Every finding on record at Sterling Health Care and Rehab Center

Based on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that the residents' environment remained free of accident hazards for one of four residents (Resident 1) identified as an elopement risk. This was identified as a past non-compliance for Resident R1. Findings include: Review of facility policy Wandering and Elopements dated November 2025, stated Missing Resident- Process:. if a resident is missing, initiate the elopement/missing resident emergency procedure; determine if the resident is out on an authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Nursing Home Administrator and the Director of Nursing Services, the resident's legal representative, the attending physician, and law enforcement officials and( as necessary) volunteer agencies. Review of Resident 1's clinical record revealed Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's clinical record revealed diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance,(general loss of cognitive abilities, including memory without specific behavioral symptoms )psychotic disturbance(disruption in a person's thoughts and perceptions) mood disturbance(involves prolonged emotions that can be either excessively sad or excessively happy, and anxiety(persistent and excessive worry). Review of facility investigation documentation revealed that on April 14, 2026, Resident 1 closely followed the housekeeper through the double doors on the ground floor into the back hallway and out the side door. The housekeeper was unaware the resident came through the door. Review of information submitted by the facility to Department of Health, dated April 14, 2026, revealed that On 4/14/2026, An elopement alarm was activated after the resident was not accounted for on the secured unit. The facilities established protocols were immediately initiated, including notification of local law enforcement. The resident was located a short time later and safely returned to the facility without injuries. Review of facility investigation documentation revealed a written statement dated April 14, 2026, from Director of Nursing that stated A call was received from local police regarding an individual found matching the description of resident (Resident 1). The Corporate Nurse, Business Office Director and I responded to the provided location. Upon arrival Resident 1 was observed sitting in a relaxed manner conversing appropriately with officers and holding a beverage (coke). He presented with no visible injuries and denied any pain or discomfort.When asked about his whereabouts, he stated he was attempting to get to 69th street and reported that a woman had approached him to ask if he needed assistance or if he was lost. He also mentioned intending to take a train but acknowledged he had gone in the wrong direction. Review of facility documentation provided by facility of receipt from McDonald's dated April 14, 2026, at 1:53pm revealed evidence of a purchase Resident 1 had made of a filet o-fish sandwich and a small coke. Review of Resident 1 clinical record revealed progress note dated April 14, 2026, at 17:01 a health status note stated Resident noted not on unit and a immediate search was conducted with administration/staff notified. Proper authorities notified and family notified by administration of event. Resident returned safely after aggressive search completed. Skin check completed by 3-11 charge nurse. Message left with answering service of Team Health for CRNP on call@ 4:35 pm. Resident currently in his room eating dinner. Observations made on the ground floor on April 27, 2026, 2026, at 11:10am revealed that a code is required to be entered to exit the unit and the floor. Observations made on the ground unit confirmed that the unit is a locked unit. Observed Resident 1 on April 27, 2026, at 11:20 am sitting at table writing in notepad. Resident 1 was wearing a shirt and jacket with dress pants, and wander guard was on left wrist. Interview with Resident 1 on April 27, 2026, at 11:21am, on the April 14, 2026, incident, Resident 1 stated It was taking too long to get out the building, and so I waited for the opportunity and took it Resident 1 stated They brought me here and wouldn't let me leave. I wanted to go back to my place. Interview with the Nursing Home Administrator on April 27, 2026, at 1:45pm confirmed that the staff failed to ensure Resident 1's safety by not checking for residents before and after exiting the unit. The facility self-identified the deficient practice at the time of the incident, April 14, 2026. The facility implemented a corrective action of staff education and review of residents for elopement risk. The facility's immediate action plan included the following: QAPI (Quality Assurance Performance Improvement) conducted April 14, 2026. Signs were placed on doors to check for residents before and after exiting doors.Resident 1 was immediately placed on 1:1 supervision Facility Maintenance Director changed the facility door codes. Facility Maintenance Director checked facility door to ensure securement and function. Nursing Home Administrator reviewed the elopement policy. Education was completed for Employee 4 including a documented counselling warning on April 16, 2026. Education was initiated for all facility staff on the policy of Elopement, which includes recognizing, preventing and responding to resident elopement to ensure resident safety. All staff completed training by April 19, 2026. Residents were reviewed for elopement risk and to ensure interventions were in place. No other residents were identified as immediate risk. Residents with code alert bracelets/ wander guards were checked for placement and functioning. Facility Maintenance Director or designee will check exit doors daily for function and security. Maintenance immediately intervenes if a door is identified with any issues. Results of these checks are reviewed by the QAPI committee for further actions as needed. Director of Nursing or designee will review newly completed elopement assessments daily for 5 days, weekly for 3 weeks, then monthly to ensure residents identified with risk have a plan in place. Results of these checks are reviewed by the QAPI committee for further recommendations as needed. Nursing Home Administrator or designee will complete door audits daily for 5 days and weekly for 3 weeks and monthly for 3 months. During an interview on April 14, 2026, at 11:35 a.m. LPN (Licensed Practical Nurse) Employee E5 verified receiving education on Elopement and was able to verbalize understanding. During an interview on April 14, 2026, at 11:40 a.m. CNA (Certified Nurse Assistant) Employee 6 verified receiving education on Elopement and was able to verbalize understanding. The facility has demonstrated compliance with the above since April 15, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of the significant change in weight for one of two residents reviewed (Resident CL1).Findings include:A review of the facility's policy titled Weight Assessment and Intervention , dated 2001, revealed that the threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month-5% weight loss is significant; greater than 5% is severe.A review of the facility's policy titled Change in Resident's Condition or Status , dated 2001, revealed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/and mental condition.A review of Resident CL1's diagnoses list revealed Dementia (cognitive loss) and a femur fracture.A review of Resident CL1's weights and vitals revealed a weight of 153.6 pounds on August 4, 2025, and 139.9 pounds on September 2, 2025, a 13.8 pounds (8.98%) weight loss in less than a month.A review of the Dietitian's assessment dated [DATE], revealed that the resident was seen for a triggered weight loss, with open areas noted; reweigh required. The same note revealed that nursing reported a significant decrease in PO (Per Orem-by mouth) intake of the resident since readmission.A review of the nursing progress notes dated September 2, 2025, revealed that the resident's weight was taken twice, with a weight of 139.8 pounds.Clinical records review failed to reveal that the physician was notified of Resident CL1's significant weight loss until September 23, 2025, three weeks after it was identified. An additional supplement was ordered by the physician.An interview with the Director of Nursing conducted on October 29, 2025, at 1:00 p.m., revealed that it was the nurses' responsibility to inform the physician of Resident CL1's significant weight loss. The DON confirmed that the physician was not timely notified of Resident CL1's significant weight loss.The facility failed to ensure Resident CL1's physician was notified of the significant weight loss of the resident.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, hospital records, facility investigative documentation, and staff interviews, it was determined the facility failed to provide an environment free from physical abuse and timely abuse reporting for one of 28 residents reviewed (Resident 78). The facility's failure to protect Resident 78 resulted in Resident 78 being sent to the hospital for facial bruising and a hematoma (collection of blood that pools outside of a blood vessel in an organ, tissue, or body space) to the forehead. The facility's failure to timely report the witnessed abuse continued to put Resident 78 and residents from two of four units at risk for further abuse when Employees E3 and E4 continued to provide care. The facility's failure to provide an environment free from abuse and timely notification of witness physical action placed residents at the facility in an Immediate Jeopardy situation. This was identified as a past non-compliance situation. Findings include: Review of the facility's policy titled Abuse, neglect, Exploitation or misappropriation-Reporting and investigating, dated 2001, revealed that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of the unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Review of Resident 78's diagnosis list revealed the following: Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Bipolar Disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Psychosis (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality). Review of Resident 78's Quarterly Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 24, 2024, revealed resident had a severe cognitive impairment. Review of Resident 78's care plan initiated in June 2020, revealed resident was non-compliant with hygiene care and getting out of bed. Interventions listed were as follows: Avoid confrontations, speak in a gentle, firm voice when re-directing; explore possible reasons for my resistance to care and adjust; accordingly, and if rejecting re-approach, me later. Review of Resident 78's physician's note dated February 19, 2024, at 3:07 p.m., revealed Resident 78 was seen at the request of nursing after an incident where allegedly a staff punched the resident in the face. Given the resident's dementia, the resident was unable to remember events and complained of mild pain on the right side of the face. The resident had ecchymosis (bruise) to the right eye and a frontal right forehead hematoma. The same note revealed that due to being on anticoagulation and history of trauma by staff, the resident will be sent to ED (Emergency Department) for evaluation and documentation of injury. Review of Resident 78's hospital records dated February 19, 2024, revealed resident was seen in the ED because she/he was punched in the right eye and forehead. An imaging of the head was obtained since patient was taking blood thinners which confirmed no signs of bleeding into the patient's brain. Diagnosis was trauma to the eye. The resident was sent back to the facility. Review of facility documentation titled, Resident incident investigation skin breakdown, bruise, skin tear revealed on February 19, 2024, at 8:00 a.m., Resident 78 was observed with a bruise to the right eye and a hematoma to the forehead, the investigation was initiated. Review of the facility's documentation including document titled, Incident Report dated February 19, 2024, at 11:19 a.m., revealed a Nursing Assistant (NA) reported to the charge nurse Resident 78 had been hit by another NA after resident became combative while they were attempting to give care. The same report revealed resident's right eye was black and a large hematoma over the right eye was present. Review of non-licensed Employee E3's statement, completed on February 19, 2024, revealed the date of the incident was February 18, 2024. Employee E3 reported another Nursing Assistant (Employee E4) asked for help with Resident 78's care. The resident was being combative swinging at the NA and then NA swung and hit the resident and then left the room. Employee E3 stated, I was scared to say anything at that time. Review of non-licensed Employee E4's statement, completed on February 19, 2024, revealed on February 18, 2024, Employee E4 was (providing incontinence care) to Resident 78 when she/he became combative, so another NA (Employee E3) was asked to help. The statement further revealed, during the care Employee E4 told Employee E3 to pull Resident 78 over so Employee E4 could change the resident and every time Resident 78 would swing, Employee E4 would cross the residents' arms. Review of non -licensed Employee E5's statement, completed on February 19, 2024, revealed on February 18, 2024, at 2:00 p.m., Employee E5 was working on the first floor when she/he witnessed two nursing employees punch the resident in the face. The statement further revealed both employees punched resident in the face more than once and that they were happy about it. Employee E5 further stated, At first I thought they were playing with the resident, but they were hurting her/him. Review of information dated February 18, 2024, submitted on February 19, 2024, by the facility to Department of Health revealed the alleged incident occurred on February 18, 2024, at 2:00 p.m. The submitted information included, Resident was assessed and has a bruise to her right eye and a hematoma above right eye. Bruise also observed to left eye. The abuse allegation investigation was initiated on February 19, 2024, at 10:18 a.m. Investigation finding revealed Employee E3 reported Employee E4 hit Resident 78 when the resident became combative during care. Resident 78 was swinging her/his arms at staff when Employee E4 swung back hitting the resident. Employee E3 was unable to say the exact location where a resident was hit but was certain Employee E4 hit the resident. During the investigation, the facility identified Employee E5 as being outside the room during the incident. Employee E5 reported observing both Employee E3 and E4 hitting the resident in several places on Resident 78's body. Review of facility documentation failed to reveal documentation that Employee E5 reported the witnessed altercation of February 18, 2024, at 2:00 p.m., towards Resident 78 by Employee E3 and E4 until the facility initiated an investigation upon observation of physical signs of trauma to Resident 78's facial area on the morning of February 19, 2024. Review of facility staffing documents revealed both Employees E3 and E4 worked on the first-floor unit with different assigned resident rooms on February 18, 2024, from 7:00 a.m., until 3:00 p.m. Further review of the facility staffing schedules revealed on February 19, 2024, Employee E3 worked on the first-floor unit while Employee E4 worked on the second-floor unit. Both staff worked on February 19, 2024, from 7:00 a.m., until 10:00 a.m., when they were relieved of duty pending outcome of the investigation after abuse allegations were identified by the facility. Review of facility documentation revealed after the witnessed incident by Employee E3 and Employee E4 physically assaulting Resident 78 on February 18, 2024, at 2:00 p.m., Employee E3 continued to monitor and provide as needed care for Resident 78 until the end of the shift at 3:00 p.m. Further review of facility documentation revealed non-licensed Employee E4 continued to provide care for the other residents on her/his assignment, until relieved of duty on February 19, 2024, approximately 10 a.m., putting residents of assignment at risk of abuse. Additional review of facility documentation revealed that both Employee E3 and E4 returned to the facility to provide care for residents on the first and second floor units, the morning of February 19, 2024, placing these residents at risk and in jeopardy of abuse. An Immediate Jeopardy (IJ) situation was identified by survey team on October 22, 2024, approximately 2:36 p.m. and Immediate Jeopardy template presented to the Nursing Home Administrator (NHA) on October 22, 2024, at 4:00 p.m., related to the witnessed physical abuse of Resident 78. The NHA was made aware that Immediate Jeopardy existed for the facility's failure to provide an environment free from physical abuse and timely reporting of physical abuse placing Resident 78 for further potential abuse and residents on two of four units at risk for possible abuse, an immediate action plan was requested. The facility initially identified the jeopardy on February 18, 2024, after initiating an abuse investigation due to observed bruising on Resident 78's face. The facility initiated and completed an plan of correction on February 24 2024. The survey team requested and received an action plan on October 22, 2024, which included: Assessment of Resident 78, notifying the physician, and sent to the hospital for further assessment and possible treatment as the resident was on an anticoagulant. The facility has terminated the employment of non-licensed Employee E3 and E4. Administration informed Department staff that criminal charges have been filed by the police department. Re-education of Employee E5 on abuse and neglect; a comprehensive house review of all residents was conducted to determine any residents who have injuries of unknown origin to investigate and rule out for abuse; Education was provided to staff before the start of the shift; Reviewed facility policy to ensure appropriateness and completion of the abuse policy, identifying, and reporting of suspected abuse. The policy was reviewed and was deemed appropriate; and monitoring the effectiveness of staff training such as auditing for specified (determined by the facility administration) (questionnaire, on-the-spot, teach back, live drills, etc.) with the results of the audits going to QAPI meeting for review and recommendations. The facility's action plan was accepted on October 22, 2024, at 7:30 p.m. On October 23, 2024, upon review of audits, documentation of completed employee education, and interviews with 21 staff members revealed the facility had completed their self-identified interventions developed for their action plan on February 24, 2024. Immediate Jeopardy was lifted on February 24, 2024 then upon review of completion and implementation of facility's action plan which the survey team verified on October 23, 2024, at 11:45 a.m. The Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy, past noncompliance. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 8/21/24. 28 Pa. Code: 201.18(b)(1) Management Previously cited 8/21/24, 10/27/23, 12/30/22 28 Pa. Code: 201.29(a) Resident rights 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services Previously cited 8/21/24, 10/27/23, 12/30/22

Based on review of facility policy, clinical record, facility investigation documentation, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in a laceration to the forehead requiring 10 staples to close, for one of seven residents reviewed (Resident 97). Findings Include: Review of Resident 97's clinical record revealed diagnoses including but not limited to; Unspecified Dementia (neurodegenerative disease effecting memory, thinking, and social abilities), lack of coordination, Abnormal posture, muscle weakness, Anxiety disorder, and Intervertebral Disc Degeneration lumbar region (cartilage between the vertebrae begins to deteriorate). Review of Resident 97's risk of falls care plan revealed an intervention, revised March 3, 2023, indicating Resident 97's transfer status is 2 person assists with Hoyer lift into wheelchair. Review of facility policy, titled Mechanical Lift, most recently dated 2016, revealed Guidelines: The portable lift is to be used by two (2) staff (Registered Nurse, Licensed Practical Nurse or nursing assistants) to perform the procedure. Review of information dated August 4, 2024 submitted by the facility on August 5, 2024 revealed on August 4, 2024, at 9:10 a.m. Resident was being transferred by [his/her] cna (certified nurse aide) when [he/she] fell to the floor hitting [his/her] head. Resident has a laceration to [his/her] forehead. Nurse assessed resident and [he/she] has no other injuries observed. CNA stated he transferred the resident alone using a Hoyer lift when he was trying to pull the Hoyer pad and move the Geri chair the resident slid from Hoyer pad falling on to the fall mat. Md (Medical Doctor) and RP (Responsible Party) were notified. Md gave order to send to the ER (emergency room ) for evaluation. Incident is substantiated. Further review of information submitted by the facility on August 5, 2024 revealed [Resident 97] returned from the ER (emergency room ) with 10 staples in placed and non-adherent dressing. New order to hold [resident's] Plavix for one dose and remove staples in 10 days . New intervention is staff to ensure 2 persons utilized for Hoyer lift transfers. Resident 97 was unavailable for an interview due to scoring a Brief Interview for Mental Status (BIMS) of a 00 (severe impairment). Review of the facility's investigation revealed on August 4, 2024, non licensed Employee E13 provided a written statement stating I tried to transfer the above by using the Hoyer lift .all by myself because all other (nurse aides) were helping with resident trays . Further review of the facility's investigation revealed a written statement from Licensed Practical Nurse (LPN) Employee E12 dated August 4, 2024, stating A staff member came to me and said that a resident had fallen on the floor; however, by the time I got to the room the resident was on [his/her] bed and bleeding from [his/her] head. An assessment was completed for further physical and neurological evaluations. Review of facility's investigation findings revealed, non licensed Employee E13 admitted to transferring Resident 97 independently instead of using a two-person assist with the lift. Employee E13 was terminated after the investigation was completed on August 9, 2024. During an interview with the Nursing Home Administrator (NHA) on October 23, 2024, at 11:03 AM, the NHA stated all transfers conducted with a Hoyer lift require two (2) staff members to assist and confirmed the above findings. Non licensed Employee E13 failed to provide the appropriate assistance level when transferring Resident 97 using a Hoyer lift, resulting in Resident 97 hitting his/her head on the floor, causing a laceration that required 10 staples in the emergency room . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations and staff interviews, it was determined that the facility failed to maintain safe and sanitary conditions in the kitchen area. Findings include: Observation during a tour of the kitchen was conducted on October 22, 2024, at 10:00 a.m., in the presence of the Dining Director Employee E8. Observation during the tour revealed a black colored substance on the ceiling with peeling white paint above the sink by the dishwasher machine area. Further observation also revealed that the vent right above the dishwasher had a moderate amount of black lint covering the edges of the vent. Interview with Employee E8 conducted on October 22, 2024, at 10:15 a.m., revealed maintenance took care of the ceiling a few months ago. Employee E8 was unable to say how long the black-colored substance on the ceiling above the sink had been present. Observation conducted on October 25, 2024, at 9:21 a.m., revealed the black-colored substance on the ceiling above the sink and the moderate amount of lint on the vent above the dishwasher was still present. Interview with the maintenance staff Employee E11 was conducted on October 25, 2024, at 9:30 a.m. Employee E11 was unable to say how long the black-colored substance on the ceiling above the sink had been present. Employee E11 reported that the ceiling was painted back in April 2024. Employee E11 reported that the black substance on the ceiling was marks from the steam of water which was estimated as 20 feet long in size. Employee E1 reported that the vent above the dishwasher machine was cleaned a few times a year but was unable to say the last time it was cleaned/serviced. The above information was conveyed to the Nursing Home Administrator on October 25, 2024, at 11:30 a.m. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services

Based on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by ensuring resident were provided an environment free from abuse or potential of abuse and staff report abuse situations timely. Findings include: Review of the Nursing Home Administrator's (NHA) job description includes the following responsibilities: Operate the facility by the established policies and procedures of the governing body in compliance with federal, state, and local regulations; Establish systems to enforce the facility policies and procedures; Act as liaison to the governing body for the medical, nursing, and other professional staffs and all facility departments; Supervise all depart supervisors and administrative staff; Observe all facility policy and procedures relating to resident's rights; and Assume responsibility for identification, investigation, and follow up on concerns identified in the facility Quality indicator report. Review of the Director of Nursing's (DON) job description includes the following responsibilities: Assume responsibility for the development of nursing service objectives and performance standards of nursing practice for each category of nursing personnel; Assume accountability for the development, organization, and implementation of approved policies and procedures; Direct implementation of Resident [NAME] of Rights; Assume responsibility for nursing service compliance with federal, state, and local regulations; and Follow residents Rights policies at all times. The Nursing Home Administrator and Director of Nursing failed to fulfill their essential job duties and ensure federal and state guidelines and regulations were followed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa Code: 211.10(c) Resident care policies

Based on review of facility policy, clinical record, and staff interview, it was determined the facility failed to adequately monitor significant weight changes for two of four residents reviewed for nutrition (Residents 94 and 116). Findings include: Review of facility policy, Weight Assessment and Intervention, last revised March 2022, revealed: Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. Review of Resident 94's weights revealed that on September 2, 2024, the resident was recorded as weighing 111.5 pounds (lbs.) On September 17, 2024, the resident was recorded as weighing 123.5 lbs., a 12 lb., or 10.76%, weight gain in 15 days. Review of Resident 94's progress notes revealed a Weight Change note from the dietitian dated September 20, 2024, which questioned the accuracy of the September 17th weight and requested a reweight. Further review of Resident 94's weights revealed the next recorded weight on October 8, 2024, where the resident was recorded as weighing 137 lbs., a 13.5 lb., or 9.85% increase, from the previous weight. Further review of Resident 94's progress notes revealed a Weight Change note from the dietitian on October 9, 2024, which stated that the resident's weight gain was falsely elevated due to the resident wearing excessive clothing on the scale, and the dietitian again requested a reweight the following morning. Further review of Resident 94's weights failed to reveal a reweight following the October 8th weight. Interview with the dietitian, Employee E3, on October 25, 2024, at 11:25 a.m., confirmed the facility did not get reweights following Resident 94's significant weight changes. Review of Resident 116's weights revealed that on June 22, 2024, the resident was recorded as weighing 268 lbs. On July 17, 2024, the resident was recorded as weighing 248.2 lbs., a 20 lb., or 7.39%, weight loss in 25 days. Review of Resident 116's progress notes revealed a Weight Change note from the dietitian on July 19, 2024, which questioned the accuracy of the July17th weight and requested a reweight. Further review of Resident 116's weights revealed the next recorded weight was on August 28, 2024, where the resident was recorded as weighing 260.6 lbs., a 12.4 lb., or 5% increase, from the previous weight. Further review of Resident 116's progress notes revealed no further Weight Change notes from the dietitian. Further review of Resident 116's weights reveal a recorded weight of 260.8 lbs., on September 30, 2024, and 260.8 lbs., on October 1, 2024. Interview with the dietitian, Employee E3, on October 25, 2024, at 11:00 a.m., confirmed the facility did not get reweights following Resident 116's significant weight changes. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on review of clinical records and staff interviews, it was determined the facility failed to ensure that physician's orders for wound treatments were followed for one of seven resident reviewed (Resident 9). Findings include: Review of facility policy titled Wound Care most recent date of 2001, revealed staff must verify that there is a physician's order for this procedure and Review the resident's care plan to assess for any special needs of the resident. Interview conducted with Resident 9 on October 22, 2024, at 10:18 a.m. revealed Resident 9 had a bandage on [his/her] right hip covering a surgical incision. Resident 9 reported that [his/her] bandage had not been changed in a few days. Observations conducted of Resident 9's bandage revealed a date of October 17, 2024, written on the bandage. Review of Resident 9's clinical medical record revealed a active physician order dated October 6, 2024, with the following instructions cleanse with normal saline solution (a sterile solution of water and salt), pat dry, apply border dressing daily on Monday-Wednesday-Friday and PRN (as needed). Review of Resident 9's Treatment Administration Record (TAR) for the month of October revealed Resident 9 did not receive wound treatments on October 18, 2024, or October 21, 2024. Interview conducted with the Nursing Home Administrator (NHA) on October 24, 2024, at 11:15 a.m. confirmed the facility failed to provide Physician ordered wound treatment for Resident 9 on October 18, 2024, and October 21, 2024. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of the facility's policy, clinical records, and staff interview, it was determined the facility failed to thoroughly investigate missing personal property for one of the 36 residents reviewed (Resident 136). Findings include: Review of the facility's policy titled Personal Property, dated August 2022, revealed the resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. The facility promptly investigates any complaints of misappropriation or mistreatment of resident property. Review of the facility's policy titled Lost and Found, dated January 2008, revealed that resident or family complaints of missing items must be reported to the Director of Nursing. Review of Resident 136's diagnosis list revealed Major Depression, Anxiety disorder, and Altered Mental Status. Review of Resident 136's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents), dated July 12, 2024, revealed Resident 136 has a BIMS score of 15 indicating no cognitive impairment. Interview with Resident 136 on October 22, 2024, at 9:55 a.m., revealed a week after admission into facility, family brought in ten clothing outfits that were labeled with the resident's name. When the clothes were sent to laundry they were never returned. Resident 136 stated the missing clothes were reported to nursing staff by the resident and the resident's family. According to Resident 136, clothes from the facility's lost and found were provided as substitutes but Resident 136's clothes were never found or expense reimbursed. During Interview on October 24, 2024, at 9:38 a.m., Employee E7 stated the laundry is outsourced. Employee E7 was aware of Resident 136's missing clothes and indicated laundry services were aware of missing items. Staff have been asked to be on the lookout for Resident 136's clothes as they are labeled with the resident's name. E7 stated staff have put several outfits together from the lost and found for so Resident 136 has something to wear. E7 stated that there should be a grievance form concerning Resident 136's missing clothes. Review of facility documents failed to reveal any grievance or concerns forms related to Resident 136's missing clothes. During interview on October 24, 2024, at 11:33 a.m., with Nursing Home Administrator (NHA) and Director of Nursing (DON), it was confirmed that complaints of missing items should be reported to the DON and an inventory sheet should be filled out documenting all personal property bought into the facility. The NHA confirmed laundry is outsourced and there have been issues with clothes being lost previously. The facility purchased new color-coded laundry bags for each floor to help prevent clothes from being misplaced. The NHA stated the facility does reimburse residents for missing items. The NHA and the DON both stated they were not aware of Resident 136's missing clothes. During interview on October 25, 2024, at 9:07 a.m., E7 confirmed that Resident 136's inventory sheet had not been updated to include the additional clothing items bought in after admission. E7 stated he/she spoke with Resident 136's family on October 24, 2024, an obtained a list of all missing clothing items. On October 25, 2024, at 12:49 p.m., the NHA and the DON confirmed that staff did not report Resident 136's missing clothes to the DON per facility policy and no grievance form was completed documenting Resident 136's missing clothes. The facility failed to thoroughly investigate Resident 136's missing personal property. 28 Pa. Code 201.18(b)(1)(3)(c) Management Previously cited 11/1/21, 12/30/22 28 Pa. Code 211.5(f) Clinical records Previously cited 11/1/21, 12/30/22 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 11/1/21, 12/30/22

Based on observations and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment on the patio and loading dock area. Findings include: Observation on the loading dock area conducted on October 22, 2024, at 9:35 a.m., in the presence of Employee E8 revealed 11 cigarette butts scattered on the floor. Employee E8 took a broom and removed the cigarette butts observed on the floor. Observation on the side patio conducted on October 24, 2024, at 9:26 a.m., in the presence of licensed nurse Employee E9 revealed 10 cigarette butts scattered on the floor. Employee E9 reported the cigarette butts are from the employees. Observation on the loading dock area conducted on October 24, 2024, at 9:34 a.m., in the presence of the Housekeeping Director, Employee E10 revealed 16 cigarette butts scattered on the floor. Interview with Employee E10 on October 24, 2024, at 9:40 a.m., revealed side patio and loading dock were cleaned daily but did not get a chance to be cleaned that morning. The above information was conveyed to the Nursing Home Administrator on October 25, 2024, at 11:00 a.m. The facility failed to ensure a safe and sanitary condition on the side patio and loading dock area. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on observations and staff interview, it was determined the facility failed to ensure Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of multidrug-resistant organisms in nursing homes) were in place for residents requiring enhanced barrier precautions for one of two residents reviewed (Resident 95). Findings include: Review of the facility's current enhanced barrier precautions policy as revised by the facility dated April 23, 2024, revealed for residents for whom EBP are indicated EBP is employed when performing high contact resident care activities. This includes the use of gown and gloves for the use of accessing a feeding tube. Review of Resident 95's clinical record revealed, Resident was admitted on [DATE], with a diagnosis of Progressive Supranuclear Ophthalmoplegia Steele-[NAME]-0lszewski (rare brain disease that affects walking, balance, eye movements and swallowing) and Dysphagia (difficulty swallowing) Unspecified. The resident required enhanced barrier precautions due to utilizing tube feeding. Observation of Resident 95 on October 22, 2024, at 11:01 a.m. revealed the resident has a feeding tube (tube that is inserted through the abdominal wall and into the stomach. It is used to provide nutrition and fluids to those who are unable to eat/drink normally). Observation of Licensed Nurse Employee E12 on October 23, 2024, at 12:02 pm performing a high contact resident activity of giving a bolus in the feeding tube. Observation of Employee E12 performing the activity, surveyor noted Employee E12 failed to wear a gown as an enhanced barrier precaution. Observation of Resident 95 room on all four days of the survey failed to reveal personal protective equipment located outside the room or signage indicating Resident 95 was on Enhanced Barrier Precautions. Interview with the Director of Nursing and Nursing Home Administrator on October 25, 2024, at 11:15 am. confirmed that Resident 95 was not on Enhanced Barrier Precautions at the time of the survey despite meeting the above criteria. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(a)(d) Resident care policies

Based on review of facility policy, clinical records, facility documents, and staff interviews it was determined that the facility failed to ensure a resident was free from physical restraint (Resident R1). Findings include: Review of facility policy Restraints dated 2024, revealed Physical restraints are defined as any manual 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. Review of Resident R1's clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated June 18, 2024, indicated diagnoses of Hypo-Osmolality and Hyponatremia (chronic low sodium levels that effects energy levels and brings on a state of confusion), Major Depressive Disorder (persistent feeling of sadness), Schizophrenia (chronic mental disorder that affects how a person thinks, feels, and behaves), and Dementia (group of symptoms that affects memory, thinking, and interferes with daily life). Review of information dated August 15, 2024 submitted by the facility, indicated, Unit manager reports that [Resident R1] (BIMS of 2 out of 15-Brief Interview of Mental Status) was observed sitting in (his/her) wheelchair with a white sheet tied around (his/her) waist. The sheet was removed and [Resident 1] was assessed for injuries with none observed. CNA [Employee E1] was assigned to [Resident R1] over 11-7 shift and was suspended pending investigation. PB22 to follow. MD (Medical Doctor) and RP (Responsible Party) will be notified. Review of written witness statements obtained on August 15, 2024, including Certified Nursing Assistant (CNA) Employee E1 indicated, I [CNA Employee E1], place a sheet around [Resident R1] in the chair to prevent [resident] from falling on the floor. [Resident] was taking off (his/her) clothes as well as bending over to the floor. [Resident] didn't sleep all night. I had to sit besides [Resident R1] bed to keep (him/her) in bed. When I had to do my morning rounds that is when I put (him/her) in the chair and (he/she) was slumping over. Review of written witness statement obtained on August 15, 2024, from Certified Nursing Assistant (CNA) Employee E2 stated, I [CNA Employee E2] was trying to help a resident he was in a wheel chair and the nurse on duty was doing her meds and stood by the resident that was trying to get up out of the wheel chair the nurse was telling the resident to sit down and the unit manager walked over to him twice after that I went and stood by him so he won't fall he had a sheet and another sheet around him I moved the sheet a little and then I left and went to see if the morning staff was in. I [CNA E2] was not aware of the resident being tied to his wheelchair because he was told to sit down. I didn't see any restraints or witness any as well. Review of Investigation Statement Worksheet for nurse aide Employees E1 and non nurse aide Employee E2 revealed nurse aide Employee E1 and Nurse aide Employee E2 were suspended on August 15, 2024, after being identified as the alleged perpetrators and have not worked in the facility sense the incident. During an interview on 6/18/24, at 4:05 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain a Resident 1 was free from a physical restraint. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(a) Resident rights 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for two of three residents reviewed (Resident R1 and R2). Findings include: Review of Resident R1's clinical record revealed Resident R1 was admitted [DATE], with diagnoses of but not limited to Hematuria (blood in the urine), acute angle-closure Glaucoma (condition that causes pressure to go up quickly in the eye and block the drainage system), CVA (cerebral vascular accident - stroke), hypertension (high blood pressure), and Depression. Review of Resident R1's physician's admission orders included an order for Dorzolamide HCl Ophthalmic Solution 2%, instill 1 drop in both eyes two times a day related to acute angle-closure glaucoma, bilateral. Review of the February 2024 Medication Administration Record (MAR) revealed that Dorzolamide was not administered January 18-23, 2024 for a total of ten times. Review of progress notes of January 19, January 20, and January 21, 2024, revealed awaiting delivery and delivery is pending for eye drops. Review of progress note of January 22, 2024, revealed pharmacy was called and assured eye drop would be delivered late tonight. Review of progress note of January 23, 2024, revealed med [eye drops] not available at this time. Pharmacy said they will be here tonites run. Review of progress note of January 23, 2024, revealed staff spoke with pharmacy at 3:30 p.m. regarding the eye drops and pharmacy indicated they may need authorization from the Director of Nursing (DON) for new bottle to be delivered. Review of progress note of January 23, 2024, revealed family brought in eye drops which were administered. Review of Resident R2's clinical record revealed that Resident R2 was admitted [DATE], with diagnoses of but not limited to hypothyroidism (underactive thyroid), multiple sclerosis (disease affect the central nervous system), hypertension, type II diabetes(disease that occurs when blood sugar is too high) and respiratory failure (syndrome in which the respiratory system fails). Review of physician admission orders included orders for, but not limited to, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT 1 puff inhale orally two times a day related to respiratory failure, Ascorbic Acid Oral Tablet 500 MG (milligrams) Give 1 tablet by mouth two times a day for vitamin deficiency, Amlodipe Besylate Oral Tablet 2.5 MG Give 1 tablet by mouth one time a day related to essential (primary) hypertension, Aspirin Low Dose Oral Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for prophylaxis, : Brexpiprazole Oral Tablet 2 MG Give 1 tablet by mouth one time a day related to depression, : Benztropine Mesylate Oral Tablet 2 MG Give 1 tablet by mouth three times a day for tremors, Diclofenac Potassium Oral Capsule 25 MG Give 1 capsule by mouth two times a day related to low back pain, DULoxetine HCl Oral Capsule Delayed Release Particles 30 mg Give 1 capsule by mouth one time a day related to depression administer together with Duloxetine 60 mg for total of 90 mg, Famotidine Oral Tablet 20 mg Give 1 tablet by mouth one time a day for GERD (gastroesophageal reflux disease - digestive disorder), levetiracetam Oral Tablet 750 MG Give 1 tablet by mouth two times a day related to metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), Gabapentin Oral Tablet 800 MG Give 1 tablet by mouth four times a day related to low back pain, Omega-3 Fish Oil Oral Capsule 1000 MG, Omeprazole Oral Capsule Delayed Release 40 MG Give 1 capsule by mouth one time a day for heartburn, Myrbetriq Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day related to chronic obstructive pyelonephritis (inflammation of the kidney, Vitamin E Oral Capsule 180 MG, Torsemide Oral Tablet 20 MG Give 1 tablet by mouth one time a day related to chronic obstructive pyelonephritis,Vitamin D3 Oral Capsule 1.25 MG (50000 UT) Give 2 capsule by mouth one time a day for vitamin D deficiency, Lidocaine HCl External Cream 3 % Apply to affected area topically every day and evening shift for pain, and Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 25 unit subcutaneously at bedtime related to type 2 diabetes mellitus. Review of Resident's R2's January 2024 MAR revealed that the above medications were not administered as ordered. Review of progress note of January 23, 2024, revealed medications were not administered and were waiting on delivery from pharmacy. Interview with the Director of Nursing (DON) on February 8, 2024, at 1:20 p.m. confirmed that Resident R1 did not receive the eye drops that were ordered on admission. The facility was unable to determine if they were delivered from the pharmacy and the pharmacy required reauthorization to supply the eye drops. The DON also confirmed that the family brought in eye drops. The DON indicated the Resident R2 was a late admission at approximately 11:30 p.m. and did not meet the pharmacy's cut-off time for delivery of medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/27/23 28 Pa. Code: 211.9 (a)(1) Pharmacy services.

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment, and maintain resident care equipment, on three of four units of the facility. Findings include: Observations conducted during an environmental tour of the facility on January 23, 2024, at 11:30 a.m., included the following: Room G4 - the toilet, sink, floor, and mirror appeared cloudy and unknown residue. Further observation revelaed a soiled plastic glove on the floor behind the trash can. Obseration of area also revealed the absence of a trashcan liner to contain waste materials. The sink fixture indicated signs of corrosion and there was a broken tile on floor. Room G5 - the toilet, sink, floor, and mirror appeared dirty with residue and the sink fixture showed signs of corrosion. Room G4 - Observation of the floor and walls revealed areas of residue of unknown substances. Room G12 - Observation of the room revealed a prevalent smell of urine throughout the room. The bathroom toilet was observed with stains and resident as well as a broken floor tile noted in the area. The sink fixture indicated signs of corrosion. room [ROOM NUMBER] - Observations conducted of the room's toilet, sink, floor, and mirror revealed an unknown residue. room [ROOM NUMBER] - Observations revealed the toilet, sink, floor, and mirror noted to have unknown residue. Further observation revealed a mousetrap placed under the sink. room [ROOM NUMBER] - Observations of the room failed to reveal a trashcan liner. The toilet, sink, floor, and mirror appeared to have an unknown residue. The sink indicated signs of corrosion. room [ROOM NUMBER] - observation of the room revealed a light bulb was malfunctioning. The toilet was stained and soiled. Additiona observation revealed the room's trashcan did not have a liner. Further observation revealed a mouse trap in the room. Interview conducted with the resident occupant revealed the resident cleans the bathroom most times without assistance from staff. room [ROOM NUMBER] - Observations revelaed the toilet and floor had unknown substance/residue. The sink fixture indicated signs of corrosion. There was a large brown stain on the ceiling tile above resident's bed. room [ROOM NUMBER] - Observations of the room revealed; the floor and toilet had an unknown substance and residue. The bathroom ceiling tiles were noted to have brown stains. Further observation failed to reveal a trashcan liner in the trashcan. The sink indicated signs of corrosion. room [ROOM NUMBER] -Observations of the room revealed a brown stain on a ceiling tile. The bathroom floor, toilet, sink, and mirror were noted to have residue of unknown substance and the trashcan did not have a liner to contain waste materials. room [ROOM NUMBER] - Observations revealed multiple stained areas on ceiling tile in room above resident's head. room [ROOM NUMBER] -Observations revealed the bathroom floor, toilet, sink, and mirror had unknown substances noted on them Observations conducted of the Ground floor shower room revealed a mattress in room. The sink and shower chair were noted to have unknown substances. The toilet was not easily accessible for staff or residents as it was blocked by a shower bed. Additional observation revealed used/soiled towels on the floor Observations of the First floor shower room revealed used/soiled towels on the floor. Additional observations noted a black substance on shower curtain. The toilet, sink, and shower chair appeared soiled with unknown substance. Further observations of the First floor shower room revealed a cup, box of gloves, wheelchair legs, adult incontinence product, shirt, and a wash basin lying on the shower bed. Observations of the Third floor shower room revealed the shower wall, shower seat, toilet and sink were not soiled with an unknown substance. The trashcan did not have a liner to contain waste materials. Additional observation conducted in the Third Floor shower room revealed unknown brown stains on shower curtains. Interview conducted on January 23, 2024, at 2:45 p.m., with the Nursing Home Administrator and the Director of Nursing, when the above information was presented nd all of the environmental observations were discussed. 28 Pa Code 207.2(a) Administrator's Responsibility

Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed. Findings include: Review of staffing records and performance reviews revealed five staff members did not have annual performance reviews performed. Interview with the Nursing Home Administrator on October 27, 2023 at 1:00 p.m. confirmed staff performance reviews were not completed. 28 Pa. Code 201.20(a)(c) Staff Development

Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for five of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining. Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator on October 27, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining. 28 Pa. Code 201.20(a)(c) Staff Development

Based on observation and interviews with staff it was determined that the facility failed to ensure infection control and prevention was implemented during medication administration for three of the three residents observed (Residents 44, 61, and Resident 7) Findings include: Observation conducted of medication administration for Resident 44 with licensed nurse, Employee E4 on October 25, 2023, at 9:00 a.m. The observation revealed Employee E4 opened the medications Celexa (anti-depressive medication) and Olanzapine (anti-psychotic medication) from a blister card with her/his bare hand and placed it into the medicine cup then administered the medication to Resident 44. Employee E4 then proceeded back to the medication cart to document in the computer. Without performing hand hygiene, Employee E4 proceeded to prepare the medication for Resident 61 at 9:07 a.m. Further observation revealed Employee E4 popped medications Benztropine (medication to treat Parkinson's), Furosemide (water pill), Fluoxetine (anti-depressive medication), and Perphenazine (anti-psychotic medication) from a blister card from her/his bare hands and placed it into the medicine cup then administered the medication to Resident 61. Observation conducted of the medication administration for Resident 7 was conducted with licensed nurse Employee E5 on October 26, 2023, at 8:50 a.m. The observation revealed Employee E5 put on a clean glove, checked the resident ' s blood sugar the proceeded to administer insulin. Without changing gloves and performing hand hygiene, Employee E5 applied an eye drop to the resident ' s eyes. Interview conducted with Employee E5 on October 26, 2023, at 8:55 a.m., confirmed that he/ she should have changed gloves and performed hand hygiene before administering eye drops to Resident 7. The above information was conveyed to the Director of Nursing on October 27, 2023, at 11:00 a.m. The facility failed to ensure infection control and prevention was practiced while administering medications to Residents 44, 61, and Resident 7. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to provide an opportunity to formulate an advance directive for one of 32 residents reviewed (Resident 131). Findings include: Review of Resident 131's diagnosis list revealed diagnoses including Dementia (irreversible and progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and history of CVA (stroke). Review of Resident 131's clinical record revealed Resident 131 was admitted to the facility on [DATE]. Further review of Resident 131's clinical record failed to reveal evidence of an advance directive. Interview with the Director of Nursing on October 27, 2023 at 1:00 p.m. confirmed that Resident 131 did not have an advance directive. This interview revealed the facility failed to offer an opportunity to Resident 131's representative to formulate an advance directive upon admission. The facility failed to provide or offer an opportunity to formulate an advance directive for Resident 131. 28 Pa. Code 211.5(f) Clinical Records

Based on observation, a review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 28 residents reviewed (Resident 23). Findings include: Observation on October 26, 2023 at 9:05 a.m. revealed resident lying in bed with oxygen on at 2L(liters)/min via nasal cannula (medical device to provide supplemental oxygen therapy). Review of physician's orders included an order for oxygen at 2L/min via nasal cannula continuous every shift related to pneumonia (an infection of the air sacs in one or both the lungs), titrate (adjust) to maintain saturation (measure of how much oxygen is traveling through the body) at 92% or above. Further review of the clinical record revealed no care plan regarding the use of oxygen. Interview with the Nursing Home Administrator(NHA) on October 27, 2023, at 1:30 p.m. revealed the Pneumonia had resolved and the oxygen was used on an as needed basis. The NHA confirmed that there was no care plan in place to address the use of oxygen. 483.21 Comprehensive Resident Centered Care Plan Previously cited 12/30/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/30/22 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/30/22

Based on clinical records review and staff interviews, it was determined that the facility failed to follow a recommendation from a consulting psychiatry provider for a resident exhibiting a behavioral symptom for one of 28 residents reviewed (Resident 65). Findings include: Review of Resident 65's diagnosis list includes Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and a loss of interest), Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain), and Anxiety Disorder (mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 65's current behavioral care plan of care initiated on December 19, 2022, revealed the resident had a history of aggressive and combative behaviors, including throwing a rolling walker at the staff. Interventions were put in place. Review of Resident 65's progress notes dated August 27, 2023, at 10:23 p.m., revealed that at 6:20 p.m., the resident approached the staff and asked to be taken out to smoke. The resident became upset when staff informed him/her to wait until dinner trays were collected and that smoking time is not until 6:30 p.m., this resulted in the resident using profanities, walking through the resident's dining area, and breaking one of the windows in the back entrance with a walker. The physician was notified and ordered to notify the psyche provider. While awaiting a callback, a housekeeping staff came into the dining room to clean the area, the resident picked up the walker and attempted to throw it at the employee, 911 was called, two police officers came out, the physician was notified, and ordered to transfer the resident to the emergency room , but resident refused to be transported when the emergency transport arrived, the physician was notified. The resident was closely monitored. Review of the behavior notes dated August 28, 2023, at 8:00 a.m., revealed that Resident 65 was seen by the psychiatric provider. The resident's anti-psychotic medication dose was adjusted and a recommendation for an outpatient psychiatry transfer. Review of Resident 65's clinical records review revealed the resident's behavior was monitored. Review of the social service note dated August 28, 2023, at 9:04 a.m., revealed resident's information was faxed over to an in-patient psychiatric facility for resident transfer. Review of Resident 65's clinical records failed to reveal follow-up documentation regarding the resident's transfer to an in-patient psychiatric facility which was recommended by the consulting psychiatric provider. Interview conducted with the Social Worker, Employee E3 dated October 27, 2023, at 11:00 a.m., revealed the social worker sent Resident 65's information for transfer to two in-patient psychiatric facilities but was turned down. The clinical records review failed to reveal any documentation regarding coordination that occurred between the facility and the in-patient psyche facility regarding the resident's transfer. The clinical records also failed to reveal that the consulting psyche provider and the attending physician were notified that the recommendation to transfer Resident 65 to an in-house psyche facility was followed. The above information was reviewed with the Director of Nursing on October 27, 2023, at 1:00 p.m. The facility failed to ensure the recommendation of the psychiatric provider to transfer Resident 65 who was showing behavioral symptom to an in-house psychiatric facility was followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/30/22

Based on facility policy, clinical record review, and staff interviews, it was determined the facility failed to monitor the skin of residents at risk for skin impairment causing actual harm by discovering a pressure ulcer at an advanced stage for one of eight residents reviewed (Resident 81). Findings include: Review of the facility's policy and procedure titled Prevention of Pressure Injuries, revised in April 2020, revealed to inspect the skin daily when performing or assisting with personal care or ADLs (Activities of Daily Living). Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, etc.). Review of Resident 81's diagnosis list revealed Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), muscle weakness, Anxiety, and Bipolar Disorder. Review of Resident 81's clinical records revealed Resident 81 was readmitted to the facility on [DATE], from the hospital after post falls with a left hip fracture requiring a surgical repair. Review of the admission assessment dated [DATE], revealed Resident 81 was admitted to the facility with the following skin condition: surgical wound to the left lower hip, left upper hip, and left outer thigh, a bruise on the left groin and left knee, and a Stage 2 (shallow, crater-like wound or blister containing clear or yellow fluid) to the sacrum (tail bone). Review of Resident 81's Braden Scale (standardized tool used to identify the risk of developing pressure injury) assessment dated [DATE], revealed resident was at risk for developing a pressure ulcer. Review of Resident 81's significant change Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated June 6, 2022, revealed resident required extensive assistance with two people for bed mobility. Review of Resident 81's clinical record revealed a care plan for skin integrity and care with interventions including heel protector boot and daily skin inspection with ADL care. Review of Resident 81's clinical record revealed a physician's order initiated on June 2, 2022 for Ted stockings with instructions of Apply Ted Stockings in the morning and remove at HS (bedtime) for bilateral lower extremity edema. Review of Resident 81's clinical record including the June 2022 MAR (Medication Administration Record) revealed the Ted stockings were documented as being administered on June 2, 3, 4, 6, 7, and June 8, 2022 at 6 a.m. Additional review of the June 2022 MAR revealed the Ted stockings were documented as removed on June 2, 3, 4, 5, 6, and June 7, 2022 at 2100 (9 p.m.). Additional review of the Ted stocking order revealed the order was discontinued on June 8, 2022. Further Review of the June 2022 MAR and/or TAR (Treatment Administration Record) revealed that heel boot protector was documented as placed on/removed daily. Review of Resident 81's nursing progress notes dated June 8, 2022, (11:27 a.m.), revealed that upon removal of stockings, a purplish discolored area was observed on the resident's left heel, and the physician and family were notified. Review of the wound nurse consult dated June 8, 2022, revealed a full-thickness wound to Resident 81's left heel, measuring 4.0 x 5.6 cm (centimeter), wound base 100% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like), no drainage. The wound was identified as an unstageable wound (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Review of wound consult dated December 14, 2022 revealed the wound is considered Stage 3 with full thickness of the left heel measuring 0.5 x 0.7 x 0.1 cm. Interview with the Director of Nursing was conducted on December 30, 2022, at 10:00 a.m. The DON was unable to provide an answer as to why Resident 81's left heel wound was discovered already at an Unstageable stage, when opportunities for observation were occurring twice daily. The facility failed to ensure Resident 81's skin was appropriately monitored resulting in harm and discovering a pressure ulcer at an Unstageable stage. 28 Pa. Code 201.18(b)(1)(3)(c) Management Previously cited 11/1/21 28 Pa. Code 211.5(f) Clinical records Previously cited 11/1/21 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 11/1/21

Based on review of facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure one of three residents reviewed (Resident #87) was free of accident hazards, which resulted in actual harm to Resident #87 sustaining two hematomas to her head, requiring transfer to a diagnostic center and further treatment of [REDACTED].#87). Findings include: Review of facility policy and procedure titled, Mechanical Lift dated (YEAR), revealed the purposes of this procedure are to safely lift residents who are too heavy to lift manually and to promote comfort and to maintain good body alignment while the resident is being moved. The portable lift is to be used by two staff (RN, LPN or nursing assistants) to perform the procedure. Position the resident comfortably in the chair grasp the top of the sling with one hand and pull back on the sling while lowering the resident into the chair. One staff member should be controlling the lift with remote while the other is safely guiding the resident into the chair. Review of Resident #87's [DIAGNOSES REDACTED]. Review of Resident #87's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 17, (YEAR), revealed the resident required extensive assistance with two plus persons physically assisting for bed mobility, transfers and toilet, using a total mechanical lift. Review of Resident #87's physician's orders [REDACTED]. Review of Resident #87's care plan initiated (MONTH) 1, (YEAR), identified the use of a Hoyer lift for all transfers due to impaired transfer ability. During an interview with Resident #87 on (MONTH) 11, 2019, at 2:47 p.m. the surveyor observed a bruise to the left side of the resident's forehead and a second bruise on the left posterior side of head/scalp area. The resident reported that a nursing assistant had pulled her over in the bed by herself using the bed sheet, which caused the resident to hit her forehead on the siderail. The resident further reported that the bruise on the back of her head was caused by the nursing assistant while she used the Hoyer lift to get the resident out of bed by herself and caused the resident to bump her head on the bar of the Hoyer lift, which holds the sling in place. Review of Resident #87's health status note dated (MONTH) 17, 2019, at 1:53 p.m. revealed resident reported to this writer that CNA (nursing assistant) had bumped her head (she was hit on the top of her head) when she was using the Hoyer lift to get her OOB (out of bed). Assessment no bump, no bruise, no hematoma, no abrasion. Further review of a nursing progress note dated (MONTH) 20, 2019, at 2:13 a.m. revealed resident noted with a hematoma to the top left side of her head. No complaints of pain or discomfort. Resident immediately assessed for further injury. Nursing supervisor and physician informed. No new orders noted at this time. Review of a nursing progress note dated (MONTH) 20, 2019, at 7:06 p.m. revealed status [REDACTED]. Resident reports head feeling a bit sore but declined to take Tylenol for pain. No Epistaxis this shift. Nursing to continue to monitor. Review of facility's investigation documentation dated (MONTH) 20, 2019, at 1:55 p.m. revealed Resident noted with a hematoma to top left side of her head. Resident stated, I think it's from the other day. I'm not sure. Resident immediately assessed for pain and further injury. Area measured at 3.1 by 2.9. Resident reassessed on (MONTH) 21, 2019, resident with fading bruising 5 centimeters by 8 centimeters to her forehead and fading bruising to her left temporal area measuring 10 centimeters by 6 centimeters. Review of Resident #87's nursing progress note dated (MONTH) 22, 2019, at 10:39 a.m. revealed Resident seen by NP (Nurse Practitioner) and resident with new order CT Scan of head secondary to trauma to rule out SDH (subdural hematoma -a pool of blood between the brain and its outermost covering. Is most often the results of a severe head injury) and initiate neuro checks per policy. Review of the facility's investigation documentation dated (MONTH) 30, 2019, at 1:00 p.m. revealed resident communicated that CNA (nursing assistant) has pulled her over in bed too fast and bumped her head a few weeks ago. Resident with discolored areas to her forehead. Resident had communicated a few weeks ago that the top of the Hoyer made contact with her head during transfer on (MONTH) 17, 2019, with no discoloration at that time. MD (physician) and RP (responsible party) aware. The resident did report the Hoyer transfer to the unit manager, which occurred on (MONTH) 17, 2019, but did not report the CNA pulling her too fast in bed causing her head to bump on the siderail (which was to also occur on the same day). At the time, skin was assessed with [REDACTED]. A few days later, bruising/hematoma noted to the head. No c/o (complaint of) pain. MD and RP aware. Resident is on Eliquis (an anticoagulant) twice a day with high risk for bleeding and bruising. Upon review on (MONTH) 17, 2019, it is confirmed that CNA did improper transfer status with the Hoyer and CNA immediately admitted that she made a mistake. Review of facility investigation documentation dated (MONTH) 17, 2019, revealed an investigation statement from nursing assistant, Employee E5, which indicated, Upon entering resident room, I spoke to her and asked her how she was doing, she said ok. I told the resident I was going to do her personal care and transfer her from bed to w/c (wheelchair). After I did her care I transfer her by myself. The resident did not say anything to me about her head. Review of CT Scan report dated (MONTH) 22, 2019, revealed there was no acute [MEDICAL CONDITION]. Review of wound consult report dated (MONTH) 25, 2019, noted that the resident was accessed during a visit from the consulting wound nurse with left scalp/side of head with 50% raised firm purple in the center and 50% flat reabsorbing on the outer edge area that measures 4.7 x 5.0 cm. The procedure included hematoma of the scalp with needle aspiration with 21G (gauge) and 29G needle after topical [MEDICATION NAME] (anesthetic) applied. Approximately 4-5cc of blood aspirated and manually expressed. Hemostasis (the stopping of a flow of blood) achieved with direct pressure. Interview with the Director of Nursing on (MONTH) 15, 2019, at approximately 10:30 a.m. confirmed that the nursing assistant, Employee E5, did not follow the policy and transferred Resident #87 using a Hoyer lift by herself. The facility failed to ensure the Resident #87 was free of accidents which resulted in actual harm to Resident #87 sustaining two hematomas to her head, requiring transfer to a diagnostic center and further treatment of [REDACTED]. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 01/24/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/07/18, 12/11/17 28 Pa. Code 201.18(b)(1) Management Previously cited 11/07/18, 04/10/18, 12/11/17, 01/24/17 28 Pa. Code 201.18(b)(3) Management Previously cited 12/11/17, 01/24/17 28 Pa. Code 201.18(e)(1) Management Previously cited 12/11/17 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records Previously cited 04/10/18, 12/11/17, 01/24/17 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/11/17, 01/24/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 12/11/17 28 Pa. Code 211.12(c) Nursing services Previously cited 11/07/18, 12/11/17, 01/24/17 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 11/07/18, 04/10/18, 12/11/17, 01/24/17

Based on clinical record review and staff interview, it was determined that the facility did not monitor blood sugar levels for a resident which resulted in actual harm to one out of seven residents reviewed (Resident #87), requiring transfer to the hospital and admission to the intensive care unit with a [DIAGNOSES REDACTED]. Findings Include: Review of Resident #87 [DIAGNOSES REDACTED]. Review of Resident #87's December 2017 physician's orders [REDACTED]. Review of Resident #87's plan of care initiated November 19, 2014, revealed that the resident was not to develop complications related to diabetes. The interventions developed included to obtain Accu-checks and report abnormal findings. Review of Resident #87's nursing note revealed a note dated March 20, 2017, at 8:27 p.m. that stated the resident was sent to the hospital and admitted for influenza (a [MEDICAL CONDITION] infection that attacks the respiratory system). Further review of Resident #87's nursing notes dated March 22, 2017, confirmed that the resident was readmitted to the facility on [DATE]. Review of Resident #87's March 2017 physician's orders [REDACTED]. Review of the March 2017 physcian's orders, after the resident returned to the facility on [DATE], revealed that the Accu-checks were not re-ordered when the resident returned from the hospital on March 22, 2017, but the resident continued to receive the medication [MEDICATION NAME]. Review of Resident #87's Accu-Checks revealed there were no Accu-checks completed between March 20, 2017, and July 1, 2017. Review of Resident #87's nursing notes revealed a nursing entry dated June 25, 2017, at 12:30 p.m. stating, Resident noted with increase confusion, hallucinations and delusions. Resident aware of her surroundings but not able to hold any objects in her hand. Resident unable to make needs known. Speech a slight slurred. Change in mental status noted. N.O. (new orders) to send resident to ER (emergency room ) for Eval (evaluation). Review of hospital documentation from the physician at the hospital revealed that in the Emergency Department the, patient was found to be markedly hyperglycemic (high blood sugars), with blood sugars in the 700s (normal range 80-120). She was given critical care insulin drip (short acting insulin provided through an IV) . She was transferred to the intensive care unit. Interview with the Director of Nursing and the Nursing Home Administrator on December 11, 2017, at 11:15 a.m. revealed the resident was not being monitored for blood sugars levels after the hospitalization of March 20, 2017. The facility failed to monitor the glucose levels of a diabetic on oral diabetic medication resulting in the resident to be hospitalized in a critical state for high blood sugar levels. 42 CFR 483.25 Provide Care/Services for Highest Well Being Previously cited 01/24/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/24/17, 05/25/16, 02/29/16 28 Pa. Code 201.18(b)(1) Management Previously cited 01/24/17, 9/14/16, 05/25/16, 02/29/16 28 Pa. Code 201.18(b)(3) Management Previously cited 01/24/17, 02/29/16 28 Pa. Code 201.18(e)(1) Management Previously cited 09/14/16, 05/25/16, 02/29/16 28 Pa. Code 211.5(f) Clinical records Previously cited 01/24/17, 05/25/16, 02/29/16 28 Pa. Code 211.12(c) Nursing services Previously cited 01/24/17, 11/30/16 28 Pa. 211.12(d)(1)(5) Nursing services Previously cited 01/24/17, 11/30/16, 09/14/16, 05/25/16, 02/29/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 01/24/17

Based on facility policy review, clinical record review, and review of facility documentation, it was determined that the facility failed to ensure that one of 29 residents reviewed was free of neglect during care which resulted in actual harm by the resident falling out of bed and needing subsequent hospitalization (Resident #70). Findings include: Review of the facility policy, Abuse Reporting and Investigation, undated, defined neglect as, failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Furthermore, neglect occurs on an individual basis when a resident receives a lack of care in one or more areas. Review of Resident #70's clinical record revealed the resident had [DIAGNOSES REDACTED]. Review of Resident #70's Quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated May 4, 2017, identified the resident with short and long term memory problems. Review of the section Functional Status identified that the resident required extensive assistance of two staff members for bed mobility and was totally dependent with two staff members for transfers and bathing. The resident was assessed with [REDACTED]. Review of Resident #70's nursing notes dated July 9, 2017, revealed that the licensed nursing staff was called to the resident room at approximately 11:20 a.m. and found the resident lying on the floor naked and on the right side of his bed with his head towards the top of bed. The notes stated, His head slightly turned to the left face down, noted small pool of blood, left arm on side on body visual midline intact and right arm underneath body. O2 (oxygen) tubing in place at time of fall. B/L (bilateral) legs contracted with heel protector boots in place and knee pointing to the left side. Noted residents eyes opened, V/S (vital sings WNL (within normal limits) 114/67 (blood pressure), 123 (respiration), 20 (pulse), 100.3 (temperature) SPO2 98% (oxygen) on 3 liters N.C. (nasal cannula) I and three other staff members turn resident over onto floor. Resident awake and alert. Resident was assessed for injury .noted bleeding from nose minimal amount of bright red blood. abrasion to left side of nose and left side of face. Redness to left side of neck. Nose, lips and mouth cleansed with NSS (normal saline solution) and O2 (oxygen) reapplied . upper lip swollen and lower lip slightly swollen. Further review of the nursing note revealed that a physcian's order was obtained for the resident to be transferred to the hospital for evaluation. Review of Resident #70's nursing notes dated July 9, 2017, stated, Resident ordered to be two person assistance at all times. Review of the information dated July 9, 2017, submitted by the facility revealed that the facility initiated an investigation on resident neglect on July 9, 2017. The facility completed the investigation July 12, 2017, and the facility determined that the Nursing Assistant, Employee E9, was providing care to Resident #70 without the assist of another staff member and that when she went to turn the resident, he rolled out of bed. The facility substantiated the allegations of neglect. Interview with the Nursing Home Administrator and Director of Nursing on December 11, 2017, at approximately 1:00 p.m. confirmed that a two person assist was not provided during care resulting in the resident falling out of bed and being transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 01/24/17, 05/25/16, 02/29/16 28 Pa. Code 201.18(b)(1) Management Previously cited 01/24/17, 9/14/16, 05/25/16, 02/29/16 28 Pa. Code 201.18(b)(3) Management Previously cited 01/24/17, 02/29/16 28 Pa. Code 201.18(e)(1) Management Previously cited 09/14/16, 05/25/16, 02/29/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/24/17, 11/30/16, 09/14/16 28 Pa. Code 211.12(c) Nursing services Previously cited 01/24/17, 11/30/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 01/24/17, 11/30/16, 09/14/16, 05/25/16, 02/29/16

Based on clinical record review, facility documentation and staff interviews, it was determined that the facility failed to provide and implement interventions including adequate supervision and monitoring to ensure the safety of residents at risk for falls for two of three residents reviewed (Residents CL1 and CL2) resulting in actual harm to Residents CL1 and CL2. Findings include: Review of Resident CL1's electronic medical record revealed that the resident was admitted to the facility May 15, 2014, with the following Diagnoses: [REDACTED]. (a mental illness marked by periods of great excitement, euphoria, delusions, and overactive) and depression (feelings of severe despondency and dejection)), dementia (irreversible, progressive loss of memory, reality contact and functioning ability), coronary artery disease (narrowing of the blood vessels which supply the heart with blood and oxygen) and a history of falls. Based on an occupational therapy evaluation, completed on October 26, 2015, revealed that Resident CL1 was identified with impaired safety awareness, being at risk for falls and requiring staff supervision and assistance with transfers, mobility, hygiene, grooming toileting and dressing. Review of facility documentation and Resident CL1's nursing notes revealed that the resident sustained [REDACTED]. Review of the facility's fall investigation documentation addressing Resident CL1's fall dated November 11, 2015 at 9:48 a.m., revealed that the resident was found sitting on the floor in the bathroom and stated, I fell . The resident sustained [REDACTED]. Measures that were put into place to prevent further fall occurrences included apply tab alarm (an alarm box that features a pull-string that attaches magnetically to the alarm with garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm this causes the alarm to sound, alerting the caregiver) to the resident's bed/chair, and to keep the resident in a supervised area, as tolerated. Although this intervention was added to the plan of care on November 11, 2015, the intervention for the tab alarm failed to direct staff as to where the tab alarm should be attached (bed or chair). Review of the facility's fall investigation referenced above, indicated the planned interventions, which included: call bell in reach, encourage resident to use the call bell, wait for nurse for assistance with transfer, and encourage supervised areas while awake, were updated on the plan of care on November 11, 2015, but these interventions could not be carried out by the resident due to the resident's level of cognitive impairment. Review of the physical therapy evaluation dated December 23, 2015, identified Resident CL1 as a fall risk due to an unsteady gait and weaken muscles of the trunk, hips and upper legs. The physical therapy discharge summary dated February 1, 2016, revealed that a recommendation was made for staff supervision with transfers, ambulation, and bathing. Review of Resident CL1's quarterly MDS assessment (Minimum Data Set - periodic assessment of resident needs) dated February 1, 2016, indicated that the staff assessment for mental status was completed and identified that the resident had short term and long term memory impairment, was moderately impaired (decisions poor; cues/supervision required) for cognitive skills for daily decision making, and required limited assistance of one staff for transferring, bathing, ambulation, dressing and toileting. Review of the facility's fall investigation dated February 2, 2016 at 8:14 a.m., and the nursing note dated February 2, 2016 at 8:20 a.m., indicated that Resident CL1 was observed lying face up on the bedroom floor next to the bed. The resident stated, I was trying to get from my bed to the wheelchair. There was no documentation available for review to indicate that the tab alarms were present on Resident CL1's bed or wheelchair at the time of the fall. There was no documented evidence that the facility provided additional monitoring and supervision of the resident to prevent falls as recommended by the physical therapy. Review of the documentation on the facility's fall investigation dated March 12, 2016 at 5:00 p.m., and the nursing note dated March 12, 2016 at 10:28 p.m., revealed that Resident CL1 was observed in the dining room in a sitting position on the floor in front of the wheelchair after trying to ambulate independently. The fall was witnessed by a nursing assistant. Review of the facility's fall investigation dated April 24, 2016 at 4:24 p.m., and nursing note dated April 24, 2016 at 6:52 p.m., indicated that Resident CL1 was found lying face up on the floor in another resident's room. There was no documentation to indicate that an alarm was present on Resident CL1's wheelchair at the time the fall occurred. Documentation revealed that, at the time of the fall, the resident complained of left hip pain. The physician was notified and an X-ray of the left hip was ordered and obtained at the facility that evening. The X-ray results revealed that the resident had an acute fractured left hip. Resident CL1 was transported to the hospital on April 24, 2016 at 11:57 a.m., by emergency ambulance and admitted with a [DIAGNOSES REDACTED]. There was no evidence provided to indicate that the facility increased measures to monitor and supervise Resident CL1 as recommended by the physical and occupational therapists which resulted in actual harm to Resident CL1, sustaining a fractured left hip. Review of Resident CL2's [DIAGNOSES REDACTED]. Documentation on the physical therapy evaluation dated April 21, 2016, identified Resident CL2 as a fall risk due to an unsteady gait and decreased lower extremity strength with impaired balance. The physical therapy discharge summary dated May 2, 2016, made a recommendation for staff supervision with transfers, ambulation, bathing, dressing and toileting. Review of Resident CL2's quarterly MDS assessment dated [DATE], indicated that the resident had a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 3 indicating long and short term memory loss and severely impaired cognitive skills for daily decision making. Resident CL2 also had physical and verbal behavioral symptoms directed at others. Resident CL2 required the extensive assistance of two staff for bed mobility, transferring, ambulation, and toileting. Documentation in the nursing notes revealed that Resident CL2 was observed making transfers independently without staff assistance, as follows: April 22, 2016, at 5:17 a.m., resident made several unassisted transfers throughout the shift. April 22, 2016, at 10:46 p.m., resident transferred unassisted x 2. April 23, 2016, at 10:48 p.m., resident transferred unassisted x 3. April 24, 2016, at 3:05 p.m., gets up out of wheelchair unassisted. April 24, 2016, at 10:21 p.m., resident transferred unassisted x 2. April 25, 2016, at 5:51 a.m., multiple unassisted transfers to bathroom, and 10:52 p.m., continued unassisted transfer. April 26, 2016, at 5:58 a.m., resident continues to be awake throughout the shift. Resident observed not being able to get comfortable as evidenced by getting up, moving and fidgeting around. April 26, 2016, at 10:38 p.m., patient chooses not to follow safety measures, redirected with extreme difficulty. April 27, 2016, at 6:22 a.m., resident continues to transfer and ambulate unassisted. April 27, 2016, at 10:18 p.m., resident ambulate unassisted, during the shift, not easily redirected most of the times, got physical and abusive with staff after dinner. April 30, 2016, at 2:50 p.m., one episode of unassisted transferring/ambulation. Documentation on the nursing note dated April 30, 2016, at 10:58 a.m., stated that a licensed nursing staff, Employee E3, heard a thump, entered the dining room and found Resident CL2 on the floor. The resident communicated to Employee E3 that she had hit her eye when she fell . Review of Resident CL2's updated plan of care following the fall on April 30, 2016, revealed the intervention to encourage the resident to ask for assistance with ambulation. Documentation on the facility's fall investigation revealed that Resident CL2 would be unable to carry out this intervention because the resident was identified as being cognitively impaired, at risk for falls, had a history of [REDACTED]. Review of a nursing note on May 3, 2016, at 6:43 a.m., revealed that Nursing Assistant, Employee E4, was sitting in front of Resident CL2's room and heard the bed alarm sounding. The employee asked the resident to wait a minute and went in to help the resident. While entering the room, Employee E4 stated that the resident had already started to get up and lost the balance and fell . The resident fell on to their buttocks before the employee got there to help. The resident screamed out in pain when the staff attempted to assist the resident back to bed. The attending physician was notified and a physician's orders [REDACTED]. Further documentation in the nursing note dated May 3, 2016, at 6:43 a.m., indicated that the resident was admitted to the hospital with [REDACTED]. The facility failed to provide proper monitoring and supervision to Resident CL2 with a history of unassisted transfers, resulting in actual harm to Resident CL2 requiring transfer and admission to the hospital with a [DIAGNOSES REDACTED]. Interviews conducted on May 25, 2016, at 12:30 p.m. with the Nursing Home Administrator and the Director of Nursing, confirmed that there was no documentation on the facility's fall investigation for Resident CL1 and CL2's that included interventions to increase measures to monitor and supervise the residents. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 12/12/14 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 02/29/16, 10/16/15, 12/12/14 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 02/29/16, 10/16/15, 12/12/14 28 Pa. Code 211.5(f) Clinical records Previously cited 02/29/16, 01/15/15, 12/12/14 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 02/29/16, 10/16/15, 01/15/15, 12/12/14 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/29/16, 01/15/15, 12/12/14

Based on clinical record review, staff interview, and facility documentation review it was determined that the facility failed to provide physician ordered care for obtaining laboratory tests and failed to notify the physician of the test results, failed to follow the care plan resulting in hospitalization and delay in assessment and treatment for one of two residents reviewed. (Resident R1). Findings Include: A review of resident R1s demographic sheet revealed the resident was admitted to the facility on [DATE]. A review of resident R1s [DIAGNOSES REDACTED].), and the resident had a history of [REDACTED]. A review of the resident 's admission physician orders [REDACTED]. A care plan dated March 8,2013 was developed for the risk of bleeding due to blood thinning medications ( [MEDICATION NAME], asprin and [DIAGNOSES REDACTED]. A review of the resident Bowel and Bladder Detailed Entry Report revealed on March 8, 2013 the resident had a large bowel movement, March 9, 2013 the resident had three bowel movements, on March 10, 2013 the resident had one bowel movement, on March 11, 2013 the resident had three bowel movements, and on March 12, 2013 the resident had three bowel movements. This is a total of 11 opportunities for the facility to obtain the three heme occult blood test as ordered for the physician. Review of nurses progress notes dated March 10, 2013 at 1:02 a.m. stated Hemetest stool collected this shift, results positive. Two more specimens needed to complete study. An entry dated March 12, 2013 at 6:51 a.m. revealed resident stool heme tested with positive results. Another entry dated March 12, 2013 at 11:47 p.m. revealed resident with positive bowel movement that was heme test positive. The third occult blood stool heme test was obtained five days after the initial order although opportunities for obtaining the all three stool samples were possible on March 8-9, 2013. Further review of nurses notes revealed there was no documentation that the facility informed the physician of the positive heme occult blood test. An entry dated March 13, 2013 at 6:46 p.m. revealed resident had a temp of 101.0 and the physician was notified and gave orders for a CBC (Complete Blood Count- a test that gives information about the cells in a patient's blood). An entry dated March 14, 2013 at 4:54 a.m. revealed that the results of the labs were reported to the nurse as Hemoglobin (is the iron-containing oxygen-transport protein in the red blood cells) of 6.3 (Normal range is 13.8-18.0) and Hematocrit (is the volume percentage of red blood cells in blood) of 19 (normal range is 41-53 percent). The physician then gave an order to send the resident to the hospital where the resident was readmitted for a GI bleed. The facility failed to follow the physician's orders [REDACTED]. This was confirmed during an interview with the administrator on April 8, 2013 at 11:15 p.m. F 309 483.25 Quality of Care Prevously cited 2/4/13 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/4/13 28 Pa. Code: 211.10 (c) Resident Care Policies. Previously Cited: 2/4/13 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing services Previously Cited: 2/4/13