Every finding on record at Watsontown Rehabilitation and Nursing Center

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to appropriately respond to a resident's change in condition for two of five residents (Resident R1 and R21).Findings include: Review of the United States Food and Drug Administration prescribing information for duloxetine (Cymbalta, an antidepressant medication) dated 08/2023, indicated, in the Warnings and Precautions section revealed abnormal bleeding was included. Review of the facility policy, Change in Condition dated 6/1/25, indicated, The facility shall notify the resident, his or her attending physician, and representative of changes in theresident's medical/mental condition and/or status. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 1/13/26, included diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and history of a stroke. Review of Resident R1's physician orders indicated Resident R1 was ordered fluoxetine (Prozac, an antidepressant medication) originally on 11/19/22, and continuously reordered without a gap in the orders on 2/24/24, 4/23/24, 7/31/25, and 10/1/25, through 1/30/26. Review of a psychiatry progress note dated 1/26/26, 7:00 p.m. indicated Resident R1's dosage of fluoxetine was to be increased from 30 mg daily to 40 mg daily. Review of a physician's order dated 1/30/26, indicated for Resident R1 duloxetine 40 mg once daily. Review of Resident R1's Medication Administration Records (MARs) for January 2026, and February 2026, indicated Resident R1 received duloxetine on 1/30/26, 1/31/26, and 2/1/26. Review of a progress note dated 1/29/26, at 2:21 p.m. indicated, Psychiatric consult has made the following recommendation that Prozac from 30mg daily to 40mg for MDD (major depressive disorder). Review of a progress note dated 2/1/26, at 3:49 a.m. indicated, Resident noted to have bloody tissues and a small blood clot on their tray table. When prompted resident stated he doesn't know how it got there or where it came from. Resident was noted to have a bit of dried blood around his nares. Resident had no other complaints at this time. Review of a progress note dated 2/2/26, at 12:24 a.m. indicated, Resident received incorrect medication Duloxetine 40mg X 3 doses. Placed on Alert charting with vital signs QShift (every shift) for 24hrs. Review of a progress note dated 2/3/26, at 10:22 p.m. indicated, Resident noted to have active epistaxis (nosebleed) with large blood clots present. Vitals WNL (within normal limits), resident has no c/o dizziness or light headiness. Pressure applied to nares and blood cleansed from surrounding skin. Review of a progress note dated 2/4/26, at 5:49 a.m. indicated, Resident noted to have intermittent epistaxis beginning on second shift yesterday and continuing into third shift overnight, with increasing frequency and amount. During most recent episode, large clots observed. Resident had tissue placed in nares and refused removal, stating no, don't remove it if you do it just drips and drips. Tissue left in place per resident request. Medical provider notified of recurrent nosebleeds with clot formation. New orders received to hold Eliquis (anticoagulant medication) and aspirin for three (3) days and initiate alert charting. Review of a progress note dated 2/4/26, at 7:50 a.m. indicated, Upon arrival resident noted to have blood dripping from nose with large clot size of half dollar. Blood noted to be on floor to right of bed at approx. 15mls. Pressure applied x 15 minutes with no relief. Tissue wrapped and placed up right nostril. Active bleeding continues. Resident complains of weakness and dizziness. The progress note further indicated Resident R1 was provided orders to go to the hospital for cauterization. During an interview on 3/13/26, at 10:45 a.m. Licensed Practical Nurse (LPN) Employee E7 stated that excessive bleeding can be an adverse effect of anticoagulant use. When listing side effects to look for in a resident taking duloxetine, LPN Employee E7 was unaware that excessive bleeding can be an effect. During an interview on 3/13/26, at 10:55 a.m. LPN Employee E8 stated that nosebleeds can be an adverse effect of anticoagulant use. When asked what side effects to look for in a resident taking duloxetine, LPN Employee E8 stated, I honestly don't know. During an interview on 3/13/26, at 10:59 a.m. LPN Employee E9 stated that nosebleeds can be an adverse effect of anticoagulant use. When listing side effects to look for in a resident taking duloxetine, LPN Employee E9 stated only behavioral side effects. During an interview on 3/13/26, at 11:05 a.m. LPN Employee E10 stated that nosebleeds can be an adverse effect of anticoagulant use. When listing side effects to look for in a resident taking duloxetine, LPN Employee E10 confirmed that excessive bleeding can be an effect, and stated that after Resident R1 was hospitalized , she and other staff looked up the side effects of duloxetine as they were unaware that excessive bleeding can be an effect. During an interview on 3/13/26, at 2:15 p.m. LPN Employee E11 stated that bruising and excessive bleeding can be adverse effects of anticoagulant use. When listing side effects to look for in a resident taking duloxetine, LPN Employee E11 stated only behavioral side effects. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of anemia (too little iron in the body causing fatigue), urinary tract infection, and the presence of a pressure ulcer (injury to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). Review of a progress note dated 3/8/26, at 11:52 a.m. indicated, Resident had bottle of mixed pills in her room, staff is unaware what she took. All medication in the room was taken out of room and given to the RN (registered nurse) supervisor. CNA (nurse aide) came out of this resident room and notified, this writer that resident had multiple bottles of pills in her room. Resident this morning had slurred speech, leaning to the side, eye pinpoint. RN supervisor notified and made aware. This writer went back to resident room and educated resident we can't allow bottle of pills in her room. We will have to take all medication and hand it in to the supervisor. She was worried if she was going to get the medication back if she leaves here. Medication was taken to supervisor at the nursing station, resident had multiple bottles of mixed pills. There was Creon (pancreatic enzyme), Tylenol 3's (acetaminophen and codeine combination medication), Mucinex (expectorant), Tylenol Pm (acetaminophen and Benadryl combination medication) and a lot more. Resident's husband came in and he was notified of the pill situation, and that he will have to take all medication home she wasn't allowed to have medication in her room due to policies here. He came out multiple times to try and get the medication to take back into the room, Husband was informed we can only give him the medication when he is about to leave. This writer was also worried what she took this morning all AM medications were held except the Creon that the RN supervisor told this writer to give. Residents husband came out of the room and stated, she need pain medication. RN supervisor was made aware. RN said it was fine to give, but this writer was still concerned about what she took prior to us finding the pills in her room, with all the slurred speech, leaning to the side, and eyes pinpoint. Review of a progress note dated 3/8/26, at 1:08 p.m. indicated the RN Supervisor provided pain medication to Resident R21. Review of Resident R21's medication administration record revealed Resident R21 received Tramadol (a narcotic pain medication) on 3/8/26, at 11:18 a.m. and gabapentin (medication to treat seizures and pain, with the side effect of drowsiness) at approximately 2:00 p.m. Review of a progress note dated 3/8/26, at 3:37 p.m. indicated, This resident had a large amount of medications in various pill bottles/container. These were removed from the bedside. She has T-3 tabs which were recognized and investigated. It is this writer's perception that she may have taken these independently as this am she had slurred speech and appeared to be under the influence. Review of a progress note dated 3/8/26, at 6:15 p.m. indicated, Spouse and son report increase in altered mental status and request she be sent to ED (emergency department). Call placed to on call [provider] new order received to send to ED for evaluation and treatment. Family updated, 911 called for transport. Further review of Resident R21's progress notes failed to reveal that the possibility of Resident R3 consuming narcotic pain medication (Tylenol-3) when symptomatic for opiate ingestion was addressed by the facility and failed to reveal documentation of notification to the provider of possible consumption of narcotic pain medication in addition to the Tramadol provided by the RN Supervisor and the gabapentin provided by LPN E12 until concerns voiced by family members. During an interview on 3/15/26, at approximately 1:30 p.m. the Nursing Home Administrator and the Director confirmed the facility failed to appropriately respond to a resident's change in condition for two of five residents. 483.25 Quality of CarePreviously cited 9/12/25 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop person-centered care plans related to safe positioning during meals for 19 of 32 residents (Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20).Findings include: Review of the facility, Comprehensive Care Plan Policy dated 6/4/25, indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 3/2/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), brain cancer, and dysphagia (difficulty swallowing). Review of Resident R2's Speech Therapy Discharge summary dated [DATE], included the discharge recommendation of, out of bed for meals. During an interview on 3/13/26, at 10:48 a.m. the Director of Rehabilitation Employee E1 confirmed that Resident R2 needed to be out of bed and/or seated upright to consume meals safely. Review of Resident R2's care plan for nutritional problems reviewed 3/12/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R2's Kardex failed to include directions for assisting the resident out of bed for meals. Review of a list of residents, provided by the Director of Rehabilitation, on 3/13/26, included 32 residents that required staff to ensure they are out of bed during meals for swallowing safety. Of those 32 residents, the following was noted: Review of Resident R3's care plan for dysphagia reviewed 1/6/26, failed to include interventions related to safe positioning for meals. Review of Resident R3's Kardex (document that outlines the patients' activities of daily living [ADLs], continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies utilized by nurse aide staff) failed to include directions for assisting the resident out of bed for meals. Review of Resident R4's care plan for nutritional risk related to therapeutic diet with thickened liquids reviewed 3/10/26, failed to include interventions related to safe positioning for meals. Review of Resident R4's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R5's care plan for nutritional problem related to history of difficulty chewing related to poor dentition with need for texture modified diet reviewed 2/3/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R5's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R6's care plan for dysphagia reviewed 1/29/26, indicated Speech Therapy to address deficits through active treatment plan but failed to any further information on interventions included in that treatment plan and failed to include interventions related to safe positioning for meals. Review of Resident R6's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R7's care plan for nutritional risk related to therapeutic and mechanically altered diet reviewed 1/20/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R7's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R8's care plan for biting/chewing difficulty reviewed 2/10/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R8's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R9's care plan for inadequate oral intake reviewed 1/27/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R9's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R10's care plan for limited food acceptance reviewed 2/26/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R10's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R11's care plan for swallowing problem related to dysphagia reviewed 2/26/26, failed to include interventions related to safe positioning for meals. Review of Resident R11's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R12's care plan for inadequate oral intake and the need for altered textured diet reviewed 3/10/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R12's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R13's care plan for dysphagia reviewed 12/23/25, indicated Speech Therapy to address deficits through plan of care but failed to any further information on interventions included in that treatment plan and failed to include interventions related to safe positioning for meals. Review of Resident R13's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R14's care plan for potential for biting/chewing difficulties related to lack of teeth reviewed 12/18/25, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R14's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R15's care plan for dysphagia reviewed 1/6/26, indicated Speech Therapy to address deficits through active treatment plan but failed to any further information on interventions included in that treatment plan and failed to include interventions related to safe positioning for meals. Review of Resident R15's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R16's care plan for dysphagia reviewed 2/26/26, indicated Speech Therapy to address deficits through active treatment plan but failed to any further information on interventions included in that treatment plan and failed to include interventions related to safe positioning for meals. Review of Resident R16's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R17's care plan for nutritional problem: altered texture diet reviewed 2/24/26, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R17's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R18's care plan for inadequate oral intake reviewed 12/16/25, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R18's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R19's care plan for nutritional problems reviewed 2/26/25, indicated that speech therapy would screen the resident but failed to include interventions related to safe positioning for meals. Review of Resident R19's Kardex failed to include directions for assisting the resident out of bed for meals. Review of Resident R20's care plan for nutritional problem related to CVA (cerebrovascular accident, stroke) reviewed 2/17/25, indicated to monitor for signs and symptoms of dysphagia but failed to include interventions related to safe positioning for meals. Review of Resident R20's Kardex failed to include directions for assisting the resident out of bed for meals. During interviews completed on 3/13/26, nurse aide staff were asked to state how they know if a resident has specific positioning requirements for meals. Nurse Aide (NA) Employee E2 stated that they review the Kardex.NA Employee E3 demonstrated how to navigate to the Kardex on the electronic hallway kiosk.NA Employee E4 stated that they review the kiosk or if they know they are a high aspiration risk.NA Employee E5 stated that they use a paper census sheet. Review of the census sheet at this time revealed that meal positioning requirements were not documented on the sheet.NA Employee E6 stated that they review the kiosk. During an interview on 3/13/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that resident care plans failed to consistently include meal positioning requirements which prevented nurse aide staff from having accurate information available to provide safe care. During an interview on 3/13/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to develop person-centered care plans related to safe positioning during meals for 19 of 32 residents. 483.21 (b)(1)(i) Comprehensive care planPreviously cited 9/12/25 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation, review of facility policy, resident interviews, clinical records, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of five residents reviewed (Resident R1).Findings include: Review of the United States Food and Drug Administration prescribing information for duloxetine (Cymbalta, an antidepressant medication) dated 08/2023, indicated, The recommended starting dosage in adults with MDD is 40 mg/day (given as 20 mg twice daily). Review of the facility policy Medication Error Reporting dated 6/4/25, indicated medication errors are documented and reported in an effort to identify the causes of the errors and develop strategies to prevent medication errors. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 1/13/26, included diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and history of a stroke. Review of Resident R1's physician orders indicated Resident R1 was ordered fluoxetine (Prozac, an antidepressant medication) originally on 11/19/22, and continuously reordered without a gap in the orders on 2/24/24, 4/23/24, 7/31/25, and 10/1/25, through 1/30/26. Review of a psychiatry progress note dated 1/26/26, 7:00 p.m. indicated Resident R1's dosage of fluoxetine was to be increased from 30 mg daily to 40 mg daily. Review of a physician's order dated 1/30/26, indicated for Resident R1 duloxetine 40 mg once daily. Review of Resident R1's Medication Administration Records (MARs) for January 2026, and February 2026, indicated Resident R1 received duloxetine on 1/30/26, 1/31/26, and 2/1/26. Review of a progress note dated 1/29/26, at 2:21 p.m. indicated, Psychiatric consult has made the following recommendation that Prozac from 30mg daily to 40mg for MDD (major depressive disorder). Review of a progress note dated 2/2/26, at 12:24 a.m. indicated, Resident received incorrect medication Duloxetine 40mg X 3 doses. Placed on Alert charting with vital signs QShift (every shift) for 24hrs. During an interview on 3/13/26, at approximately 10:30 a.m. the Director of Nursing confirmed that duloxetine was inadvertently ordered in place of fluoxetine. During an interview on 3/13/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that facility failed to make certain that residents are free of significant medication errors for one of five residents. 28 Pa Code: 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(1)(3) Nursing Services. 28 Pa Code: 201.18 (b)(1)(3) Management.

Based on review of select facility policies, observation, clinical record review, and staff and resident interview, it was determined that the facility failed to assess for the risk of side rail entrapment for 6 of 7 residents reviewed for accident hazards (Residents 2, 6, 8, 22, and 64). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become trapped. FDA is recommending 60 mm (two and three-eighths inches) as an appropriate dimension for neck diameter. The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA concurs with the dimension of 318 mm (12.5 inches) to represent chest depth for the population vulnerable to entrapment and has used this dimension as the basis for its recommended dimensional limits. This guidance describes seven zones in the hospital bed system where there is potential for patient entrapment. Zone six is the space between the end of the rail and the side edge of the headboard or footboard. This space may present a risk of either neck entrapment or chest entrapment. Review of the facility's current policy entitled Bed Safety, last reviewed June 4, 2025, revealed it is the facility's policy when using side rails for any reason, the staff shall take measures to reduce related risks. A Bed Entrapment Grid attached to the policy revealed areas of entrapment risk include zone one (within the rail), two (between the top of compressed mattress to the bottom of the rail, between rail and supports), three (in the horizontal space between rail and mattress), four (between the top of the compressed mattress and the bottom of the rail at the end of the rail), and zone 6 (entrapment between the rail and the edge of the head/foot board). Observation of Resident 8 on September 10, 2025, at 11:08 AM revealed she was in bed. Her bed was equipped with a headboard, footboard, and an assist rail on the right side of her bed. Clinical record review for Resident 8 revealed an active physician's order dated October 20, 2023, for her to have a right bed rail to assist her with increased mobility in bed and with transfers as able. A Bed System Measurement Device Test Results Worksheet dated September 3, 2025, indicated that the bed rail installed for Resident 8 passed inspection for zones one through four; however, zone four was only assessed at the proximal edge of the rail (closest to the headboard). Zone four was not assessed at the distal end (closest to the footboard). There was no evidence that other potential risks were assessed such as the area between her mattress and her headboard/footboard (zone seven) or the area between the edge of the siderail and the headboard (zone six). Observation of Resident 22's room on September 9, 2025, at 1:26 PM revealed a right-sided bed rail installed on his bed. Clinical record review for Resident 22 revealed an active physician's order dated September 1, 2025, for the use of a right-sided bed rail to increase bed mobility. A Bed System Measurement Device Test Results Worksheet dated September 3, 2025, indicated that the bed rail installed for Resident 22 passed inspection for zones one through four; however, zone four was only assessed at the proximal edge of the rail. Zone four was not assessed at the distal end. There was no evidence that other potential risks were assessed such as the area between her mattress and her headboard/footboard (zone seven) or the area between the edge of the siderail and the headboard (zone six). Interview with Employee 3 on September 11, 2025, at 12:25 PM revealed that he was told by someone, that zone four for the distal part of the rail was not assessed because there were no split rails on the bed; however, he confirmed that his directions indicate that zone four is the distance between the bottom of the rail and the mattress, which was applicable for Resident 8's and Resident 22's rails. The surveyor reviewed the above concerns regarding Resident 8's and Resident 22's bed rails during an interview with the Nursing Home Administrator and the Director of Nursing on September 11, 2025, at 2:30 PM. Observation of Resident 2 on September 9, 2024, at 12:10 PM revealed she was in bed sleeping. Bilateral enabler bars were observed on her bed. In a follow up interview with Resident 2 on September 10, 2025, at 10:41 AM she stated she uses the enabler bars to move in bed and hold herself to her side during care. Review of a Bed System Measurement Device Test Results Worksheet dated September 3, 2025, revealed facility staff assessed Resident 2 for the risk of entrapment for zones one through four. There was no evidence that the resident was assessed for the zone 6 the area between the rail and the headboard. Observation of Resident 64's bed on September 10, 2025, at 10:18 AM revealed an enabler bar on the left side of her bed. Resident 64 indicated she used the enabler bar to move around in bed. In an interview with Employee 3, maintenance director, on September 11, 2025, at 12:24 PM, Employee 3 confirmed zone 6 was identified in the facility's policy for bed entrapment zones as a potential risk of entrapment. Employee 3 also confirmed there was no evidence zone 6 was assessed for Residents 2 and 62. Observation of Resident 6's bed on September 10, 2025, at 9:14 AM revealed an enabler bar on the left side of his bed. Resident 6 indicated he uses the enabler bar to move around in bed. Review of a Bed System Measurement Device Test Results Worksheet dated September 3, 2025, revealed facility staff assessed Resident 6 for the risk of entrapment for zones one through four. There was no evidence the resident was assessed for the risk a zone 6 between the rail and the headboard. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on September 11, 2025, at 2:45 PM. 483.25 (n) (1) (3) (4) Bed railsPreviously cited 10/25/24 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observation and staff interview, it was determined the facility failed to maintain a safe and sanitary environment in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on September 9, 2025, at 10:12 AM revealed flooring throughout the main kitchen was blackened. Dirt/debris buildup was observed in several areas of the grout and under equipment. Significant black buildup was observed under the dish machine area, which was covered in water as staff were washing breakfast dishes during the observation. The cove base molding surrounding the kitchen contained black buildup. Several broken and cracked floor tiles were also observed in the area outside the dry storage room and corridor to the receiving dock. Employee 6, dietary manager, indicated during the observation that the flooring and cove base has been a repeated issue, and he has tried scrubbing it but has not been able to get it clean. The above findings were reviewed with the Nursing Home Administrator on September 10, 2025, at 2:30 PM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to maintain an infection prevention and control and water management program to provide an environment to help prevent the development and transmission of communicable diseases and infections on two of two nursing units (Upper Level, Residents 4, 6, 19, 32, 57, 59, 64, 78, 123; and Lower Level, Residents 45 and 70). Findings include: The facility policy entitled, Infection Prevention and Control Program, last revised June 1, 2025 revealed that the elements of the infection prevention and control program consist of items that included coordination/oversight, policies, surveillance, and outbreak management. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist) or designee. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Data gathered during surveillance is used to oversee infections and spot trends. Outbreak management is a process that includes determining the presence of an outbreak, managing affected residents, preventing the spread to other residents, and monitoring for recurrences. The facility policy entitled, Infection Surveillance, last reviewed without changes on June 4, 2025, indicated that the infection preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that may require transmission-based precautions and other preventative measures. The facility's Infection Control Plan dated August 4, 2025, indicated that the plan outlined the infection prevention and control strategies implemented at the facility to prevent the spread of infectious diseases within the facility; and that the facility would adhere to federal guidelines established by the Centers for Disease Control and Prevention (CDC). Infection preventionist duties include ongoing facility-wide surveillance and reporting of HAI (Health Acquired Infections) and outbreaks. Surveillance is an ongoing process to identify MDROs (multi-drug-resistant organisms, bacteria or viruses that are resistant to many commonly used medications/antibiotics that can cause infections), communicable diseases, outbreaks, infection control practice breaches, and potential HAIs resulting from or involving any service rendered at the facility. Sources for surveillance data include, but are not limited to, laboratory records, infection control rounds and/or interviews, verbal reports from staff, infection document records, pharmacy records, antibiotic review, and transfer logs/summaries. Transmission-based precautions (TBPs) are a set of additional infection control practices used in healthcare settings to prevent the spread of infectious agents that can be transmitted through direct contact, droplets, or airborne particles. These precautions are implemented when a resident is known or suspected to be infected with a highly contagious pathogen and are used in conjunction with standard precautions (which are applied to all residents regardless of infection status). The type and duration of TBPs used at the facility are based on CDC's Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). The use of isolation signage, medical record flag, and chart documentation is used to ensure the healthcare personnel are aware of the precautions in place. The facility can use the CDC-approved signs for all three types of isolation (contact, droplet, and airborne). Enhanced Barrier Precautions (EBP) is an approach to target gown and glove use during high-contact resident care activities, designed to reduce the transmission of an MDRO. EBP may be applied to residents with wounds or indwelling medical devices, regardless of MDRO colonization status; or to resident with infection or colonization with an MDRO. The facility has a Water Management Plan (WMP) to mitigate waterborne pathogens transmission risks. The facility's Legionella Water Management Pan, last reviewed June 19, 2025, defined Legionnaires' disease as an uncommon form of pneumonia caused by the legionella bacterium. Infection occurs when legionella bacteria has been released into the air from a contaminated source. Bacteria can live in all types of water (including water sources such as hot and cold water systems). Control and prevention includes good design and maintenance to prevent growth. Control Measures and Corrective Actions included identify the routine process of monitoring control measures, complete a flow diagram that can be easily understood by all members of the team, describe where control measures should be applied, describe how to monitor your control measure, and establish ways to intervene when control limits are not met. The facility will utilize the CDC Legionella Control Toolkit (included in the program packet). The facility will clean and maintain water system components weekly. The facility flow diagram for monitoring and controls indicated that temperatures were monitored for five water heaters in the basement. The CDC Toolkit for Controlling Legionella defined control limits as the maximum value, minimum value, or range of values acceptable for the control measures being monitored to reduce risk for Legionella growth and spread. Design recommendations include to install thermostatic mixing valves as close as possible to fixtures to prevent scalding while permitting circulating hot water temperatures above 120 degrees Fahrenheit. Store hot water at temperatures above 140 degrees Fahrenheit and ensure hot water in circulation does not fall below 120 degrees Fahrenheit. Store and circulate cold water at temperatures below the favorable range for Legionella (77 to 113 degrees Fahrenheit). During an interview with the Nursing Home Administrator and the Director of Nursing on September 9, 2025, at 9:30 AM the onsite survey team requested that the facility provide the following information within four hours of entrance:Infection prevention and control program standards, including evidence of the facility's infection surveillance plan and an accurate, complete, matrix for all residents. An observation of Resident 4's room on September 9, 2025, at 12:03 PM revealed a sign outside the resident's door indicating contact precautions (infection control practices used to prevent the spread of diseases transmitted through direct or indirect contact with a patient or their environment). The sign indicated that before entering the room that hand hygiene and putting on a gown and gloves was required and upon leaving the room disposing of the gloves, and gown was required along with performing hand hygiene. In a concurrent interview with Resident 4, the resident indicated the precautions were in place due to a urinary tract infection, which the resident indicated was ESBL (extended-spectrum beta-Lactamase, a highly resistant bacteria that required strict hygiene practices to prevent spread). Resident 4 stated she was still taking an antibiotic but was feeling better. Resident 4 also indicated she shared a bathroom with her roommate and residents in an adjoining room. Upon exit of Resident 4's room, there were no bins to place the used gown or gloves nor any bags to place the items in to remove them from the room. Resident 4 indicated staff sometimes place bins in the front of the room, but they didn't this time because they get in her and her roommates' way. Continued observations on the upper nursing unit revealed a contact precaution sign as noted above on the door where Residents 32 and 78 resided and the door where Residents 123 and 59 resided. Red disposal bins were noted at the front of both rooms near the bathroom. A review of the facility matrix provided to the survey team on September 9, 2025, between 9:30 and 12:20 PM revealed no residents were identified on the matrix as requiring transmission-based precautions even though the contact precautions signs were observed posted for residents above. At 12:20 PM on September 9, 2025, the Director of Nursing was made aware of the conflicting information between the facility matrix and postings on resident doors on the upper level and was shown the posting on the rooms of the residents noted above (Residents 4, 32, 59, 78 and 123). The Director of Nursing was not sure why the resident rooms were labeled with contact precautions or why they were not identified on the matrix. At 1:00 PM on September 9, 2025, Employee 1 (regional director of clinical services) was made aware of the conflicting information regarding the transmission-based precautions on the facility matrix and what was observed on the upper nursing level unit as well as the lack of bins/bags to dispose of used personal protective equipment in Resident 4's room. Interview with Employee 1 and the Nursing Home Administrator on September 9, 2025, at 2:50 PM again reviewed discrepancies between the facility matrix provided versus observations on the nursing units related to residents identified on transmission-based precautions. The survey team reiterated a request for an accurate resident matrix that included residents on TBP. Clinical record review for Resident 4 revealed a physician's order dated September 4, 2025, for the resident to be on contact precautions for E. Coli (Escherichia coli, a common bacterium found in the gastrointestinal tract, and urinary tract infections), for 10 days. Results of a lab urine test for the resident obtained on August 28, 2025, due to the resident complaining of burning with urination revealed the resident tested positive for E. Coli in her urine and was ordered Macrobid (antibiotic) on September 2, 2025, to be administered for seven days. In a follow up interview with Employee 1 on September 10, 2025, at 8:50 AM, Employee 1 provided the survey team with an updated matrix. Resident 4, nor the rooms where Residents 32, 78, 123, or 59 were identified as having contact precautions. Employee 1 indicated the contact precautions signage was not needed outside the rooms where residents 32, 78, 123, or 59 resided and were removed, and Resident 4's contact precautions were removed because the resident completed her antibiotic treatment on September 9, 2025. Employee 1 also indicated the prior concerns for Resident 4 of no personal protective equipment bins to dispose of used items or the resident using the bathroom with others was not a concern because it was determined the resident did not need contact precautions for her urinary tract infection because it was E. Coli and not ESBL. Employee 1 provided a note from Resident 4's physician dated September 8, 2025, (but signed on September 9, 2025, at 11:50 PM, after it was brought to the facility staff's attention), that due to Resident 4 having E. Coli, not ESBL, and having minimal symptoms, contact precautions were not definitively indicated. However, Resident 4's order for contact precautions dated September 4, 2025, was signed by the same physician. Further clinical record review revealed Resident's 4's order for contact precautions had been discontinued on September 9, 2025. Further review of the updated matrix provided by Employee 1 on September 10, 2025, at 8:50 AM revealed the matrix now indicated a resident on the upper level (Resident 52) as being on transmission-based precautions. Observation of Resident 52's room on September 10, 2025, at 9:30 AM revealed no evidence of signage on the resident's door to indicate transmission-based precautions were required to enter the resident's room. Clinical record review did not reveal any transmission-based precautions were ordered for this resident. Employee 1 indicated Resident 52 should not have been added to the matrix as being on transmission-based precautions. The surveyor requested evidence of the facility's surveillance of resident infections in the building (e.g., line listing, tracking of infectious organisms that may or may not require TBP used to identify and address potential outbreaks or patterned clusters of infections in the facility) during an interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:30 PM. The surveyor reiterated the request for the facility's surveillance of resident infections in the building during an interview with Employee 2 (registered nurse, infection preventionist) on September 11, 2025, at 11:39 AM. Employee 2 confirmed that the facility had a line listing and map of resident infections in the facility. Interview with the Nursing Home Administrator and the Director of Nursing on September 11, 2025, at 2:30 PM confirmed that the facility's infection surveillance line listing provided did not match the facility roster matrix or observations on the nursing units. Interview with the Director of Nursing on September 12, 2025, at 9:01 AM confirmed that the facility roster matrix used by the onsite survey team for the first three days of the survey was incorrect related to residents who required TBP. The interview confirmed that staff required clarification related to the implementation of TBP versus the implementation of EBP (enhanced barrier precautions). The interview indicated that the facility could not provide a list of residents residing in the building who met the criteria for the implementation of TBP. Interview with Employee 2 on September 12, 2025, at 12:25 PM revealed that she assumed the role of infection preventionist in the past four to six weeks. Employee 2 stated that she may review information regarding the new onset of resident infection and/or new physician orders for antibiotic use daily, every other day, or weekly, depending on time constraints. Employee 2 stated that the staff who previously held the infection preventionist position converted to per diem employment and assists in implementing the infection surveillance in the building sporadically. The surveyor requested evidence of the facility's implementation and monitoring of control measures (e.g., water temperature testing of hot water tanks in the basement) during interviews with the Nursing Home Administrator on September 10, 2025, at 2:30 PM September 11, 2025, at 2:30 PM and September 12, 2025, at 9:14 AM. Interview with the Nursing Home Administrator on September 12, 2025, at 9:14 AM confirmed that the only evidence of monitoring water temperatures indicated that the facility completed water temperature monitoring for resident safety (which indicated that water temperatures were less than 110 degrees Fahrenheit besides those taken from the laundry and kitchen dishwasher supply). Interview with Employee 3 (maintenance director) on September 12, 2025, at 11:59 AM indicated that the facility monitors hot water heater temperatures daily, which were greater than 113 degrees. The interview did not provide evidence that the facility ensures hot water temperatures are 140 degrees Fahrenheit at storage sites (hot water heaters in the basement) per CDC guidelines. Interview with Employee 3 on September 12, 2025, at 1:11 PM revealed that the facility could provide temperature monitoring logs for four hot water heaters; however, only one of the five hot water heaters indicated temperatures that ranged greater than 140 degrees Fahrenheit. The logs indicated that three of the four hot water tanks tested for temperatures that ranged less than 130 degrees Fahrenheit. The facility was unable to provide evidence of any corrective actions taken in response to the water temperature findings. An observation of the upper-level nourishment room on September 9, 2025, at 12:21 PM revealed two gel type ice packs in the resident food freezer labeled with Resident 64's name, and one gel type ice pack with Resident 19's name. Upon further observation as to the use of the ice packs noted, Employee 4, registered nurse, and Employee 3, licensed practical nurse (LPN), indicated at 12:37 PM that the ice packs were used for Resident 19's left shoulder pain, and Resident 64's were used for leg pain. Concerns regarding the ice packs being stored in the resident food freezer with ice cream and other frozen food items were concurrently reviewed with Employees 3 and 4. An observation of the upper-level nourishment room on September 10, 2025, at 12:00 PM revealed one ice pack remained in the freezer for Resident 64, and one ice pack for Resident 19. The above observations of ice packs being used for medical use being stored in the resident food freezer were reviewed with the Nursing Home Administrator and Director of Nursing on September 10, 2025, at 3:00 PM. Observation on September 11, 2025, at 12:15 PM of a dressing change for Resident 6 with Employee 4, LPN, revealed Employee 4 donned a gown and gloves. The gown was noted to have thumb loops which Employee 4 placed over the gloves. Employee 4 entered Resident 6's room and cleansed the wound on the Resident 6's buttocks and performed incontinence care, while the thumb loops were over their thumb and around the palm of their hand. Employee 4 then removed the thumb loops, removed the gloves, and performed hand hygiene. Employee 4 donned clean gloves and used their gloved hands to replace the thumb loops back on top of their newly gloved hands. Employee 4 continued to complete the dressing change with the contaminated thumb loops on the exterior of the gloves. Employee 4 indicated she was not aware of how to utilize the thumb loops on the gown. The above information was relayed to the Nursing Home Administrator and the Director of Nursing on September 11, 2025, at 3:05 PM. Review of the facility policy titled, Infection Control; Transmission Based Precautions, last reviewed without changes on June 4, 2025, revealed that transmission-based precautions are to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. The facility will make every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Further review of the policy revealed a section titled, Contact Precautions, that noted in addition to standard precautions, implement contact precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary is evaluated on a case-by-case basis. Clinical record review for Resident 70 revealed a current order dated October 24, 2024, that indicated the resident was on enhanced barrier precautions and the reason indicated a history of ESBL. Clinical record review for Resident 70 revealed a urinalysis (laboratory test of the urine) and associated culture completed on April 18, 2025, that indicated the resident had Escherichia coli ESBL in the urine and was treated with antibiotics. Resident 70's care plan revealed the resident is on EBP that was initiated on October 24, 2024, and interventions included: EBP, ensure immunizations are up to date, and maintain transmission-based precautions when providing resident care. Observation of Resident 70's room on September 9, 2025, at 10:23 AM and 1:05 PM revealed the resident had a sign on the door along with a tote holding various personal protective equipment (PPE). The sign indicated the resident was on contact precautions. An interview with Employee 13, licensed practical nurse, on September 9, 2025, at 1:08 PM revealed that staff utilize the orders section of the chart to view if the resident is on any isolation precautions. Employee 13 confirmed that Resident 70 is on enhanced barrier precautions, and it was unclear why the contact isolation precautions sign was on the resident's door and not EBP signage as noted in the current physician orders. Clinical record review for Resident 45 revealed a diagnosis list that included a pressure ulcer on the resident's back. Clinical record review for Resident 45 revealed a current physician's order for contact precautions dated September 9, 2025, for a wound infection until September 17, 2025. Review of the current physician orders for Resident 45 revealed orders for wound care and dressings every day shift every three days related to a pressure ulcer of the back. There was also an order for an antibiotic for this pressure ulcer. Observation during a medication pass on September 11, 2025, at 8:33 AM revealed a sign hanging next to Resident 45's door, outside of the room, that indicated contact precautions. There was also an associated tote that held PPE hanging next to the door outside of the resident's room. Continued observation of Resident 45's room revealed that Employees 10 and 14, LPN's, entered the resident's room during medication pass without donning (putting on) full PPE (gown and gloves) and proceeded to administer medications to the resident while utilizing only gloves. The staff members then proceeded to reposition the resident as she sat in a chair so they could place a medicated topical patch on the resident's back for pain relief. A follow-up interview with Employee 10 on September 11, 2025, at 9:05 AM revealed that Resident 45 is on contact isolation per the signage and physician orders. Employee 10 reported she did not initially see the sign upon entry into Resident 45's room. An interview with the Nursing Home Administrator and Director of Nursing on September 12, 2025, at 2:30 PM revealed that there are no associated cultures for Resident 45's wound. The physician wanted to treat the wound and ordered antibiotics. Per the Director of Nursing, the expectation would be for staff to utilize a gown and gloves if anticipated to come into direct contact with the resident or the resident's environment for a resident that is on contact precautions. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 10/25/24 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(2.1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer residents pneumococcal immunizations for four of five residents reviewed for immunizations (Residents 3, 8, 31, and 76).Findings include: Review of the policy entitled Pneumococcal Vaccine Guidelines, last revised March 10, 2025, revealed that the facility will offer residents the pneumococcal vaccine to aid in preventing pneumococcal infections as applicable per physician order. The procedure noted that previous immunization information will be requested during the pre-admission process. A representative from the admissions office/designee will obtain and forward copies of the immunization records to the admitting nurse. Staff will verify the data with the resident and/or authorized representative when applicable. The pre-admission immunizations will be added to the electronic immunization record/EMR. The immunization record/EMR will be updated with each offer (administrations and refusals) of the pneumococcal vaccine. Each age-appropriate and/or diagnosis appropriate resident will be offered a pneumococcal vaccination per physician order, to minimize the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia; unless the vaccine is medically contraindicated, or the resident has already been vaccinated within the designated timeframe. Pneumococcal vaccines recommended for adults (refer to CDC, Centers for Disease Control, pneumococcal vaccine timing for adults) include: 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13)15-valent pneumococcal conjugate vaccine (PCV15, Vaxneuvance)20-valent pneumococcal conjugate vaccine (PCV20, Prevnar 20)23-valent pneumococcal conjugate vaccine (PPSV23, Pneumovax 23) The nurse will document the administration of the vaccine in the electronic medical record (EMR). Facility and physicians will refer to CDC Pneumococcal Vaccine Timing for Adults along with resident's pneumococcal vaccine history prior to obtaining/writing physician orders for pneumococcal vaccines. The resident or resident's representative can refuse the vaccination. Declinations must be uploaded into the resident's electronic health record. The surveyor requested the availability of immunization information beyond what was available in the residents' electronic medical records (e.g., a binder of consents or evidence of education provided) during interviews with the Nursing Home Administrator and Director of Nursing on September 10, 2025, at 2:30 PM and September 11, 2025, at 2:30 PM. Clinical record review for Resident 8 revealed that the facility admitted her on October 31, 2017. Resident 8's clinical record indicated that she received a PPSV23 (pneumococcal, pneumovax) immunization on October 1, 2011 (at the age of 64 years), January 1, 2014 (at the age of 68 years), February 3, 2022 (at the age of 75 years), and April 13, 2023 (at the age of 77 years). Resident 8's clinical record contained no evidence of any pneumococcal immunizations except the PPSV23 vaccine. Clinical record review for Resident 3 revealed that the facility admitted him on January 29, 2018. Resident 3's clinical record indicated that he received the PPSV23 immunization on April 3, 2012 (at the age of 51 years). Resident 3's clinical record contained no evidence of any pneumococcal immunizations while a resident at the facility. Clinical record review for Resident 31 revealed that the facility admitted him on February 17, 2022. Resident 31's clinical record indicated that he received the PPSV23 immunization on February 24, 2022 (at the age of 73 years). Resident 31's clinical record contained no evidence of any pneumococcal immunizations except the PPSV23 vaccine. Clinical record review for Resident 76 revealed that the facility admitted her on February 22, 2022. Resident 76's clinical record indicated that she received the PPSV23 immunization on June 22, 2010 (at the age of 64 years), February 28, 2022 (at the age of 75 years), and on April 11, 2023 (at the age of 76 years). Resident 76's clinical record contained no evidence of any pneumococcal immunizations except the PPSV23 vaccine. Resident 76's clinical record indicated that Resident 76's responsible party refused a Prevnar 20 (pneumococcal) immunization May 20, 2025; however, the same documentation indicated that the facility did not provide education regarding the risks and benefits of the vaccine. The surveyor reiterated to the Director of Nursing that the facility had yet to provide additional immunization information beyond what was available in the residents' electronic medical records as requested during the afternoon meetings on September 10 and 11, 2025, during an interview on September 12, 2025, at 9:01 AM. The Director of Nursing instructed the surveyor to email resident immunization concerns to her for review. Email communication to the Director of Nursing on September 12, 2025, at 10:11 AM reported the above immunization concerns for Residents 8, 3, 31, and 76. Interview with the Director of Nursing on September 12, 2025, at 11:35 AM indicated that the facility administered no pneumococcal immunizations in the past year. The facility had no evidence that the four residents were offered the vaccines even though they met CDC criteria for additional immunizations. 483.80(d)(1)(2) Influenza and Pneumococcal ImmunizationsPreviously cited deficiency 10/25/24 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, review of facility documentation, clinical record review, and staff and resident interviews, it was determined that the facility failed to provide professional dental services for three of three residents reviewed for dental concerns (Residents 8, 31, and 56).Findings include: Interview with Resident 31 on September 10, 2025, at 10:32 AM revealed that she had natural teeth; however, she was missing some teeth. Observation of Resident 31 on the date and time of the interview confirmed that she had natural teeth with noticeable gaps from missing teeth. Clinical record review for Resident 31 revealed documentation by the facility's consultant dentist dated March 13, 2024, that recommended a treatment plan that included an annual exam. Resident 31's clinical record contained no evidence of additional services from the consultant dentist in the 18 months since March 13, 2024. Interview with Resident 8 on September 10, 2025, at 10:57 AM revealed that she had no teeth or dentures in her top jaw and had some natural teeth on her bottom jaw. Resident 8 stated that she was missing teeth in her bottom jaw. Resident 8 stated that she had services to obtain impressions for dentures two months ago; however, she had no indication when she would receive them. Clinical record review for Resident 8 revealed an annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE]; an admission MDS following a hospitalization dated July 24, 2024; and an annual MDS dated [DATE], that assessed Resident 8 as having obvious or likely cavities or broken natural teeth. Documentation by the facility's contracted dental provider dated July 19, 2022, and December 20, 2023, revealed that Resident 8 expressed a desire to have a full upper denture and a partial lower denture. Documentation on both dates indicated that the provider would apply to Medicaid for the fabrication of the upper and lower appliances. Documentation by the facility's contracted dental provider dated October 22, 2024, confirmed that Resident 8 had no upper teeth and numerous missing lower teeth. The documentation revealed that the plan of treatment included a recall for an annual exam on April 22, 2025, and Fabrication of full upper denture (DFU); Fabrication of partial lower denture (DPL). The documentation indicated that the provider Refiled [NAME] (Pennsylvania Medicaid) today for F/P (full/partial). Resident 8's clinical record contained no evidence of a recall visit with the dentist in April 2025. Documentation by the facility's contracted dental provider dated July 7, 2025, noted Resident 8's partial dentition, and she would like an upper denture and a lower partial denture. The documentation indicated that impressions for dentures occurred; but again, noted that a dental recall would be based on the pay source frequency. Resident 8's clinical record contained no evidence of a recall visit with the dentist after July 7, 2025. Clinical record review for Resident 56 revealed a diagnosis list that included dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons), and a need for assistance with personal care. Further clinical record review for Resident 56 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated July 17, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 3, which indicated cognitive impairment. Resident 56's care plan initiated on December 12, 2024, noted the resident has oral/dental health problems and upper and lower dentures were noted under interventions. Clinical documentation for Resident 56 dated December 12, 2024, at 11:00 AM titled, admission Nursing Evaluation, documented the resident as having upper and lower dentures. Nursing documentation for Resident 56 dated December 12, 2024, at 11:26 AM revealed that the resident arrived at the facility and staff documented Upper/Lower dentures. Nursing documentation for Resident 56 dated July 6, 2025, at 2:27 PM revealed that the resident's family made the nurse aware that the resident's bottom dentures are missing and have been missing since Friday. The documentation noted that the nurse looked through the resident's room and did not find the dentures. Care plan meeting documentation for Resident 56 dated August 12, 2025, at 2:34 PM revealed that the family brought to nursing's attention of missing dentures and a .concern form filed with social services. The above information for Resident 56 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 10, 2025, at 2:30 PM and September 11, 2025, at 2:30 PM. The Nursing Home Administrator reported during the meeting on September 11, 2025, that he confirmed with the resident that he did not have any lower dentures. An interview with Resident 56 on September 12, 2025, at 10:22 AM revealed the resident is unsure what happened to the dentures. The resident pulled down his lower lip to reveal no bottom dentures were present. A review of facility documentation concern logs from February 2025 to September 2025, revealed no concern forms for Resident 56. It was confirmed with the Nursing Home Administrator on September 12, 2025, at 12:28 PM that there was no concern log related to Resident 56's dentures. A review of the dental visits for Resident 56 revealed the following: September 2, 2025, the resident declined dental hygiene treatment; June 3, 2025, dental hygiene practitioner was seen, and upper denture was cleaned; March 6, 2025, the dental provider documented the resident was not seen and to reschedule. The documentation did not mention anything about missing dentures for the visits. An interview with Employee 7, social services, on September 12, 2025, at 11:36 AM revealed that Resident 56 is on the dental list for this month. Employee 7 reported he was not aware of any concern form submitted or missing dentures despite the documentation from the care plan meeting on August 12, 2025, at 2:34 PM. The facility failed to provide any further documentation or evidence that Resident 56's missing dentures were addressed by the facility. The above information for Resident 56 was reviewed in a meeting with the Nursing Home Administrator on September 12, 2025, at 12:28 PM. 483.55(b)(1)(3)(5) Routine/emergency Dental ServicesPreviously cited deficiency 10/25/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.15. Dental services

Based on a review of financial accounting records, clinical record review, and resident and staff interview, it was determined that the facility failed to provide medically-related social services to assist a resident with financial matters for one of 24 residents reviewed (Resident 22).Findings include: Interview with Resident 22 on September 9, 2025, at 12:49 PM revealed that he did not believe that he had any money in a personal account, that he did not receive a statement, and that he did not know where any personal allowance funds were maintained. An interview with the Nursing Home Administrator on September 10, 2025, at 2:30 PM confirmed that Resident 22 entered the facility following his release from prison, and the facility determined that he had no resources. The surveyor requested Resident 22's financial accounting (e.g., monthly charges and payments for those charges) since his admission to the facility. The interview confirmed that Resident 22 had no designated responsible party. Resident 22 was his own responsible party; therefore, there would be no other individual that would receive a monthly personal fund statement. The interview indicated that because the facility believed that he had no monetary resource, he had no monthly personal allowance; therefore, he had no resident fund statement to provide. Clinical record review of census information for Resident 22 revealed that the facility admitted him on December 16, 2024, for Medicaid-provided services. Interview with Employee 11, assistant business office manager, on September 11, 2025, at 1:00 PM confirmed that Resident 22 arrived directly from incarceration at a prison in December 2024. The facility staff believed that the prison staff submitted documentation to have Resident 22's social security and Medicare benefits reinstated; however, the facility had no documented evidence (communication) between the prison and the facility to support that. The interview confirmed that the facility submitted the required documentation in January 2025 to obtain Medicaid payment for Resident 22's stay in the facility by entering that Resident 22 had no income. The facility did not assist Resident 22 to contact the Social Security Administration (SSA, United States government agency that administers monetary benefits to retired or disabled individuals) to have Resident 22's benefits (including monthly income) reinstated immediately after his incarceration. The interview indicated that the facility determined in May 2025 (five months after his admission) that the prison staff likely did not submit the necessary documentation to have Resident 22's benefits reinstated; therefore, the facility staff assisted Resident 22 at that time. The interview indicated that outside providers contacted the facility due to the Medicare non-payment of services during the time from December 2024 to May 2025. The interview with Employee 11 on September 11, 2025, at 1:00 PM revealed that, on this date, Employee 11 contacted the SSA to inquire about the backpay of Resident 22's social security benefits that he was entitled to from December 2024 to May 2025. Employee 11 discovered that the SSA deposited Resident 22's money in an account that he no longer had a banking access card to obtain. Employee 11 then assisted Resident 22 to obtain a new banking card to access the more than $1700.00 (seventeen hundred dollars) deposited into his account. The interview indicated that it would take several business days to receive the new banking card. A review of a Health and Human Service Benefits application dated January 7, 2025, indicated that the facility's contracted provider applied for Medicaid benefits for Resident 22 for a requested effective date of December 16, 2024. The application indicated that Resident 22 had a checking or savings account with an estimated resource value of $1,654.94 (one thousand six hundred fifty-four dollars and 94 cents). The application indicated that Resident 22 received money from one or more sources other than a job; and that source was supplemental security income (SSI, a federal program that helps people with disabilities and older adults who have low income and few resources) of $985.10 monthly. The facility, who had reasonable knowledge to determine Resident 22 was entitled to monthly monetary benefits, failed to assist Resident 22 to obtain financial assistance timely. The surveyor confirmed the above findings with the Nursing Home Administrator on September 11, 2025, at 1:45 PM. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to coordinate hospice services per a coordinated plan of care for one of one resident reviewed for hospice care concerns (Resident 13).Findings include: Clinical record review for Resident 13 revealed nursing documentation dated April 1, 2025, at 3:17 PM that Resident 13 was admitted to a contracted hospice provider. Observation of Resident 13 on September 9, 2025, at 1:43 PM revealed that the registered nurse from the contracted hospice provider was at his bedside. The registered nurse explained to Resident 13 that he was not receiving services from the hospice aide because the contracted hospice provider did not have enough nurse aides currently on the schedule. The registered nurse explained to Resident 13 that people receiving hospice services in the community would get preference when assigning nurse aide services. Interview with Employee 9 (registered nurse from the facility's contracted hospice provider) on September 9, 2025, at 2:29 PM confirmed that according to her electronic hospice medical record (accessed via a small electronic tablet carried by her) Resident 13 was to receive nurse aide services three times a week on Mondays, Wednesdays, and Fridays; however, he had not received nurse aide services in at least two weeks. Employee 9 reviewed a binder of information available at the Lower-Level nurses' station that contained all communication and documentation for Resident 13 that pertained to his hospice services and confirmed that the last documentation completed by a hospice nurse aide was dated June 27, 2025. The interview confirmed that the facility's contracted hospice provider lost the nurse aide assigned to Resident 13 and the service area he resided in. Although the binder of handwritten documentation available at the facility did not include evidence of nurse aide services provided, Employee 9 stated that the electronic documentation available to her (not the facility) indicated that a nurse aide last provided services on August 29, 2025 (a Friday, 11 days earlier). The interview with Employee 9 confirmed that the information contained in Resident 13's binder did not include a plan of care that provided the information regarding what, and how often, hospice disciplines provided services to Resident 13 (e.g., frequency of visits from a hospice registered nurse or nurse aide or what days the facility could anticipate those services). The interview indicated that the hospice registered nurse visited the facility two days a week on Tuesdays and Thursdays. The interview indicated that the registered nurse completes a brief handwritten note (documented on the blank space on the back of a blank hospice nurse aide documentation form) in the hospice binder at the facility but the registered nurse completes a more comprehensive electronic note for the hospice provider's medical record, which is not supplied to the facility or incorporated into Resident 13's medical record at the facility. Previous electronic entries by the registered nurse were not in the hospice provider's binder or in the electronic medical record for Resident 13. The interview confirmed that four handwritten notes on the back of the nurse aide form was the only evidence of registered nurse visits at the facility. The handwritten notes did not include a full date (missing year) or staff name, signature, or discipline (e.g. RN' or registered nurse). Interview with Employee 8 (licensed practical nurse) on September 9, 2025, at 2:29 PM with Employee 9 revealed that the facility's second contracted hospice provider (different company) utilized pre-printed forms for registered nurses to document onsite visits (not the back of a blank nurse aide form). Review of Resident 13's electronic medical record at the facility revealed a scanned document from the contracted hospice provider entitled, Hospice Comprehensive Assessment, for a certification period of May 31, 2025, to July 29, 2025, that indicated, Coordination of Care with Facility, included that facility staff would be knowledgeable and involved in the hospice plan of care at initiation of hospice services/facility placement and with any update to the plan of care, and Resident 13 would receive, aide services, specific to patient care needs by April 2, 2025. The document included that the skilled nurse would initiate hospice aide services via physician's order and aide plan of care. The plan of care available in Resident 13's medical record at the facility initiated July 9, 2025, to address that he received hospice services noted only that a hospice aide would assist with care as needed (PRN) and that the facility would work cooperatively with the hospice team to ensure the resident's spiritual; emotional; intellectual; physical and social needs are met. The plan of care did not include that a registered nurse from the hospice provider would provide services or the frequency/days the hospice aide or hospice nurse would provide services. Neither Resident 13's facility medical record nor the hospice provider binder included a Hospice Comprehensive Assessment, for a certification period in effect after July 29, 2025. The surveyor reviewed the above concerns regarding the coordination of Resident 13's hospice services during an interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:30 PM. On September 11, 2025, the facility provided a plan of care documented on a Hospice IDG Comprehensive Assessment and Plan of Care Update Report, for benefit period dates from July 30, 2025, to September 27, 2025, that noted, Please Add HHA Visits to M-W-F (please add home health aide visits to Monday, Wednesday, and Friday). Interview with the Nursing Home Administrator on September 12, 2025, at 11:15 AM confirmed that the facility had no evidence that staff revised Resident 13's facility plan of care to include the initiation of hospice services until July 9, 2025; although he began those services on April 1, 2025. The facility did not provide additional documentation to evidence that Resident 13 received hospice aide services three times a week per his plan of care. The facility failed to ensure the coordination of hospice services with facility services for Resident 13. 483.25 Quality of CarePreviously cited deficiency 10/25/24 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 implement a comprehensive person-centered care plan regarding a cardiac pacemaker for one of 24 residents reviewed (Resident 38) and develop a comprehensive and person-centered care plan for one of two residents reviewed with a tracheostomy (Resident 42).Findings Include: Clinical record review for Resident 38 revealed a diagnosis list that included the presence of a cardiac pacemaker (an electronic device to help regulate the beating of the heart) and sick sinus syndrome (a disorder that causes the heart to beat abnormally). Nursing documentation for Resident 38 on admission to the facility on August 20, 2025, at 5:07 PM revealed that the resident had a cardiac pacemaker. Hospital documentation for Resident 38 dated August 14, 2025, noted a problem list for the resident that included a history of a cardiac pacemaker. Review of Resident 38's care plan revealed no current comprehensive, person-centered care plan that addressed the resident's pacemaker, any associated pacemaker checks, assessments, and/or precautions. The above information for Resident 38 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 10, 2025, at 2:30 PM. Review of the policy titled, Tracheostomy Care Policy, last reviewed without changes on June 4, 2025, revealed a purpose to guide tracheostomy care and the cleaning of reusable tracheostomy findings. Under the section titled, General Guidelines, the policy noted that a replacement tracheostomy tube must be available at the bedside at all times. Clinical record review for Resident 42 revealed a diagnosis list that included a tracheostomy (trach, an artificial opening through which a medical tube is placed through the front of the neck into the airway to facilitate breathing). Review of the current physician orders for Resident 42 revealed orders for daily and as needed tracheostomy care that included changing the inner cannula. Further review of the physician orders revealed an order that instructed staff to perform trach care as per policy and check skin integrity around the trach site and neck. Resident 42's care plan revealed the resident has a tracheostomy related to the medical history. The care plan interventions included the following: ensure that trach ties are secured at all times, head of bed is elevated to prevent any shortness of breath while flat, provide good oral care daily and as needed, and suction as necessary. Further clinical record review for Resident 42 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 3, which indicated cognitive impairment. The care plan also noted a tracheostomy. Observation of Resident 42 on September 9, 2025, at 10:30 AM and September 12, 2025, at 10:16 AM revealed the resident had a tracheostomy present. Further review of Resident 42's tracheostomy care plan revealed the current care plan did not address possible complications (such as unplanned extubation or unplanned removal of the tracheostomy, or any other type of potential airway complication). The care plan did not address any emergency kit as indicated by staff or having an emergency tracheostomy tube at the bedside at all times as indicated in the policy. The above information for Resident 42 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 12, 2025, at 12:28 PM 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 accurate clinical documentation for one of 24 residents reviewed for clinical documentation issues (Resident 44; Residents 34 and 122).Findings include: Review of Resident 44's clinical record revealed a section of the electronic health record (EHR) where various documents are uploaded to the medical record for staff to review as needed. Further review of this section for Resident 44 revealed that scans for two other residents, Residents 34 and 122, were uploaded to Resident 44's clinical record. The following documents were erroneously uploaded to Resident 44's medical record: A POLST (Physician Orders for Life-Sustaining Treatment) form for Resident 122 that had an upload and effective date of July 21, 2025. A medication clarification notice for Resident 34 that was dated July 25, 2025. The Nursing Home Administrator and Director of Nursing were informed of the findings on September 10, 2025, at 2:30 PM. The facility failed to ensure an accurate clinical record for Resident 44. 483.70(h) Medical RecordsPreviously cited deficiency 3/6/2025 28 Pa. Code 211.5(i) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide respiratory and tracheostomy care consistent with professional standards of practice for one of two residents reviewed with a tracheostomy (Resident 42).Findings include: Review of the policy titled, Tracheostomy Care Policy, last reviewed without changes on June 4, 2025, revealed a purpose to guide tracheostomy care and the cleaning of reusable tracheostomy findings. Under the section titled, General Guidelines, the policy noted that a replacement tracheostomy tube must be available at the bedside at all times. Clinical record review for Resident 42 revealed a diagnosis list that included a tracheostomy (trach, an artificial opening through which a medical tube is placed through the front of the neck into the airway to facilitate breathing). Review of the current physician orders for Resident 42 revealed orders for daily and as needed tracheostomy care that included changing the inner cannula. Further review of the physician orders revealed an order that instructed staff to perform trach care as per policy and check skin integrity around the trach site and neck. Resident 42's care plan revealed the resident has a tracheostomy related to the medical history. The care plan interventions included the following: ensure that trach ties are secured at all times, head of bed is elevated to prevent any shortness of breath while flat, provide good oral care daily and as needed, and suction as necessary. Further clinical record review for Resident 42 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 3, which indicated cognitive impairment. The care plan also noted a tracheostomy. Observation of Resident 42 on September 9, 2025, at 10:30 AM and September 12, 2025, at 10:16 AM revealed the resident had a tracheostomy present. Observation of Resident 42's room and concurrent interview with Employee 10, licensed practical nurse (LPN), on September 12, 2025, at 10:22 AM revealed that the facility keeps an emergency kit at the bedside; however, Employee 10 was unable to locate a kit or replacement tracheostomy tube at the bedside. Employee 10 reported that the resident sometimes will carry the items off and voiced it may be at the nurse's station. Employee 10 was unable to locate an emergency kit after searching the nursing station. A second LPN present was also unable to locate the items. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on September 12, 2025, at 12:28 PM. 483.25(i) Respiratory/tracheostomy Care and SuctioningPreviously cited deficiency 10/25/2024 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to assess and implement interventions to maintain a resident's continence status for one of one resident reviewed (Resident 19).Findings include: In an interview with Resident 19 on September 10, 2025, at 10:21 AM the resident indicated she was admitted to the facility without any history of being incontinent of her bowel or bladder and knows when she needs go to the bathroom but has since had several instances of being incontinent of bladder since her admission to the facility. Resident 19 indicated she has to wait a long time for staff at times on the evening or night shift to assist her to the bathroom and even started to ring her bell early to give the staff more time to get to her, but they don't always make it to her in time. Resident 19 also stated sometimes the staff come in and shut off her bell and say they will be back, but they don't come back and she pees the bed because of waiting. Resident 19 stated she sometimes can get up from her bed herself, but when she can't she rings the bell for staff to help her. Clinical record review for Resident 19 revealed the resident was admitted to the facility on [DATE]. A modified admission MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 24, 2025, revealed facility staff assessed the resident as always continent of urine and bowel. The resident was also assessed as requiring partial/moderate assistance for a toilet transfer and to walk 10 feet. A review of Resident 19's documentation of bowel and bladder continence records for July 2025 through September 10, 2025, revealed the following: Resident 19 was documented as not having any incontinent episodes of bowel or bladder from July 17, 2025, (admission) until the evening shift on July 27, 2025. The resident was documented as being incontinent of urine on the night shift on July 28 and 31, 2025. Review of the August 2025 bladder elimination record revealed the resident was documented as being continent of urine August 1-19, 2025, and then incontinent on evening shift August 20, 21, 27, and the day shift (documented at 6:23 AM) on August 28, 2025. Review of the September 2025 bladder elimination records revealed the resident was documented as being incontinent on the evening shift on September 2, 5 and 10, 2025. Resident 19 had one episode of bowel incontinence documented on August 29, 2025, on day shift (documented at 6:23 AM). There was no ability to review call bell log activations to potentially correlate with the resident shifts of incontinence. There was no evidence facility staff evaluated or assessed Resident 19's episodes of incontinence primarily on the evening and night shift as noted above or developed any toileting plans to help the resident remain continent. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on September 11, 2025, at 3:00 PM. 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)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain professional podiatry services for one of two residents reviewed for skin conditions (Resident 76).Findings include: Clinical record review for Resident 76 revealed her diagnoses list included diabetes (high blood sugar) and polyneuropathy (nerve damage that can include pain, numbness, weakness, and coordination issues, often affecting the hands and feet). Documentation by the facility's contracted podiatry provider dated January 16, 2025, revealed that the practitioner assessed Resident 76's nails as thickened, that she had complaints of burning in both of her feet, and that her diagnoses included peripheral angiopathy (diseased blood vessels) and diabetes. Documentation by the facility's contracted podiatry provider dated May 27, 2025, revealed that the practitioner continued to assess Resident 76's nails as thickened, that she had complaints of burning in both of her feet, and that her diagnoses included peripheral angiopathy and diabetes. The documentation indicated that Resident 76 had extensive symptomatic dry skin involving the feet, and the practitioner ordered lotion daily to affected areas. The documentation included that Resident 76 had underlying systemic risk factors for wound development if left untreated or unresolved. A physician's order dated March 26, 2025, instructed staff to apply Ketoconazole cream (antifungal medicated lotion) to Resident 76's bilateral feet every day. Review of Resident 76's treatment administration records dated July, August, and September 2025 revealed that licensed nursing staff initialed the completion of the foot lotion daily. There was no evidence in Resident 76's medical record that a foot care professional provided services in more than three months since May 27, 2025. Interview with Resident 76 on September 9, 2025, at 12:36 PM revealed that she believed that she had a raised area on her right foot, believed to be a callous, that was painful when she pressed on it in a certain way. Resident 76 could not recall the last time a podiatrist provided her care. The surveyor requested evidence of professional podiatry services for Resident 76 in the last 12 months during an interview with the Nursing Home Administrator and Director of Nursing on September 10, 2025, at 2:30 PM due to her complaints of a painful site on her right foot. Nursing documentation dated September 11, 2025, at 3:23 PM (following the surveyor's questioning) revealed that a physician assessed Resident 76 and provided a new order, for podiatry asap for corn on bottom of right foot. Observation of Resident 76 on September 12, 2025, at 1:31 PM with Employee 12 (licensed practical nurse) revealed a hardened, calloused, and dry area that was the size of an eraser head to dime-sized in diameter that was raised several millimeters from the surface of the skin on the right lateral side of Resident 76's right foot. Resident 76's feet appeared dry and scaley. Interview with Employee 12 at the time of the observation confirmed that the area of concern did not appear to have developed quickly; but had developed over some time. Interview with the Nursing Home Administrator on September 12, 2025, at 1:37 PM confirmed that Resident 76 had not received podiatry services in more than three months. The facility was unable to provide evidence that any staff identified the change in Resident 76's foot, notified the physician, or obtained professional podiatry services timely to address the issue before the surveyor's questioning although physician-ordered treatment required licensed staff to look at Resident 76's feet daily. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview, it was determined that the facility failed to obtain routine services from an eye care professional for one of one resident reviewed for vision concerns (Resident 31).Findings include: Interview with Resident 31 on September 10, 2025, at 10:34 AM revealed that she used eyeglasses only for reading. Resident 31 stated that she could not recall when the last time was she saw a doctor or eye care professional for vision services. Resident 31 stated, I need stronger ones (glasses). Clinical record review for Resident 31 revealed that the facility admitted her on February 17, 2022. Resident 31's diagnoses list included diagnoses known to create the potential for eye health concerns as follows: Diabetes (high blood sugar)Long-term use of non-steroidal anti-inflammatories (long term use of medications that can cause complications of the cornea, or outer surface of the eye)Hypertension (high blood pressure)Hyperlipidemia (high levels of fats/cholesterol in the blood) Documentation by the facility's contracted eye care professional dated April 23, 2025, indicated that Resident 31's appointment for services was cancelled. The, Reason for Cancelled Visit: Time Constraint; Comments: ran out of time; will reschedule. Documentation by the facility's contracted eye care professional dated June 17, 2025, indicated that Resident 31's appointment for services was cancelled. The Reason for Cancelled Visit: Refused. Resident 31's clinical record contained no evidence of any attempt to obtain professional eye care services in the last 12 months before April 23, 2025, or after June 17, 2025. The surveyor reviewed the above concerns regarding Resident 31's eye care services during an interview with the Nursing Home Administrator on September 12, 2025, at 11:15 AM. 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate clinical records for one of five residents reviewed (Resident CR1). Findings include: Clinical record review revealed the facility admitted Resident CR1 on February 14, 2025, for a respite (a short stay to give his caregiver a break from their responsibility) stay. Review of the admission orders provided by Resident CR1's physician from the community, revealed that he was to have his blood sugar monitored four to five times a day. Review of Resident CR1's physician orders revealed that the order for his blood sugar checks never got transcribed to his physician orders on admission and his blood sugars were not being monitored. Interview with the Nursing Home Administrator on March 6, 2025, at 12:30 PM confirmed the above noted findings related to Resident CR1's order to monitor his blood sugars. The facility failed to ensure a complete and accurate clinical record for Resident CR1. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the physician of a resident's change in condition requiring interventions for one of five residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed nursing documentation dated March 1, 2025, at 9:35 PM that indicated he was unable to swallow. A nursing progress note dated March 2, 2025, at 10:11 AM indicated that Resident CR1's medications were not given because it was not safe due to him not responding. A nursing progress note dated March 2, 2025, at 11:32 AM revealed that Resident CR1's daughter called and wanted updates on the resident. The resident was assessed by the documenting nurse and indicated his vital signs were within normal limits, his heart rate (HR) was regular, and he had no edema. His feet were cool to touch, and he had coarse lung sounds. He was mouth breathing. His HR was 98 beats per minute, his temperature was 96.6 degrees Fahrenheit, and his blood pressure was unable to be obtained. The daughter declined for Resident CR1 to go to the emergency room at this time and said she would be coming in. A nursing progress note for Resident CR1 dated March 2, 2025, at 12:36 PM revealed that he was not responding and was dead weight. He had no response to a drink or spoon touching his mouth. A nursing progress note for Resident CR1 dated March 2, 2025, at 12:41 PM indicated the resident was in no distress, he was breathing even, his pulse was thready (weak and difficult to feel), and his blood pressure was not able to be obtained. A nursing progress note for Resident CR1 dated March 2, 2025, at 12:45 PM revealed that Resident CR1's blood sugar was checked per the daughter's request. His blood sugar was 374 mg/dL (milligrams per deciliter; normal range is between 70 to 100 mg/dL). The daughter requested the resident be sent to the emergency room . A progress note for Resident CR1 dated March 2, 2025, at 1:06 PM revealed that Resident CR1 left for the ER due to being lethargic, arousable only to physical stimuli, unable to administer meds, no intake by mouth, and a blood sugar of 374 mg/dL. Further clinical record review revealed that the only notification to the physician during Resident CR1's change of condition occurred on March 2, 2025, at 12:39 PM when the facility faxed a form entitled Physician Call Report (a form used to communicate with physicians) to the physician's office. The form indicated that Resident CR1 was lethargic, responding to physical stimuli, vital signs were within normal limits, blood sugar was 374 mg/dL, staff were unable to give morning medications, resident had coarse lung sounds, his apical pulse was regular, positive bowel sounds, and he had no intake by mouth. The form was faxed back to the facility signed and dated by the physician on March 2, 2025, at 2:30 PM. The form indicated to send Resident CR1 to the emergency room , which the nurse had already done at 1:06 PM the same day. Closed clinical documentation for Resident CR1 revealed that he had a change in condition that started March 1, 2025, at 9:35 PM that required interventions, and the facility failed to notify his physician in a timely. Interview with the Nursing Home Administrator on March 6, 2025, at 12:15 PM confirmed the above noted findings related to physician notification for Resident CR1's change in condition that required intervention. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, observations, and resident and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on two of two nursing units (upper level nursing unit and lower level nursing unit; Resident 53) and failed to exercise reasonable care for the protection of the resident's property from loss for two of 20 residents reviewed (Residents 60 and 102). Findings include: Observation of the upper-level nursing unit shower room on October 25, 2024, at 8:30 AM revealed the following: A shower gurney had a build-up of a dry, white substance and a used resident brief underneath the layer of padding. A handrail located in a resident shower stall was loose and the wall tile was cracked where the handrail met the wall. The above information for the upper-level nursing unit shower room was reviewed with the Nursing Home Administrator on October 25, 2024, at 12:06 PM. Observation of the lower-level nursing unit on October 22, 2024, at 11:10 AM revealed the cove base was off the wall outside of Resident room [ROOM NUMBER]. Observation revealed there were screws exposed. Observation of the locked brief room on the lower-level east nursing unit on October 23, 2024, at 10:03 AM with Employee 1 (licensed practical nurse) revealed that the ceiling tiles were stained with large black areas. Interview with the Nursing Home Administrator on October 23, 2024, at 2:26 PM revealed the black spots appeared to be mold. He stated the kitchen's walk-in freezer is above the brief room and in the spring Department of Safety Inspection (DSI) made the facility remove spray foam under the walk-in freezer, thus causing moisture to accumulate in that area. The above information for the lower-level nursing unit brief room and cove base was reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on October 23, 2024, at 2:06 PM. Review of the facility's active policy entitled, Inventory of Resident Personal Belongings/Property, revealed that the facility will inventory and record all personal clothing and property belonging to each resident. The purpose of the policy is to identify and record resident belongings at the time of admission and throughout the residents' stay at the facility and assure that the personal belongings are returned to the resident/family upon discharge. The procedures noted in the policy included that all items brought in for the resident must be taken to the receptionist. The receptionist/designee will complete an inventory witnessed by the resident/responsible party (if possible). If the resident or responsible party are unable to witness, two employees will witness the recording via the software. This will be documented in the note section in the software. If the responsible party is not present during inventory an email will be sent to them with the inventory of each item that is logged. The admitting nurse/designee will ensure that any medical assistive devices (i.e., dentures, glasses, hearing aids, etc.) are labeled with the resident's name. When preparing a resident for discharge from the facility, social service/nursing will review the items listed with the resident/responsible party to ensure the belongings/valuables are accounted for. All inventory forms must be reviewed and signed for via the electronic tracking system. Clinical record review for Resident 60 revealed nursing documentation dated September 13, 2024, at 7:37 PM that Resident 60 arrived at the facility, was hard of hearing, and had, .hearing aids in place, can hear with mild difficulty. Wears glasses for reading . A plan of care initiated by the facility on September 13, 2024, to address Resident 60's communication problem and difficulty hearing indicated that he utilized a hearing aid in his left and right ears. A plan of care initiated by the facility on September 13, 2024, to address Resident 60's impaired vision indicated that he wore glasses. Activity staff documentation dated September 18, 2024, at 1:46 PM noted that Resident 60 wore glasses and hearing aids. Nursing documentation dated October 15, 2024, at 12:15 PM indicated that Resident 60 was, .missing his hearing aids on a string and his second pair of eyeglasses. Nursing staff has been instructed to go look through the room with a fine tooth comb. His roommate is agreeable to allow staff to clean the room and go through his things as well in order to be thorough. There was no further documentation in Resident 60's medical record regarding his hearing aids or glasses. Observation and interview with Resident 60 on October 23, 2024, at 10:57 AM revealed he was without his hearing aids. Resident 60 originally stated that he was wearing one in each ear; however, upon further questioning, he confirmed that he did not have them in. Social services late documentation created October 24, 2024, at 9:22 AM (for October 23, 2024, at 9:20 AM) revealed that another skilled nursing facility reported that they had an available bed for Resident 60's admission. The documentation indicated that Resident 60's family would transport him on October 24, 2024, at 8:30 AM. An attempt to observe Resident 60 on October 24, 2024, at 9:48 AM revealed that he was already discharged from the facility. Interview with Employee 7 (registered nurse/assistant director of nursing/infection preventionist) on October 24, 2024, at 10:35 AM revealed that the facility could not locate Resident 60's personal property documentation. The surveyor reviewed the missing property concerns for Resident 60 during an interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM. The facility was unable to provide evidence that measures contained in the facility policy to protect resident property from loss or theft were followed for Resident 60 (e.g., evidence that staff inventoried Resident 60's property on admission or upon discharge or investigated and acted upon the report of lost items). Closed clinical record review for Resident 102 revealed that the facility admitted her on July 15, 2024, and discharged her on August 3, 2024. Nursing documentation dated August 3, 2024, at 10:05 AM revealed that staff provided discharge instructions to the resident and her husband and indicated that there was, No inventory sheet to be signed. Interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM confirmed that the facility had no evidence that staff inventoried Resident 102's personal property on admission or upon discharge as required by the facility policy to assure that personal belongings are returned to the resident/family upon discharge. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency 11/17/23 28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to residents or the residents' responsible parties for five of 13 residents reviewed for hospitalization concerns (Residents 17, 65, 62, 80, and 83). Findings include: Clinical record review revealed that Resident 17 was transferred to the hospital on September 28, 2024, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. Clinical record review revealed that Resident 65 was transferred to the hospital on September 8, 2024, after he had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital. The Nursing Home Administrator and Director of Nursing confirmed these findings for Residents 17 and 65 on October 25, 2024, at 10:07 AM. Clinical record review for Resident 62 revealed nursing documentation dated July 9, 2024, at 4:43 PM that he continued with hematuria (blood in the urine), that the certified registered nurse practitioner was made aware, and provided an order to send Resident 62 to the emergency room for evaluation. Nursing documentation dated June 29, 2024, at 4:57 PM indicated that Resident 62 was sent to the emergency room due to hematuria and pain. Nursing documentation dated June 12, 2024, at 11:17 PM revealed that Resident 62 complained of chest pain. Resident 62 requested a transfer to the emergency room for evaluation. Nursing documentation dated June 13, 2024, at 2:19 AM indicated that the hospital admitted Resident 62 for congestive heart failure (insufficient pumping of the heart that affects the body's ability to circulate blood effectively). The surveyor requested evidence that the facility provided the required bed-hold notices to Resident 62's responsible party on the dates of the above noted hospitalization s during an interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM. Clinical record review for Resident 80 revealed nursing documentation dated September 24, 2024, at 7:51 AM that indicated Resident 80 was having difficulty breathing, had an elevated temperature, and an increased heart rate. The certified registered nurse practitioner provided an order to send Resident 80 to the emergency room for evaluation. Nursing documentation dated September 28, 2024, at 4:46 PM revealed that Resident 80 returned to the facility from the hospital. The surveyor requested evidence that the facility provided the required bed-hold notice to Resident 80's responsible party for the above noted hospitalization during an interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM. Clinical record review for Resident 83 revealed nursing documentation dated August 7, 2024, at 10:50 AM that indicated Resident 83 was short of breath, holding her chest and right flank, was yelling out, and was visibly upset. The facility sent Resident 83 to the emergency room for evaluation. Nursing documentation dated August 7, 2024, at 5:56 PM indicated that Resident 83 returned to the facility with a new diagnosis of a urinary tract infection. Nursing documentation dated July 27, 2024, at 3:45 PM revealed that Resident 83 was experiencing seizure-like activity (spasmic movements of extremities and head) and difficulty maintaining her airway. The facility transferred Resident 83 to the emergency room for evaluation. Nursing documentation dated July 28, 2024, at 12:01 AM revealed that the hospital admitted Resident 83 with a diagnosis of seizures (neurological condition that often results in a temporary loss of consciousness/altered mental status, and spasmic jerking motions of limbs). Nursing documentation dated July 30, 2024, at 3:57 PM indicated that the facility readmitted Resident 83 with diagnoses of a urinary tract infection and seizures. Nursing documentation dated July 31, 2024, at 9:37 AM revealed that staff notified Resident 83's physician that she showed signs of difficulty breathing and her oxygenation assessments were low (percentages in the mid 60's to 70's, normal is greater than 90 percent). She was pale and felt clammy. The facility sent Resident 83 to the emergency room for evaluation. Nursing documentation dated July 31, 2024, at 10:05 PM indicated that the hospital admitted Resident 83 with a diagnosis of syncope (fainting, often caused by a drop in blood pressure). The surveyor requested evidence that the facility provided the required bed-hold notices to Resident 83's responsible party for the above noted hospitalization s during an interview with the Nursing Home Administrator and the Director of Nursing on October 24, 2024, at 2:15 PM. Interview with the Nursing Home Administrator on October 25, 2024, at 8:35 AM, revealed that the facility had no further information regarding the provision of written bed-hold notices to Resident 62, 80, or 83's responsible party. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(f) Resident rights

Based on observation, closed clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to to provide the services necessary to prevent accidents resulting in multiple sustained fractures for one of five residents reviewed resulting in actual harm (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a nursing note dated [DATE], at 9:09 PM noting the resident was being turned by a nurse aide and rolled off the bed onto the floor. It was noted the resident had a left dorsal head bump and complaints of severe left hip pain. A follow up nursing note for Resident CR1 dated [DATE], at 9:23 PM indicated the physician had provided a verbal order to send the resident to the emergency room due to the severe left hip pain. Nursing documentation dated [DATE], at 11:34 PM summarized the incident that occurred prior to being transferred to the hospital. The writer noted they heard a loud thump outside of Resident CR1's room and entered the room to find Resident CR1 on the floor between the resident's bed and the first bed in the room. It was noted a hematoma (bruise) was observed on the back of the resident's head on the left side, and the resident had complaints of hip pain. A nurse aide in the room was questioned as to how the incident occurred and what side the resident landed on. The nurse aide in the room replied with, I don't know. The nurse aide was halfway between the resident's bed and bathroom when the writer entered. The writer indicated that based on experience, the resident is unable to roll independently and will continue to roll if she is rolled by the nurse aide and let go. The writer noted the resident left the facility at 9:35 PM to go to the emergency room . A review of Resident CR1's documents from the emergency room visit revealed the resident received several tests in the emergency room dated [DATE], to include x-rays of her bilateral hips, chest, and left shoulder as well as CT scans of her cervical spine, head/brain, chest/abdomen, and pelvis. Review of the resident's emergency department provider summary of the visit revealed the resident was diagnosed with a scalp hematoma (bruise), right hip fracture, multiple left-sided rib fractures, and a left scapular (shoulder blade) fracture. It was noted the residents responsible party declined surgery for the resident's hip fracture. A nursing note dated [DATE], at 5:55 AM for Resident CR1 indicated the resident returned to the facility from the emergency department at 5:00 AM and staff were not able to complete a full skin assessment due to the resident being in too much pain. Nursing staff administered Morphine (an opioid medication used to treat severe pain). Continued review of Resident CR1's nursing notes after her return to the facility revealed multiple entries of the resident being in pain and requiring increased doses of Morphine. A referral for hospice services to assist with pain management was noted on [DATE], at 8:01 AM. Nursing documentation dated [DATE], at 11:39 AM noted Resident CR1 had a significant decline, noting the resident was unable to eat breakfast, intermittently crying out in pain, presenting cognitive decline, and unable to swallow pills safely. The resident's pain regimen was changed, and the resident was placed on hospice care as of [DATE], at 12:31 PM. Resident CR1 continued to have noted decline, and expired at the facility on [DATE], at 10:23 AM. Closed record review for Resident CR1 revealed the resident was listed in care tasks as requiring maximum assistance of two and a bed rail to the left side for bed mobility since [DATE], and at the time of the incident noted above. A review of Resident CR1's plan of care for ADL deficits (activities of daily living) initiated [DATE], identified an intervention added to the care plan dated [DATE], that the resident required maximum assistance and a bedrail to the left side of the bed for bed mobility. A quarterly MDS (minimum data set, an assessment completed at periodic intervals of time to determine resident care needs) for Resident CR1 dated [DATE], revealed facility staff assessed the resident as requiring extensive assistance of two people physical assist for bed mobility. Review of a statement dated [DATE], obtained from Employee 1, nurse aide, who was identified as the nurse aide in the room at the time of the incident with Resident CR1 on [DATE], indicated Employee 1 was dressing and cleaning the resident, turned the resident to her side to clean her bottom and fix the pad underneath the resident, and the resident kept yelling about her bottom hurting and kept trying to turn off her side. Employee 1 asked the resident to stop rocking. Employee 1 indicated she got the pad under the resident and when she went to roll the resident towards her the resident said no, and ended up turning toward the nurse aide and fell off the bed noting she tried to catch the resident but was not able to hold onto her. Employee 1 did not indicate any staff were assisting her with providing care to the resident in bed as the resident required. Interview with the Nursing Home Administrator on [DATE], at 10:45 AM revealed that Employee 1 was staffed from a nursing agency and had first worked at the facility on Saturday, [DATE], again on [DATE], and [DATE], the day of the incident with Resident CR1. A review of Employee 1's Quick Start orientation packet for the facility, which included information on abuse and reporting, resident rights, proper body mechanics, and incidents and accidents, was dated [DATE], the employee's second day of work at the facility. The orientation packet did not include any information on how to access the Point of Care system or how to find a resident Kardex in the electronic system to determine resident care needs, which indicate a resident's needed level of assistance for tasks such as bed mobility, eating, transferring, bathing, and ambulation. Interview with the Nursing Home Administrator on [DATE], at 1:20 PM revealed that Employee 1 did not complete the orientation packet until [DATE] due to the first day of work ([DATE]th) being a Saturday and confirmed the orientation packet had no information as to where to find or determine a resident's care needs prior to providing care to residents. Review of information submitted by the facility on [DATE], for the above incident regarding Resident CR1 and Employee 1, indicated Employee 1, nurse aide, was providing care to Resident CR1 at the time of the above incident, and while providing care the resident rolled out of bed and sustained multiple fractures. The report indicated Employee 1 was immediately suspended at the time of the incident to complete an investigation, and the facility substantiated neglect had occurred as Employee 1 provided care to the resident independently without the resident's required assistance of two people, despite the fact that the facility failed to provide this information to Employee 1. The facility noted Employee 1 was placed on do not return status with the agency. As further intervention, the facility indicated nurse aides had been educated regarding care on the resident Kardex in Point of Care (system location to find resident care needs) and the agency orientation packet that agency staff complete when starting at the facility would have a bed mobility and transfer status section added to it to identify resident care needs. An observation in the facility on [DATE], at 11:30 AM revealed Employee 2, nurse aide, providing care to residents on the upper level of the facility. In a concurrent interview with Employee 2 she indicated she was agency staff who was called into the facility and arrived at the facility around 8:40 AM. Employee 2 indicated it was the first time she had worked at the facility. Employee 2 stated she was not provided nor completed any orientation packet upon arrival to the facility or prior to providing care to residents in the facility. Employee 2 indicated she was provided a user log in for the Point of Care system but had not logged into it yet, and only knew how to obtain a resident Kardex due to using the same system in another facility she had worked at. Employee 2 was able to demonstrate to the surveyor after multiple attempts to log in to the electronic system how to find a resident Kardex and that it was like another place she had worked. Further review of the facility's follow up to the above incident and interventions facility staff indicated would be implemented in the information submitted revealed the facility did not complete nurse aide and licensed practical nurse education until [DATE], on utilizing the resident's Kardex on the Point of Care system. The facility's current Quick Start orientation packet agency staff are to complete when starting at the facility remained unchanged from the packet Employee 1 signed off as completing on [DATE]. Interview with the Nursing Home Administrator on [DATE], at 2:52 PM confirmed no changes had yet been made to the packet to include the information regarding the resident Kardex and Point of Care system to determine resident care needs. The Administrator was made aware agency staff were actively working in the facility and Employee 2 was permitted to start working with residents in the facility without completing an agency orientation packet or any competency that the employee could access information to determine resident care needs prior to her start of work with residents in the facility. The Administrator also confirmed Employee 1 had no record of education or competency on identifying resident care needs prior to the incident, which caused harm to Resident CR1. 483.25 (d) Free from accident hazards Previously Cited [DATE] 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on observation, clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid actual harm related to a fracture on one of two nursing units (Upper level, Resident 1). Findings include: An observation of Resident 1 on December 11, 2023, at 12:16 PM revealed the resident sitting in a wheelchair in front of his bed. A brace was observed on his right leg. When Resident 1 was asked why he was wearing the brace on his leg he stated, one person, (as he held up one finger), tried to put me in bed and didn't use the disc thing. Resident 1 stated it was immediate pain. Resident 1 stated it was the staff members first time working with him, and he has not seen her since. Resident 1 did not know the staff member's name. Resident 1 pointed to an electric wheelchair sitting by his door and stated, I can't use that now, and indicated he had to wear the brace for six weeks. Clinical record review for Resident 1 revealed a nursing progress note dated November 18, 2023, at 4:38 AM noting the staff member was called to the resident's room to evaluate new onset right knee pain, noting the resident was reporting that when he was placed into bed the prior evening, he felt pain in his right leg. It was noted the resident's right knee was swollen and he was reporting a 10 out of 10 pain. Further review for Resident 1 revealed an in-house x-ray was ordered and completed at the facility on November 18, 2023. A nursing note dated November 18, 2023, at 11:54 PM noted the X-ray results were received and there was no acute right knee pathology/trauma. A review of the X-ray report of Resident 1's right knee completed in the facility dated November 18, 2023, confirmed the report findings were of no acute fracture or dislocation. A nursing note dated November 19, 2023, at 6:14 AM indicated the resident had utilized as needed pain medications during the shift related to right knee pain along with a topical pain relief gel and ice throughout the shift and noted noticeable swelling/edema to the right knee. A follow up note on November 19, 2023, at 1:30 PM noted the resident's son was at the facility and requested Resident 1 be sent to the hospital. An order was obtained, and the resident was noted to be at the hospital on November 19, 2023, at 2:08 PM. Nursing documentation dated November 19, 2023, at 7:46 PM noted Resident 1 returned to the facility with a diagnosis of closed fracture of the right tibial plateau and had a knee immobilizer to be on at all times, with an appointment scheduled with orthopedics. Review of Resident 1's Results History from the hospital dated November 19, 2023, at 4:40 PM revealed and X-ray of the right knee confirmed findings of a nondisplaced fracture of the lateral tibial plateau as noted in the nursing note above. Resident 1 was seen by orthopedics on November 21, 2022, at 10:30 AM with recommendations to continue the knee immobilizer for six weeks. A review of Resident 1's clinical record task/Kardex revealed Resident 1 was noted to have a transfer status of maximum assistance of two, with pivot disc due to right lower extremity limited mobility from April 14, 2023, to November 22, 2023, after the incident at which time the resident was changed to a Hoyer lift for transfers. An annual MDS (Minimum Data Set, an assessment completed at periodic intervals of time to determine resident care needs) dated November 16, 2023, revealed facility staff assessed the resident as having a BIMS (brief interview of mental status), score of 13, indicating the resident is cognitively intact, and requiring extensive assistance of two persons plus physical assistance for transfers. A resident concern form dated November 17, 2023, completed by a licensed practical nurse with initials matching Employee 3, licensed practical nurse, for Resident 1 noted a concern the resident was transferred with only one nurse aide on November 17 at 8:15 PM and the resident complains of pain in right leg and lower knee. A review of the facility's staff deployment sheet for November 17, 2023, revealed Employee 1, nurse aide, was scheduled on the upper-level north hall where Resident 1 resided and Employee 2, nurse aide was scheduled on the upper-level south hall and Employees 1 and 2 were doing the north and south hall together. Employee 3, licensed practical nurse, was also scheduled on the upper-level north hall with Resident 1. A review of a witness statement completed by Employee 3, licensed practical nurse, which was not dated, noted an incident date of November 17, 2023, at 8:00 PM stating Resident 1 was injured during transfer and the resident was transferred with one nurse aide. The statement indicated the resident told Employee 3 his leg was twisted, and he felt instant pain and a nurse aide told her she did transfer the resident alone. The statement did not indicate a name for the nurse aide. In an interview with Employee 3 during the onsite investigation on December 11, 2023, at 10:33 AM, regarding the evening shift of November 17, 2023, Employee 3 indicated the statement referenced above was written by her, and she did forget to sign the statement. Employee 3 indicated she completed the statement before she left for her shift at 9:00 PM. Upon interview Employee 3 stated Employee 1 was scheduled on the north hall where Resident 1 resided and close to when she was getting ready to leave her shift Employee 1 came to her and said Resident 1 was having pain in his leg, probably because I had to transfer him myself. Employee 3 stated Employee 1's reason for transferring the resident herself was because they were short staffed. Employee 3 stated Employee 2, and herself were scheduled on the north and south hall and all work together to help each other for transfers. Employee 3 stated she was getting ready to leave for the night, but she went to check on Resident 1 and did not see any apparent injury and asked him what his pain level was which she indicated he stated a 3. Resident 1 declined need for any pain medication and then Employee 3 stated she reported off to the registered nurse, wrote a statement, and left for the night. There was no evidence of any documentation in Resident 1's record dated November 17 ,2023, regarding an assessment of the resident by Employee 3, or any registered nurse assessment of the resident until the nursing note referenced above dated November 18, 2023, at 4:38 AM, which noted the new onset of pain and per the facility staffing deployment sheet for November 17, 2023, was the night shift registered nurse. The registered nurse scheduled for the evening shift on November 17, 2023, was attempted to be reached by telephone by the surveyor during the onsite investigation and was not able to be reached. Employee 3's documentation in Resident 1's record dated November 18, 2023, at 1:33 PM noted while administering 2100 medications to the resident he told this nurse that he was having right knee pain, and when asked what happened, the resident stated he was transferred with one assist and his knee twisted, RN was notified. Employee 3 then documented on November 18, 2023, at 1:52 PM that the facility attempted to call the son last evening regarding injury and the son was unable to be reached due to his number being disconnected and the nurse supervisor spoke with the son today. In an interview with Employee 3 at 11:41 AM on December 11, 2023, she stated she did not provide documentation in Resident 1's record on November 17, 2023, because she was in a hurry to get out of the facility and just forgot to document that night. There was no evidence an investigation into Employee 1 who was assigned to Resident 1 on the evening shift on November 17, 2023, was completed until November 20, 2023. Employee 3 stated Employee 1 reported to her that she transferred him by herself, and the resident was having leg pain before Employee 3 left for the end of her shift at 9:03 PM, which was verified upon observation of Employee 3's time card. Review of a timecard for Employee 1, the alleged nurse aide, revealed she continued to work on the evening shift through the night shift for November 17, 2023, until 2:00 AM. In an interview with the Nursing Home Administrator and Director of Nursing on December 11, 2023, at 3:00 PM they indicated they were not aware of the incident or allegation regarding Resident 1 until they returned to work after the weekend on Monday, November 20, 2023, and began the investigation into the incident. A statement from Employee 1, nurse aide, dated November 20, 2023, stated the gentleman was ready to go to bed, but she was the only aide down the north hall and she asked another aide down the other hallway if she could help her and she said he was a one person and she does him by herself, and a nurse said, no, he is not, he is a two person, so the lady helped her put him in bed, but when they were standing him up he said his leg was hurting. Employee 1 stated the lady helped her change him in bed. Employee 1 stated she let the nurse know he was in pain. Employee 1 stated she did not remember the lady's name and assumed it was the regular nurse that works the north hallway. Further interviews conducted by facility administration revealed Employee 2 who was working the south hall and who was to help Employee 1 on north hall, stated she was not in the room during Resident 1's transfer into bed and was called to help roll him in bed after the resident was already in the bed, and Employee 3, the licensed practical nurse on the unit also did not assist Employee 1, or have any recollection of a conversation about transferring Resident 1 to bed as Employee 1 indicated in her statement. A review of a report submitted by the facility on November 29, 2023, indicated Employee 1 stated she did transfer Resident 1 appropriately with two assist, but all other staff involved stated this was false and no one was in the room with Employee 1 at the time of the injury. Resident 1 was noted in that report as competent and confirmed he was transferred by one person and neglect was substantiated. Employee 1 was noted in the above mentioned report to be agency nursing staff and was placed on a do not return list for the facility and the employee's agency was contacted. There was no evidence the facility conducted any plan of correction to the facility staff regarding timely reporting and timely investigation of allegations of abuse/neglect and protecting other residents from the potential of abuse/neglect upon report of an allegation as Employee 1 continued to work in the facility until 2:00 AM after Employee 3 indicated she reported the incident prior to leaving for her shift at 9:03 PM. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on December 11, 2023, at 3:00 PM who confirmed neglect was substantiated regarding the incident above with Resident 1, resulting in a fracture. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions and assure equipment was in working order to prevent accidents for one of six residents reviewed resulting in harm with a fracture (Resident 1). This deficiency is cited as past non-compliance. Findings include: Closed clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], from the hospital emergency room . An admission nursing assessment completed on June 29, 2023, revealed the resident was assessed as an elopement risk and was ordered a wander guard device (a device worn on a resident, which activates wander guard equipped doors to alarm/not open for resident safety), on the day of admission. Resident 1 was also listed as having a diagnosis of Alzheimer's disease and dementia. Review of nursing notes dated June 30, 2023, at 8:01 PM noted Resident 1 was exit seeking, trying to open several doors to closets, and entering other resident rooms on the upper level, and noted to be wandering the hallways asking which door will get him outside. An additional note at 10:44 PM noted the resident wandered the halls this evening, redirected out of other resident rooms. A progress note for Resident 1 dated July 2, 2023, at 1:46 AM noted a nurse went around approximately 9:15 PM to administer meds, resident was found at approximately 9:30 PM outside leaning against the fence. Resident 1 was not able to definitively indicate if he fell or not. An immediate assessment of Resident 1 revealed the resident was guarding his right hip but able to move all extremities, and abrasions and skin tears were noted on the resident's arms, elbows, and hand. An x-ray was ordered of the right hip. Results of the x-ray noted on July 2, 2023, at 11:09 AM indicated the resident had a mildly displaced right femoral head fracture. Resident 1 was transferred to the emergency roiagnom on [DATE], and discharged from the facility. Review of the facility's investigation of the incident based on staff interview and review of security camera surveillance revealed that Resident 1, unwitnessed, entered one of the facility's main kitchen doors located in the upper-level dining room at 9:10 PM, after dietary staff had left for the night. It was noted the resident was last seen in his hall (South Hall), which is located at the opposite side of the building, at 9:00 PM. The resident continued through the kitchen and directly out an exit door straight ahead to the kitchen delivery/loading dock. Resident 1 was viewed on the surveillance video at 9:11 PM exiting the dock door, closing it behind him and standing on the dock looking around, turning to the right and proceeded to step off the dock and out of the cameras view. In an interview with the Nursing Home Administrator on July 10, 2023, at 11:31 AM she indicated Resident 1 was able to enter the kitchen after hours through an unlocked door, and then exit the facility from the kitchen through a failed keypad magnetic lock door to the dock area. The investigation revealed a cook locked the doors to/from the kitchen/dining room area at 8:04 PM. At 8:19 PM Employees 1 and 2, dietary aides, attempted to exit the kitchen from one of the doors and pushed on the door and it did not open. Employee 1 was seen turning the latch to unlock the door and trying to push the door open and it did not open as it was a pull door. Employee 1 was seen pushing, not pulling, on the door. Employees 1 and 2 then exited the kitchen to the dining room via another door equipped with a keypad to leave for the night, unknowingly leaving the door to the kitchen from the dining room unlocked. At 8:20 PM the cook was observed leaving for the night via the keypad door to the dining room, which the Nursing Home Administrator indicated was the appropriate exit at the end of the night, bypassing the push/pull doors as the cook had locked them prior. Further review at 10:30 PM on July 1, 2023, revealed the kitchen loading dock door is key padded with a magnetic lock and the lock was not connecting, allowing the door to be opened without the key code entered. There was no evidence to indicated failure of the key padded magnetic lock door to the loading dock prior to the incident. Observation of the kitchen loading dock area on July 10, 2023, at 8:30 AM revealed a concrete area four to five foot in height surrounded by metal railings on each side and down a set of stairs. A yellow chain was observed connected from the stair railing to the opposite side of the dock over the open area for loading. Fresh yellow paint was observed on the edges of each step on the stairs. An interview with Employee 3, dietary manager on July 10, 2023, at 1:49 PM revealed the yellow chain and painted step edges were implemented after the incident on July 1, 2023, as a safety measure. Review of facility documentation revealed the magnetic lock on the kitchen dock door was repaired on July 1, 2023. All wander guard doors and magnetic lock doors were audited for appropriate function on July 1, 2023. All residents determined at risk for elopement were audited for appropriate safety measures on July 1, 2023. All staff education on the elopement policy was initiated on July 2, 2023. Audio door alarms were installed on the kitchen dock door, and the set of push/pull doors to the kitchen from the dining room (activated after kitchen hours) on July 3, 2023. Dietary and nursing staff education on the operation of the alarms, and dietary staff education of kitchen opening and closing procedures checklist, which includes activation of the door alarms and locking of the kitchen/dining room doors was completed on July 3, 2023. Audits of kitchen staff closing, and proper entry and exit were initiated and continue. Employees 1 and 2 were educated and received disciplinary action. Review of facility documents revealed the demonstration and evidence of compliance audits and education as of July 4, 2023. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on closed clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement interventions to prevent accidents for one of six residents resulting in harm with a subarachnoid hemorrhage (Resident 80). Findings include: Closed clinical record review for Resident 80 revealed the resident was admitted to the facility on (MONTH) 9, 2019. An interdisciplinary screen for physical therapy, occupational therapy, and speech therapy dated (MONTH) 9, 2019, and signed (MONTH) 16, 2019, listed resident on hospice, in the comments section with no evidence to indicate a screen was performed by the therapy disciplines listed. An admission MDS (Minimum Data Set, an assessment completed at specific intervals of time to determine resident care needs) dated (MONTH) 16, 2019, assessed Resident 80 as requiring extensive assistance of one-person physical assistance for transfers, and one-person physical assistance for walking in her room. Review of physician orders [REDACTED]. and symptoms, and attending to their emotional and spiritual needs), for end stage disease process. Further review of Resident 80's closed clinical record revealed the resident had a fall on (MONTH) 4, 2019, at 6:30 PM. She was found forward over the foot of the bed on the mattress. No injuries were noted. Review of facility documentation entitled Resident Incident/Accident, dated (MONTH) 4, 2019, indicated a one-time therapy evaluation would be requested as an intervention for the fall. In addition, a nurse's note dated (MONTH) 4, 2019, at 9:19 PM noted the resident as being assessed post fall and a therapy screen was given to therapy. There was no evidence to indicate a therapy screen was completed. Closed clinical record review revealed Resident 80 sustained another fall in her room on (MONTH) 18, 2019, at 2:30 PM. A nurse's note dated (MONTH) 18, 2019, at 2:50 PM indicated the resident had a fall, no injuries were noted, and a therapy screen was placed. Facility documentation entitled screen/referral form, signed and dated by an occupational therapist on (MONTH) 19, 2019, indicated the resident had a fall, was at risk for falls, and noted resident currently on hospice in the comments. A nurse's note dated (MONTH) 19, 2019, at 1:39 PM noted that hospice was called requesting an order for [REDACTED]. fall on (MONTH) 18, 2019. Closed clinical record review revealed Resident 80 fell again on (MONTH) 4, 2019, at 7:50 PM from her wheelchair. Review of the facility incident/accident report for the fall on (MONTH) 4, 2019, indicated no injuries were present, and a physical therapy screen for wheelchair positioning as an intervention. A nurse's note dated (MONTH) 10, 2019, at 2:50 PM noted hospice was called for an order for [REDACTED]. Resident 80 fell on (MONTH) 10, 2019, at 6:50 PM, sliding from the edge of her bed, with no injuries. An intervention was noted on the resident incident/accident report that a note was sent to occupational therapy for dycem, (a non-slip material), to be placed under the resident wherever she is seated, whether it is on the edge of the bed or a chair. Review of Resident 80's plan of care indicated the dycem was initiated on (MONTH) 10, 2019, although an interdisciplinary screening form and a screen/referral form signed by an occupational therapist dated (MONTH) 11, 2019, both indicate resident currently on hospice, in the comments of the form. Further review of facility incident/accident reports for Resident 80 revealed the resident fell again on (MONTH) 10, 2019, at 11:20 PM, in her room and was found on the floor at the foot of the left side of the bed. Staff noted a 1cm (centimeter) long laceration to her right temporal region of her head, and a 1 cm wide laceration to her right fourth finger. Resident 80 was noted as unresponsive to verbal and physical stimuli. A physician's orders [REDACTED]. The facility indicated on the (MONTH) 10, 2019, 11:20 PM incident report the resident's plan of care was updated, therapy screen initiated, and noted to ensure non-skid footwear is in place, and every 15 minute checks. Resident 80 was admitted to the hospital on (MONTH) 11, 2019, as a result of the fall on (MONTH) 10, 2019, at 11:20 PM and returned to the facility on (MONTH) 12, 2019, with a hospital discharge [DIAGNOSES REDACTED]. Resident 80's plan of care revealed interventions of non-skid footwear and every 15 minute checks were initiated on the plan of care on (MONTH) 13, 2019, one day after the resident returned from the hospital. A facility incident and accident report for Resident 80 dated (MONTH) 13, 2019 at 12:30 PM indicated the resident was found on the floor between the bed and the wall and regular socks were on. A change of status form for Resident 80 indicating the resident has had frequent falls dated (MONTH) 15, 2019, was signed by an occupational therapist and indicated under other recommendations, hospice. The resident expired at the facility on (MONTH) 19, 2019. The surveyor reviewed the above findings for Resident 80 with the Nursing Home Administrator and Director of Nursing on (MONTH) 22, 2019, at 2:13 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], and [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], and [DATE]

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding wound management for one of five residents reviewed, which resulted in harm (Resident CR1). Findings include: Review of Resident CR1's closed clinical record revealed that the facility admitted him on October 22, 2017, with a [DIAGNOSES REDACTED]. Review of Resident CR1's admission orders [REDACTED]. Review of Resident CR1's facility physician orders [REDACTED]. Review of Resident CR1's TAR (Treatment Administration Record, a form used by nursing staff to document the administration of physician ordered treatments) dated October 2017, revealed that the wound treatment was discontinued on October 23, 2017. There was no documented evidence in Resident CR1's closed clinical record to indicate that communication took place with Resident CR1's surgical physician regarding the discontinuation of wound care to his left surgical stump incision. The facility failed to change Resident CR1's dressing to his left stump incision from October 23, 2017 until October 30, 2017, at which point bloody drainage was coming through the dressing. Nursing documentation dated October 30, 2017, at 2:33 PM indicated that the facility called the vascular department and obtained an order to change Resident CR1's dressing to his left stump. Interview with Employee 1, registered nurse, on November 21, 2017, at 11:04 AM revealed that she called the vascular department on October 30, 2017, and that when she called the vascular department they inquired what is wrong with Resident CR1's incision, the facility is already supposed to be changing his dressings every day. This interview with Employee 1 was confirmed again at this time with Employee 1, the Director of Nursing, and the Administrator present. Nursing documentation dated October 31, 2017, indicating that Resident CR1 was now scheduled for an appointment with the vascular department and the physician who did his surgery to his left [MEDICAL CONDITION]. Resident CR1 returned from this appointment with a debridement (the medical removal of dead, damaged, or infected tissue) and placed on antibiotics for a [DIAGNOSES REDACTED]. Resident CR1 now needed his open wound to his left stump packed daily with a wet to dry dressing. Nursing documentation dated November 2, 2017, at 2:15 PM indicated that nursing staff completed Resident CR1's dressing change to his left stump wound and indicated that the area had a foul smell with slough (dead yellow tissue). Resident CR1 was transferred again on November 3, 2017, for an appointment with his vascular surgeon requiring another surgical debridement of his left stump wound. Resident CR1 did not return to the facility after this appointment. The facility failed to follow physician orders [REDACTED]. The findings were discussed with the Administrator and Director of Nursing on November 21, 2017, at 11:10 AM. Interview revealed that there was no additional documented evidence to indicate that the facility followed Resident CR1 physician orders [REDACTED]. 483.24 Provide Care/Services for Highest Well Being Previously cited 9/29/17, 5/23/17, 3/24/17 28 Pa. Code 211.10(c)(d) Resident care policies Previously cited 9/29/17, 5/23/17, 3/24/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 9/29/17, 6/21/17, 5/23/17, 3/24/17 28 Pa. Code 211.12(d)(2) Nursing services Previously cited 9/29/17

Based on clinical record review, review of select policy and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate and implement interventions to prevent falls for two of 21 residents reviewed (Residents 12 and 7) and failed to prevent serious injury for one of 21 residents reviewed who fell from the bed and sustained a fractured femur (Resident 67). Findings include: The policy entitled Occurrence Investigation, last reviewed without changes on February 21, 2017, indicated that upon an occurrence of an incident that may have caused injury to a resident, the resident is evaluated to include identification of events, which may have precipitated the incident. The facility will identify the cause as well as potential contributing factors with a description of how the event occurred. The facility will also include the immediate corrective action taken after the incident. Review of Resident 67's clinical record revealed a quarterly Minimum Date Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated February 7, 2017, that revealed the facility assessed him as needing the extensive assistance of two staff members for toileting, which included how he uses a bed pan. The facility initiated a plan of care regarding his risk for falls on November 8, 2016. Review of Resident 67's task list (a list that includes how the resident should be cared for by the nurse aides) revealed that the nursing staff are to use two caregivers for toileting. Review of the information submitted by the facility for Resident 67 dated March 19, 2017, at 7:15 PM revealed that a nurse aide stated he (Resident 67) rolled too far while rolling for care. Resident 67's bed was in the high position. Employee 5's, nurse aide, witness statement indicated, I was trying to roll him and he rolled off the bed. Resident 67 landed on the floor beside his bed. Another witness statement from Employee 6, a nurse aide, indicated that Employee 5 asked Employee 6 to help place Resident 67 on the bedpan on March 19, 2017 (no time indicated) and that Employee 6 did not think the side rails were up. Employee 6 indicated that Employee 5 did not ask her to help remove Resident 67 from the bedpan. Review of additional statements from Employee 5 indicated that she was taking Resident 67 off the bedpan on March 19, 2017 (no time indicated) and that she had no reason for not requesting a second staff member to help. Employee 5 indicated that she usually has help to do so. Employee 5 also indicated that she stood on the right side of the bed and rolled Resident 67 away from her to the left side of the bed. Resident 67 received a CT (computed tomography- a test that can detect diseases and condition) scan on March 21, 2017, that indicated a fracture to his right femoral neck (upper right leg). The facility failed to implement interventions of two caregivers for Resident 67's toileting needs resulting in a serious injury. Clinical record review for Resident 12 revealed nursing documentation dated March 17, 2017, at 10:15 AM indicating that while staff transferred Resident 12 from the toilet to the wheelchair, Resident 12 sat on the floor. The documentation indicated that the nurse aide was behind the resident and assisted her to the floor without injury. Review of task list documentation dated as active since September 30, 2016, revealed that the assistance of two staff is necessary for transferring and toilet use. An annual MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE], assessed Resident 12 as requiring the physical extensive assistance of two staff for transfers. Review of the facility's investigation of Resident 12's fall on March 17, 2017, revealed the identification of only one witness to the event indicating that staff failed to implement the intervention of two caregivers for Resident 12 during the transfer to the toilet. The facility failed to identify this failure as a precipitating factor in Resident 12's fall. Clinical record review for Resident 7 revealed nursing documentation dated November 24, 2016, at 7:07 AM indicating that staff observed Resident 7 fall in her room sustaining a hematoma (swelling caused by the collection of blood under the skin following trauma) to the back of her head. Review of the facility's investigation of the November 24, 2016, fall indicated that the facility implemented a personal alarm (a device attached to a resident intended to alarm should the resident attempt to transfer/ambulate without staff assistance) as a protective intervention. Review of Resident 7's plan of care developed by the facility to address Resident 7's moderate risk for falls revealed interventions that included the use of a personal tab alarm in and out of bed as of November 24, 2016. Nursing documentation dated January 26, 2017, at 3:47 PM indicated that at 7:00 AM, Resident 7 got out of bed without assistance and fell to her knees on the floor. Review of the facility's investigation of the January 26, 2017, fall revealed no evidence that staff were alerted to Resident 7's fall via the care planned personal alarm. The facility's investigation failed to identify the omission of the personal tab alarm. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Nursing documentation dated February 1, 2017, at 7:01 AM revealed that Resident 7 attempted to get out of bed, the wheels on the bed were not locked, and staff found Resident 7 on her stomach on the floor. The documentation noted, .bed alarm problem corrected and functioning. Review of the facility's investigation of the February 1, 2017, fall substantiated that the alarm did not alert staff to Resident 7's attempt to get out of bed; however, neither the nursing documentation nor the investigation indicated whether it was equipment failure, staff neglect, or resident tampering that caused the, bed alarm problem. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Nursing documentation dated February 9, 2017, at 7:32 PM revealed that staff noted Resident 7 sitting on her buttocks beside her bed. The documentation indicated that her roommate reported that Resident 7 was in her chair, stood, tried to sit on the bed, and slid to the floor. Review of the facility's investigation of the February 9, 2017, fall substantiated that staff became aware of Resident 7's fall because the roommate yelled for staff. The facility failed to identify the omission of the personal tab alarm. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Nursing documentation dated February 10, 2017, at 9:41 PM revealed that staff noted Resident 7 sitting on her buttocks in the threshold of her bedroom. The documentation stipulated that Resident 7's bed alarm was not sounding. Review of the facility's investigation of the February 10, 2017, fall (incorrectly dated and timed as February 9, 2017, at 9:15 PM) substantiated that Resident 7's plan of care included an alarm; however, it was not functioning at the time of the incident. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Neither the nursing documentation nor the investigation indicated whether it was equipment failure, staff neglect, or resident tampering, etc. that caused the absence of the alarm. Late entry nursing documentation created February 27, 2017, at 1:07 PM for February 23, 2017, at 8:05 PM as a, follow up to February 23, 2017 6:29 PM nurses note, revealed that Resident 7's grandson stated that he was helping Resident 7 get ready for bed and had taken her shoes off when Resident 7 stated that she needed to use the bathroom. Resident 7's grandson was waiting outside the bathroom when he heard her fall. He stated understanding that she needed nonskid footwear on at all times. Review of the facility's investigation of Resident 7's February 23, 2017, fall failed to identify that staff or a visitor was involved in the accident. The investigation failed to identify that equipment was involved in the incident. Neither the nursing documentation nor the facility's investigation identified or addressed the absence of the personal alarm. Resident 7's nephew's statement substantiated that he removed her shoes; however, he did not indicate the removal of an alarm. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Neither the nursing documentation nor the investigation indicated whether it was equipment failure, staff neglect, or resident/visitor tampering, etc. that caused the absence of the alarm. Nursing documentation dated February 24, 2017, at 4:31 PM revealed that staff found Resident 7 on the floor in front of her chair with the pressure alarm not sounding. Review of the facility's investigation of the February 24, 2017, fall revealed that staff found the pressure alarm, turned off. The investigation stipulated that no employee or equipment were involved in this incident. The facility failed to identify the staff responsible for this resident at the time of the fall or obtain any witness statements from the staff attesting to the implementation of the intervention. Neither the nursing documentation nor the investigation indicated whether it was equipment failure, staff neglect, or resident/visitor tampering, etc. that caused the absence of the alarm. An interview with the Nursing Home Administrator and the Director of Nursing on March 23, 2017, at 2:00 PM verified Resident 7's multiple falls. 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices Previously cited 9/9/16, 6/28/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/17/16, 9/9/16, 6/28/16 28 Pa. Code 201.18(e)(1) Management Previously cited 9/9/16, 6/28/16

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent resident accidents with injury for two of six residents reviewed (Residents 2 and 59). Findings include: The facility policy entitled, Occurrence Investigation, last reviewed March 18, 2016, revealed the investigation process steps included that the administrator or administrator's designee directs the investigation. Evaluations or tasks that are performed may include identification of events that may have precipitated the incident and collection of any other situational information. The incident report contains factual information and is completed in a thorough and succinct manner. Identify the cause, if known, as well as any potential contributing or precipitating factors with a description of how the event occurred. Also, include the immediate corrective actions taken. Completion of the culpability analysis assists the facility in resolution of the issue. The analysis includes answers to what steps need to be taken to protect the individual or similar residents, what systems or processes need put in place, and what educational presentations need to be developed and presented. Clinical record review for Resident 2 revealed a plan of care developed by the facility to address her risk for falls that as of July 4, 2016, instructed the staff to utilize one staff, assist to w/c (wheelchair) - to bathroom and back to chair - no walker to bathroom. Nursing documentation dated August 8, 2016, at 10:15 PM revealed that the staff assessed bleeding from Resident 2's finger. The documentation indicated that the nurse aide prevented Resident 2 from falling by utilizing the gait belt; however, Resident 2 bumped her chin on her bedside stand and sustained a skin tear to her left pointer finger. Review of the facility's investigation of Resident 2's above noted incident described the facts of the incident as, Resident was walking with CNA (nurse aide) from the bathroom reached out to put glasses on bedside stand .lost balance - aide caught her with gait belt. A witness statement from the nurse aide reiterated that the incident occurred when Resident 2 was ambulating from the bathroom. The investigation did not identify that Resident 2 should not have been ambulating from the bathroom per her plan of care. Interview with the Director of Nursing on September 9, 2016, at 11:43 AM confirmed that Resident 2's care plan stipulated that the staff should utilize a wheelchair to transport Resident 2 to and from the bathroom at the time of the August 9, 2016, incident. The facility provided no evidence of any corrective action to prevent future episodes of the staff ambulating Resident 2 to or from the bathroom. Clinical record review for Resident 59 revealed a physical therapy program discharge instruction form dated March 22, 2016, that stipulated the staff to use a gait belt for walking and transfers. Interview with Employee 1, a Physical Therapist, on September 9, 2016, at 10:15 AM confirmed that the department had no further instructions for the staff regarding Resident 59's transfer status after her discharge from the program in March 2016. Review of Caretracker (an electronic medical record system used by staff to document the provision of care) restorative program instructions dated April 18, 2016, alerted the staff that Resident 59 transfers and ambulates with a gait belt. Nursing documentation dated September 6, 2016, at 9:14 PM revealed that Resident 59's, .knees gave out and (the nurse aide) helped lowered the resident to the floor .no gait belt was used. Resident 59 complained of pain in her right knee, which hurt when moved. Nursing documentation dated September 6, 2016, at 9:40 PM indicated that the physician ordered the facility to transport Resident 59 to the hospital emergency room for evaluation. Nursing documentation dated September 7, 2016, at 2:35 AM revealed that the report from the local hospital emergency room included that the hospital admitted Resident 59 for a right femur (thighbone) fracture. Review of the facility's investigation of Resident 59's fall on September 6, 2016, confirmed that the nurse aide failed to utilize a gait belt while assisting her to bed from a seated position. The facility provided education regarding the use of a gait belt for all transfers to the nurse aide following the incident. Interview with the Director of Nursing on September 9, 2016, at 11:43 AM revealed that it is the facility's practice to require the staff to utilize a gait belt when assisting residents with transfers and ambulation; however, the staff failed to do this for Resident 59 as noted above. 483.25(h) Free Of Accident Hazards/supervision/devices Previously cited deficiency 6/28/16, 5/29/15 28 Pa. Code 201.18(e)(1) Management Previously cited 6/28/16, 5/29/15 28 Pa. Code 211.10(d) Resident care policies Previously cited 6/28/16, 5/18/16, 9/15/15, 5/29/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/28/16, 5/18/16, 9/15/15, 5/29/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 6/28/16, 5/29/15