/air conditioner and her bed. Nurse Aide (NA) Employee E15 was present in the room at the time, and she stated that she was changing resident's brief when the fall occurred. NA Employee E15 stated when she rolled the resident on her left side facing the window, she turned from the resident to reach for a brief, when she turned back, the resident had fallen onto the floor. Review of a facility completed incident report dated 7/7/21, indicated, Nurse Aide self-reported that she did leave the resident on her side to retrieve a brief from the closet resulting in a fall. Review of the clinical record indicated that Resident R50 was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] (paralysis of all four limbs), [CONDITION(S)] (a birth defect that affects the spine), [CONDITION(S)] (loss of the ability to express speech), and dysphagia (difficulty swallowing). An MDS dated [DATE], indicated above diagnoses remain current. Review of Resident R50's MDS assessment dated [DATE], Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, indicated that Resident R50 required extensive assistance of two or more staff members. Review of Resident R50's Activities of Daily Living (ADL) Verification Worksheet (a calendar grid for a resident, showing the resident's tasks/intervention description) indicated that from 2/24/22, through 3/4/22, Resident R50 had bed mobility documented on 17 times, with 7 of those times (approximately 41%) documented as having required two persons. Review of a progress note dated 3/4/22, at 11:19 a.m., written by Licensed Practical Nurse (LPN) Employee E6 indicated that Resident R50 was being provided a.m. care in bed. During bed mobility resident assisted onto left side for sling placement and forward momentum causing resident to roll out of bed onto floor and indicated that Resident R50 reporting inability to move right arm. Review of Facility Incident Statement dated 3/4/22, written by Certified Occupational Therapist Assistant (COTA) Employee E7 stated that while Employee E7 was performing incontinence care for Resident R50, who was rolled on her left side and was holding onto the left side rail to maintain side lying position, Employee E7 placed her left hand on Resident R50's right side of abdomen and attempted to tuck a brief underneath Resident R50's left hip when Resident R50's right leg fell over the side of the bed and resident R50 rolled out onto the floor. Review of clinical record indicated that Resident R50 received multiple x-rays to right side on 3/4/22, that were negative. However, additional x-rays performed on 3/7/22, indicated that resident had a displaced fracture of her right humerus (arm) and x-ray on 3/10/22, indicated that resident had a fracture of her right tibia (shin). During an interview on 7/8/22, at 10:13 a.m. with Director of Nursing and Nursing Home Administrator, it was confirmed that the facility failed to provide the assistance of two people during bed mobility for Resident R50. Review of the clinical record indicated that Resident R65 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's dementia, [CONDITION(S)] (difficulty seeing), and [CONDITION(S)] (difficulty sleeping). A MDS dated [DATE], indicated the diagnoses remained current. Review of a clinical note dated 10/12/21, indicated staff identified a hematoma on the back of Resident R65's right hand near her knuckle. An incident report indicated that the bruise was from unknown origin. Review of a clinical note dated 10/15/21, indicated the bruise investigation to include communication with staff identifying that the bruise was acquired after being placed at the table and getting her hand caught between the table and the arm of the chair. Staff had been educated on monitoring placement of residents hands when she is placed at the table. During an interview on 7/8/22, at 10:15 a.m. the Nursing Home Administrator confirmed that the facility had not provided Resident R65 assisstance without causing an injury. 28. Pa Code 210. 14 (a) Responsibility of licensee. previously cited 4/16/21. 28. Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services. previously cited 4/16/21.

Based on a review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility neglected to provide adequate supervision while providing care, when staff turned around, to answer a question by another staff member, resulting in the resident rolling out of bed causing harm in the form of a fracture for one of 6 residents reviewed (Resident R81). Findings include: Review of facility policy, Abuse, Prevention of Resident Abuse, Neglect (Act 28) Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property, dated 10/7/20, indicated that the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from . neglect. Review of facility policy, Prevention of Injury related to agitated behavior, dated 10/7/20, indicated the safety of residents must be preserved despite situations which may arise related to the inability of the resident to maintain self-controlling all settings and circumstances. A supportive environment will be maintained at all times. Review of Resident R81's clinical record, Admission Record Report, indicated Resident R81 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R81's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation, Incident Report Documentation, dated 12/16/20, indicated Resident R81 was receiving care from Nurse Aide, Employee E4, at 6:00 a.m. when Resident R81 rolled out of bed. Review of the incident report documentation revealed that Resident R81 was, physically aggressive resistive to care verbal outburst self-inflicting injury. A witness statement review indicated NA, Employee E4 turned around to answer her coworker during the time the incident occurred. Review of a note entitled, clinical notes report, dated 12/16/20, indicated that resident had a witnessed fall without injury. NA Employee E4 stated that the resident rolled self out of bed while receiving care. Review of facility clinical records, Care Plan Report, printed on 3/26/21, with a goal date of 4/19/21, for Behavior that indicted, I have occasional episodes of becoming combative during care with risk for injury to self and others. Interventions included, I will be administered [CONDITION(S)]/psychoactive medication(s) as ordered and will be monitored for side effects and effectiveness. Review of MAR (Medication Administration Record) for December 2020, revealed [MEDICATION(S)] 0.5 mg PRN - indicated Resident R81 received PRN (as needed) medication for behaviors on December 3,18, 21, 25, 29, and 31, 2020. [MEDICATION(S)] 0.5 mg PRN was not provided to Resident R81 on 12/16/20, the date of the incident, for behaviors. During an interview on 4/16/21, at 12:59 p.m. the Director of Nursing confirmed that Resident R81 rolled off of the bed when the NA turned around, and received an acute transcondylar elbow fracture. The facility neglected to provide the necessary supervision for a resident which resulted in the resident falling off the bed when staff turned around to answer a question, resulting in a fracture for one of six residents reviewed. 28. Pa Code 201.14(a) Responsibility of licensee. 28. Pa Code 201.18(b)(1)(e)(1) Management. 28. Pa. Code 201.29(d) Resident rights. 28. Pa. Code 211.10(c)(d) Resident care policies. 28. Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to provide supervision during care resulting in a fracture for one of 6 residents reviewed (Resident R81). Findings include: Review of facility policy, Resident Incident or Accident Report, dated 10/7/20, indicated that all incidents or accidents involving a resident shall be recorded on the, Incident/Accident Report, form. The form shall be completed in full. A factual description of the incident or accident including information or circumstances that led up to the event and any witnesses accounts of what happened will be included. Review of Resident R81's clinical record, Admission Record Report, indicated Resident R81 was admitted to the facility on [DATE], with diagnoses of chronic [CONDITION(S)] (a condition that results in an inability to effectively exchange [MEDICATION(S)] and oxygen), severe intellectual disabilities (damage to or abnormal development of central nervous system) and [CONDITION(S)] (a disorder marked by sudden recurrent episodes of loss of consciousness, or convulsions) which remained current as of 2/25/21. A new diagnosis of displaced transcondylar fracture of the right humerus (a break in the lower end of the upper arm bone - can make elbow motion difficult) was noted as of 12/18/20. Review of Resident R81's care plans, printed 3/26/21, indicated a history of falling with the intervention of, I will be provided supervision/assistance for transfer, ambulation and toileting and checked visually on rounds. Review of facility submitted documentation, Incident Report Documentation, dated 12/16/20, indicated that Resident R81 was an assist of one for care. Review of the facility documentation, Incident Report Documentation, dated 12/16/20, indicated Resident R81 was receiving care, from Nurse Aide (NA), Employee E4, at 6:00 a.m. when Resident R81 rolled out of bed. Review of the facility documentation entitled, Employee/Witness Statement Form, and a provided witness statement on a sheet of paper that was not on the Employee/Witness Statement Form, indicated that the bed was in the three foot high position, which was the position needed to provide care. NA Employee E4 turned around to answer NA Employee E3's questions, and while NA Employee E4's back was toward the resident, Resident R81 rolled off the bed onto the floor. Review of radiology report dated 12/18/20, indicated that Resident R81 had a displaced transcondylar fracture of the right humerus. During an interview on 3/28/21, at 1:05 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the incident with Resident R81, and according to the witness statement, NA Employee E4 turned around to answer a question from NA Employee E3 and Resident R81 rolled out of bed resulting in a displaced transcondylar fracture of the right humerus. Review of facility documentation dated 4/23/20, revealed that NA Employee E4 had been informed how to provide care for Resident R81 and had received training on neglect. The facility failed to provide adequate supervision during care resulting in a fall and actual harm for Resident R81 who sustained a displaced transcondylar fracture of the right humerus. 28. Pa Code 210. 14 (a) Responsibility of licensee. 28. Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services.

Based on review of manufacturer's instructions, review of clinical records, and staff interviews, it was determined that the facility failed to safely transfer a resident using a mechanical lift (partial lift) resulting in actual harm, for one of five residents (Resident R1). Findings include: The manufacturer's instructions for the Sabina II lift (a sit to stand partial lift) designed for residents that have difficulty standing up on their own or with poor balance stated, "personnel must receive appropriate instruction and training" and "an individual resident assessment is necessary for optimal function and security." The Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 9/29/10, indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also indicated that Resident R1 was cognitively impaired, required extensive assistance of at least one staff for all care, and was unable to sit or stand safely without physical assistance and/or positioning devices. The Restorative Nursing Program of Care notes dated 11/1/10 through 11/4/10, indicated that Resident R1 required verbal cues and extensive assist of two with transfers and was resistive to walking or standing or that the resident would not stand at all. Nursing notes dated 11/4/10, at 8:00 a.m., indicated that Resident R1 had a sudden unresponsive episode when getting out of bed, was subsequently returned to bed and remained on bedrest until 11/5/10. Nursing notes dated 11/6/10, at 2:10 a.m., stated that during a transfer with a partial lift Resident R1 slipped out of sling onto the floor. The 72 Hour Resident Fall Assessment follow-up form dated 11/6/10, on the 11:00 p.m.-7:00 a.m., shift indicated, "multiple bruises on arms and legs and lacerations to right cheek, upper lip, right shin, right and left knee, right elbow, and medication given for pain." Physician notes dated 11/8/10, indicated Resident R1 had a fall from a lift with head trama and the family requested that the resident not be sent out for evaluation. Physician documentation also indicated Resident R1 has limited responsiveness, very poor swallowing, would not voluntarily open eyes, mumbled un-intelligible sentences, had pain with position change, had a bruise on forehead, had acute decreased mental status, was suspicious for subdural, and had a poor prognosis. During an interview on 11/23/10, at 1:30 p.m., Resident R1's physician confirmed that the resident was compromised and should not have been placed on a partial lift. During an interview on 11/26/10, at 1:50 p.m., the Director of Nursing confirmed that Resident R1 was not assessed for use of a sit to stand partial lift, was not care planned in the use of a partial lift, did not have a physician order [REDACTED]. 28.Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/13/10. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 5/13/10. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 12/11/09. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/13/10, 1/4/10, 12/11/09.