Every finding on record at Townview Health and Rehabilitation Center

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance for bed mobility to prevent accidents which resulted in actual harm of a bruise to the left eye for one of two residents (Resident R1). Findings include: Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Review of the facility policy Incident and Accident reporting and Follow Up, dated 3/25/26, with a previous review date of 3/26/25, indicated that an incident is any unusual occurrence that occurs to the resident. This may include, but is not limited to injuries of unknown origin, falls, etc. Review of the facility policy Resident Rights, dated 3/25/26, with a previous review date of 3/26/25, indicated that residents have a right to reasonable care and treatment and support for daily living safely. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of a physician order dated 4/13/27, and remained current indicated, upper half side rails to both sides. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/11/26, included diagnoses of progressive neurological disorder identified as Multiple Sclerosis (a progressive disease involving damage to nerve cells in the brain and spinal cord causing impaired speech, muscle coordination and severe fatigue), anxiety, chronic pain and hypothyroidism. Review of Section GG: Functional Abilities indicated that Resident R1 was totally dependent on staff (Dependent - Helper does ALL the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity). Review of Resident R1's plan of care for ADL (activities of daily living) failed to include information regarding bed mobility requirements prior to 8/12/26. The date of the survey and six days after the injury occurred. Review of Resident R1's Nurse Aide Flow Sheet documentation dated from July 2026, and August 2026, identified staff utilizing two staff while performing bed mobility tasks. Review of an incident report dated 8/6/26, indicated that Nurse Aide Employee E1 was turning Resident R1 towards her in the bed after Resident R1's shower and Resident R1's head hit the nightstand on the right side of the bed causing a bruise to Resident R1's left eye. The report indicated that the Nurse Aide was educated to make certain residents in center of bed before turning side to side. During an interview on 8/12/26, at approximately 10:46 a.m., Resident R1 stated that the Nurse Aide turned her to her right side to remove shower pad and her head rolled into the nightstand as it is close to bed when her head is lowered. The resident stated that she has no control to stop her head or limb control from holding herself any longer due to the MS (Multiple Sclerosis), although the side rails are on the bed, she cannot hold herself to utilize them. The bruise is still noticeable with center being purple and edge yellowish red in color. Resident R1 indicated the side rails were up during care but cannot assist in using them.Attempts to interview Nurse Aide Employee E1 were unsuccessful. During multiple interviews with care staff on 8/12/26, at approximately 11:20 a.m., through 12:00 p.m., regarding Resident R1's care indicated they do try to use two staff members when providing care because Resident R1 has poor trunk control related to her diagnosis. Review of the incident did not identify that the facility had submitted a therapy evaluation of Resident R1 for bed mobility re-evaluation. Resident R1's plan of care identified that the facility added bed Mobility assist X1 to the interventions on 8/12/26, prior to any evaluations. During an interview on 8/12/26, at approximately 12:39 p.m., the Nursing Home Administrator and Director of Nursing were made aware of the facility failure to provide adequate supervision to prevent injury that resulted in the actual harm of a bruise to the left eye for one of two residents. 28 Pa. Code: 201.14 (a) Responsibility of Licensee28 Pa. Code: 201.20 (a)(1) Staff Development28 Pa. Code: 211.10 (b)(c)(d) Resident Care Policies28 Pa. Code: 211.12 (d)(2)(3)(5) Nursing Services

Based on review of facility policy, clinical record, facility documentation, and staff interview, it was determined the facility failed to ensure that one of three residents (Resident R1) were free from significant medication errors which resulted in actual harm requiring increased monitoring and intravenous placement, and administration of replacement fluids to increase blood pressure for one of two residents (Resident R1).Findings include: Review of the facility policy Medication Administration dated 3/25/26, with a previous review date of 3/26/25, indicated that medications are to be administered safely and following state and federal regulations. Residents are to be identified utilizing a name band and or photo before administration of medications. Review of the facility policy Medication Error, dated 3/25/26, with a previous review date of 3/26/25, indicated that medications are to be administered according to the 5 rights:Right resident 2. Right medication 3. Right dose 4. Right route 5. Right time The following events constitute a medication error: Not adhering to the five rights and failure to follow professional standards. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/11/26, included diagnoses of progressive neurological disorder identified as Multiple Sclerosis (a progressive disease involving damage to nerve cells in the brain and spinal cord causing impaired speech, muscle coordination and severe fatigue), anxiety, chronic pain and hypothyroidism. Review of the clinical record identified that Resident R1 does not have high blood pressure as a diagnosis and her vital signs indicated in the clinical record on 7/6/26, blood pressure of 128/66, heart rate at 75 and oxygen level at 96% on room air. Review of a Medication Error Report dated 7/9/26, identified that Licensed Practical Nurse Employee E2 had given Resident R1 the wrong bedtime medications including Pepcid 20mg (antacid), Lipitor 80mg(statin), Clonidine 0.3mg (blood pressure) and Gabapentin (anticonvulsant). The physician was notified and indicated to monitor resident and vital signs every 4 hours. Resident R1's bedtime medications were held until approximately 2:00 a.m., after Physician contact was made. Review of the clinical progress notes identified that on 7/10/26, at 1:37 a.m., Resident R1's blood pressure(bp) was 95/57, heart rate 82 and oxygen level at 95% on room air. The resident indicated that she is anxious since she did not receive her medications and her heart is pounding and she feels loopy. Review of the clinical record indicated that on 7/10/26, at 5:54 a.m., her vital signs were bp was 75/46 and rechecked again at same level. the Nursing Supervisor was notified; no further action was taken at that time. Review of the clinical record indicated that on 7/10/26, at 9:39 a.m., vital signs were bp 88/66, heart rate 82 and oxygen level at 96% room air. The resident stated that she feels tired and fluids were encouraged. The physician was paged at that time. Review of the clinical record indicated the physician returned the call on 7/10/26, at 2:00 p.m., four and half hours later, indicating the initiation of intravenous fluids of normal saline at 100 milliliters per hour x 1 liter. vital signs at that time documented as blood pressure 102/70. Review of a progress note date 7/11/26, at 2:00 p.m., indicated the fluids were discontinued in the morning and resident stated she felt much better. During an interview with Resident R1 on 8/12/26, at approximately 10:46 a.m., Resident R1 stated that she was fearful and felt loopy when she was given the wrong medications, she stated that she had never seen the nurse before nor has she since as she thinks the facility does not allow her to return. Resident R1 stated that she was given the resident across the hall medications that included Gabapentin and a blood pressure medication and her blood pressure dropped, which made her more fearful, and she did not get her regular medications, which caused her not to sleep because she was so anxious.During interviews of licensed care staff from approximately 11:00 a.m. through 12:00 p.m., indicated to utilize the five rights prior to administering all medications. During an interview on 8/12/26, at approximately 12:39 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that one of three residents (Resident R1) were free from significant medication errors which resulted in actual harm requiring increased monitoring and intravenous placement, and administration of replacement fluids to increase blood pressure for one of two residents (Resident R1). 28 Pa Code 201.18(b)(1)(e)(1) Management28 Pa Code: 211.10 (c) Resident care policies

Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to prevent accidents, which resulted in actual harm, requiring further treatment for aspiration pneumonia for one of six residents (Resident R1). Findings include: Review of the facility Fall and Accident Prevention Program policy dated 3/26/25, indicated the facility will provide a safe environment that is free from hazards and activities that may result in an accident. Review of the facility policy Restorative Nursing-Eating/Swallowing policy dated 3/26/25, indicated activities will be provided to improve or maintain feeding food and fluids that may include providing total assistance for eating to maintain the ability to consume nutrition. Review of Resident R1's face sheet indicated the resident was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses of MS multiple sclerosis (long lasting chronic disease of the nervous system), chronic pain, depression, and anxiety. The resident is alert and oriented, is understood, and understands. Resident R1 is dependent on staff for all ADL's (activities of daily living). Review of Resident R1's care plan dated 3/31/25 indicated the resident is dependent on staff for all ADL's and to provide assistance as needed. A review of the facility Electronic Charting System (ECS-identifies resident care needs) dated 9/22/25, indicated Resident R1 is dependent on staff for eating meals. The nurse aide will keep the resident in an upright position, observe for signs and symptoms of aspiration, and provide small bites and sips of food and liquids. Review of the nurse progress notes dated 1/11/26 indicated at dinner time, Resident R1 was eating and started to cough, felt like food was stuck, and was having a hard time breathing. Further review indicated Resident R1 was choking and vomiting food, was assessed, the physician was notified, and a chest Xray was ordered. Review of a nurse progress note dated 1/12/26 indicated the X-ray impression was minimal right base atelectasis (blockage in the air sacs of the lung) and Augmentin (an antibiotic) 875/125 mg (milligrams) PO (by mouth) BID (two times a day) times seven days for pneumonia was ordered. A review of a physician order dated 1/15/26, indicated Unasyn (an antibiotic) 3 grams, intravenous (IV) every six hours for seven days for aspiration pneumonia. A review of physician orders dated 1/14/26 indicated DuoNeb (a medication to open up airways and treat shortness of breath) administer three times a day for pneumonia. Oxygen at 2-4 L (liters) per minute via nasal cannula (a tube that goes into the nose) for shortness of breath as needed. A review of the Medication administration Record (MAR) dated January 2026 indicated Resident R1 received all medications as ordered. During an interview on 2/18/26 at 9:30 a.m., Resident R1 was noted to be in bed with the head elevated at a 45-degree angle. Resident R1 indicated Certified Nursing Assistant (CNA) Employee E1 was feeding the meal on 1/11/26. Resident R1 stated, I was choking on my food because my head was too flat (lower than I am now). I said I couldn't do it. I got pneumonia and was sick, it scared me. It should never happen again. Resident R1 was very upset and tearful, blaming self that the incident occurred, because [Resident R1] did not say anything to the caregiver about being positioned too low and did not want to get staff in trouble. During a telephone interview on 2/18/26, at approximately 12:55 p.m. CNA Employee E1 revealed on 1/11/26, Resident R1 was positioned properly damn near 90 degrees and started to cough due to talking while eating. Employee E1 did not know where to find the resident's care needs for eating, and stated I just know they are a feed A review of Employee E1's personnel file indicated a start date of 11/6/25 and completed training and a satisfactory evaluation for assisting residents unable to feed themselves on 11/18/24. During interviews on 2/18/26, from 10:30 a.m. through 12:00 p.m., CNA Employees E5, E6, E8, and E9 confirmed they locate resident's care needs in the ECS system and were able to confirm Resident R1's needs for eating as defined in the care plan. During an interview on 2/18/26, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to prevent an accident that resulted in actual harm of aspiration pneumonia for Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to investigate a choking incident to rule out possible neglect for one of five residents (Resident R1).Findings include: Review of facility policy Abuse Prevention Policy dated 3/26/25, indicated all alleged violations involving abuse/neglect are promptly and thoroughly investigated. An incident report should be completed by the nurse assigned to the resident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses of MS multiple sclerosis (long lasting chronic disease of the nervous system), chronic pain, depression, and anxiety. The resident is alert and oriented, is understood, and understands. Resident R1 is dependent on staff for all ADL's (activities of daily living) A review of the facility Electronic Charting System (ECS-identifies resident care needs) indicated Resident R1 is dependent on staff for eating meals. Review of the nurse progress notes dated 1/11/26 indicated at dinner time, Resident R1 was eating and started to cough, felt like food was stuck, and was having a hard time breathing. Further review indicated Resident R1 was choking and vomiting food, was assessed, the physician was notified, and a chest Xray was ordered. Review of a nurse progress note dated 1/12/26 indicated the X-ray impression was minimal right base atelectasis (blockage in the air sacs of the lung) and Augmentin (an antibiotic) 875/125 mg (milligrams) PO (by mouth) BID (two times a day) times 7 days for pneumonia was ordered. During an interview on 2/18/26 at 9:30 a.m., Resident R1 stated Certified Nursing Assistant (CNA) Employee E1 was feeding the meal. I was choking on my food because my head was too flat, I said I couldn't do it, and I got pneumonia. Resident R1 stated that Administration was aware of the incident and interviewed them the following day. The resident was tearful that the incident occurred and did not want to get staff in trouble. During an interview on 2/18/26, at approximately 9:20 a.m. the Director of Nursing was aware of the incident and was asked to provide the investigation documents and incident report for Resident R1's choking incident. The Director of Nursing stated no documentation was completed. A review of the facility Incident and Accident Log dated January 2026 did not include a choking incident for Resident R1 on 1/11/26. During an interview on 2/18/26, at approximately 12:00 p.m. Medical Director Employee E3 stated that Resident R1's choking incident on 1/11/26 should have been investigated per facility policy. During an interview on 11/15/25, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to investigate an incident of possible neglect for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to implement policies and procedures to report possible neglect for one of five residents (Resident R1).Findings include: Review of facility policy Abuse Prevention Policy dated 3/26/25, indicated alleged violations involving abuse/neglect are reported immediately to the Administrator, and report results of all investigations to the Administrator and to the PA Department of Health within 5 working days of the incident. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses of MS multiple sclerosis (long lasting chronic disease of the nervous system), chronic pain, depression, and anxiety. The resident is alert and oriented, is understood, and understands. Resident R1 is dependent on staff for all ADL's (activities of daily living) A review of the facility Electronic Charting System (ECS-identifies resident care needs) indicated Resident R1 is dependent on staff for eating meals. Review of a nurse progress notes dated 1/11/26 indicated at dinner time, Resident R1 was eating and started to cough, felt like food was stuck, and was having a hard time breathing. Further review indicated Resident R1 was choking and vomiting food, was assessed, the physician was notified, and a chest Xray was ordered. Review of a nurse progress note dated 1/12/26 indicated the X-ray impression was minimal right base atelectasis (blockage in the air sacs of the lung) and Augmentin (an antibiotic) 875/125 mg (milligrams) PO (by mouth) BID (two times a day) times 7 days for pneumonia was ordered. During an interview on 2/18/26 at 9:30 a.m., Resident R1 stated Certified Nursing Assistant (CNA) Employee E1 was feeding her meal. I was choking on my food because my head was too flat, I said I couldn't do it, and I got pneumonia. Resident R1 stated that Administration was aware of the incident and interviewed them the following day. The resident was tearful that the incident occurred and did not want to get staff in trouble. During an interview on 2/18/26, at approximately 9:20 a.m. the Director of Nursing was aware of the incident and was asked to provide the investigation documents for Resident R1's choking incident. The Director of Nursing stated no documentation was completed. A review of the facility incident and accident log dated January 2026 did not include a choking incident for Resident R1 on 1/11/26. Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible neglect to Resident R1. During an interview on 2/18/26, at approximately 12:00 p.m. Medical Director Employee E3 stated that Resident R1's choking incident on 1/11/26 should have been reported per facility policy. During an interview on 11/15/25, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to implement policies and procedures to report possible neglect for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

Findings include: Review of the facility policy, Nursing Documentation dated 3/26/25, indicated, changes in resident condition must be noted and charted and communication with family should be documented as well. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 5/2/25, indicated diagnoses of MS multiple sclerosis (long lasting chronic disease of the nervous system), chronic pain, depression, and anxiety. The resident is alert and oriented, is understood, and understands. Review of a nurse progress note dated 1/11/26 indicated Resident R1 was choking and vomiting food, was assessed, the physician was notified, and a chest Xray was ordered. Review of a nurse progress note dated 1/12/26 indicated the X-ray impression was minimal right base atelectasis (blockage in the air sacs of the lung) and Augmentin (an antibiotic) 875/125 mg (milligrams) PO (by mouth) BID (two times a day) times 7 days for pneumonia was ordered. During an interview on 1/18/26 at 9:30 a.m., Resident R1 stated my son was not notified, and I had pneumonia for a week. Review of the progress notes failed to reveal a notification to the resident's family of Resident R1's change in condition. During an interview on 2/18/26, at approximately 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to notify the family of a change in condition for Resident R1. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of the facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for thirteen of the eighteen residents reviewed (Resident R5, R19, R25, R27 R30, R46, R51, R52, R59, R60, R64, R86, R87). Findings include: A review of the facility policy Advanced Directives last reviewed 3/27/24, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R5 was readmitted to the facility on [DATE], with diagnoses that included diabetes, dementia (decline in the ability to perform everyday activities), gastro-esophageal reflux disease (GERD-severe heartburn), transient ischemic attack (brief stroke-like attack that can have weakness on one side, slurred speech, vision problems-resolves in minutes to hours). A review of the clinical record failed to reveal and advance directive or documentation that Resident R5 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R19 was readmitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), anxiety, obstructive and reflux uropathy (urinary tract conditions that can cause urine to flow abnormally), hypoxemia (low level of oxygen in the blood). A review of the clinical record failed to reveal and advance directive or documentation that Resident R19 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R25 was readmitted to the facility on [DATE], with diagnoses that include cerebral infarction (serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), GERD, depression, schizophrenia (affects a person's ability to think, feel, and behave clearly). A review of the clinical record failed to reveal and advance directive or documentation that Resident R25 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R27 was readmitted to the facility on [DATE], with diagnoses that include Parkinson's (affects muscles making it difficult to walk), depression, high blood pressure, diabetes (high blood sugar). A review of the clinical record failed to reveal and advance directive or documentation that Resident R27 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R30 was admitted to the facility on [DATE], with diagnoses that include chronic kidney disease (disease of kidneys that leads to kidney failure), high blood pressure, cerebrovascular disease (affects blood vessels of the brain and cerebral circulation), cardiomegaly (enlarged heart). A review of the clinical record failed to reveal and advance directive or documentation that Resident R30 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R46 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, diabetes, pulmonary hypertension (affects arteries in lungs and heart), arthritis (swelling and tenderness in one or more joints). A review of the clinical record failed to reveal and advance directive or documentation that Resident R46 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R51 was admitted to the facility on [DATE], with diagnoses that include morbid obesity (severely overweight), high blood pressure, convulsions (uncontrolled jerking, loss of consciousness, blank stares), neuromyelitis optica (autoimmune disease that attacks the optic nerve making it difficult to see) . A review of the clinical record failed to reveal and advance directive or documentation that Resident R51 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R52 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, diabetes, atrial fibrillation (irregular, often rapid heart rate), dementia. A review of the clinical record failed to reveal and advance directive or documentation that Resident R52 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R59 was admitted to the facility on [DATE], with diagnoses that include diabetes, depression, transient ischemic attack, hyperlipidemia (high cholesterol). A review of the clinical record failed to reveal and advance directive or documentation that Resident R59 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R60 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, diabetes, Alzheimer's (progressive disease that destroys memory and other important mental functions), insomnia (problem falling or staying asleep). A review of the clinical record failed to reveal and advance directive or documentation that Resident R60 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R64 was readmitted to the facility on [DATE], with diagnoses that include diabetes, alzheimer's, dysphagia (difficulty swallowing), hypokalemia (low potassium level). A review of the clinical record failed to reveal and advance directive or documentation that Resident R64 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R86 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, atrial fibrillation, heart failure (heart doesn't pump blood as well as it should), pulmonary hypertension. A review of the clinical record failed to reveal and advance directive or documentation that Resident R86 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R87 was admitted to the facility on [DATE], with diagnoses that include vascular dementia (causes memory loss), hypothyroidism (thyroid doesn't produce enough thyroid hormone), depression, hearing loss. A review of the clinical record failed to reveal and advance directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive. During an interview on 10/25/24 at 9:05 a.m. the Social Worker and the Assistant Director of Nursing (ADON) confirmed that the clinical record did not include documentation that Resident R5, R19, R25, R27 R30, R46, R51, R52, R59, R60, R64, R86, R87 were not afforded the opportunity to formulate Advance Directives. 28 Pa. Code: 211.15(f) Clinical records. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of four residents (Resident R51). Findings include: Review of the facility policy, ADL (Activities of Daily Living) Documentation dated 3/27/24, indicated the nursing assistant will review the CNA Flowsheet which includes mobility and transfers needs. At the end of the shift the Nursing Assistant will document bed mobility and transfers. ADL documentation includes the level of resident's ability to perform tasks and the amount of staff assistance needed. Before change over, the Unit Manager, or designee will review each resident's ADL information and revise as necessary. Review of the American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down. Resident R51 was admitted to the facility on [DATE]. Review of Resident 51's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/5/24, included diagnoses of morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), neuromyelitis optica (NMO) autoimmune disease of the central nervous system (can cause blindness in one or both eyes, weakness or paralysis in the legs or arms, and painful spasms) and paraplegia (paralysis that occurs in the lower half of the body). Review of Resident R51's MDS dated [DATE] assessments, Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, indicated that Resident R51 required extensive assistance of two or more staff members. Review of Resident R51's plan of care for Impaired Mobility quarterly review dated 9/11/24, indicated extensive to total assistance for ADL tasks. Review of a physician order dated and 9/26/24, indicated Resident R51 required an assist of two staff members for mobility. Review of the September and the October 2024 Task CNA (nurse aide) Flowsheet for the 3:00 p.m. to 11:00 p.m. shift indicates Resident R51 requires assistance of two for mobility. Review of the CNA Employee E9 3:00 p.m. to 11:00 p.m. Assignment Sheet for 10/1/24 indicated Resident R51 is an assist of two. Review of a progress note dated 10/1/24, at 8:08 p.m. indicated, CNA Employee E9 reported resident had fallen out of bed during care. CNA Employee E9 stated residents' legs slid off the right side of the bed. Per resident baseline she has no control on movement of bilateral lower extremities Resident was lowered to a laying position on the floor by four staff members a Hoyer lift was used with assistance of four staff to return resident to bed. During this time resident had complaints of intermittent pain to her head and left shoulder. MD (doctor of medicine) and resident sister notified. Resident was sent to the hospital at 6:00 pm. Review of emergency room documentation dated 10/1/24, indicated Resident R51 was treated for a fall and closed head injury. Resident R51 imaging did not reveal any major injury related to the fall as reflected in the facility progress notes. Resident R51 returned to the facility at 9:00 p.m. the same date of the fall. Review of facility submitted information dated 10/2/24, indicated, On 10/1/2024 at approximately 5:15 p.m. Resident R51 is non-ambulatory and transfers with a Hoyer lift and assist of 2, she is an assist of 2 for mobility. CNA Employee E9 went in to provide care turning the resident on her side positioning her in the center of the bed. CNA Employee E9 went to the bathroom to get the washcloths and when she was returning Resident R51 grabbed the siderail pulling herself over and her legs went off the side of the bed, pulling her to the floor to a sitting position before CNA Employee E9 could reach her. Resident R51 is alert and oriented x3. Review of an employee statement written by CNA Employee E9 dated 10/1/24, indicated, She [Resident 51 R51] was on her side facing the door turned away from me. I had went to wet more washcloths and she was positioned in the middle of the bed. When I came back from getting the wet washcloths she was holding onto the railing and was pulling herself over more and her bottom half starred rolling over the side of the bed before I could get her legs to stop it from happening. Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/2/24, included the information, Staff member did not follow MD orders for two-person bed mobility. The CNA Employee E9 was educated on the importance of following MD orders for bed mobility and abuse and Neglect. Review of the facility Employee Discipline Warning Notice dated 10/2/24, the CNA Employee E9 received a written warning for policy breach and not following professional standards. Additional documentation included The employee failed to follow physician's orders for two person assist for bed mobility. The employee must follow MD orders. Any further infraction of this nature will result in further disciplinary action up to and including termination. This document was signed by the CNA Employee E9 and the Assistant Director of Nursing. During an interview on 10/22/24 at approximately 1:45 p.m., Resident R51 stated CNA Employee E9 rolled her onto her side while providing her care. CNA Employee E9 then left the bedside and went to get more supplies leaving the resident unattended. Resident R51 was holding onto the railing to keep herself on her side and her legs slid out of the bed and she fell . Resident R51 reported that two staff members provide her care and confirmed that only CNA Employee E9 was providing care when she fell . During staff interviews on 10/24/24 Employees CNA Employee E1, RN Employee E2, LPN Employee E3, and CNA employee E4 verbalized the facility policy for ADL care and the location in the record for resident mobility. This included receiving the information at the start of each shift. During an interview on 10/25/24 at approximately 9:55 a.m. the NHA confirmed Resident R51 required assistance of two for bed mobility and the facility failed to provide adequate supervision to prevent falls for one of four residents (Resident R51). 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(e)(1) Management. 28 Pa. Code: 201.20(b)(1) Staff development. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for two of nine residents reviewed (Residents R27, and R46). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy for diabetes reviewed 9/27/23 and 3/27/24, indicated the facility will recognize, assist, and document the treatment of complication commonly associated with diabetes. Step #1 indicated to obtain physician orders for fingerstick blood sugar testing including parameters for intervention. Documentation should reflect the carefully assessed diabetic resident and include level of consciousness, assessment, results of fingerstick blood monitoring, interventions to stabilize blood glucose levels\, and notification to physician of unstable and/or significant variances from base line per physician order. Review of the facility policy Management of Hypoglycemic Reaction reviewed 9/27/23 and 3/27/24, indicated if resident's blood glucose results are less than 70 mg/dl, regardless of symptoms are present, give eight ounces (oz) of orange juice, one tube of glucose gel, prepackaged cookies or other sweetened snack. Recheck blood glucose after 15 minutes. Notify physician as ordered or indicated. Review of the facility policy for change in resident's condition reviewed 9/27/23 and 3/27/24, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a residents' condition. Document assessment data, attempted or actual correspondence with physician, and physician's response in the medical record. Review of the facility policy Nursing Documentation reviewed 9/27/23 and 3/27/24, indicated to provide an accurate method for demonstrating that care had been provided which reflects current standards or practice, meets resident needs and reflects compliance with state, federal, and provider requirements. Changes in residents' condition or significant resident care issues must be noted and charted until the resident's condition is stabilized ot the situation is resolved. Review of the clinical record indicated Resident R27 was readmitted to the facility on [DATE], with diagnoses that included Parkinson's disease (chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), depression, and high blood pressure. Review of Resident R27' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 10/17/24, indicated the diagnoses remain current. Review of a physician's order indicated for fingerstick blood monitoring results less than 70: implement hypoglycemic protocol. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 7/21/24, at 4:41 p.m. the CBG was noted to be 43. Review of the care plan dated 3/21/23, indicated the following interventions: -Observe for hypo/hyperglycemia -Perform Accu-Checks as ordered and document -Administer insulin as ordered -Notify MD (doctor) as needed is signs/symptoms of hyper/hypoglycemia occur Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of a clinical record indicated Resident R46 was admitted to the facility on [DATE], with diagnoses that included diabetes, depression, and anxiety. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician's orders indicated Accuchecks three times a day before meals with Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) sliding scale coverage. If fingerstick blood monitoring results are greater than 400, give 15 units of insulin. Review of Resident R46's eMAR revealed that the resident's CBG's were as follows: On 11/23/23, at 5:17 p.m. the CBG was noted to be 406. On 11/29/23, at 4:01 p.m. the CBG was noted to be 490. On 12/4/23, at 5:40 p.m. the CBG was noted to be 452. On 12/28/23, at 4:38 p.m. the CBG was noted to be 419. On 12/29/23, at 5:14 p.m. the CBG was noted to be 410. On 1/10/24, at 4:33 p.m. the CBG was noted to be 463. On 1/13/24, at 5:36 a.m. the CBG was noted to be 473. On 1/15/24, at 5:00 p.m. the CBG was noted to be 425. On 1/19/24, at 6:00 a.m. the CBG was noted to be 57. On 1/31/24, at 5:05 p.m. the CBG was noted to be 510. On 2/12/24, at 5:18 p.m. the CBG was noted to be 442. On 3/2/24, at 11:46 a.m. the CBG was noted to be 524. On 4/4/24, at 5:20 p.m. the CBG was noted to be 405. On 4/8/24, at 5:49 a.m. the CBG was noted to be 451. On 4/11/24, at 11:54 a.m. the CBG was noted to be 442. On 4/13/24, at 5:42 p.m. the CBG was noted to be 475. On 5/4/24, at 5:57 a.m. the CBG was noted to be 411. On 5/6/24, at 4:53 p.m. the CBG was noted to be 417. On 5/7/24, at 4:49 p.m. the CBG was noted to be 423. On 5/9/24, at 3:58 p.m. the CBG was noted to be 418. On 5/12/24, at 4:39 p.m. the CBG was noted to be 422. On 5/13/24, at 4:03 p.m. the CBG was noted to be 406. On 5/30/24, at 6:44 p.m. the CBG was noted to be 438. On 6/18/24, at 4:12 p.m. the CBG was noted to be 456. On 7/1/24, at 8:01 p.m. the CBG was noted to be 445. On 7/8/24, at 4:53 p.m. the CBG was noted to be 417. On 7/25/24, at 5:24 p.m. the CBG was noted to be 436. A review of Resident R46's care plan dated 11/20/23, indicated the following interventions: -Accuchecks as ordered, and document -Observe for s/s of hypo/hyperglycemia -Administer medications as ordered and monitor for side effects and effectiveness Review of Resident R46's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. During an interview on 10/24/24, at 10:35 a.m. Registered Nurse (RN) Employee E2 stated for blood glucose results under 70, they would give juice and/or snacks, hold insulin, and recheck the blood glucose in 15 minutes. They would check the ordered parameters to find out when to call the doctor. If blood glucose was greater than 400, they would give the ordered dose of insulin, call the doctor, and recheck the blood glucose according to doctors orders. They would document in the Nurse's Notes. During an interview on 10/24/24, at 10:37 a.m. Licensed Practical Nurse (LPN) Employee E5 stated if the blood glucose was under 70, they would give a snack or juice. If the blood glucose was greater than 400, they would give the ordered insulin, call the doctor, and recheck the blood glucose in 15-30 minutes. They would document in the Nurse's Notes. During an interview on 10/24/24, at 10:42 a.m. LPN Employee E3 stated if the blood glucose was less than 70, they would give juice or snacks. If blood glucose was over 400, they call the doctor and go from there according to any orders received. They would document in Nurse's Notes. During an interview on 10/24/24, at 10:45 a.m. RN Employee E6 stated for blood glucose less than 70, they would start hypoglycemic protocol, call the doctor, follow any orders received, and recheck the blood glucose in 30-60 minutes. For blood glucose greater than 400, they would check the ordered parameter, give the ordered dose of insulin, and call the doctor. They would monitor the resident, and recheck the blood glucose in 15, 30, and 60 minutes. They would document in the Nurse's Notes During an interview on 10/24/24, at 10:50 a.m. LPN Employee E7 stated for blood sugars less than 70, they would follow the facility's hypoglycemic protocol. If the blood glucose was greater than 400, they would call the doctor. During an interview on 10/24/24, at 10:54 a.m. RN Employee E8 stated they would check the resident's ordered parameters first. If the blood glucose was less than 70, they would give juice or snacks. If the blood glucose was greater that 400, they would call the doctor, monitor the resident, and recheck the blood glucose in 15-30 minutes. They would document in the Nurse's Notes. During an interview on 10/25/24, at 9:05 a.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, and failed to document an assessment or interventions used related to blood glucose for Residents R27, and R46. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on a review of facility documents, information from the State Ombudsman Office and staff interviews it was determined that the facility failed to notify the State Ombudsman Office of resident transfers and discharges for past year, 10/2023 through 10/2024, as required. Findings include: A request to review facility documents on 10/23/24, of the facility's compliance in notifying the State Ombudsman Office revealed that the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time period of 10/23/23 through 10/23/24. A review of information on 8/1/24, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 10/2021. During an interview on 10/23/24, at 10:21 a.m. the Nursing Home Administrator confirmed that the facility failed to report resident transfers and discharges to the State Ombudsman Office for a year period from 10/23/23 through 10/23/24, as required. PA Code: 201.29(f)(g) Resident rights.

Based on review of the pharmacy recommendations, clinical record, and staff interview, it was determined that the facility failed to provide documentation that pharmacy recommendations were reviewed and acted upon for two of five residents (Resident R25 and R79). Findings include: Review of Resident R25's pharmacy review progress note in the electronic medical record dated 7/27/23, at 6:59 p.m. indicated the MRR (medication regimen review) was complete, see recommendation. Review of Resident R25's pharmacy review progress note in the electronic medical record dated 10/27/23, at 6:26 p.m. indicated the MRR was complete, see recommendation. Review of the remainder of Resident R25's pharmacy review progress notes reviewed indicated no recommendations. Review of Resident R79's pharmacy review progress note in the electronic medical record dated 8/28/23, at 10:08 a.m. indicated the MRR was complete, see recommendation. Review of the remainder of Resident R79's pharmacy review progress notes reviewed indicated no recommendations. During an interview on 11/2/23, at 12:30 p.m. the Assistant Director of Nursing Employee E2 was unable to provide documentation of the pharmacy recommendation, or documentation that the physician responded to a recommendation. During an interview on 11/2/23, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide documentation that pharmacy recommendations were reviewed and acted upon for two of five residents. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, observation, clinical records, and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent for one of four residents (Resident R242). Findings include: Review of the facility policy Medication Administration Guidelines dated 9/27/23, indicated Only medications that are crushable can be crushed. (See list Medications That Cannot Be Crushed). Review of the facility provided document Meds That Should Not Be Crushed dated 02/2023 indicated Crushing extended-release meds can result in administration of a large dose all at once. Crushing delayed-release meds can alter the mechanism designed to protect the drug from gastric acids or prevent gastric upset. This list included: -Bupropion SR (sustained release) -Metoprolol succinate ER (extended release) -Potassium chloride The observations listed below revealed three medication errors out of 25 opportunities resulting in a medication error rate of 12.00%. Review of a physician's orders dated 10/24/23, indicated Resident R242 received: -10 mEq (milliequivalents) of potassium chloride, once daily. -200 mg (milligrams) of Bupropion SR, once daily. -12.5 mg of Metoprolol ER, once daily. During a medication administration observation on 10/31/23, at 8:24 a.m. Registered Nurse (RN) Employee E1 placed the above listed three medications in a crushing envelope. Just prior to RN Employee E1 pulling the handle to crush the medications, the surveyor stopped RN Employee E1, and instructed her that potassium chloride cannot be crushed. RN Employee E1 removed the potassium and crushed the remainder of the medications. During a review of Resident R242's physician's orders to verify accuracy of the remaining medications provided, it was noted that the metoprolol and the Bupropion were extended release medications. During an interview on 11/2/23, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to maintain a medication error rate of less than five percent for one of four residents. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 28 Pa. Code: 211.12(d)(5) Nursing services.

Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for three of 12 residents (Resident R26, R52, and R82). Findings include: Review of the facility policy Bed Safety dated 9/27/23, indicated the facility provides services that promote safe use of beds, mattresses, and bed rails. The facility will evaluate beds, mattresses, if indicated side rails upon admission and then quarterly for risk of entrapment. Documentation of the evaluation will be maintained. Review of the clinical record indicated that Resident R26 was admitted to the facility on [DATE]. Review of Resident R26's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/4/23, indicated diagnoses of Multiple Sclerosis (MS - the immune system eats away at protective covering of nerve cells), chronic pain, and hypothyroidism (thyroid gland doesn't produce enough thyroid hormone). Review of Resident R26's physician order dated 6/16/23, indicated upper half rails on both sides. Review of Resident R26's care plan dated 8/22/23, indicated complete side rail assessment on admission, quarterly and with any change and half side rails up bilaterally for bed mobility. Review of Resident R26's Nurse Aide Flow Sheet dated 11/1/23, indicated upper half rails on both sides of the bed. Review of Resident R26's clinical record revealed the most current Bed Safety Review assessment was completed on 10/8/22. Observation of Resident R26's room on 10/30/23, at 9:25 a.m. indicated upper half bed rails on each side of the bed. Review of the clinical record indicated that Resident R52 was admitted to the facility on [DATE] . Review of Resident R52's MDS dated [DATE], indicated diagnoses of anemia (the blood doesn't have enough healthy red blood cells), high blood pressure, and heart failure (heart doesn't pump blood as well as it should). Review of Resident R52's physician order dated 10/23/23, indicated upper half rails on both sides. Review of Resident R52's care plan dated 8/22/23, indicated perform side rail assessment per protocol, adjust plan of care accordingly, and half side rails up bilaterally for bed mobility. Review of Resident R52's Nurse Aide Flow Sheet dated 11/1/23, indicated upper half rails on both sides of the bed. Review of Resident R52's clinical record revealed the most current Bed Safety Review assessment was completed on 10/8/22. Observation of Resident R52's room on 10/30/23, at 9:30 a.m. indicated upper half bed rails on each side of the bed. Review of the clinical record indicated that Resident R82 was admitted to the facility on [DATE] . Review of Resident R82's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and heart failure. Review of Resident R82's physician order dated 10/19/23, indicated upper half rails on both sides. Review of Resident R82's care plan dated 8/18/23, indicated perform side rail assessment per protocol, adjust plan of care accordingly, and half side rails up bilaterally for bed mobility. Review of Resident R82's Nurse Aide Flow Sheet dated 11/1/23, indicated upper half rails. Review of Resident R82's clinical record revealed the most current Bed Safety Review assessment was completed on 5/18/23. Observation of Resident R82's room on 10/30/23, at 9:40 a.m. indicated upper half bed rails on each side of the bed. Interview on 11/1/23, at 1:08 p.m. the Director of Nursing confirmed that the facility failed to conduct ongoing accurate assessments to ensure that bed rails were used to meet residents' needs and the risks associated with bed rail usage for three of 12 residents (Resident R26, R52, and R82). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.29(a)(d) Resident Rights. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to provide adequate supervision that resulted in an resident elopement resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of three residents reviewed (Resident R64). This was identified as past non-compliance for one resident (Resident R64). Findings include: A review of the facility policy Elopement, reviewed 9/27/23, indicated the residents are assessed upon admission, quarterly, and change in condition by staff members to determine if they are at risk for elopement. The following may be used for residents identified as high risk for elopement: frequent monitoring of resident ' s whereabouts, individual to maintain interest level, environmental controls such as secure units with appropriate Code Alert device, alarmed doors, and restricted window openings. A review of the facility document Code Alert Procedure for the Secured Unit (Second Floor) reviewed 9/27/23, indicated the elevator on the second floor is equipped with an electronic system that will prevent a resident with a special alert bracelet (code alert) from exiting the unit via elevator. When a resident with the code alert bracelet appears in proximity to the elevator, the elevator will not close the doors unless a special code is entered into the keypad next to the elevator. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R64 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and right hip fracture (partial or complete break in the bone). Review of Resident R64's MDS dated [DATE] indicated the diagnoses remain unchanged. Review of the Section C: Cognitive Patterns indicated that Resident R64's BIMS score was 06, indicating severe impairment. Review of an elopement assessment completed on 10/5/23, at 10:33 a.m. indicated Resident R64 was not at risk for elopement. Review of a progress note dated 10/5/23, at 8:21 p.m. indicated the physician was made aware of resident ' s wandering and exit seeking behavior, family was notified. Review of an elopement assessment completed on 10/6/23, at 10:07 a.m. indicated Resident R64 was deemed at risk for elopement and transferred to the secure second floor at that time. Review of a progress note dated 10/6/23, at 1:23 p.m. indicated Resident R64 was transferred from the fourth floor to the secured second floor due to wandering and exit seeking. Review of facility documents dated 10/8/23, at 5:30 p.m. indicated Resident R64 was discovered missing on the second floor while staff delivered dinner to the residents. Resident R64 was seen in the hallway in his wheelchair between 5:30 p.m. and 6:00 p.m. Review of a progress note dated 10/8/23, at 7:56 p.m. revealed Resident R64 left the facility unobserved while staff delivered dinner trays to residents. A progress note dated 10/8/23, at 8:40 p.m. the resident was returned to the facility via ambulance at 8:20 p.m. Review of facility documents dated 10/8/23, Resident R64 was transferred to the hospital for evaluation following elopement incident. No injuries were noted. During an interview on 11/1/23, at 2:00 p.m. the Nursing Home Administrator stated Resident R64's code alert bracelet was found on the floor of the dining room intact and stretched out. Review of the care plan indicated for staff to record episodes of attempting to leave unit, determine if there is a pattern to attempts to leave unit, attempt to redirect resident as needed, ensure safety at all times, and know where about at all times. On 10/9/23, the facility completed education for all staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Nurse Aides (NAs), housekeeping, dietary, therapy, and administration to review elopement policy, code alert bracelets, and checks. Review of facility documents indicated an elopement assessment audit was completed for all residents on 10/10/23, to ensure compliance. On 10/12/23, the facility conducted an elopement drill. The facility reviewed resident care plans and modifications made if needed related to interventions. During an observation/demonstration on 11/2/23, at 11:00 a.m. Resident R64's code alert bracelet battery was checked and found to be working properly, when the bracelet was in proximity of the elevator, the alarm sounded and the elevator doors did not close. During an interview on 11/2/23, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision resulting in an elopement from the facility for Resident R64. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the Main Kitchen which created the potential for cross contamination (Main Kitchen). Findings include: Review of facility policy Cleaning Instructions: Ice Machine and equipment dated 6/29/22, indicated the ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. During an observation on 11/7/22, at 9:30 a.m. it was revealed the ice machine in the main kitchen contained a brown substance inside the machine. During an interview on 11/7/22, at 9:50 a.m. the Dietary Manager Employee E4 confirmed the brown substance in the ice machine creating the potential for cross contamination. 28 Pa Code: 201.14(a) Responsibility of licensee Previously cited 8/8/22

Based on facility policy, clinical record reviews, and staff interviews it was determined the facility failed to investigate an injury of unknown origin for two of seven residents reviewed (Residents R42 and R50) and failed to identify, investigate and/or report two allegations of abuse and one allegation of possible neglect for one of seven residents (Resident R45). Findings include: A review of the facility policy Incident Report Documentation and Follow Up dated 6/30/21 and reviewed 6/29/22, indicated all incidents will be reported and investigated in a timely manner. An incident is any unusual occurrence that occurs to the resident and may include injuries of known or unknown origin. A review of the facility policy Abuse Prevention reviewed on 6/29/22, indicated that the facility maintains a comprehensive program dealing with all facets of abuse, neglect and mistreatment through education, which encompasses screening, training, prevention, identification, investigation, protection and reporting. Abuse is defined by the facility as a willful infliction of injury, intimidation, punishment with resulting physical harm, pain or mental anguish; or necessary to attain or maintain physical, mental and psychosocial well -being. The facility has mechanisms in place to identify and recognize abuse with utilizing accident and incident reporting, grievance and complaint procedures, resident council minutes and the Ombudsman program. A review of the clinical record indicated Resident R42 was admitted to the facility 2/7/13, with diagnoses that include dementia. A review of the MDS (Minimum Data Set-resident assessment and care screening) dated 9/5/22, indicated the diagnoses remain current and the resident is severely cognitively impaired. A review of a nurse progress note dated 10/10/22, indicated resident R42 had a skin tear to the right forearm measuring 6.3 cm (centimeters) x 0.5 cm, area cleansed and steri strips (dressing used to close a wound) applied. A review of the facility Incident and Accident logs dated October 2022, indicated Resident R42 sustained a skin tear on 10/10/22. A review of an incident report dated 10/10/22, indicated Resident R42 had a skin tear to the right forearm. There was no investigation into the cause of the skin tear. During an interview on 11/10/22 at 11:00 a.m., the Nursing Home Administrator (NHA) verified the above findings and no investigation into the cause of the skin tear was completed. A review of the clinical record indicated Resident R50 was admitted to the facility 6/5/15 with diagnoses that included dementia. A review of the MDS dated [DATE] and 11/8/22, indicated the diagnoses remain current and the resident is severely cognitively impaired. A review of a nurse progress note dated 1/18/22, indicated Resident R50 had a bruise 2 cm x 1.5 cm to left upper chin close to mouth and Nursing Assistant (NA) suspects it may have happened during dinner while trying to retrieve a foreign object from resident's mouth and she resisted. A review of the facility Incident and Accident logs dated January 2021, indicated Resident R50 sustained a bruise on 1/18/21. A review of an incident report dated 1/18/21, indicated Resident R50 had a bruise to the chin 2 cm x 1.5. cm. There was no investigation into the cause of the bruise. During an interview on 11/9/22, at 11:50 a.m. the NHA verified the above findings and no investigation into the cause of Resident R50's bruise was completed. A review of a complaint received from the Ombudsman office indicated that the facility had removed property of Resident R45's from her room that had been ordered by the physician causing Resident R45 potential for skin breakdown. A review of the clinical record indicated that Resident R45 had been admitted to the facility on [DATE], with diagnoses that included irregular heart rhythm, osteoarthritis, hearing loss and cervical cancer. A review of Resident R45's plan of care dated 5/28/21, indicated Resident R45 was to be out of bed into her wheelchair with a ROHO cushion (cushion used to prevent pressure ulcers). A review of a Physician visit dated 12/22/21, indicated that Resident R45 complained of low back pain while standing for nurse aide and felt a pop in her back with pain. A review of a Physician visit dated 2/2/22, indicated that Resident R45 stated an aide was transferring her on 1/24/22, and hurt her ribs. A review of the facility incident and accident reports dated December 2021 and January 2022, did not include the above incidents during transfer to be investigated as the potential for abuse/neglect. A review of a Physician visit dated 9/21/22, indicated Resident R45 was seen for leg weakness and review of MRI of spine of 9/14/22. Resident R45 had been identified as having compression fractures of multiple areas of her spine requiring her need to be referred to a pain management group. A review of a Physician visit dated 10/19/22, indicated that Resident R45 was upset because the facility had mistakenly taken her ROHO cushion. A review of the facility incident and accident reports and the grievance log dated October 2022, did not include documentation that the facility had identified and or investigated the removal of the ROHO cushion. A review of the current Physician orders dated November 2022, indicated the use of the ROHO cushion for Resident R45's wheelchair. A review of a progress note dated 10/15/22, indicated that the resident's son had called in about the ROHO cushion and that therapy had removed the cushion. The cushion was not available for Resident R45 to use in her wheelchair. During an interview on 11/9/22, at 10:19 a.m., Resident R45 stated that the cushion had been returned to her. During an interview on 11/9/22, at 12:15 p.m., Therapy Manager Employee E2 stated that she had her staff remove the cushion from Resident R45's wheelchair as she no longer required it as it was for pressure ulcers and the facility needed the cushion for another resident however, after the call from the son, the facility returned it to the resident. During an interview on 11/9/22, at 12:25 p.m. the Unit Manager Employee E3 stated that she remembers the occurrence with the Roho cushion and when the statement was made she had begun to look into it and never got around to it. During an interview on 11/9/22, at 12:45 p.m. the Nursing Home Administrator, the Director of Nursing and the Assistant Director of Nursing confirmed that the above allegations were not identified, investigated and reported to rule out abuse/neglect. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 8/8/22. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical Records

Based on facility policy, review of facility provided documentation, review of clinical records and staff interview it was determined that the facility failed to provide an environment free from neglect for one of seven residents (Resident R10). Findings include: Review of the facility policy Abuse Prevention reviewed on 6/29/22, indicated that the facility maintains a comprehensive program dealing with all facets of abuse and neglect through education, which encompasses screening, training, prevention, identification, investigation, protection and reporting. The facility identified neglect as a failure to provide good and services necessary to avoid physical harm mental anguish or mental illness. Review of facility provided documentation dated 10/12/22, indicated that Resident R10 had an incident identified as neglect when Nurse Aide (NA) Employee E1 left Resident R10 in the bathroom with no supervision. Resident R10 attempted to self transfer and fell which required neuro checks and xrays of her right wrist and hand, increased pain and medication. On 10/20/22, additional xrays were required for left shoulder pain. Radiology reports indicated no fractures. Review of the clinical record indicated that Resident R10 had been admitted to he facility on 11/11/21, with diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, diabetes, anxiety disorder, osteoporosis, and a history of falls. An MDS (Minimum Data Set- periodic review of resident care needs) dated 9/20/22, indicated the diagnoses remained current and Section (G0110 I) indicated Resident R10 was an assistance of one for toileting and Section (G0300 D) indicated Resident R10 required assistance for moving on and off toilet and unsteady with balance only stabilized with staff assistance. During an interview on 11/9/22, at 12:45 p.m the Nursing Home Administrator confirmed that the facility failed to provide an environment free from neglect for Resident R10. 28 Pa. Code: 201.18(b)(1)(2) Management. 28 Pa. Code: 201.29(a))c)(d)(j)(m) Resident rights. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, review of facility provided documentation, clinical records and staff interview, it was determined that the facility failed to make certain each resident receives adequate supervision and assistance to prevent accidents for one of seven residents (Resident R10). Findings include: Review of the facility policy Incident Report Documentation and Follow Up reviewed on 6/29/22, indicated that an incident is any unusual occurrence that occurs and all incidents reported are investigated timely and plans of care revised. Any employee who provided care that contributed to the incident or who did not follow the plan of care will receive in-servicing addressing the concern. Disciplinary action will also be determined. Review of the facility provided documentation dated 10/12/22, indicated that Resident R10 had an incident identified as neglect when Nurse Aide (NA) Employee E1 left Resident R10 in the bathroom with no supervision or adequate assistance according to Resident R10's plan of care. Resident R10 attempted to self transfer and fall which required neuro checks and xrays of her right wrist and hand and increased pain medication. On 10/20/22, Resident R10 required additional xrays of her left shoulder due to pain. Radiology reports indicated no fractures. Review of the clinical record indicated that Resident R10 had been admitted to he facility on 11/11/21, with diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, diabetes, anxiety disorder, osteoporosis, and a history of falls. An MDS (Minimum Data Set- periodic review of resident care needs) dated 9/20/22, indicated the diagnoses remained current and Section (G 0110 I) indicated resident was an assistance of one for toileting and Section (G 0300 D) indicated Resident R10 required assistance for moving on and off toilet and unsteady with balance only stabilized with staff assistance. During an interview on 11/9/22, at 12:45 p.m the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision and assistance for Resident R10. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 8/8/22. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, reports submitted to the state, clinical records, and staff interview it was determined that the facility failed to prevent an instance of neglect and potential abuse for one of three clinical records reviewed (Resident R1). Findings include: Review of the facility policy Abuse Prevention dated 6/29/22, indicated that the Abuse is defined as the willful infliction of injury, unreasonable confinement; intimidation; punishment with resulting physical harm, pain or mental anguish; or necessary to attain or maintain physical, mental, and psychological well -being. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the policy also indicated that under section Prevention The facility provides residents, family, and staff information on the reporting requirements for concerns incidents and grievances. Review of the policy section Action: Upon occurrence of an abuse or suspected abuse the following actions should be taken: Anyone witnessing or suspecting any type of abuse towards a resident by any individual will immediately report the instance to the supervisor on duty. Review of Resident R1 clinical record indicated that resident was admitted to the facility on [DATE], with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Which remained curtain as of the MDS (minimum data set a periodic brief assessment of resident needs) dated 7/21/22. Review of Resident R1 MDS dated [DATE], Section G ADL's indicated that resident transfer with extensive assistance as a two person assist. Review of Resident R1 physician orders dated 6/28/22, indicated that Resident transfer with an assist of two people. Review of facility provided documentation indicated that Resident R1 had an injury of unknown origin found on 7/27/22. During facility investigation Housekeeper Employee E1 revealed that Housekeeper Employee E1 was standing across form Resident R1's room. Housekeeper Employee E1 stated that yelling could be heard room across the hallway and coming from Resident R1 room. Housekeeper Employee E1 stated that Nurse Aide Employee E2 came out of Resident R1 room, after the employee overheard Nurse Aide Employee E2 yelling, and a sound that sounded like skin to skin contact coming from Resident R1's room. NA Employee E2 step out of the room looked at Employee E1 and closed the door, Housekeeper Employee E2 heard Resident R1 say F**k you to NA Employee E2. Housekeeper Employee E1 failed to report this incident . During review of the investigation into the injury of unknown origin NA Employee E2 admitted to transferring Resident R1 with a transfer of one instead of two - and was aware of the order to transfer as a two. NA Employee E2 denied seeing any bruise on Resident R1. During an interview on 8/5/22, at 2:15 p.m. Housekeeper Employee E1 confirmed that he overheard NA Employee E2 yelling at Resident R1. Heard a sound that sounded like skin on skin contact and did not report this to administration, this employee was previously trained on abuse and neglect. Housekeeper Employee E2 confirmed that he did not report this incident . During an interview on 8/8/22, at 3:55 p.m. with NHA and DON confirmed that Resident R1 sustained an injury of unknown origin - a bruise on forehead; that NA Employee E2 transferred Resident R1 without an assist of two and that the facility failed to protect Resident R1 from an incident of neglect with a transfer. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pal. Code 201.18 (b)(1)(3)e(1) Management.

Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to maintain sanitary conditions and properly store food products in the Main Kitchen (Main Kitchen). Findings include: A review of facility Food Storage policy dated 6/30/21, indicated that scoops are to be provided for bulk food. Scoops are not to be stored in the food, but are stored covered in a protected area near the container. All food stock must be rotated with each new order received. Rotating stock is essential to make certain the freshness and highest quality of all foods. A review of facility General Food Preparation and Handling Policy dated 6/30/21, indicated that all food equipment should be cleaned, sanitized and air dried. A review of facility Handling Clean Equipment and Utensils dated 6/30/21, indicated that staff is to avoid touching the parts of equipment that come in contact with food products. Clean equipment and utensils will be stored in a clean, dry location that protects them from splashed, dust and other contamination. Flatware and utensils will be handled by the hand piece only. A review of facility Food safety - Director of Food and Nutrition Services' Responsibilities dated 6/30/21, indicated it is the responsibility of the Director of Food and Nutrition Services to make certain that sanitary conditions will be maintained in the food storage, preparation and serving areas. All food products will be stored properly. During an observation of the Main Kitchen on 11/1/21, at 9:15 am the following was revealed: * stored on the bread storage rack was five packages of hamburger buns with an expiration date of 10/30/21, * stored in the reach in refrigerator was an opened, undated gallon container of whole milk * the window sill above the freezer chests contained a build up of debris * the window sill above the three compartment ware washing sink contained a build up of debris, stored on the window sill was two buckets and two paring knives. * the outside of the freezer chests, and reach in freezer units contained a black substance. * scoops were stored in the bulk containers of flour, sugar, and food thickener. * stored on a shelf above the cooking area (grille, stove, etc) contained open, undated boxes of cream of wheat cereal and cream of rice cereal. * stored on a spice shelf area contained a white substance and opened, undated containers of chopped chives, [MEDICATION(S)], garlic powder, cumin, sage, lemon pepper seasoning, ground black pepper and mild chili powder. The lids of the the spice containers contained a build up of spice, dust and debris. * stored on the drain board of the three compartment ware washing sink was three plastic containers containing clean serving utensils that were uncovered and not inverted. * the inside of the microwave contained a brown substance on the microwave plate. During an interview on 11/1/21, at 9:30 am the Food Service Director Employee E1 confirmed that the facility failed to properly store food products, and maintain the Main Kitchen in a sanitary condition. During an observation on 11/2/21, at 12:15 pm it was revealed that a scoop remained stored inside the bulk container of food thickener in the food product. During an interview on 11/2/21, at 12:20 pm the Food Service Director Employee E1 confirmed that the facility failed to properly store scoops utilized for bulk food products. 28 Pa. Code: 211.6 (c)(d) Dietary services

Based on review of facility policies, clinical records and incident reports, and staff interview, it was determined that the facility failed to provide adequate assistance during a transfer, resulting in actual harm (fractured rib) for one of six residents (Resident R1). Findings include: The facility Physician order [REDACTED]. The RN/LPN will review the summary and adjust orders as needed. The facility Minimum Data Set and Interdisciplinary Care Plan policy last reviewed 8/29/18, indicated the resident will have a comprehensive assessment completed within the required time frame that includes physical functioning and overall changes in care needs. The care plan is to include measurable goals, a specific time frame, and intervention to achieve goals. Revisions to the plan of care are communicated to the unit staff. Review of the Quarterly Minimum Data Set assessment (MDS- periodic assessment of care needs) dated 5/15/19, indicated Resident R1 was admitted on [DATE], with current [DIAGNOSES REDACTED]. The MDS indicated Resident R1's use of toilet room, commode, and transfers off/on toilet was a total dependence with two-staff persons. Review of physician orders [REDACTED]. Review of the care plan dated 4/23/19, indicated Resident R1's assistance level was changed to assist of two-staff and physical therapy was to screen. Review of a facility incident report dated 4/30/19, indicated Resident R1 fell in the bathroom while being assisted by Nurse Aide Employee E1. As Resident R1 stood with his wheeled-walker, he fell striking his right side. Review of Resident R1's nurse notes dated 4/30/19, indicated Nurse Aide Employee E1 called for a nurse. Resident R1 was found with hematoma, bruising to top of his head, and a bruise on mid-back measured 6 cm x 3.5 cm. Review of Nurse Aide Employee E1 written statement dated 4/30/19, indicated she was standing with Resident R1 at the sink without assistance of another staff. She directed Resident R1 to stand with the walker while she turned on the water and Resident R1 fell . Review of physician orders [REDACTED]. Review of Resident R1's X-ray report dated 5/2/19, indicated there was a [MEDICAL CONDITION] seventh rib. During an interview on 5/30/19, at 8:47 a.m. the Director of Nursing (DON) confirmed that Nurse Aide Employee E1 failed to follow the physician order [REDACTED]. During an interview on 5/30/19, at 11:02 a.m. the Licensed Practical Nurse (LPN) Employee E3 stated Resident R1 transfer status had changed to two staff-person assistance prior to his fall, and at the time of the incident he did complain of substantial pain. During an interview on 5/31/19, at 10:12 a.m. with the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed the facility failed provide adequate staff assistance during a transfer resulting in actual harm to Resident R1 (a fractured rib). The facility failed to make certain that Resident R1 was provided adequate staff assistance during a transfer resulting in actual harm to the resident. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. 28 Pa Code: 201.14 (a) Responsibility of licensee. Previously cited 6/14/17 and 10/5/17. 28 Pa Code: 201.18 (e)(1) Management. Previously cited 6/14/17, 10/5/17 and 11/2/18. 28 Pa Code: 211.10 (c)(d) Resident care policies. Previously cited 10/5/17 and 11/2/18. 28 Pa Code: 211.11 Resident care plan.