Every finding on record at Tunkhannock Rehabilitation & Health Care Center

Based on review of clinical records, facility policy, investigative documentation provided by the facility, and staff interviews, the facility failed to protect one of 11 sampled residents (Resident CR1) from neglect when staff did not help a resident after a witnessed fall, leaving the resident on the floor, neglecting to immediately assess and care for the resident. This deficiency is cited as past noncompliance.Findings include: A review of a facility policy titled Abuse, Neglect, and Exploitation, last reviewed by the facility on April 8, 2025, revealed it is the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse and neglect. The policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish (severe emotional distress), or emotional distress. The policy indicated neglect includes withholding or inadequately providing care or services necessary to maintain resident safety and well-being. A review of the clinical record revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to brain tissue caused by loss of blood supply due to blockage of an artery) and a history of frequent falls. A physical therapy assessment dated [DATE], documented Resident CR1 required the use of a wheelchair for mobility. A review of progress notes revealed the resident experienced multiple behavioral symptoms from admission through discharge, including confusion, hallucinations (perceiving things that are not present), verbal outbursts, and episodes of aggression toward staff. A review of CR1's clinical record revealed a physical therapy assessment completed on March 13, 2026, documented resident CR1 was able to mobilize with the assistance of a wheelchair. A review of Resident CR1's progress notes revealed the resident experienced a fall on March 13, 2026, at 8:51AM, where the resident was observed standing from his wheelchair without assistance. The resident did not experience any injury at the time of the incident. The clinical record revealed Resident CR1 had frequent outbursts, and behavioral issues, with a documented incident on March 14, 2026, when the resident was observed to be gripping a nurse aides' wrist, yelling profanities at the employee. The clinical record revealed from the time of admission to the time of discharge Resident CR1 had multiple behavioral outbursts including yelling at staff, hallucinations, and episodes of confusion. A nursing progress note dated March 16, 2026, at 5:05 AM documented Resident CR1 frequently ambulated without assistance despite requiring a wheelchair for mobility. The note documented that the resident intermittently refused to remain seated and attempted to exit through doors. The note further documented the resident spoke about generals and colonels related to his history of being at war, and was aggressive to staff, stating staff are controlling him. A nursing progress note dated March 16, 2026, at 5:30 AM documented Resident CR1 fell after self-propelling in the wheelchair and was assisted back into the chair with no injury observed. A nursing progress note dated March 17, 2026, at 3:04 AM documented Resident CR1 attempted to stand from the wheelchair when the wheelchair rolled backward, resulting in the resident falling to the right side. A review of facility investigative documentation revealed an email dated March 19, 2026, at 3:50 AM from Employee 1 (Nurse Aide) to the Director of Nursing (DON) reported Resident CR1 experienced two falls on March 17, 2026. The email documented that Employee 3 (Registered Nurse Supervisor) and Employee 4 (Licensed Practical Nurse) were aware of the second fall and instructed staff that no incident report or witness statements were required. The email documented staff were instructed to allow the resident to remain on the floor because he could get up on his own. Employee 1 wrote that she forgot to make the DON aware of the incident sooner. An interview with the DON on April 8, 2026, at 9:30 AM revealed the facility initiated an investigation immediately upon receipt of the email reporting concerns that staff did not report the second fall and allegedly indicated Employee 3 (Registered Nurse Supervisor) advised staff to allow the resident to remain on the floor after the fall. A review of employee witness statements revealed Employee 2 (Nurse Aide) documented she witnessed Resident CR1 on the floor and assisted the resident back to his wheelchair. Employee 2 (Nurse Aide) wrote she then witnessed the resident on the floor a second time but was told by Employee 3 (Registered Nurse Supervisor) that the resident could get up on his own. Employee 2 (Nurse Aide) documented that Resident CR1 was observed crawling on the floor. Employee 2 (Nurse Aide) wrote she asked Employee 3 (Registered Nurse Supervisor) if a witness statement was needed regarding the details of the fall, and Employee 3 (Registered Nurse Supervisor) responded, no. A review of a written witness statement from Employee 3 (Registered Nurse Supervisor) dated March 19, 2026, documented that on March 17, 2026, at 2:50 AM, the resident was observed to fall after attempting to stand from his wheelchair. Employee 3 (Registered Nurse Supervisor) wrote she assisted the resident back to a seated position in the wheelchair and assessed him for injuries. Employee 3 (Registered Nurse Supervisor) documented that 10 to 15 minutes later, Resident CR1 rose from the wheelchair to a standing position, lost his balance, and was observed to fall again. Employee 3 (Registered Nurse Supervisor) wrote the resident was crawling on the floor and was asked if he was ready to get up, to which Resident CR1 responded no. Employee 3 (Registered Nurse Supervisor) documented that due to the resident's history of combative behavior (combative behavior means the resident may physically resist care, such as hitting, grabbing, or pushing staff), she did not assist the resident to a standing position until the resident verbalized he was ready to return to his wheelchair. A phone interview with Employee 4 (Licensed Practical Nurse) on April 8, 2026, at 9:38 AM, revealed she was working in the area of the second fall but did not witness the fall occur. Employee 4 (Licensed Practical Nurse) stated she went to the nurse's station when Employee 3 (Registered Nurse Supervisor) stated, Guess who is on the floor again. Employee 4 (Licensed Practical Nurse) stated she asked Employee 3 (Registered Nurse Supervisor) if staff should assist the resident up, and Employee 3 (Registered Nurse Supervisor) stated, No, He will just throw himself on the ground again. Employee 4 (Licensed Practical Nurse) confirmed she did not report the fall or write a witness statement regarding the incident. Employee 4 (Licensed Practical Nurse) stated she was under the impression that Employee 3 (Registered Nurse Supervisor), who was the supervisor on duty, would report the incident. A phone interview with Employee 3 (Registered Nurse Supervisor) on April 8, 2026, at 11:05 AM, revealed Employee 3 (Registered Nurse Supervisor) believed she was helping the resident by allowing him to remain on the floor. Employee 3 (Registered Nurse Supervisor) stated the resident appeared to be acting as though he was fixing something on the wheelchair, and she feared he would become combative if she attempted to assist him to stand. Employee 3 (Registered Nurse Supervisor) stated she remained nearby and observed the resident until he indicated he was ready to get up. Employee 3 (Registered Nurse Supervisor) stated that at no time was the resident left alone but was unable to determine the length of time the resident remained on the floor following the fall. Employee 3 (Registered Nurse Supervisor) stated she did not report the second fall to the Director of Nursing because the first and second falls occurred close together in time. Attempts to contact Employee 1 Nurse Aide and Employee 2 Nurse Aide on April 8, 2026, were unsuccessful. A review of Employee 3's personnel file revealed documentation dated January 6, 2026, confirming completion of orientation training, which included education regarding the facility's abuse and neglect policy and required reporting procedures. During an interview on April 8, 2026, at 12:45 PM, the Director of Nursing and Nursing Home Administrator confirmed the facility investigation determined Employee 3 (Registered Nurse Supervisor) and Employee 4 (Licensed Practical Nurse) did not follow the facility's abuse and neglect policy related to resident protection and reporting requirements and failed to provide timely assistance after a witnessed fall inconsistent with accepted standards of practice reflecting neglect. The Director of Nursing and Nursing Home Administrator confirmed Employee 3 and Employee 4 were removed from the work schedule immediately pending investigation and were subsequently terminated. The deficient practice was cited as past noncompliance; The facility implemented the following corrective actions immediately following the incident. The resident was assessed for any injury. Employee 3 and Employee 4 were immediately terminated.The facility completed an audit on residents who had documented falls within the last 30 days and conducted interviews to determine the prompt response time to the incident and the behavior of the staff during these incidents.The facility immediately conducted facility wide education on the abuse/neglect policy.To sustain compliance, the facility administration initiated a plan to conduct five random audits regarding staff reporting, these audits scheduled weekly for one week, bi-weekly for two weeks, and weekly for one month.The results of the audits are to be reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) Committee for oversight and recommendations. The facility achieved compliance with this regulatory requirement on March 23, 2026. This deficiency is cited as past noncompliance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for two of 13 residents sampled (Residents 2 and 45).Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 2025, requires that each MDS assessment accurately reflect the resident's status during the assessment reference period (the specific look-back period of days the assessor must review). The Manual requires that a registered nurse conduct or coordinate each assessment with participation of appropriate health professionals. The assessment process must include direct observation of the resident and communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (also known as mixed dementia, is a form of dementia that is characterized by a combination of two or more types of dementia where the individual experiences symptoms that are typically seen in different types of dementia, making it difficult to diagnose and treat), hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body), cerebrovascular disease (a disorder affecting blood flow to the brain, often resulting in stroke) and moderate protein-calorie malnutrition (occurs when the body does not receive enough protein and calories to maintain proper health and functioning. It is common among terminally ill patients due to numerous factors, such as reduced appetite, difficulty eating, and weakened immune system). A physician's order dated June 25, 2025, at 4:21 PM, directed the use of right and left quarter side rails in bed as enablers. Quarter side rails are short bed rails that extend along a portion of the bed. Bed rails may be considered a restraint if they restrict a resident's freedom of movement or ability to voluntarily get out of bed. A review of Resident 2's quarterly MDS assessment dated [DATE], revealed the assessment was coded to indicate the resident required substantial to maximal assistance to roll from left to right while lying on her back in bed and with transfers between bed and chair. Section P-P0100 (Restraints and Alarms Used in Bed) was coded to indicate the resident had bedrails in place daily as a form of restraint. Section P of the MDS captures the use of physical restraints. A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that restricts freedom of movement or normal access to the body and that the resident cannot remove easily. Clinical record review revealed the resident had right and left quarter side rails in place. The clinical record failed to demonstrate documentation that the quarter side rails restricted the resident's freedom of movement, prevented voluntary exit from the bed, or otherwise met the definition of a restraint. The record also lacked documentation identifying the quarter side rails as a restraint or providing clinical justification for coding them as such in Section P. During an interview with the Nursing Home Administrator (NHA) on October 23, 2025, at 2:10 PM, the above information was reviewed. At that time, it was acknowledged that Resident 2's quarterly MDS dated [DATE], Section P- P0100 (Restraints), had been coded to indicate the presence of a restraint, and the coding was identified as an error. A clinical record review revealed Resident 45 was admitted to the facility December 3, 2025, with diagnoses that included acute and chronic respiratory failure with (a condition in which the lungs cannot adequately exchange oxygen and carbon dioxide, resulting in low blood oxygen levels). A review of the Resident 45's admission MDS dated [DATE], section N (section addressing medications including high risk drug classes including antipsychotic, antianxiety, and antidepressants) Section N0415, High- Risk Drugs Use and Classification documented Resident 45 was not administered antipsychotic drugs (medications used to treat a collection of symptoms that affect the ability to tell what's real) during the assessment reference period. Section N0450 (Antipsychotic Medication Review) indicated the resident had not received antipsychotic medication since admission. A review of Resident 45's physician orders revealed an order dated December 3, 2025, for Quetiapine Fumarate Oral Tablet 25 mg (antipsychotic medication), one tablet by mouth at bedtime for depression with behaviors. Medication Administration Record review confirmed Resident 45 received Quetiapine Fumarate 25 milligrams nightly during the assessment reference period of December 3, 2025, through December 9, 2025. During an interview on February 19, 2026, at 1:10 PM, the Registered Nurse Assessment Coordinator (RNAC) acknowledged the admission MDS dated [DATE], did not accurately reflect the resident's routine daily use of an antipsychotic medication since admission. 28 Pa. Code 211.5(f)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on select facility policy, a review of clinical records, the Resident Assessment Instrument (RAI) manual, and staff interviews, it was determined the facility failed to follow the care plan process after the completion of a comprehensive assessment for one out of 13 residents sampled (Resident 8).Findings include: A review of facility policy entitled Resident Care Planning Requirements (reviewed April 8, 2025) revealed the facility will develop and implement a person-centered care plan that supports the residents' highest practicable physical, mental, and psychosocial well-being. The policy further indicated a comprehensive care plan, and a care plan meeting will be held seven days after a comprehensive Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment. According to the facility policy, the MDS Coordinator will schedule the interdisciplinary team (IDT) meeting within required time frames. The Resident Assessment Instrument (RAI) (2025, October) manual is a standard tool published by the federal government and serves as a guide for completing accurate, timely resident assessments and care plan processes. According to the RAI manual, a significant change in status MDS assessment is a comprehensive assessment required when a nursing home resident enrolls in a hospice program (specialized model of care for a resident with a terminal illness that focuses on comfort and quality of life). The comprehensive assessment ensures a coordinated plan of care exists between hospice and the facility according to the RAI manual. A comprehensive care plan must be developed by an IDT (interdisciplinary team) including but not limited to the attending physician, registered nurse with responsibility for the resident, the resident and / or representative and other staff or professionals as determined by the resident needs (e.g. hospice). The care plan completion date cannot be later than seven days after completion of the comprehensive assessment. A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (loss of cognitive functioning including thinking, remembering, and reasoning to an extent that it interferes with daily life), hyperlipidemia (high levels of fats in the blood), and anxiety (feelings of worry, unease, nervousness). A review of physician orders revealed an order dated November 11, 2025, for Resident 8 to be admitted to hospice services with the diagnosis of end stage senile degeneration of the brain (the brain is the final stage of dementia when significant and permanent damage of the brain exists). The clinical record revealed a comprehensive Significant Change Minimum Data Set (MDS) assessment dated [DATE], and reflected hospice services for Resident 8. However, the clinical record lacked documentation of the comprehensive, IDT care plan process completed within seven days of the comprehensive MDS. The record lacked evidence of a documented IDT meeting involving the physician, registered nurse, resident and/ or representative, and other disciplines relevant to Resident 8's care, care plan revision, or documentation reflecting integration of hospice services into the comprehensive care plan during the required timeframe.During an interview on February 19, 2026, at 2:00 PM, the Social Service Worker confirmed the facility could not provide documentation to support that an interdisciplinary care plan meeting occurred within seven days after completion of the comprehensive MDS assessment. The absence of an interdisciplinary care plan meeting communicating the integration of hospice care for Resident 8 contradicts the facility policy and RAI manual emphasizing the care plan process must be interdisciplinary and completed within seven days following a comprehensive assessment. During a subsequent interview on February 19, 2026, at 2:15 PM, the Nursing Home Administrator and Director of Nursing reviewed the above findings and acknowledged the facility did not complete an interdisciplinary care plan meeting after the Significant Change MDS dated [DATE]. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and implement nutritional interventions for one resident out of 13 residents sampled (Resident 2).Findings include: A review of a facility policy entitled Resident Heights and Weight Policy last reviewed by the facility April 8, 2025, indicated residents will be weighed upon admission to facility and on day two after admission. After the second day weight, all newly admitted residents will be weighed weekly for four weeks and then on a monthly basis unless otherwise specified. The resident weights will be recorded in the electronic medical record. Reweights will be obtained for any residents whose weight fluctuations by plus or minus five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 pounds. The licensed nurse will notify the Director of Nursing or designee, Physician, and Registered Dietitian of significant weight changes of 5 percent loss or gain in one month, or a 7.5 percent loss or gain in 3 months, or a 10 percent loss of gain in 6 months. Notify the resident's representative regarding significant weight loss and any recommendations from the resident's provider and registered dietitian. The registered dietitian will notify the charge nurse of any significant weight changes and follow up with documentation in the resident's medical record. Review of the facility policy titled Weight Assessment and Intervention, last reviewed April 8, 2025, indicated that for any weight change of five percent or more since the last assessment, a reweight would be obtained the next day for confirmation. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (also known as mixed dementia, is a form of dementia that is characterized by a combination of two or more types of dementia where the individual experiences symptoms that are typically seen in different types of dementia, making it difficult to diagnose and treat), hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body), cerebrovascular disease (a disorder affecting blood flow to the brain, often resulting in stroke) and moderate protein-calorie malnutrition (occurs when the body does not receive enough protein and calories to maintain proper health and functioning. It is common among terminally ill patients due to numerous factors, such as reduced appetite, difficulty eating, and weakened immune system). A review of Resident 2's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 23, 2025, revealed Resident 2 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment) was not on a therapeutic diet, and able to self-feed after set-up. Resident 2's comprehensive care plan, initiated June 17, 2025, identified the resident at risk for nutritional decline related to dementia, hemiplegia, hemiparesis, moderate protein calorie malnutrition, and a history of pressure wounds. The care plan identified the desired outcome that the resident would maintain adequate nutritional status as evidenced by stable weight without significant weight changes. The plan directed staff to monitor, record, and report to the physician as needed signs and symptoms of malnutrition, including emaciation, (extreme thinness resulting from significant loss of body fat and muscle mass); muscle wasting; weight loss of three pounds in one week; greater than five percent in one month; greater than 7.5 percent in three months; and greater than 10 percent in six months. Additional interventions included providing the diet as ordered and requiring the Registered Dietitian (RD) to evaluate the resident and make diet change recommendations as needed. A review of a nutritional assessment completed by the facility's Registered Dietitian dated June 17, 2025, documented that Resident 2 was ordered a regular diet with regular texture and thin liquids and was not prescribed oral nutritional supplements at that time. The Registered Dietitian documented a height of 60 inches and a weight of 152.4 pounds. Estimated nutritional needs were calculated at 1500 calories per day, 59 grams of protein per day, and 1500 milliliters of fluids per day, with staff instructed to encourage fluid intake. The assessment documented the resident's Body Mass Index was in the overweight range. Body Mass Index is a numerical value calculated from a person's height and weight that is used as a screening tool to categorize weight status and assess potential health risk. Despite the Body Mass Index classification, the Registered Dietitian identified the resident as at risk for malnutrition due to underlying diagnoses and documented fair meal intake with continued monitoring planned. Review of the weight record revealed the following:On June 16, 2025, at 1:24 PM, the admission weight was recorded as 129.4 pounds. The facility did not obtain weekly weights on June 23, 2025, or July 1, 2025, as required by policy. The next recorded weight occurred three weeks later on July 7, 2025, at 12:35 PM, at 130 pounds. No additional weight was recorded until August 5, 2025, at 7:10 PM, at 119.6 pounds. This reflected a weight loss of 10.4 pounds from July 7, 2025, which equals approximately eight percent weight loss in one month and met the facility's definition of significant weight loss. The facility did not obtain a reweight the next day as required by policy. The next weight was obtained seven days later on August 12, 2025, at 7:40 PM, and again recorded 119.6 pounds, confirming significant weight loss of 10.4 lbs. or 8 percent in one month. The clinical record did not reveal documentation that the Registered Dietitian identified and addressed the significant weight loss between July 7, 2025, and August 5, 2025. A nutrition/dietary note dated August 12, 2025, at 11:19 AM, documented awareness of new wounds and fair intake and recommended liquid protein twice per day to support healing. It was indicated the physician and responsible party were made aware. The record did not demonstrate timely development and implementation of additional nutritional interventions following identification of significant weight loss and development of wounds. On August 12, 2025, following identification of significant weight loss, the facility updated Resident 2's comprehensive care plan to include nutritional interventions. The care plan documented initiation of Prosource daily, (a concentrated liquid protein supplement intended to increase dietary protein intake); Magic Cup, (a high calorie, high protein nutritional supplement served as a frozen dessert); and Ensure daily, (a commercially prepared high calorie, high protein oral nutrition supplement designed to promote weight stability). The care plan was later revised on February 19, 2026, during the onsite survey. Despite documenting these interventions in the care plan, the facility was unable to provide documented evidence demonstrating timely implementation of Magic Cup or Ensure supplementation following the resident's significant weight loss and development of wounds. A dietary progress note completed by the Registered Dietitian on August 31, 2025, documented that Resident 2 had experienced significant weight loss and remained on liquid protein supplementation for wound healing. The note indicated fluctuating meal intake and documented that family members were providing additional meals and encouragement with intake. The RD documented continued monitoring and consideration of additional supplementation at follow up. The weight record revealed that no weights were obtained between August 12, 2025, and September 17, 2025. On September 18, 2025, at 8:56 AM, a quarterly nutrition assessment revealed the Registered Dietitian documented the most recent available weight as 119.6 pounds from August 12, 2025, reflecting a 10.4 pound loss and triggering for significant weight loss. The assessment noted the resident remained at risk for malnutrition with fair meal intake. Later that same day, at 7:48 PM, nursing staff recorded a weight of 117.4 pounds, demonstrating continued weight decline. A follow up dietary note dated September 30, 2025, at 12:26 PM, documented that the resident's weight continued to decrease with fair to poor meal intake. The Registered Dietitian noted that family continued to provide snacks and additional food. The liquid protein supplement continued, and the Registered Dietitian recommended adding Magic Cup once daily to promote increased oral intake. On October 6, 2025, at 2:02 PM, the resident's weight was recorded at 114.6 pounds. On October 9, 2025, at 2:03 PM, a dietary progress note documented that the resident continued to trigger for significant weight loss and that weight continued to trend downward. The note indicated that Magic Cup had recently been added and recommended initiation of Ensure once daily to further promote oral nutrient intake and weight stability. On November 1, 2025, at 2:34 PM, the resident's weight was recorded at 110.6 pounds, reflecting ongoing decline. A dietary progress note dated November 6, 2025, at 12:07 PM, documented continued significant weight loss and indicated Ensure had been added in addition to Magic Cup approximately one month earlier. The note documented that the resident was accepting supplementation with variable meal intake. Review of the clinical record failed to demonstrate timely development and documented implementation of Magic Cup and Ensure supplementation following the initial identification of significant weight loss in August 2025. The record reflected progressive weight decline and ongoing wound concerns without evidence that ordered nutritional interventions were implemented in a timely manner to prevent further deterioration. During an interview on February 19, 2026, at 2:15 PM, the Nursing Home Administrator and Director of Nursing reviewed the findings and confirmed the facility could not provide additional documentation demonstrating timely weight monitoring, timely reweights as required by policy, or timely implementation of oral nutritional supplementation to address Resident 2's progressive weight loss and associated wound development. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on review of select facility policy, observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with physician orders and professional standards for two residents out of eight residents sampled (Resident 45 & Resident 29).Findings include:A review of the facility policy titled Oxygen Administration last reviewed by the facility on April 8, 2025, revealed it is the facility's policy to provide oxygen therapy in a safe manner consistent with physician orders and the resident's care plan. A clinical record review revealed Resident 45 was admitted to the facility December 3, 2025, with diagnoses that included acute and chronic respiratory failure with hypoxia (condition in which the lungs cannot exchange gases, leading to low oxygen levels). A physician orders initially date December 3, 2025, included administration of oxygen at 3 liters (L) per minute via nasal cannula (small flexible tube with two short prongs placed in the nostril to provide oxygen). The physician orders indicated to change the oxygen tubing and humidifier (the cylinder device used to keep the air from the source of oxygen moist) weekly. A review of the Resident 45's plan of care initiated January 19, 2026, revealed the resident had underlying respiratory status. The identified goal was for Resident 45 to be free from signs of respiratory infection and maintain adequate breathing patterns daily. Interventions included monitoring for signs of respiratory infection including confusion and restlessness, providing assistance with changing Resident 45's position to support movement of air and fluid through the lungs and administering oxygen by a nasal cannula continuously. An observation on February 18, 2026, at 10:45 AM, revealed Resident 45 was awake sitting in her wheelchair in a common resident area. Resident 45 was observed to be receiving oxygen by a nasal cannula connected to an oxygen tank on the back of Resident 45's wheelchair. The oxygen tubing connecting Resident 45 from the nasal cannula to the oxygen tank was dated February 5, 2026, exceeding the seven-day (weekly) duration as ordered. During an interview on February 18, 2026, at 11:33 AM, Employee 1, Registered Nurse (RN), confirmed Resident 45's oxygen tubing should have been replaced every seven days and the date on the tubing (February 5) exceeded the seven-day duration as per the physician orders. The above information was reviewed during an interview on February 18, 2026, at 2:30 PM, with the facility DON and Administrator. A review of Resident 29's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Relapsing Remitting Multiple Sclerosis, ( an autoimmune condition that affects the central nervous system where the immune system attack's the myelin, the protective cover over nerve fibers including those of the brain and spinal cord, causing inflammation and nerve damage). A review of the clinical record revealed a physician's order dated July 2,2025, for Oxygen at 2L/min via Nasal cannula PRN (as needed) for SOB (shortness of breath). Check liter flow and placement every four hours. Further review revealed a physician's order dated July 2,2025, to change the oxygen tubing, bubble humidifier, rinse filter and date tubing and humidifier weekly. An observation on February 18 ,2026 at 1:18 PM revealed the nasal canula tubing that the resident was using was dated February 5, 2026. During the same observation, a clear plastic bag used for storing oxygen tubing was noted with the date of February 5, 2026, written on the front of the clear plastic bag. An interview with Employee 1 RN confirmed the tubing and bag were dated February 5,2026. An interview was conducted with the Director of Nursing (DON) on February 18,2026, at 2:15 PM to review the above findings related to the facility's failure to maintain respiratory equipment in a manner to promote optimal functioning. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and interviews with staff and residents, it was determined that the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and a scalp laceration requiring hospitalization, representing actual harm for one resident out of one sampled for abuse prohibition.Findings include: Review of the facility's policy entitled Abuse, Neglect, and Exploitation last revised by the facility March 2025, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of the facility to protect the residents from abuse, misappropriation of property, corporal punishment and involuntary seclusion. Resident 1's clinical record revealed admission to the facility on August 1, 2025, with diagnoses including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots or stroke), a history of cerebral infarction (stroke), and hypertension (high blood pressure). Review of Resident 1's admission MDS assessment (Minimum Data Set a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2025, revealed the resident had a BIMS score of 00 (Brief Interview for Mental Status, a tool used to evaluate cognitive impairment and assist with dementia diagnosis. A score of 0-7 equates to severe cognitive impairment) and required assistance of staff for activities of daily living (ADL's). Review of Resident 1's current comprehensive person-centered care plan, initiated on August 5, 2025, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to confusion, musculoskeletal impairment and a history of stroke. Planned resident centered interventions revealed the resident required two-staff assistance with transfers to move between surfaces, required two-staff participation for bathing/showering and required assistance of one staff for bedpan use and brief changes, personal hygiene and oral care and eating. A review of a fall care plan for at risk for falls initiated August 5, 2025, revealed interventions to include, ensure that the resident is wearing appropriate footwear when ambulating and mobilizing in the wheelchair. Additionally, the resident's impaired cognitive function care plan indicated the resident had impaired cognition. A physician's order dated August 12, 2025, indicated Eliquis 2.5 mg twice daily for atrial fibrillation. Review of the August 2025 medication administration record showed the resident received Eliquis as prescribed through August 17, 2025. (Eliquis is an anticoagulant medication that increases bleeding risk.) A nurse's note written by Employee 1 (Registered Nurse), dated August 18, 2025, at 5:15 AM, documented that Employee 2 (nurse aide) exited Resident 1's room and stated, I need a nurse, Resident 1 is on the floor. Employee 2 reported transferring the resident from bed to wheelchair alone, despite the care plan requirement for two-staff assistance. She stated the bed alarm activated, and while she turned her back to silence it, Resident 1 fell forward out of the wheelchair, the nurse aide was unable to prevent the resident from falling. The RN found Resident 1 lying face-down on the floor, on the door side of her bed on her stomach with her head facing her bed, barefoot, and no nonskid socks in place, with the wheelchair near her feet. The resident had a large hematoma (collection of blood between layers of tissue) and a moderately bleeding forehead laceration (wound). A pressure dressing was applied Emergency services were contacted, and the resident was transported to the hospital for evaluation and treatment. Hospital records dated August 18, 2025, at 6:08 AM, documented that Resident 1 presented as a Level II trauma (requiring urgent trauma care) with head and knee pain. A CT scan (computed tomography imaging test that uses X-rays and a computer to get detailed images of an injury) of the head revealed multiple subdural hematomas (collections of blood between the brain and its protective covering), a small subarachnoid hemorrhage (bleeding between the brain and protective membranes), and a 3 cm forehead laceration. The resident was admitted to the Progressive Care Unit (unit in a hospital unit that provides a level of care between the general medical-surgical units and the Intensive Care Unit) for treatment and remained hospitalized until August 23, 2025. The CT results were as follows: The resident was diagnosed with a right superior tentorium hyperdense subdural hematoma. A subdural hematoma is bleeding that becomes trapped between the brain's surface and its tough outer covering, called the dura. The tentorium is a thick membrane inside the skull that separates the upper and lower parts of the brain. The term hyperdense means the bleeding is new or fresh and appears brighter on the CT scan, indicating recent injury. The scan further showed left anterior and right mid parafalcine hyperdense subdural hematomas, each measuring 4 millimeters. The falx is another protective fold of tissue that separates the left and right halves of the brain. Parafalcine means the bleeding is located next to this divider. The small size (4 millimeters each) indicates small but significant fresh blood collections near the brain's central dividing structure. Additionally, the CT scan identified bilateral parafalcine hypodense subdural hematomas measuring 7 millimeters. Bilateral means on both sides of the brain. Hypodense means the blood appears darker on the scan, suggesting it is older or less recent. This finding reflects older blood collections on both sides of the brain near the dividing fold (falx), and their size (7 millimeters) indicates a larger volume than the acute bleeds. Finally, the CT scan revealed a small hypodense subarachnoid hemorrhage located beneath the left frontal lobe. A subarachnoid hemorrhage is bleeding in the space between the brain and the arachnoid membrane (one of the thin protective coverings of the brain). The term hypodense again suggests this bleed was either resolving or less acute. The left frontal lobe is the front part of the brain, just behind the forehead, which plays a role in thinking and movement. The scan showed both new and older areas of bleeding inside the skull, including fresh blood along internal brain membranes, older blood collections on both sides of the brain, and a small bleed beneath the left frontal brain region. These findings represented significant head trauma. A review of the facility's investigative documentation completed by Employee 1 (RN Supervisor) on August 18, 2025, at 5:01 AM, revealed that Employee 2 (nurse aide) walked out of Resident 1's room and approached Employee 1 (RN), stating, I need a nurse, Resident 1 is on the floor. Employee 2 (nurse aide) reported that she had transferred Resident 1 from the bed to the wheelchair, which caused the bed alarm to start ringing. She stated that she turned her back to the resident to turn the alarm off and, when she turned back around, the resident was falling forward out of the wheelchair. Employee 2 stated she was unable to stop the fall. Employee 1 (RN) documented that upon entering Resident 1's room, the resident was found lying on her stomach on the floor near the door side of the bed, with her head facing the bed. The resident was barefoot with no footwear or non-skid socks in place. The wheelchair was noted to be near the resident's feet. Blood was observed under the left side of the resident's forehead. The resident was rolled onto her back and found to have a laceration with a large hematoma and moderate bleeding above her left eye. A pressure dressing was applied, the physician was contacted, and the resident was transferred to the hospital for evaluation. Human resources documentation revealed that Employee 2 (nurse aide) was suspended from employment on August 18, 2025, and terminated on August 19, 2025. A written witness statement completed by Employee 1 (RN Supervisor) on August 18, 2025 (no time indicated) revealed that Employee 2 (nurse aide) reported, Resident 1 was on the floor. Employee 2 further stated that the resident had fallen out of her wheelchair after she transferred her from bed to the chair. She stated she had turned her back to shut off the bed alarm, and the resident was found face down on the floor, barefoot, with the wheelchair near her feet. Employee 1 documented that a forehead laceration and hematoma were observed. A telephone interview conducted with Employee 1 (RN Supervisor) on September 16, 2025, at 2:00 PM revealed that at approximately 5:00 AM on August 18, 2025, she was walking down the hallway toward Resident 1's room when Employee 2 (nurse aide) exited the room and stated, Resident 1 is on the floor. Employee 1 confirmed the bed alarm was sounding. Both entered the room and observed Resident 1 lying face down on the floor. Employee 2 (nurse aide) stated, She [Resident 1] fell out of the wheelchair. Employees 3 (nurse aide) and 4 (nurse aide), who were also on duty, were called to assist. Using a mechanical lift, the staff returned Resident 1 to bed. The physician and family were notified, and Resident 1 was transferred to the hospital. Employee 1 stated she obtained witness statements from all three nurse aides on duty, including confirmation from Employees 3 and 4 that Employee 2 had transferred Resident 1 by herself and, when turning her back to shut off the alarm, Resident 1 fell forward from the chair. A written statement from Employee 2 (nurse aide), dated August 18, 2025 (no time indicated), documented: Resident 1 was in a locked wheelchair. I turned to shut off the bed alarm and as I began to turn back towards her, she fell forward and hit the left part of her forehead on the floor. During the on-site survey on September 16, 2025, a call was placed to Employee 2 at 1:30 PM to gather additional details regarding the incident of August 18, 2025; however, Employee 2 did not return the call. A written witness statement from Employee 3 (nurse aide), dated August 18, 2025 (no time indicated), documented: Myself and Employee 4 were getting a mechanical lift weight on Resident 2 in the resident's room when Employee 2 came to the room and stated, 'Resident 1 is on the floor.' When we had Resident 2 back in bed, we went to Resident 1's room where the resident was laying on the floor. A phone call was placed to Employee 3 at 1:35 PM on September 16, 2025, for further details; however, Employee 3 did not return the call. A written witness statement from Employee 4 (nurse aide), dated August 18, 2025 (no time indicated), documented: While using a mechanical lift on Resident 2, Employee 2 came to the room stating, 'I need one of you to come down and help me with Resident 1.' When Employee 3 and I asked what was wrong, Employee 2 stated 'She [Resident 1] is on the floor, and I need someone to help. I dropped her.' A telephone interview conducted on September 16, 2025, at 1:45 PM with Employee 4 (nurse aide) revealed: Employee 2 came into the room and stated, 'I need one of you to come with me right now.' I asked her, 'Why, what's wrong?' Employee 2 stated that Resident 1 was on the floor and that she dropped her. Employee 4 further stated that he and Employee 3 had to safely return Resident 2 to bed before going to Resident 1's room, where they observed Employee 1 (RN) and Employee 2 (nurse aide) attending to Resident 1 on the floor. Review of human resources documentation revealed Employee 2 was hired March 14, 2025, and completed initial in-service training on that date, including abuse prevention education. Mandatory annual in-service documentation, completed March 14, 2025, indicated Employee 2 was deemed competent to perform her duties.There was no documented evidence that Employee 2 followed the resident's care plan, which required two staff members for safe transfers. Instead, Employee 2 transferred Resident 1 by herself at approximately 5:00 AM on August 18, 2025, turned her back to silence the alarm, and left the resident unattended, resulting in Resident 1 falling forward from the wheelchair, sustaining a forehead laceration and hematoma. Employee 2 then left the resident on the floor while she went to seek help from two other nurse aides in the building. During an interview on September 16, 2025, the facility's Nursing Home Administrator and Director of Nursing confirmed that the facility's investigative findings substantiated that Employee 2 neglected Resident 1 by failing to follow the planned two-person transfer intervention. The neglect resulted in Resident 1 sustaining multiple subdural hematomas, a scalp laceration, and hospitalization for five days. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident care policies, 28 Pa. Code 211.12 (d)(5) Nursing Services.