Every finding on record at Vibra Rehabilitation Center

Based on clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for one of 10 residents reviewed (Resident 5). Findings Include: Review of Resident 5's clinical record revealed diagnoses that included hypertension (high blood pressure) and depression. Review of Resident 5's fall care plan revealed a care plan, dated May 30, 2026, stating that Resident 5 was a high risk for falls related to impulsiveness. Review of Resident 5's ADL (activities of daily living) care plan revealed an intervention, dated May 30, 2026, stating that Resident 5's transfer status was a two moderate assist related to impulsiveness and unsteadiness. Review of Resident 5's incident report, dated June 9, 2026, revealed that at approximately 4:10 AM, Employee 1 (Nurse Aide) was assisting Resident 5 to the bathroom, after Resident 5 activated her call bell for toileting assistance. The incident report further stated that, per nurse aide report, Resident 5 was transferred to a wheelchair and transported to the bathroom doorway. The bathroom door was partially closed and the nurse aide instructed the Resident to wait while the nurse aide opened the door. The report stated that as soon as the door was opened, Resident 5 attempted to propel herself into the bathroom and immediately fell forward, landing face down with her hands extended. Review of Employee 1's witness statement, dated June 9, 2026, revealed that Resident 5 rang her call bell to use the bathroom. Employee 1 went into the room to help her to the bathroom. The bathroom door was halfway open and Employee 1 stated she told Resident 5 to hold on while Employee 1 opened the door. Further review of the statement revealed that as soon as Employee 1 opened the door, Resident 5 tried to wheel herself into the bathroom and she fell on her face with her hands up. Based on review of the incident report and Employee 1's statement, there was no evidence that Employee 1 had a second assist to help transfer Resident 5 to her wheelchair, per Resident 5's care plan. Review of a witness statement from Employee 2, dated June 12, 2026, revealed that on that day, Employee 2 and another employee assisted Resident 5 to the toilet. As Employee 2 was waiting for Resident 5 to finish, the other employee left to answer call bells. Employee 2 then stated that Resident 5 grabbed the bar and Employee 2 transferred her to her wheelchair. Resident 5 was in her wheelchair as Employee 2 was zeroing the weight chair. Employee 2 stated she observed Resident 5 sliding off of her chair. Employee 2 stated she called for the nurse and they lowered Resident 5 to the floor. Based on review of Employee 2's statement, Employee 2 transferred Resident 5 from the toilet to her wheelchair without a second assist, per Resident 5's care plan. Review of Resident 5's clinical record revealed no documentation of the incident on June 12, 2026. During an interview with the Director of Nursing (DON), on June 15, 2026, at 12:35 PM, she stated that an incident report was not completed for the June 12, 2026, incident. She stated the change of plane was not considered a fall, since Resident 5 slid out of her wheelchair and it did not occur while she was being transferred. In a follow up interview with the DON on June 15, 2026, at 1:57 PM, she stated that Resident 5's care planned assist level should have been followed during her transfers. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for three of four residents reviewed for pressure ulcers (Residents 1, 2 and 4), which resulted in actual harm for Resident 2 as evidenced by increased size and surface area of the pressure ulcer.Findings Include: During an interview with the Director of Nursing (DON) on June 3, 2026, at 2:41 PM, it was revealed that the facility does not have a pressure ulcer policy. Review of Resident 1's clinical record revealed she was readmitted to the facility from the hospital on May 19, 2026, with diagnoses that included pressure ulcer of sacral region stage 3 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (HTN- persistent high blood pressure), and weakness. Review of Resident 1's hospital records revealed Pressure Injury Prevention Recommendations: Turn patient every 2 hours when in bed (use pillows or wedges) and every one hour when in the chair, dated May 18, 2026. Review of Resident 1's physician orders revealed that the order for Turn and reposition every 2 hours was not started until June 3, 2026. Review of Resident 1's comprehensive care plan revealed a focus area for her pressure ulcer with an intervention for follow facility protocols for treatment of injury. Review of Resident 1's wound note from May 20, 2026, revealed The patient has the following risk factors that affect wound healing: Advanced age, fecal incontinence, generalized weakness, HTN, inability to position self, reduced mobility, risk of pressure ulcer formation, urinary incontinence. The following plan is in place to address these factors: Frequent education, heel offloading, medical management per the primary team, offload pressure per facility protocol, turn and reposition. Review of Resident 1's wound note from May 27, 2026, revealed The resident has a wound that has healed today. They will be discharged from wound care services. Please consult the wound care team as needed for alterations in skin. Continue preventative measures: repositioning schedule per protocol, incontinence management. During an interview with the DON on June 3, 2026, at 12:33 PM, she revealed the turning and repositioning order should have been entered earlier, consistent with her hospital recommendations, and she would expect the wound nurse's recommendations to be implemented timely. Review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and atrial fibrillation (AFib- an irregular and often very rapid heart rhythm). Review of Resident 2's nursing progress notes revealed an admission note on May 15, 2026, stating that Resident 2 has a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the left buttock. Further review of the note revealed no nursing assessment of the pressure injury to include measurements, description of the pressure ulcer's characteristics, progress toward healing or identification of potential complications, and no mention if infection was present. Review of Resident 2's facility form titled IDT admission Evaluation with Baseline Care Plan, dated May 15, 2026, revealed Resident 2 was documented as having a stage 2 pressure injury to the sacrum and an unstageable scabbed area to the right buttock. Further review of the form revealed no assessment of the pressure ulcer to include measurements, description of the pressure ulcer's characteristics, progress toward healing or identification of potential complications, and no mention if infection was present. Review of Resident 2's MAR (medication administration record) and TAR (treatment administration record), dated May 2026, revealed no treatment orders were put into place for the pressure ulcer upon admission to the facility. On May 20, 2026, Resident 2 was seen by the facility's wound consultant. Review of the consult revealed Resident 2 had a stage 2 pressure ulcer to the sacral area and it was present on admission to the facility. Measurements of the area were 1 cm (centimeter) x 0.2 cm x 0 cm, with a calculated surface area of 0.2 sq (square) cm. Further review of the consult revealed treatment recommendations to cleanse the area with soap and water and pat dry, apply zinc oxide paste to periwound and base of the wound, leave open to air, every shift and as needed. Review of Resident 2's physician orders and MAR and TAR for May 2026, revealed the recommended treatment was not ordered and no other orders were placed for treatment of Resident 2's pressure ulcer. Review of Resident 2's wound consultant note, dated May 27, 2026, revealed the pressure ulcer to the sacral area had increased in size. Measurements were 1.5 cm x 1.1 cm x 0 cm with a calculated area of 1.65 sq cm. Treatment recommendation was the same recommendation from the prior visit on May 20, 2026, which was never implemented. On May 27, 2026, treatment orders were placed for Resident 2, per the recommendations from the wound consultant. During an interview with the DON on June 3, 2026, at 2:41 PM, she stated that she would expect that wound care recommendations be followed and implemented. The facility failed to implement wound care orders for Resident 2's pressure ulcer and failed to implement wound care orders per recommendation from the wound consultant. Resident 2 had no assessment of his pressure ulcer until May 20, 2026, and no treatment orders for the stage 2 pressure ulcer from May 15 through May 27, 2026. Wound assessment on May 27, 2026 revealed the pressure ulcer had grown in size since May 20, 2026, when no treatment was in place. Review of Resident 4's clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF- when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues) and hypertension. Review of Resident 4's admission nursing progress note, dated May 13, 2026, revealed the Resident was noted with a stage 2 pressure ulcer to the coccyx (tailbone). Further review of the note revealed no nursing assessment of the pressure injury to include measurements, description of the pressure ulcer's characteristics, progress toward healing or identification of potential complications, and no mention if infection was present. Review of Resident 4's facility form titled IDT admission Evaluation with Baseline Care Plan, dated May 13, 2026, revealed the Resident had a stage 2 pressure ulcer to the coccyx. Further review of the form revealed no assessment of the pressure ulcer to include measurements, description of the pressure ulcer's characteristics, progress toward healing or identification of potential complications, and no mention if infection was present. Review of Resident 4's TAR, dated May 2026, revealed a treatment order, dated May 13, 2026, to cleanse the area with soap and water, pat dry, apply zinc oxide, every shift for stage 2 pressure ulcer. On May 24, 2026, the treatment order was changed from every shift to every four hours. Review of Resident 4's provider note, dated May 23, 2026, revealed stage 2 pressure ulcer was noted over the sacral area, no drainage or infection noted. The note further stated that the assessment and plan would include wound care monitoring per nursing protocol and monitor for progression or signs of infection. The note did not include wound measurements or description of the pressure ulcer's characteristics. Review of Resident 4's provider note, dated May 26, 2026, revealed the pressure ulcer was not reassessed in detail on this date. Review of Resident 4's provider note, dated June 2, 2026, revealed the pressure ulcer was noted to be improving with ongoing wound care and better nutritional intake and there were no signs of infection. The note did not include measurements of the pressure ulcer or a description of the ulcer's characteristics. Review of Resident 4's clinical record from admission on [DATE] through June 3, 2026, revealed no assessments of the pressure ulcer to include measurements or description of the pressure ulcer's characteristics. In an email correspondence from the DON on June 4, 2026, at 9:48 AM, she stated that Resident 4 was not seen by the outside wound consultant provider. She stated the family was deciding between hospice and further care so the facility held off a week to see if she would rebound. In a follow up email from the DON on June 4, 2026, at 1:06 PM, she stated that Resident 4's treatment order was changed on May 24, 2026, to every four hours because that is what it originally was supposed to be but there was a transcription error and it was put in initially as every shift. No additional information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for one of seven residents reviewed (Resident 4). Findings Include: Review of Resident 4's clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF- when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues) and hypertension (elevated blood pressure). Review of Resident 4's admission nursing progress note, dated May 13, 2026, revealed the Resident was noted with a stage 2 pressure ulcer to the coccyx (tailbone). Review of Resident 4's facility form titled IDT admission Evaluation with Baseline Care Plan, dated May 13, 2026, revealed the Resident had a stage 2 pressure ulcer to the coccyx. Review of Resident 4's TAR, dated May 2026, revealed a treatment order, dated May 13, 2026, to cleanse the area with soap and water, pat dry, apply zinc oxide, every shift for stage 2 pressure ulcer. On May 24, 2026, the treatment order was changed from every shift to every four hours. Review of Resident 4's current care plan revealed a care plan dated May 17, 2026, stating I have potential/actual impairment to skin integrity of the (SPECIFY location) r/t [related to]. The care plan did not specify that Resident 4 had an actual pressure ulcer nor the location of the pressure ulcer. During an interview with the Director of Nursing on June 3, 2026, at 2:44 PM, the DON was made aware of the care plan concern for Resident 4. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that its residents are free of any significant medication errors for two of seven residents reviewed (Residents 2 and 5). Findings include: Review of Resident 2's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and atrial fibrillation (AFib- an irregular and often very rapid heart rhythm). Resident 2 also had a history of a liver transplant and kidney transplant. Review of Resident 2's physician orders revealed an order, dated to start May 16, 2026, for Tacrolimus (an immunosuppressant medication that prevents the body from rejecting transplanted organs) ER (extended release) oral tablet 4 mg (milligrams), give one tablet in the morning for kidney transplant, give with 2 mg to equal 6 mg. Further review of Resident 2's physician orders revealed an order, dated to start May 16, 2026, for Tacrolimus 1 mg, give 2 mg by mouth in the morning for kidney transplant, give with 4 mg to total 6 mg. Review of Resident 2's MAR (medication administration record), dated May 2026, revealed that on May 17, 18, 19, and 20, the 4 mg Tacrolimus and 2 mg Tacrolimus were signed off as 5, meaning hold/see progress note. Review of the corresponding eMAR progress notes revealed the following: May 17- Medication not available, awaiting pharmacy's delivery; May 18- on order; May 19- on order; May 20- do not have from pharmacy. Review of Resident 2's clinical record revealed no evidence that the provider was made aware that Resident 2 did not receive his Tacrolimus on May 17, 18, or 19, 2026. Review of Resident 2's nursing progress note dated May 20, 2026, at 3:51 PM, revealed the nurse spoke with Resident 2's family member who would bring in his Tacrolimus on May 21, 2026. Review of Resident 2's MAR revealed he received his Tacrolimus on May 21, 2026, and everyday thereafter for the duration of his admission. Review of Resident 2's provider note, dated May 20, 2026, revealed that the provider was informed that the Resident had not received his Tacrolimus since admission due to medication availability issues. The provider note stated that the medication should be resumed as soon as possible to reduce the risk of transplant complications. The provider also contacted Resident 2's transplant team who recommended the medication should be resumed immediately at his previous dose and a Tacrolimus level should be obtained in one week for monitoring. Review of Resident 2's Tacrolimus level on May 26, 2026, was 9.5 (target level is listed as 5-20). During an interview with the Director of Nursing (DON), on June 3, 2026, at 11:05 AM, she stated that the Resident's family was supposed to bring the medication in. The surveyor asked why it wasn't documented that the wife was to provide the medication but was instead documented that it was not available from pharmacy. DON was also asked how the staff would know that the wife was to provide the medication, as it was not ordered that way and there was no documentation in the clinical record to indicate that. No answer was given to those questions. In a follow up interview with the DON on June 3, 2026, at 12:33 PM, she stated that staff told the family to bring in the medication, but facility was unable to provide documentation of that. In a final interview with the DON on June 3, 2026, at 2:42 PM, she confirmed that staff did not promptly notify the provider of Resident 2's missed medication and stated that is why they were given a write up. Review of Resident 5's clinical record revealed diagnoses that included presence of cardiac pacemaker (a medical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle, ensuring it beats at a normal rate) and atrial fibrillation (irregular heart rhythm). Review of Resident 5's clinical record revealed a pharmacy recommendation on May 22, 2026, to increase her anticoagulant medication (apixaban) to twice a day and to review the black box warning (warning designed to alert health care providers and patients to serious, life-threatening, or permanently disabling risks associated with the drug's use, should an adverse reaction occur) associated with her heart rhythm disorder medication. The recommendation sheet was signed that the physician reviewed the black box warning and was in agreement with the recommendation to increase her apixaban on May 25, 2026. Review of Resident 5's physician orders revealed an order for Apixaban Oral Tablet 2.5 MG, Give one tablet by mouth two times a day for blood clot [prevention], with a start date of May 25, 2026. Review of Resident 5's May MAR revealed it was blank for four administrations, indicating the medication was not administered as ordered between May 25-27, 2026. Review of Resident 5's clinical record failed to reveal any indication as to why the medication was not administered as ordered. During an interview with the DON on June 3, 2026, at 12:33 PM, she revealed the apixaban was not administered during those times because there were warnings for interactions with her other medications, but there should have been notation in the clinical record that was the reason why it was held. She further revealed her expectation that staff would indicate in the clinical record that they are holding a medication and why it is being held, and communicate with the physician for clarification. 28 Pa. Code 211.2(d)(3) Medical Director28 Pa Code 211.9(a)(1) Pharmacy Services28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services consistent with professional standards of practice for two of 7seven residents reviewed (Residents 1 and 7).Findings include: Review of Resident 1's clinical record revealed she was readmitted to the facility from the hospital on May 19, 2026, with diagnoses that included pressure ulcer of sacral region stage 3 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (HTN- persistent high blood pressure), and weakness. Review of Resident 1's IDT admission Evaluation with Baseline Care Plan assessment revealed it was signed by the Director of Nursing (DON) on May 31, 2026. The assessment noted Resident 1 had a pressure ulcer but did not note the measurements of the pressure ulcer. Review of Resident 1's nursing progress notes failed to reveal any notes or assessments related to her being readmitted to the facility or details surrounding her physical status on May 19 or 20, 2026. During an interview with the DON on June 3, 2026, at 11:56 AM, she revealed no one completed the admission assessment for Resident 1 when she returned from the hospital, so she completed it late on May 31, 2026. She further revealed she did assess Resident 1 upon her return from the hospital but did not write a note or complete the assessment at that time, and she did not measure Resident 1's pressure ulcer. She further revealed her expectation that admission assessments would contain wound measurements and be completed timely after admission or readmission. Review of Resident 1's physician orders revealed an order for Wound care- stage 3 sacrum- gently wash with wound cleanser normal saline apply xeroform every shift for impairment to sacrum, with a start date of May 22, 2026. Review of Resident 1's wound note from May 27, 2026, revealed The resident has a wound that has healed today. They will be discharged from wound care services. Please consult the wound care team as needed for alterations in skin. Continue preventative measures: repositioning schedule per protocol, incontinence management. During an interview with the DON on June 3, 2026, at 12:33 PM, she revealed Resident 1's treatment order to her sacrum should have been discontinued when her wound resolved and she was discharged from wound care on May 27, 2026. She further revealed she would expect the wound nurse's recommendations to be followed and treatment orders to be discontinued as indicated. Review of Resident 7's clinical record revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included Rheumatoid Arthritis (RA-a chronic autoimmune disorder where the immune system mistakenly attacks the lining of the joints) and chronic venous insufficiency (occurs when damaged vein walls and valves in the legs fail to efficiently return blood to the heart). Review of Resident 7's TAR for May 2026, revealed an order dated to start May 9, 2026, for wound VAC therapy (also known as negative pressure wound therapy-a medical device that uses gentle suction to accelerate the healing of complex, large, or slow-to-heal wounds) to right thigh wound, 100 mmHg negative pressure continuous (pressure setting for the wound VAC). Review of Resident 7's clinical record revealed that she went to an outside appointment on May 14, 2026, for a wound VAC dressing change. Resident 7 returned to the facility with orders to continue the wound VAC at 100 mmHg negative pressure continuously and to return on May 21, 2026, for another wound VAC change, and to send wound VAC supplies with for the next appointment. Review of Resident 7's wound center consult dated May 21, 2026, revealed that Resident's wound cannister was not changed appropriately. The consult stated that the cannister should have been changed earlier that morning but wasn't and was not functioning since 5:00 AM. Review of Resident 7's progress notes revealed a note written by Resident 7's provider, on May 22, 2026, copying the wound care note from the wound consult provider from May 21, 2026. The note stated that Resident 7 presented for a wound VAC change. The Resident's canister was full that morning at 5:00 AM and instead of replacing the wound VAC canister at the nursing home, they just disconnected it. Resident then presented at 3:00 PM with suction off for 10 hours. Review of Resident 7's progress notes revealed no nursing progress note regarding the wound VAC being turned off or disconnected, and no evidence that the provider was made aware that the wound VAC was turned off or disconnected. Review of Resident 7's TAR dated May 2026, revealed that on day shift on May 21, 2026, the wound VAC was signed off as running continuously at 100 mmHg negative pressure. During an interview with the DON on June 3, 2026, at 11:00 AM, she stated that the replacement canister for the wound VAC was not at the facility, so it wasn't changed. She stated Resident 7's wound VAC was different than what the facility usually uses. She stated that extra canisters were allegedly delivered but stated nobody could find them. The DON provided a medical equipment delivery ticket for Resident 7's wound VAC supplies, with a delivery date of May 21, 2026. The ticket was not timed. During an interview with the DON on June 3, 2026, at 2:48 PM, the DON stated that Resident 7's wound VAC canisters needed to be changed once or twice a day. The surveyor requested the date that the canisters were actually ordered. As of June 4, 2026, at 1:15 PM, no purchase order or other evidence was provided to the surveyor showing when the additional wound VAC canisters and other supplies were actually ordered for Resident 7. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided for a resident with hypoglycemia (low blood sugar) in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs, for one of 18 residents reviewed (Resident 1), which resulted in actual harm as evidenced by Resident 1 becoming unresponsive and requiring hospitalization. Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). Review of Resident 1's Medication Administration Record (MAR) dated May 2026, revealed an order, with a start date of May 1, 2026, to check Resident 1's blood glucose level at 6:00 AM and 9:00 PM. Further review of Resident 1's MAR revealed PRN (as needed) orders, with a start date of April 19, 2026, for Glucose Gel 40%, give 15 grams by mouth as needed for blood glucose less than 60, administer if blood glucose is less than 60 and resident is alert enough to swallow; and an order for Glucagon 1 mg (milligram), inject 1 mg intramuscularly as needed for blood glucose less than 60, administer if blood glucose is less than 60 and Resident is NOT alert enough to swallow. Review of Resident 1's MAR revealed that on May 9, 2026, at 9:00 PM, Resident 1's blood glucose was documented as being 57. Further review of the MAR revealed that neither the glucose gel nor the glucagon were given at that time, per PRN order to be given for blood glucose less than 60. Review of Resident 1's clinical record revealed no nursing progress note about Resident 1's blood glucose level of 57, no evidence of any assessment of Resident 1, no evidence that the provider was made aware, and no evidence that a follow up blood glucose level was checked. Review of Resident 1's MAR revealed that on May 10, 2026, at 6:00 AM, Resident 1's blood glucose was documented as being 44. Further review of the MAR revealed that neither the glucose gel nor the glucagon were given at that time, per PRN order to be given for blood glucose less than 60. Review of Resident 1's clinical record revealed no nursing progress note about Resident 1's blood glucose level of 44, no evidence of any assessment of Resident 1, no evidence that the provider was made aware, and no evidence that a follow up blood glucose level was checked. Review of Resident 1's nursing progress note, dated May 10, 2026, revealed that the nurse entered Resident 1's room at around 10:10 AM and Resident 1 appeared to be sleeping. Blood glucose level was checked and it was 47. PRN glucagon was administered and the RN supervisor was notified and arrived to Resident 1's room. When staff attempted to put the Resident's head of the bed down to reposition the Resident, she became unresponsive and had projectile vomited. The note further stated that the PRN glucagon was not effective as the blood glucose level was rechecked and it was 37. A second PRN glucagon was administered and 911 was notified. Prior to leaving the facility, Resident 1's blood glucose level was checked and it was 89. Review of Resident 1's MAR revealed she received PRN glucagon at 10:11 AM for a blood glucose level of 47 and again at 10:22 AM for a blood glucose level of 37. During an interview with the Director of Nursing (DON) on May 19, 2026, at 10:48 AM, she stated that the facility does not have policies on insulin administration, blood glucose monitoring, or hypoglycemia. On May 19, 2026, at 12:20 PM, the DON stated that per Employee 2, she was aware of the blood glucose level of 44, but the Resident was talking so they didn't recheck the blood glucose until she went unresponsive. She further confirmed that there is no documentation of anything that Employee 1 did regarding the blood glucose levels of 57 and 44. The DON provided a statement from Employee 2, undated, which stated that Resident 1 was in her room, awake and talking, eating breakfast. The aides were talking to the Resident and tried to take her tray away twice and she said she was still eating. At about 9:00 AM, they took her tray. At about 10:00 AM is when Employee 2 found Resident 1 in her room unresponsive, gave two doses of glucagon and transferred her to the hospital. The DON provided a form titled Employee Corrective Action Form for Employee 1, that was dated May 14, 2026. Under the section Statement of the Issues revealed Blood sugar of 44- [Employee 1] said she gave glucose tabs/nothing documented-no call to provider. The form further revealed, under Employee Comments, Employee 1 stated that it was the end of her shift, she gave in report all interventions and requested the oncoming nurse to follow up. Employee 1 signed the form on May 14, 2026. During an interview with the DON on May 19, 2026, at 2:01 PM, the DON stated that glucose gel is kept in the medication cart so there is no record of when the medication is removed from the cart to be administered. She stated that there is no documentation that Employee 1 gave Resident 1 glucose gel or glucagon, per PRN order to be given for blood glucose less than 60. The facility failed to provide interventions to Resident 1 for blood glucose levels of 57 and 44, resulting in Resident 1 becoming unresponsive and requiring hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 18 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). Review of Resident 1's TAR (treatment administration record) dated April 2026, revealed that on April 24, 2026, a treatment order was received for Resident 1's left elbow skin tear. The order stated to cleanse the left elbow skin tear with normal saline solution and then apply bordered gauze, every day shift. Review of Resident 1's clinical record, including progress notes, revealed no mention of how Resident 1 obtained the left elbow skin tear. Review of Resident 1's TAR dated May 2026, revealed that the treatment order to the left elbow skin tear was signed off as 5, meaning hold/see nurses note on the following days: May 3, 5, 6, 7, 8, and 9. On May 4, there was no documentation that the treatment was completed. Review of the corresponding eTAR progress notes revealed that on May 3, 5, 6, 7, 8 and 9, 2026, it was documented that Steri-Strips were in place. Review of Resident 1's clinical record revealed no documentation regarding when the Steri-Strips were placed and by whom. On May 21, 2026, at 4:21 PM, the facility provided a statement from the Nurse Practitioner, which stated that they put Steri-Strips on Resident 1's elbow. The statement further stated that Resident 1 had very fragile skin, and she told the Nurse Practitioner that she bumped it against the side table. Review of Resident 1's clinical record revealed no documentation that the Nurse Practitioner applied the Steri-Strips and when, and no documentation on how Resident 1 stated she obtained the skin tear. During an interview with the Director of Nursing on May 22, 2026, at 10:42 AM, no additional information was provided. 28 Pa Code 211.5(f)(ii)(iv)(ix) Medical records28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident received care, consistent with professional standards of practice, to treat pressure ulcers for one of 18 residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough of it) and congestive heart failure (CHF-when the heart muscle doesn't pump blood as well as it should, leading to a backup of fluid in the lungs and body tissues). Review of Resident 1's nursing progress notes revealed an eMAR note on April 23, 2026, at 5:03 AM, stating that Resident 1 was reporting a 4/10 buttock pain, concern for stage 2 pressure injury. Zinc oxice paste was applied, which provided relief. Review of Resident 1's nursing progress note on April 23, 2026, at 6:00 AM, revealed that zinc oxide was applied, but does not specify where. The note further stated that the Resident had a foam dressing on her buttock prior to finding the pressure injury. Skin inspection completed and refer to evaluation for details. Review of Resident 1's facility form titled Skin Inspection Daily on admission x 72 hours, dated April 23, 2026, revealed Resident 1 has a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the sacrum. Under comments, it was documented that zinc oxide was applied and that the Resident had a foam dressing on her buttock prior to finding the pressure injury. Further review of the form revealed no measurements, no description of the pressure ulcer's characteristics, no progress toward healing or identification of potential complications, and no mention if infection was present. Review of Resident 1's TAR (treatment administration record), dated April 2026, revealed that on April 23, 2026, zinc oxide paste was ordered to be applied to buttocks every shift for stage 2 pressure injury. Review of Resident 1's admission MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated April 26, 2026, revealed in Section M, Resident 1 was coded as having one stage 2 pressure ulcer, that was not present on admission. Review of Resident 1's nursing progress note on April 28, 2026, revealed zinc oxide applied, but does not state where it was applied. The note further states that the Resident had a foam dressing on her buttock prior to finding the pressure injury. Skin inspection as completed and refer to evaluation for details. Review of Resident 1's facility form titled Skin Inspection Daily on admission x 72 hours, dated April 28, 2026, revealed Resident 1 has a stage 2 pressure ulcer to the sacrum. Under comments, it was documented that zinc oxide was applied and that the Resident had a foam dressing on her buttock prior to finding the pressure injury. Further review of the form revealed no measurements, no description of the pressure ulcer's characteristics, no progress toward healing or identification of potential complications, no mention if infection was present, and no pain assessment. Review of Resident 1's clinical record revealed no pressure ulcer assessments were completed after April 28, 2026. On May 22, 2026, at 8:44 AM, the Director of Nursing (DON) stated that the facility does not have a pressure ulcer policy. She further stated that the nursing progress note on April 23, 2026 says suspected stage 2 and there were no measurements because there was no pressure found, they were just applying zinc as preventative. On May 22, 2026, at 8:57 AM, the surveyor questioned the DON regarding her statement of no pressure ulcer found and that the zinc was just preventative. Surveyor referenced the treatment order of the Zinc, that was ordered for a stage 2 pressure ulcer, the two skin inspection forms that state Resident 1 has a stage 2 pressure ulcer and the MDS being coded that Resident 1 has a stage 2 pressure ulcer. No additional information was provided by the DON. In a follow up interview with the DON on May 22, 2026, at 10:42 AM, the surveyor again made the DON aware of the concern that Resident 1's pressure ulcer assessments did not include measurements, wound characteristics, identification of potential complications and no mention of possible infection. No additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to establish Enhanced Barrier Precautions (EBP) and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections on two of two nursing units; and failed to maintain an effective infection control program related to the administration of medications for one resident observed during medication administration observation (Resident 63). Findings include: Review of facility policy, Enhanced Barrier Precautions (EBP), effective 2024 and revised 2024, read, in part, EBP are indicated for residents with any of the following: infection or colonization with a CDC [Center for Disease Control] targeted MDRO when Contact Precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Chronic wounds include unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A short-term peripheral intravenous line (PIV) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, device care or use: central line, urinary catheter, feeding tube, trach/ventilator, wound care: any skin opening requiring a dressing. Review of Resident 40's clinical record review documented diagnoses that included urinary tract infection. Interview with Resident 40 on August 26, 2025, at 9:50 AM revealed she received an intravenous antibiotic for a urinary tract infection, and it finished on August 25th, 2025. Surveyor observed empty medication bags hanging from the intravenous (IV) pole. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible near Resident 40's room. Further clinical record review documented physician orders that included: place midline (peripheral catheter longer than a standard IV positioned in the vein of the upper arm near the armpit) for IV antibiotic one time, started August 15, 2025; normal saline 10 ml intravenously every shift for midline maintenance, started August 15, 2025, and discontinued August 27th, 2025; Zosyn intravenous 100 ml every 6 hours for 10 days, started August 15, 2025, and discontinued August 25th, 2025, at 2:00 PM. Review of Resident 40's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 46's clinical record documented diagnoses that included lumbar spine incision wound care, osteomyelitis (bone infection) of vertebra. Further clinical record review documented physician orders that included: Cefepime 2 gram intravenously every 8 hours, started August 19, 2025, discontinue September 26, 2025; heparin injection 5000 units subcutaneously two times a day for clot prevention, started August 25, 2025; IV Site - Change dressing once weekly and as needed every Tuesday on day shift and measure extending line and check for displacement - if more than 1 cm notify physician for further orders, started August 26, 2025; lumbar spine incision - keep dressing in place and monitor for increase redness, swelling, drainage daily on day shift - notify provider, started August 20, 2025. Progress note dated August 19, 2025, at 5:33 PM, read, in part, PICC line right upper extremity. Further review of progress notes documented the weekly sterile PICC dressing change was completed on August 26th, 2025, at 6:35 PM. Review of Resident 46's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Review of Resident 47's clinical record documented diagnoses that included fracture right ulna (thin bone in the forearm) and retention of urine. Further clinical record review documented physician orders that included: Foley Catheter 16 FR 10 ml balloon for (urine retention), revised August 20, 2025; foley catheter care every shift and as needed- soap and water cleanse at meatus and down catheter tubing every shift, started August 24, 2025; foley catheter and drainage bag change as needed for infection, obstruction, or when the closed system is compromised as needed, started August 24, 2025. Review of Resident 47's August 2025 medication and treatment administration record documented catheter care was documented as completed August 20th through 27th, and the catheter was changed on August 24th. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 49's clinical record revealed diagnoses that included acute and subacute endocarditis (a life-threatening inflammation of the inner lining of the heart's chambers and valves usually caused by an infection) and cellulitis (skin infection) of the chest wall. Review of Resident 49's physician orders revealed the following orders: Wound vac therapy to left upper chest surgical wound continuous at 75 mm HG (millimeters of mercury) dated August 17, 2025; and IV [intravenous]site - Change dressing once weekly and PRN [as needed]. Measure extending line and check for displacement. If more than 1 cm, notify physician for further orders, dated August 25, 2025. Observation of Resident 49 on August 26, 2025, at 10:14 AM, revealed that his IV site was a double lumen central line located on his right chest. His wound vac was in place to his left upper chest. Observation failed to reveal any notation thatResident 49 was on EBP. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible Review of Resident 53's clinical record documented diagnoses that included a urinary tract infection. Further clinical record review documented physician orders that included: foley catheter 16 FR 10 ml balloon for (retention - failed voiding trial), started August 25, 2025; foley catheter care every shift and as needed, started August 25, 2025; foley catheter and drainage bag change as needed for infection, obstruction, or when the closed system is compromised, started August 25, 2025; irrigate foley catheter with 60 ml normal saline every shift until hematuria (blood in urine) clears, started August 26, 2025. Review of Resident 53's August 2025 medication and treatment administration record documented catheter care was documented as completed August 25th through 27th. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Interview with Resident 59 on August 26,2025, at 9:24 AM, reveled he's receiving an intravenous antibiotic for sepsis. Observation revealed empty medication bags hanging from intravenous pole. No EBP signage or Personal Protective Equipment readily visible near Resident 59's room. Review of Resident 59's clinical record review documented diagnoses that included sepsis (blood infection), acute cholecystitis (inflammation of the gallbladder), and bacteremia (bacterial infection in the blood). Further clinical record review documented physician orders that included: change IV site dressing weekly and as needed every Monday dayshift, start September 1, 2025; IV Tubing changes, started August 25, 2025; empty chole/biliary drain and record output evening shift every 3 days, started August 25, 2025; Wound care - chole drain right upper quadrant of abdomen - cleanse with soap and water - pat dry, apply split gauze around drain - cover with foam dressing every evening shift, started August 25, 2025; Ampicillin 2 grams intravenously every 4 hours for sepsis, started August 25, 2025, until September 24,2025; Vancomycin 1 gram intravenously two times a day for cellulitis bilateral lower extremities, started August 27,2025; ceftriaxone 2 gram intravenously two times a day for sepsis, started August 25, 2025 until September 24,2025; normal saline flush 10 ml intravenously every shift for PICC (peripherally inserted central catheter- thin tube inserted into a vein in the arm guided to a large vein near the heart) patency started August 25, 2025. Review of Resident 59's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. Review of Resident 60's clinical record documented diagnoses that included pneumonia and bacteremia (bacterial infection in the blood). Further clinical record revealed physician orders that included: Cefepime Intravenous Solution 1 GM/50ML every 8 hours for 6 weeks, started August 24, 2025, and discontinue September 26, 2025; Normal Saline Flush 10 ml intravenously every shift for PICC maintenance Flush both ports every shift started August 25, 2025; IV site dressing change once weekly and as needed, and measure extending line and check for displacement. If more than 1 cm, notify physician for further orders day shift every Monday started August 31, 2025. Review of Resident 60's August 2025 medication and treatment administration record documented the aforementioned physician orders were administered. No enhanced barrier precaution signage or Personal Protective Equipment (PPE- masks, gowns, gloves) were readily visible. Interview with the Director of Nursing (DON) on August 27, 2025, at 1:40 PM, it was revealed that EBP haven't been implemented per facility policy. Review of facility policy titled, Medication Administration; Eye Drops, last reviewed September 10, 2024, revealed that subsection 16 (procedure after eye drop administration) stated, Remove and dispose of gloves. Discard any barrier used forcarrying or storing the medication and supplies. Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer. During observation of medication administration on August 26, 2025, at approximately 8:32 AM, Employee 1 (Licensed Practical Nurse) was observed using his gloved hands to apply eye drops in both of Resident 63's eyes. Employee 1 then left the Resident's room with Resident 63's water cup. Employee 1 was then observed to utilize the common room's ice scoop to scoop ice from the container with the gloved hands. Employee 1 was then observed dispensing water from a water dispenserlocated in the common area using gloved hands. Employee 1 returned to Resident 63's room, provided Resident 63 with the ice water, then removed his gloves and performed hand hygiene. During a staff interview on August 27, 2025, at approximately 1:20 PM, DON confirmed that Employee 1 should have removed gloves and performed hand hygiene after applying eye drops to Resident 63 and prior to accessing the icecontainer and water dispenser in the unit common area. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa code 211.10(d) Resident care policies28 Pa code 211.12(d)(1)(2)(5) Nursing services

Based on facility documentation review and staff interview, it was determined that the facility failed to ensure that the governing body was responsible and accountable for the facility Quality Assurance Performance Improvement (QAPI) program.Findings include: Review of the facility Quality Assurance Performance Improvement (QAPI) Plan undated indicated the following, in part, VibraLife's governing body is ultimately responsible for overseeing the QAPI committee. The owner/president has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of QAPI attendance sign-in sheets for January-March 2025, failed to reveal that the facility Medical Director (MD) or the Nursing Home Administrator (NHA) attended any of the monthly meetings in the quarter. Review of QAPI attendance sign-in sheets for April-June 2025, failed to reveal that the facility MD or NHA attended any of monthly meetings in the quarter. Review of a Memorandum with the Subject of Administrator Coverage dated August 12, 2024, provided by Employee 3, revealed that the designated Administrator of Record (NHA) had appointed Employee 3 as the full-time, permanent administrator on-site. The memorandum further indicated, in part, that the Administrator of Record remains actively engaged with facility operation; his office is located just three miles from the facility, enabling him to be on-site daily as needed; and that the NHA and Employee 3 communicate regularly, ensuring that all operational aspects are aligned with both state regulations and corporate objectives. This memorandum was signed by both the Administrator of Record and Employee 3 on October 17, 2024. During a staff interview with Employee 3 (Executive Director), the Director of Nursing, and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:49 PM, Employee 3 confirmed that although he is not the NHA, he has attended the QAPI meetings. Employee 3 further indicated that the NHA is also the Vice-President of Operations for the company that owns the facility and, in that capacity, also serves as part of the governing body. Employee 3 confirmed that the facility's NHA nor the MD have attended the QAPI meetings January through June 2025. Employee 3 indicated that he communicates via phone with the NHA at least twice a week, and often daily, but confirmed that he does not necessarily discuss or send QAPI minutes to him to review nor does he remind him to read meeting minutes in the facility electronic database even though the NHA also serves as a member of the governing body. Employee 3 was unable to provide any written documentation between him and the NHA/governing body in correlation to QAPI or ensuring that the MD attends the QAPI meetings. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.

Based on review of the facility provided attendance sign-in sheets for the facility's Quality Assurance Performance Improvement (QAPI) Committee and staff interview, it was determined that two of the required members failed to attend at least one meeting in two out of three quarters.Findings include: Review of QAPI attendance sign-in sheets for January-March 2025, failed to reveal that the facility Medical Director or the Nursing Home Administrator (NHA) attended any of the monthly meetings in the quarter. Employee 3 (Executive Director) had signed as the NHA. Review of QAPI attendance sign-in sheets for April-June 2025, failed to reveal that the facility Medical Director or the NHA attended any of monthly meetings in the quarter. Employee 3 had signed as the NHA. During a staff interview with Employee 3, the Director of Nursing, and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:49 PM, Employee 3 confirmed that he is not the NHA, and that the facility's NHA nor the Medical Director had attended the QAPI meetings. He further indicated that he communicates via phone with the NHA at least twice a week and most of the time daily, but confirmed that he does not necessarily send QAPI minutes to him to review. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen, in one of two nourishment centers (300/400 pantry), and in the creamery (an accessible lounge area).Findings include: Review of facility policy, Food Safety Requirements, not dated, read, in part, keep foods covered or in a tight container; and label, date and monitor foods to ensure they are utilized by the use-by date or frozen or discarded. Review of facility policy, Use and Storage of Food Brought in by Family or Visitors, not dated, read in part, all food items brought into the facility must be labeled with content and dated. Review of facility policy, Ice machines and Portable Ice Carts, revised and implemented August 27, 2025, read, in part, it is the policy of the facility to ensure that ice machines are clean and maintained. Ice machines will be cleaned at a frequency specified by the manufacturer. Review of manufacturer use and care guide, page 10, read, in part, maintenance should be completed on a semi-annual basis or more based on usage and location. Observation in walk-in freezer on August 25, 2025, at 6:17 PM, revealed a tray of muffins and 1/3 tray of marble cake open covered in plastic wrap with no date. Observation in walk-in refrigerator on August 25, 2025, at 6:15 PM, revealed feta cheese and mozzarella cheese open and not dated. Observation in dry storage on August 25, 2025, at 6:18 PM, revealed 1 bag ziti, 1 bag golden raisin, and 1 bag granola open, covered in plastic wrap, not dated; and 1 box chocolate chip gluten free cookies open and not securely closed in a box with other gluten free items dated 6/23. Observation in the main kitchen on August 25, 2025, at 6:23 PM, revealed one bulk bin of onions, not dated. Observation on the shelf above the 3-compartment sink on August 25, 2025, at 6:25 PM, revealed four individually wrapped sugar cookies, not dated. Observation in the creamery on August 25, 2025, at 6:28 PM, revealed a damp white towel with brown liquid marks was visible under the sink. The drip shield inside the ice machine contained a black moist substance along the bottom edge that was able to be wiped away with a paper towel. Observation in the 300 /400 nourishment center refrigerator on August 25, 2025, at 6:30 PM, revealed one vanilla might shake, thawed and not dated, with a thaw or use by date (product is to be utilized within 14 days once thawed); clear liquid on the bottom of the inside of the refrigerator; and 1 Styrofoam container of buffalo wings and celery without a resident identifier and not dated. Interview with Employee 11 (Food service Supervisor) on August 25, 2025, at 6:18 PM, revealed the aforementioned items should be securely closed and date marked when opened. Interview with Employee 2 (Food Service Director) on August 27, 2025, at 11:34 AM, it was revealed the aforementioned items should be securely closed and date marked once opened. Review of the most recent facility provided ice machine service contract documentation dated October 31, 2024, revealed preventive maintenance was completed on the kitchen ice machine. There was no documentation for preventive maintenance on the ice machine in the creamery. Observation and interview with Employee 3 (Executive Director) on August 28, 2025, at 9:36 AM, it was revealed that the ice machine in the creamery is utilized by staff to obtain ice for the residents. The drip shield on the inside of the ice machine contained a moist black substance that was able to be wiped away with a paper towel. Employee 3 confirmed that the ice machine needed to be cleaned. It was also revealed that the contracted service on the ice machine was last completed October 31, 2024, and service should've been performed in April 2025. The contract company was contacted and service was scheduled for September 2, 2025. Employee 3 moved the towel from underneath the sink, a water mark stained the flooring, and stated he would contact maintenance regarding the sink. Observation in the creamery on August 28, 2025, at 10:30 AM, revealed the towel remained under the sink and the ice machine drip shield remained soiled. Interview with the Employee 3 on August 28, 2025, at 2:30 PM, revealed food items should be date marked once opened or pulled from the freezer, resident items should be labeled with a resident identifier and date marked, and ice machines should be cleaned bi-annually or as needed. 28 Pa code 211.6(f) - Dietary Services

Based on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by failing to determine residency status in order to perform the accurate criminal history background checks prior to hire for five of five personnel files reviewed (Employees 9, 10, 12, 13, and 14); and failed to validate and verify licensure status for one of two nurse personnel files reviewed (Employee 10).Findings include: Review of facility policy, titled Abuse, Neglect and Exploitation, dated November 1, 2017, with a last review date of September 10, 2024, revealed Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment by the Facility in accordance with applicable state and federal regulations. Review of Employee 9's personnel file revealed her hire date was June 3, 2025, and that a Pennsylvania State Criminal Background check was completed on May 29, 2025. Employee 9's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 10's personnel file revealed her hire date was July 29, 2025, and that a Pennsylvania State Criminal Background check was completed on July 11, 2025. Employee 9's personnel file review failed to reveal that her Pennsylvania state residency status was verified in order to determine which criminal background check needed completed. Further review of Employee 10's file revealed that a copy of her Florida compact nursing license was present but failed to include that a license verification was completed to determine that the license was active and in good standing with no allegations of abuse, neglect, and exploitation of residents and misappropriation of resident property against it. Review of Employee 12's personnel file revealed her hire date was August 12, 2025, and that a Pennsylvania State Criminal Background check was completed on August 8, 2025. Employee 12's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 13's personnel file revealed her hire date was May 2, 2025, and that a Pennsylvania State Criminal Background check was completed on April 28, 2025. Employee 13's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. Review of Employee 14's personnel file revealed her hire date was June 10, 2025, and that a Pennsylvania State Criminal Background check was completed on June 9, 2025. Employee 13's personnel file review failed to reveal that her state residency status was verified in order to determine which criminal background check needed completed. During a staff interview with Employee 4 (Human Resources Director) on August 27, 2025, at 11:10 AM, Employee 4 revealed that an applicant enters their information, which includes their addresses for the past 7 years into the database that the facility uses for hiring purposes. Employee 4 confirmed that no one at the facility has knowledge of the addresses that an applicant enters in order to determine whether a state or federal background check should be completed. Employee 4 indicated that she completes a state background check on all new hires. Employee 4 confirmed that she had no additional information to offer for Employees 9, 10, 12, 13, and 14. Employee 4 indicated that the corporate recruiter generally handles the licensure verification process. Employee 4 confirmed that she had no documentation to provide to show that Employee 10's nursing license had been validated or the status verified. During a staff interview with Employee 3 (Executive Director) and the Director of Nursing on August 27, 2025, at 1:37 PM, Employee 3 confirmed that the facility had no other information to offer for Employees 9, 10, 12, 13, and 14. Employee 3 indicated that the facility would review their processes. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on observations, clinical record review, and resident and staff interviews, it was revealed that the facility failed to ensure that five of 20 residents reviewed during meal service received a therapeutic diet per physician order (Residents 17, 19, 22, 40, and 59) .Findings include: Clinical record reviews for Residents 17, 19, 22, 40, and 59 revealed diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and physician orders for a no concentrated sweets diet. During an interview with Resident 40 on August 26, 2025, at 9:50 AM it as revealed she is diabetic and feels the meals are carbohydrate heavy. A review of the diet spreadsheet for August 27, 2025, (day 23 of the Spring/Summer menu 2025) lunch meal revealed the no concentrated sweet diet (liberal diabetic diet) were to be served fruit cup in place of the pudding for dessert. Observation of tray line on August 27, 2025, at 12:05 PM, revealed Residents 17, 19, 22, 40, and 59 were ordered a no concentrated sweets diet and were served pudding vice fruit cup. The surveyor confirmed with Employee 2 (Food Service Director) on August 27, 2025, at 12:15 PM, that the Residents that ordered a no concentrated sweets diet were to be served fruit cup in place of the pudding. At that time, the pudding was removed from the aforementioned Resident's trays and a fruit cup was provided. Interview with the Employee 3 (Executive Director) on August 28, 2025, at 2:30 PM, revealed residents should be served the physician ordered diet. Pa code 211.6(a) - Dietary Services

Based on observations, staff interview, and facility policy review, it was determined that the facility failed to store drugs and biologicals in accordance with accepted professional standards for one of one medication carts observed (300/400 hall medication cart).Findings include:Review of facility policy, titled Medication Storage; Storage of Medication, last reviewed September 10, 2024, revealed subsection 12 stated, Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.During observation of the 300/400 medication cart on August 27, 2025, at approximately 10:00 AM, revealed that an insulin pen for Resident 19 had been opened and previously used with no open date written on the pen. During the observation, it was revealed that the medication cart contained a manufacturer's box of single-use polyvinyl alcohol 1.4% eye drop applicators. Review of the single-use eye drop applicators and the box that they were contained in revealed that the lot number (number assigned to a manufactured good to allow for tracking and identification of a specific manufactured good in the case of a recall) on the box did not match the lot number printed on the individual single-use eye drop applicators. The observations above were confirmed in the presence of the Director of Nursing (DON) on August 28, 2025, at approximately 9:30 AM.During a staff interview on August 27, 2025, at approximately 1:20 PM, the DON confirmed that insulin pens should be labeled with a date when they are opened. Further, medications should be stored in their original manufacturer's container and should not be placed in separate containers which have different lot numbers.211.12(d)(1)(3)(5) Nursing services

Based on review of personnel training records and staff interviews, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for one of five employee records reviewed (Employee 7); and failed to provide annual training that included dementia management for one of five employee records reviewed (Employee 8).Findings include: Review of personnel information revealed Employee 7's hire date was March 5, 2024. Review of her training record from August 29, 2024, through August 28, 2025, revealed that she had only completed 9.5 hours of annual training. Review of personnel information revealed Employee 8's hire date was May 21, 2024. Review of her training record from August 29, 2024, through August 28, 2025, revealed that she had not completed any dementia management training. During a staff interview with Employee 4 (Human Resources Director) on August 27, 2025, at 10:59 AM, she confirmed that Employee 7 did not complete the required training hours and that Employee 8 did not complete dementia training. During a staff interview with the Employee 3 (Executive Director), the Director of Nursing (DON), and Employee 6 (Assistant Director of Nursing) on August 28, 2025, at 2:18 PM, the DON confirmed that she would expect nurse aides to complete required training topics and to obtain a minimum of 12 hours of training per year. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.19(7) Personnel policies and procedures.28 Pa. Code 201.20(a)(d) Staff development.

Based on clinical record review and staff interviews, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for one of 13 residents reviewed (Resident 23).Findings include: Review of Resident 23's clinical record revealed diagnoses that included cerebrovascular disease (disease affecting blood flow to the brain), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). Further review of Resident 23's clinical record revealed that he was admitted to hospice services on July 7, 2025. Review of Resident 23's Minimum Data Set's (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of July 21, 2025, revealed that the assessment was still in progress with three sections lacking completion. During a staff interview with Employee 5 (the Registered Nurse Assessment Coordinator) on August 27, 2025, at 2:12 PM, Employee 5 confirmed that the significant change MDS had not been completed timely. She indicated that she had just completed and submitted it that day. During a staff interview with the Director of Nursing on August 27, 2025, at 2:25 PM, she confirmed that the MDS should have been completed timely. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that met each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 49).Findings include: Review of facility policy, titled Negative Pressure Wound Therapy [wound vac], last reviewed on September 10, 2024, revealed, in part, Change dressings per physician orders and manufacturer guidelines. 13. Turn pump on: a. initiate negative pressure setting on the pump as ordered (-125 mm/HG [milliliters of mercury] is a typical default setting;]. b. Establish negative pressure setting (as ordered). Document the following in the resident's medical record: 1. The wound status at time of application of negative pressure. 2. The number of sponge pieces used in the wound dressing. 3. The negative pressure and time settings on the pump. 4. The resident's tolerance of the procedure. 5. The date and time of the dressing application/change. 6. The date and time negative pressure therapy was started and stopped. 7. The name and initials of the person performing the procedure. Review of facility policy, titled Changing the Needless Connection Device and Extension Tubing, last reviewed on September 10, 2024, revealed, in part, 4. Change needless connection device with each dressing change and after blood draws as needed. 5. For multi-lumen catheters, change needleless connection device every 7 days for lumens not in use. Documentation 1. Document on treatment kardex when procedure was done. Review of Resident 49's clinical record revealed diagnoses that included acute and subacute endocarditis (a life-threatening inflammation of the inner lining of the heart's chambers and valves usually caused by an infection) and cellulitis (skin infection) of the chest wall. Review of Resident 49's physician orders revealed the following order: Wound vac therapy to left upper chest surgical wound continuous at 75mm/HG every shift document amount of drainage, dated August 17, 2025; and IV [intravenous]site - Change dressing once weekly and PRN [as needed]. Measure extending line and check for displacement. If more than 1 cm, notify physician for further orders dated August 25, 2025. Further review of Resident 49's physician orders failed to reveal an order for the frequency of his wound vac dressing changes or needleless connection device changes. Review of Resident 49's progress notes revealed a note dated August 18, 2025, at 8:24 PM, which indicated NPWT (Negative Pressure Wound Therapy] placed at 125, no leaks, currently charging, explained to patient about charging overnight, patient acknowledged that he understood the wound vac. The note failed to include the wound status at time of application of negative pressure, the number of sponge pieces used in the wound dressing, the time setting on the pump, or the resident's tolerance of the procedure. Review of Resident 49's progress notes revealed a note dated August 22, 2025, at 9:38 AM, which indicated Wound vac was changed per orders. Area is 5.0cm L by 2.5cm W. Wound bed is 90% granulation. There is a very light layer of about 10% slough at the very top of the wound. Resident denies pain to the area. Wound vac is currently plugged in, and he was encouraged to take the charger to dialysis with him. Vitals are stable this morning. The note failed to include the number of sponge pieces used in the wound dressing or the negative pressure and time settings on the pump. During an observation of Resident 49 on August 28, 2025, at 10:50 AM, with the Director of Nursing (DON), the DON indicated that the facility practice was to change wound vac dressings on Mondays, Wednesdays, and Fridays. Observation of Resident 49's dressing revealed that the dressing was not dated. During an immediate interview with Resident 49, he indicated that they did not change it last evening. He said, they changed it on Friday and Monday, but not yesterday. He further indicated that he was aware that the dressing was to be changed on Mondays, Wednesdays, and Fridays. Observation of Resident 49's wound vac pump on August 28, 2025, at 1:03 PM, with Employee 6 (Registered Nurse/Assistant Director of Nursing) revealed that Resident 49's wound vac pump was set on 125mm/HG, not the ordered 75 mm/HG. Review of Resident 49's progress notes failed to reveal any other documentation of his wound vac dressing changes or any documentation of the needleless connection device changes or baseline measurement of the extending line of the central IV line. Review of Resident 49's August 2025 Medication and Treatment Administration Records failed to reveal any documentation of wound vac dressing changes on August 20, 25, or 27, 2025; any needleless connection device changes; or any measurements of the extending line of the central IV line. During a staff interview with Employee 6 on August 28, 2025, at 2:05 PM, Employee 6 indicated that when she researched the setting on Resident 49's wound vac pump, she saw that the DON had addressed the wound vac pump setting that morning with Resident 49's physician because staff cannot change the pump settings as the pumps are pre-programmed. Employee 6 also indicated that the facility practice is to change the needleless connection devices with the weekly dressing changes. Employee 6 confirmed that the changing the needleless connection devices was not part of the order because it was a preset order in the facility's database, but that they could have entered a separate order. During a staff interview with Employee 3 (Executive Director), the DON, and Employee 6 (Registered Nurse/Assistant Director of Nursing) on August 28, 2025, at 2:22 PM, the DON indicated that nurses cannot edit batch orders in the facility database. The DON confirmed that Resident 49's wound vac setting was 125 mm/HG since it was placed on August 18, 2025. The DON indicated that she would expect staff to have followed physician orders for wound vac settings or to have addressed the issue with the pre-programmed pump setting when the order could not be followed at time of placement. The DON also confirmed that the wound vac dressing was missed on August 27, 2025. Employee 6 indicated that she had changed the dressing on August 25, 2025, before Resident 49 went to dialysis, but did not date the dressing or complete any documentation of the dressing change. The DON confirmed that there was no documentation of measurements of the extending line of the central IV line. The DON confirmed that there was no documentation of the needleless connection device changes being changed and that they should have been changed weekly. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on clinical record review, facility policy review, review of investigation documentation, as well and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse, resulting in actual harm as evidenced by skin tears, bruising, and mental anguish caused by rough treatment, for one of four residents reviewed (Resident 1). Findings include: Review of facility policy, Abuse, Neglect and Exploitation, effective November 1, 2017, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Residents must not be subject to abuse by anyone, including, but not limited to; Facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies, family members, legal guardians, friends or other individuals .The facility and its staff will: .not use verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion. Review of Resident 1's clinical record revealed diagnoses that included chronic congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and B-cell lymphoma (a type of blood cancer that affects your lymphatic system). Review of Resident 1's care plan revealed that he had a self-care deficit and needed assistance with toileting. Further review of his care plan revealed that he had potential for bleeding complications related to use of anticoagulants (blood thinners), and that he was to be handled gently during care, positioning and transfers. Review of facility Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property revealed On 1/26/25 [Employee 1], CNA [Certified Nurse Aide], was assigned to care for [Resident 1]. She took him to the bathroom and had difficulty getting him to stand after using the toilet. Per [Resident 1], [Employee 1] was rude to him, aggressive in her language, and kept grabbing him by the arm. Eventually [Employee 1] asked another CNA, [Employee 2], to come assist. [Employee 2] witnessed the mistreatment of [Resident 1] including verbal aggression and [Employee 1] grabbing him roughly by the arm. [Employee 2] intervened and asked [Employee 1] to calm down. Upon leaving the room [Employee 2] reported the event to the LPN [Licensed Practical Nurse] and the RN [Registered Nurse] supervisor. [Employee 1] was suspended pending investigation and a skin check was performed on [Resident 1]. He has bruising to his L [left] hand, a skin tear to his L inner forearm, and a skin tear to his L shin. All of this was reported to the MD [doctor] and first aide was administered. Review of Resident 1's witness statement, dated January 27, 2025, revealed, The day before yesterday I had a lot of strength. Yesterday I had no energy. She [Employee 1] was shoving me around like a rag doll. She said I saw you up yesterday moving around. She jerked me around in the bathroom and said I'm not playing games. Review of Employee 2's witness statement, dated January 26, 2025, revealed, Around 10 [Employee 1] asked me to help [Resident 1] in bathroom. She stated, 'he walked in fine yesterday' but today won't. When I went into the bathroom [Resident 1] was on toilet leaning she grabbed his left arm trying to put hand on rail couple times talking very rude and inappropriate. I told her to stop and tried to help him more gentle. During an interview with Employee 2 on January 30, 2025, at 12:20 PM, she revealed that on January 26, 2025, [Employee 1] asked her assist with getting Resident 1 up off of the toilet. Employee 2 stated that, while in the bathroom, Employee 1 was in front of Resident 1 aggressively pulling his left arm to place it on the rail next to the toilet for him to stand, but Resident 1's arm was not even long enough to reach the bar. Employee 2 reported that Resident 1 had three wrist bands on his left arm and Employee 1's hand was on top of the wrist bands when she was pulling his arm. Employee 2 stated she asked Employee 1 to stop pulling on Resident 1's arm, and repositioned him on the toilet so he was able to reach the rail. Employee 2 reported that Resident 1 was very weak and was having difficulty standing. Employee 2 stated that Employee 1 kept saying that Resident 1 was able to walk the day before, and seemed really upset that he couldn't walk to the bathroom when he did it the day before. Employee 2 stated that she felt the way Employee 1 talked to Resident 1 was not appropriate, and it was not the way someone should speak to another person. Employee 2 stated that once Resident 1 was in his wheelchair, they noticed he was bleeding on the underside of his wrist area. Employee 2 reported that the skin tear was approximately the size of one to two quarters, and bleeding was not present on Resident 1's wrist before the incident. Employee 2 stated that she reported the incident to Employee 5 (Licensed Practical Nurse [LPN]). Employee 2 and Employee 5 then put Resident 1 into bed. At that time they noticed blood on Resident 1's pant leg and found he had a skin tear on his left shin. Employee 2 stated that after the incident, Resident 1 seemed scared and shook up. Employee 2 also reported that when she cared for Resident 1 later in the shift, she noticed that the top of his left hand was black and blue. Review of Employee 5's witness statement dated January 26, 2025, revealed, At 10 am I observed [Employee 1] walk out of [Resident 1's] room and ask [Employee 2] for help. As [Employee 2] came out of [Resident 1's] room and stood at the nurse's station she was shaking her head, I asked her what happened, [Employee 2] stated, 'She was too much, she was rough with him in the bathroom.' I asked [Employee 2] who. She stated [Resident 1]. I asked [Employee 2] if she asked [Employee 1] to stop. [Employee 2] said 'yes,' but she kept on saying 'you were fine yesterday and now acting like you can't move, I'm not playing these games today.' I went to assess the resident and observed him breathing heavily seated in his wheelchair beside his bed. I observed blood running down his left leg. I asked [Employee 2] to assist me getting the resident in bed, @ that time observed resident had sustained a skin tear to his left wrist. [Employee 2] stated, 'That's where she kept grabbing his hand and forcing him to grab the siderail/handrails.' I notified the RN [Registered Nurse] supervisor of the incident. Review of Employee 3's (RN supervisor) witness statement dated January 26, 2025, revealed, This nurse called to [Resident 1's] room by LPN on duty. Resident stated he had rough care this am. Resident stated he did not feel safe with the accused caregiver caring for him. Resident was seen with a skin tear to L forearm and L shin. Resident's roommate stated accused caregiver was very rude and impatient. 2nd CNA present stated the accused caregiver was physically rough and short tempered with resident during care in the bathroom. During an interview with Employee 3 on January 30, 2025, at 10:38 AM, she reported that she went to assess Resident 1 after it was reported to her that he was mishandled by an employee. She stated that when she saw him, he was distraught, shaking and could not catch his breath. Resident 1 told her that he did not feel safe with Employee 1, and that he felt he was roughed around. Employee 3 stated that when she assessed Resident 1's skin tears, she found they were bleeding, and were nickel/quarter size (wrist) and dime size (shin). Employee 3 reported that Employee 5 cleaned up Resident 1's skin tears and applied steri-strips (surgical tape strips used to close small wounds). Employee 3 reported the incident to the on-call Assistant Director of Nursing (ADON) and sent Employee 1 home. During an interview with the ADON on January 30, 2025, at 11:11 AM, she reported that she became aware of the incident when it was reported to her on January 26, 2025, by Employee 3. She stated when she assessed Resident 1 on January 27, 2025, she noted the skin tears to his left wrist and shin were scabbed over. She also noted that the back of Resident 1's left hand was reddish-purple in color. She shared that when she questioned Resident 1 about the skin tear on his shin, he initially stated that Employee 1 kicked him, but then indicated that he was not sure exactly how it occurred. She noted that Resident 1 was slow and weak on that date, and ended up being sent to the hospital, where he was subsequently admitted , due to a decline in his condition. During an interview with Resident 2, Resident 1's roommate at the time of the incident, on January 30, 2025, at 11:55 AM, he revealed he was in the room at the time Employee 1 was providing care to Resident 1. Resident 2 stated that the curtain was partially pulled between the beds, but that he could hear the exchange and could see arms moving. Resident 2 reported that Employee 1 was very sassy, and that he told Resident 1 after she left that she should not be working there. Resident 2 stated that he did not recall exactly what was said between Employee 1 and Resident 1 but that it was hot and heavy, it was an angry exchange, and that in his opinion Employee 1 should be arrested because of the way she was acting and treating Resident 1. Review of Employee 1's witness statement dated January 26, 2025, revealed, When I went to do care on [Resident 1] this morning he stated that he couldn't do anything due to his neck injury. I told him that that's what he told me yesterday as well and he walked to and from the bathroom all day yesterday. He wouldn't sit up in the bed until I did it for him and then stood in the bathroom to get on the toilet. Once on the toilet he kept sliding sideways and trying to put himself on the floor. I told him to sit up numerous times and went and got [Employee 2] to help stand him again and finish his care. We put him back into his w/c [wheelchair]. Review of training documentation revealed that Employee 1 received abuse prevention training on October 2, 2024. During an interview with the Director of Nursing on January 30, 2025, at 9:47 AM, she revealed that Resident 1 was hospitalized with sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). She also revealed that Resident 1 had decided to press charges against Employee 1, Employee 1 was terminated, and that the facility was in the process of conducting abuse training with staff. During an interview with the Nursing Home Administrator on January 30, 2025, at 1:00 PM, he revealed the expectation that Employee 1 should have handled Resident 1 appropriately. The facility failed to ensure Resident 1 was free from abuse, resulting in actual harm as evidenced by skin tears, bruising, and mental anguish caused by rough treatment by Employee 1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights

Based on document review and staff interview, it was determined that the facility failed to ensure information regarding its transferred residents is forwarded to a representative of the Office of the State Long-Term Care Ombudsman for 32 of 37 residents transferred to the hospital for 8 of 9 months reviewed (January 2024-August 2024). Findings Include: A review of the facility's hospital transfer information beginning January 2024 revealed information regarding 32 of the 37 residents transferred was not shared with the State Long-Term Care Ombudsman. An interview with the Director of Social Services (Employee 3) on September 17, 2024, at 10:03 AM, revealed an awareness of the information not being sent and the expression that the transferred resident information would be forwarded beginning September 2024. 28 Pa. Code 201.14 (a) Responsibility of licensee

Based on select policy review, clinical record review and staff interview, it were determined that the facility failed to ensure that residents code status was accurate according to the residents wishes for two of 30 residents (Residents 2 and 189), which placed both residents at risk for harm and placed 28 residents at the facility in an Immediate Jeopardy situation (Residents 4, 8, 12, 18, 19, 23, 27, 28, 29, 30, 32, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 188, 190, 191, 192, 193, and 194). Findings Include: Review of the facility policy titled, DNR (Do Not Resuscitate-also known as no code or allow natural death, is a legal order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating) with a review date of (MONTH) 21, 2019, revealed The Pennsylvania specific form should be used to specify whether to administer CPR (Cardio-pulmonary Resuscitation-a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth) in case of a medical emergency. Pennsylvania specific form is: a. Pennsylvania Orders for Life-Sustaining Treatment (POLST). The Interdisciplinary Care Planning Team will review advance directives with the patient during the forty-eight-hour care plan meeting and with any change in condition to determine if the patient/legal representative wishes to make changes in such directives. The patient's Attending physician will clarify and present any relevant medical issues and decisions to the patient's or legal representative as the patient's condition changes in an effort to clarify and adhere to the patient's wishes. The physician will enter, sign, and date the Do Not Resuscitate (DNR) order in the following place: a. The POLST and/or Physician Order Sheet. b. The order must contain the words 'Do Not Resuscitate' or 'DNR'. Review of the facility's admission packet (a packet of information to include information about rights as a resident of a nursing facility) revealed d) Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). The Resident has a right to formulate advance directives consistent with applicable state and federal law. The Community shall act in accordance with the Resident's advance directives, if the advance directives are legally binding under applicable state law and the Resident provides the Community with a copy of the executed advance directives. It is the responsibility of the Resident to timely provide the Community with copies of the Resident's advance directives for reference and incorporation into the Resident's medical record. On (MONTH) 11, 2019, at 11:50 AM surveyors requested the advanced directive policy from the Director of Nursing (DON). At 12:33 PM the surveyors were still waiting on the advanced directive policy. At that time the surveyor asked the receptionist to get the DON for an update on the policy. At approximately 12:40 PM the DON provided the surveyors with a copy of the DNR policy and the CPR policy. The DON stated those were the only policies she could find related to advanced directives. Review of Resident's 2 clinical record revealed he was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Further review of Resident 2's clinical record revealed a document titled, Living Will Declaration signed by Resident 2 and witnessed by a Notary Public on (MONTH) 23, 2004, which revealed that Resident 2 did not want cardiac resuscitation. Further review of the Living Will revealed that Resident 2 appointed his wife as his surrogate and his children as additional surrogates, in case his wife is unable or unwilling to act for Resident 2. An additional review of Resident 2's clinical record revealed a POLST form, signed by Resident 2's daughter on (MONTH) 22, (YEAR), and signed by the physician on (MONTH) 17, (YEAR), stating that Resident 2 is a Do Not Attempt Resuscitation/DNR (Allow Natural Death). Review of Resident 2's physician orders as of (MONTH) 11, 2019, revealed an order dated (MONTH) 19, (YEAR), for a Full Code (meaning that CPR will be performed in the event Resident 2's heart stops). Review of Resident 2's electronic medical record revealed that Resident 2 was listed as a Full Code. Review of Resident 2's Medication Administration Record [REDACTED]. listed as FULL CODE revised on [DATE]; pt's POLST in his chart signed [DATE], by decision maker says DNR; physician signed on [DATE]-please re-eval (reevaluate) one time only for Verification on code status for 1 day starting on (MONTH) 29, 2019, at 6:00 AM. On (MONTH) 29, 2019, at 2:40 PM Licensed Practical Nurse (LPN) 2 put a check mark on the MAR, indicating that the code status was verified. As of (MONTH) 11, 2019, at 2:50 PM Resident 2's POLST stated DNR and Resident 2's physician order was for Full Code. Review of Resident 189's clinical record revealed that he was admitted to the facility on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Further review of Resident 189's clinical record revealed a form titled Living Will Health Care Directive signed by Resident 189 and witnessed by Notary Public on (MONTH) 16, 2005, that stated Resident 189 does not want cardiac resuscitation. As of (MONTH) 11, 2019, at approximately 11:30 AM Resident 189 did not have a completed POLST in his clinical record. Review of Resident 189's active orders as of (MONTH) 11, 2019, at 12:54 PM revealed an order written [REDACTED]. Review of Resident 189's electronic medical record revealed that Resident 189 was listed as a Full Code. During an interview with LPN 3 on (MONTH) 11, 2019, at 11:20 AM LPN 3 revealed in the event of an emergency staff would run to the resident's chart behind the desk and look for the code status noted on the POLST. LPN 3 also stated she would not take the time to look in the computer system to determine the resident's code status. During an interview with the nursing assistant (NA 1) on (MONTH) 11, 2019, at 11:43 AM NA 1 revealed in the event of an emergency she would find the nurse on my hall. NA 1 also stated she believes the resident code status is kept on chart. During an interview with Registered Nurse (RN) 1 on (MONTH) 11, 2019, at 11:45 AM RN 1 stated that if she needed to determine a resident's code status in an emergent situation, she would look in the paper chart at the physician orders, because it is easier than looking in the electronic medical record. She stated that in addition to the orders, she would also look at the resident's POLST. RN 1 was asked what she would do if there was a discrepancy with the orders and POLST and she stated that the Resident would be a Full Code until the discrepancy was verified. During an interview with LPN 1 on (MONTH) 11, 2019, at 11:47 AM LPN 1 stated that if he didn't know a Resident's code status during an emergent situation, he would look in their electronic medical record. On (MONTH) 11, 2019, at 1:15 PM the Director of Nursing (DON) was asked what staff were to do if a resident was found unresponsive and staff needed to know the code status of the resident. The DON stated that staff would go to the electronic health record, not the paper chart because that is too cumbersome. She stated that staff are always near a Kiosk, which are located on the wall in the hallways. The Nursing Home Administrator (NHA) and DON were notified of the Immediate Jeopardy situation on (MONTH) 11, 2019, at 2:50 PM. An immediate action plan was requested. The immediate action plan was provided by the NHA on (MONTH) 11, 2019, at 4:10 PM and was accepted on (MONTH) 11, 2019, at 5:05 PM. The plan included: -The code status of Resident 2 and Resident 189 was verified and entered consistently into all relevant locations within the electronic medical record. Resident 2 and Resident 189's charts were reviewed by the CRNP (Certified Registered Nurse Practitioner); she spoke with residents and families-both have current, active orders for Do Not Resuscitate. -Determining the code status or presence/absence of Advance Directives is required for all residents. Therefore, all residents have the potential to be affected. -The DON will educate social services, admission staff and all licensed nurses on duty regarding the documentation procedures for Advance Directives/code status. The RN on duty was trained and demonstrated a good understanding. He will educate all oncoming licensed staff regarding the documentation procedures for Advance Directives/code status. Education will be ongoing until all staff have been in-serviced. A chart audit of all residents was completed on (MONTH) 11, 2019. Discrepant findings were addressed immediately, and all needed actions were completed on (MONTH) 11, 2019. -All new admissions will be reviewed at time of admission; then every 24 hours at daily stand up. Once facility is 100% compliant for 30 days, then weekly. For a period of three months, the Director of Social Services or designee will perform weekly medical record audits of new admissions and those residents on the MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment schedule for consistent documentation of the resident's Advance Directive/code status throughout the electronic medical record and hard chart. After three months, the Director of Social Services will compete a random medical record audit of at least 10 records for consistent documentation. Results of the audits will be discussed monthly with the QAA committee until such time it is determined that substantial compliance is maintained. On (MONTH) 12, 2019, during an onsite visit, the Immediate Jeopardy was lifted at 2:05 PM after interviews were conducted with staff ensuring the immediate action plan had been implemented. The facility failed to ensure that residents' code status were accurate according to the residents wishes for two of 30 residents (Residents 2 and 189), which placed both residents at risk for harm and placed 28 residents at the facility in an Immediate Jeopardy situation (Residents 4, 8, 12, 18, 19, 23, 27, 28, 29, 30, 32, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 188, 190, 191, 192, 193, and 194). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.29(a) Resident rights. Previously cited [DATE]. 28 Pa. Code 201.29(d) Resident rights. Previously cited [DATE]. 28 Pa. Code 211.10(a)(b) Resident care policies. 28 Pa. Code 211.10(c) Resident care policies. Previously cited [DATE]. 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(c) Nursing services. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of job descriptions, facility policy review, clinical record review, and staff interviews, it was determined that the facility administration failed to effectively manage the code status for residents to ensure accuracy in accordance with the resident wishes, which placed the residents at harm and in an Immediate Jeopardy situation. Findings Include: Review of the job description for the Nursing Home Administrator (NHA), with a revision date of (MONTH) (YEAR), revealed in the Position Summary: Responsible for daily operations of the Skilled Nursing Facility and Assisted Living Facility in accordance with current applicable Federal, State, and local standards, guidelines, and regulations as directed by the policies and procedures. Ensures competence of the staff, appropriate staffing for resident setting, and facilitates clinical program development. Responsible for planning the appropriate utilization of resources, maintaining or improving the work environment, and monitoring and improving the quality and appropriateness of care. Review of the job description for the Director of Nursing (DON), with a revision date of (MONTH) (YEAR), revealed in the Position Summary: Responsible for the administration of nursing services in the Skilled Nursing Facility. Interprets facility policies and regulations to all nursing personnel and ensures compliance, as well as analyzes and evaluates nursing and related services rendered to improve quality of customer care and to better utilize staff time and abilities. Also ensures the provision of in-service training programs for nursing personnel. Further review of the job description under Job Function revealed Ensures that all physician orders [REDACTED]. Knowledge and implementation of all applicable regulations, facility and personnel policies and procedures and keeping nursing department in compliance with same. Review of the facility's admission packet (a packet of information to include information about rights as a resident of a nursing facility) revealed, d) Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). The Resident has a right to formulate advance directives consistent with applicable state and federal law. The Community shall act in accordance with the Resident's advance directives, if the advance directives are legally binding under applicable state law and the Resident provides the Community with a copy of the executed advance directives. It is the responsibility of the Resident to timely provide the Community with copies of the Resident's advance directives for reference and incorporation into the Resident's medical record. Review of Resident 2's clinical record revealed he was admitted to the facility on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. Further review of Resident 2's clinical record revealed a document titled, Living Will Declaration signed by Resident 2 and witnessed by a Notary Public on (MONTH) 23, 2004, revealed that Resident 2 does not want cardiac resuscitation. Further review of the Living Will revealed that Resident 2 appointed his wife as his surrogate and his children as additional surrogates, in case his wife is unable or unwilling to act for Resident 2. An additional review of Resident 2's clinical record revealed a POLST form, signed by Resident 2's daughter on (MONTH) 22, (YEAR), and signed by the physician on (MONTH) 17, (YEAR), stating that Resident 2 is a Do Not Attempt Resuscitation/DNR (Allow Natural Death). Review of Resident 2's physician orders [REDACTED]. Review of Resident 2's electronic medical record revealed that Resident 2 was listed as a Full Code. Review of Resident 2's Medication Administration Record [REDACTED]. On (MONTH) 29, 2019, at 2:40 PM Licensed Practical Nurse (LPN) 2 put a check mark on the MAR, indicating that the code status was verified. As of (MONTH) 11, 2019, at 2:50 PM Resident 2's POLST stated DNR and Resident 2's physician order [REDACTED]. Review of Resident 189's clinical record revealed that he was admitted to the facility on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Further review of Resident 189's clinical record revealed a form titled Living Will Health Care Directive signed by Resident 189 and witnessed by Notary Public on (MONTH) 16, 2005, that stated Resident 189 does not want cardiac resuscitation. As of (MONTH) 11, 2019, at approximately 11:30 AM Resident 189 did not have a completed POLST in his clinical record. Review of Resident 189's active orders as of (MONTH) 11, 2019, at 12:54 PM revealed an order written [REDACTED]. Review of Resident 189's electronic medical record revealed that Resident 189 was listed as a Full Code. During an interview with Licensed Practical Nurse (LPN) 3, on (MONTH) 11, 2019, at 11:20 AM LPN 3 revealed in the event of an emergency staff would run to the resident's chart behind the desk and look for the code status noted on the POLST. LPN 3 also stated she would not take the time to look in the computer system to determine the resident's code status. During an interview with Nursing Assistant (NA) 1, on (MONTH) 11, 2019, at 11:43 AM NA 1 revealed in the event of an emergency she would find the nurse on my hall. NA 1 also stated she believes the resident code status is kept on chart. During an interview with Registered Nurse (RN) 1 on (MONTH) 11, 2019, at 11:45 AM RN 1 stated that if she needed to determine a resident's code status in an emergent situation, she would look in the paper chart at the physician orders, because it is easier than looking in the electronic medical record. She stated that in addition to the orders, she would also look at the resident's POLST. RN 1 was asked what she would do if there was a discrepancy with the orders and POLST and she stated that the resident would be a Full Code until the discrepancy was verified. During an interview with LPN 1 on (MONTH) 11, 2019, at 11:47 AM LPN 1 stated that if he didn't know a resident's code status during an emergent situation, he would look in their electronic medical record. The NHA and DON were notified of the Immediate Jeopardy situation on (MONTH) 11, 2019, at 2:50 PM. An immediate action plan was requested. The immediate action plan was provided by the NHA on (MONTH) 11, 2019, at 4:10 PM and was accepted on (MONTH) 11, 2019, at 5:05 PM. The plan included: -The code status of Resident 2 and Resident 189 was verified and entered consistently into all relevant locations within the electronic medical record. Resident 2 and Resident 189's charts were reviewed by the CRNP (Certified Registered Nurse Practioner); she spoke with residents and families-both have current, active orders for Do Not Resuscitate. -Determining the code status or presence/absence of Advance Directives is required for all residents. Therefore, all residents have the potential to be affected. -The DON will educate social services, admission staff and all licensed nurses on duty regarding the documentation procedures for Advance Directives/code status. The RN on duty was trained and demonstrated a good understanding. He will educate all oncoming licensed staff regarding the documentation procedures for Advance Directives/code status. Education will be ongoing until all staff have been in-serviced. A chart audit of all residents was completed on (MONTH) 11, 2019. Discrepant findings were addressed immediately, and all needed actions were completed on (MONTH) 11, 2019. -All new admissions will be reviewed at time of admission; then every 24 hours at daily stand up. Once facility is 100% compliant for 30 days, then weekly. For a period of three months, the Director of Social Services or designee will perform weekly medical record audits of new admissions and those residents on the MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment schedule for consistent documentation of the resident's Advance Directive/code status throughout the electronic medical record and hard chart. After three months, the Director of Social Services will compete a random medical record audit of at least 10 records for consistent documentation. Results of the audits will be discussed monthly with the QAA committee until such time it is determined that substantial compliance is maintained. On (MONTH) 12, 2019, during an onsite visit, the Immediate Jeopardy was lifted at 2:05 PM after interviews were conducted with staff ensuring the immediate action plan had been implemented. The facility administration failed to effectively manage the code status for residents to ensure accuracy in accordance with the resident wishes which placed the residents at harm and in an Immediate Jeopardy situation. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/19/18, 10/10/18, 7/2/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/10/18, 7/2/18, 6/24/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/13/19, 12/19/18, 10/10/18, 7/2/18. 28 Pa. Code 201.18(e)(2) Management. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 211.12(c) Nursing services. Previously cited 7/1/19, 10/10/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 12/19/18, 7/2/18, 5/7/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/1/19, 3/29/19, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 6/24/18, 5/7/18, 7/20/17.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with physicians' orders, regarding treatment and assessment of an injury after a fall, resulting in harm of a fractured left 5th finger, which required surgery, for one of 14 resident records reviewed (Resident 19). Findings Include: Review of Resident 19's clinical record revealed [DIAGNOSES REDACTED]. to perform everyday activities). Review of Resident 19's clinical record revealed that she had a fall on (MONTH) 18, 2019. Review of facility's incident report for Resident 19 revealed that another resident at the facility observed Resident 19 attempt to wheel herself to the bathroom, lean to her left buttocks and begin to quickly slide onto her left knee. The witness stated that Resident 19 was attempting to stop her fall with her left hand when her left small (report does not indicate what 'left small' means) got caught between the wheelchair and the pressure relieving cushion. The report goes on to say that the nurse attempted to evaluate Resident 19, but she became agitated and combative and since it appeared, she was not injured, the staff assisted her back to bed. The Registered Nurse (RN) who was on duty assessed Resident 19 and noted a reddened and slightly swollen left pinky finger. Review of the RN statement on Resident 19's incident reported revealed I saw her finger and asked if I could look at it, but she shied away from me. I told her I was concerned it might be injured. She refused. I suggested an X-ray; she adamantly refused. The patient is very protective of the finger and would not let staff near the finger. Review of the incident report for Resident 19 revealed under Immediate Action Taken: Patient was reassured and comforted. Ice offered. She did tape up her 'pinky finger.' She again refused to have the finger X-rayed. The report states that the on-call physician was notified of the incident and that the resident's daughter was made aware. Review of Resident 19's progress note, written by the Nursing Home Administrator (NHA) who is also a RN dated (MONTH) 18, 2019, at 5:30 PM revealed I caught a glimpse of her left small finger. It was deep red/purple and asked her if I could see it. She quickly pulled her hand from out of my reach and shooshed me, saying it's okay. The progress note states that Resident 19 continuously asked for tape, the NHA gave Resident 19 tape and then left the room. When the NHA came back, the note states that Resident 19 had taped up her left pinky finger. The note states that Resident 19 was very secretive and did not want anyone to know about the finger. Resident 19 stated that when she fell , she bent it backward on the wheelchair. According to the progress note, the NHA suggested an X-ray a few times, but Resident 19 refused. The NHA provided her with an ice pack, which the note states Resident 19 used off and on. The progress note concludes stating that the NHA emphasized to the nurse to monitor her for pain, and to keep an eye on the left 'pinky' finger. Review of progress notes revealed a note dated (MONTH) 24, 2019, at 10:43 AM stating that the writer met with Resident 19 and noticed her left pinky and middle finger were taped together. Resident 19 stated, 'I thought it would be better by now, but it is not. Resident 19 agreed to have an X-ray done since the finger was not getting better. Review of Resident 19's progress notes revealed no mention of her pinky finger being assessed and no mention of the fingers being taped, since the initial note from (MONTH) 18, 2019. Review of Resident 19's clinical record revealed no evidence that Resident 19 had been re-approached about getting an X-ray, since (MONTH) 18, 2019 until (MONTH) 24, 2019. Further review of the clinical record revealed no orders to tape the fingers or apply ice and no evidence that the physician assessed the finger. On (MONTH) 24, 2019, Resident 19 had an X-ray of the left hand. Review of the X-ray results revealed flexion/subluxation (an incomplete or partial dislocation of a joint) at the PIP (proximal interphalangeal joint-the joints between the proximal and middle bones of the fingers) area of the 5th finger. Clinical correlation is recommended. Follow-up studies throughout therapy are also recommended for comparison. Review of progress note dated (MONTH) 28, 2019, by the CRNP (Certified Registered Nurse Practitioner) revealed no mention of the left 5th finger. Review of progress note dated (MONTH) 1, 2019, revealed Doctor in to see resident and evaluated left pinkie finger. States to leave unwrapped and no further treatment. Review of progress note from the CRNP dated (MONTH) 2, 2019, at 1:35 PM revealed left 5th finger deformity noted with significant subluxation of the finger. tender to palpations. Left 5th finger subluxation, spoke to daughter at length regarding significant subluxation. Daughter request an orthopedic (a physician who specializes in [DIAGNOSES REDACTED]. Will request referral to attempt to see in AM. Review of Resident 19's form Report of Consultation revealed that she was seen by orthopedics on (MONTH) 3, 2019. Review of the consultation revealed [DIAGNOSES REDACTED]. Review of a nursing progress note dated (MONTH) 8, 2019, revealed that Resident 19 is scheduled for surgery on her left 5th digit on (MONTH) 11, 2019. Review of Resident 19's physician note by the CRNP, dated (MONTH) 9, 2019, revealed Left 5th finger deformity noted with significant subluxation of the finger. tender to palpation. The progress note states that the resident was evaluated by orthopedics and was scheduled for surgical correction on (MONTH) 11, 2019. Review of Resident 19's progress note dated (MONTH) 11, 2019, revealed that Resident 19 returned to the facility with a pinning of the left pinky finger with instructions for dressing to remain intact until her next appointment on (MONTH) 23, 2019, and to elevate her left upper extremity and apply ice as needed. Resident 19 had a follow-up appointment with orthopedics on (MONTH) 23, 2019, and they applied a splint to her left small finger. During an interview on (MONTH) 13, 2019, at 12:35 PM the NHA stated that at the time of the incident, Resident 19 was protective of her finger. She kept it taped up and she taped it herself. NHA stated that she reported off to the next nurse to monitor the finger. She stated that she would expect the nurses to assess Resident 19, re-approach her about her finger and X-ray, every shift or at least once a day. NHA stated that there was a delay in getting Resident 19 care for her finger. At that time, the NHA also stated that staff should have been assessing the finger since Resident 19 taped it herself, making sure the tape wasn't too tight, her finger had good circulation and that the tape wasn't causing additional injury. Resident 19 taped her finger herself and there was no physician order to do so. The facility failed to ensure that residents received treatment and care in accordance with physicians' orders, regarding treatment and assessment of an injury after a fall, resulting in harm of a fractured left 5th finger, which required surgery, for one of 14 resident records reviewed (Resident 19). 42 CFR 483.25 Quality of Care. Previously cited 7/1/19, 3/29/19, 10/10/18, 5/7/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/19/18, 10/10/18, 7/2/18. 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 10/10/18, 7/2/18, 6/24/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 1/13/19, 12/19/18, 10/10/18, 7/2/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 12/19/18, 7/2/18, 5/7/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/1/19, 3/29/19, 10/10/18, 7/2/18, 5/7/18, 7/20/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 6/24/18, 5/7/18, 7/20/17.

Based on interviews and record reviews it was determined that the facility failed to adequately supervise each resident to prevent accidents. This failure resulted in the resident having a fall with harm in the form of a subdural hematoma, and ultimately death, for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed she was admitted to the facility on (MONTH) 30, 2019, with [DIAGNOSES REDACTED]. At the time of admission Resident 1 was recovering from surgery on her left lower arm and was in a splint with an Ace wrap on the left arm. Upon admission Resident 1 was assessed for risk of falling. This assessment was conducted using the Morse Fall Scale and documented as completed at 4:35 PM on (MONTH) 30, 2019. The Morse Fall scale form revealed a section titled Instructions: this section continued, fall risk is based upon fall risk factors and it is more than a total score. Determine Fall Risk Factors and Target Interventions to reduce risks. Complete on admission, quarterly, at change of condition, and after falls. The final section of the Morse Fall Scale is titled: Scoring. The scoring system is ,[DATE] low risk for falls, ,[DATE] Moderate risk for falls, and 45 and higher is a High risk the resident will have a fall. Resident 1 scored a 75 on the Morse Fall scale, nearly double the minimum for High Risk. Review of Resident 1's individualized plan of care that was current at the time of her fall on (MONTH) 30, 2019, revealed a focus care area which read, The resident is at risk for falls related to Gait/balance problems, recent fall at home. The interventions for this focus area were to, anticipate and meet the resident's needs and Physical Therapy to evaluate and treat as ordered or PRN (as needed). Further review of Resident 1's care plan revealed a hand-written note on this focused care area, was this a realistic goal for a 92 y o (year old)? During an interview with the Nursing Home Administrator on (MONTH) 11, 2019, at approximately 12:15 PM it was revealed these notes were written by her, during the review of the fall. Further review of Resident 1's clinical record revealed she had an unwitnessed fall on (MONTH) 30, 2019, in which Resident 1 was alone in her room. At 8:12 PM a family member of another resident alerted the staff that Resident 1 had fallen. The staff assessed her throughout the night and at approximately 7:45 AM on (MONTH) 31, 2019, Resident 1 was noted to be unresponsive. The resident was ordered to be transported to the acute care hospital immediately. Resident 1 died in the hospital on (MONTH) 1, 2019. The official cause of death noted on her death certificate is subdural hematoma (brain bleeding), secondary to a fall. The facility failed to develop and implement an individualized plan of care that adequately supervised a resident who was noted to be a very high fall risk, related to abnormality of gait and mobility, weakness, history of falls, recent surgery, and her left arm being in a splint and Ace wrap. This failure resulted in an accident hazard which resulted in an unwitnessed fall, subdural hematoma, and the death of Resident 1. During an interview with the Nursing Home Administrator on (MONTH) 1, 2019, at approximately 11:40 AM it was revealed that the care plan was not adequate. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited [DATE]. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.5(f) Clinical records. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.11(d) Resident care plan. Previously cited [DATE]. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(c) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].