Every finding on record at Waynesburg Nursing and Rehab

Based on review of job descriptions, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian for 12 of 12 months. (February 2025 - February 2026) Findings include:Review of facility policy Dietary Services - Staffing reviewed 1/31/25 and 1/7/26, indicated the facility employs sufficient staff with the appropriate competencies and skill set to carry out the functions of the Food and Nutrition Services. The facility will employ a qualified dietitian or other clinically qualified nutrition professional on a full time, part time, or consultant basis. If a qualified dietician is not employed full-time, the facility will designate a person to serve as director of food services who is a certified dietary manager, certified food service manager, has an associate's degree in food service management or two or more years of experience in the position of food and nutrition services in a nursing facility.Review of the job description for Registered Dietician (RD) indicated one of the essential functions in this position is to plan, organize, coordinate, and evaluate the nutritional components of dietary services for the facility. The essential job function included the following:- Assist in developing safety standards for the food and nutrition services department.- This position has supervisory responsibility for all dietary/kitchen personnel.Review of the job description for Dietary Supervisor indicated the dietary supervisor must demonstrate ability to organize, develop, and direct the overall operations of the Food Service Department in accordance with current state and local standards as well as established facility policies and procedures; assure that proper food quality and service is always provided. The essential job function included the following: - Assist in the development of, and participation in, programs designed for in-service education, on-the-job training, and orientation classes.- Inspect daily the food service area for compliance with current applicable regulations.- Develop and maintain a file of tested standard recipes.- Review the dietary requirements of each resident admitted to the facility and assist in planning of the resident's prescribed diet plan.- Check food production and food services to ensure proper procedures are always maintained.Education/Experience needed for the Dietary Supervisor position included: - High school diploma or equivalent required. - Successful completion of a reputable course in food service operation preferred. - College degree in culinary art and management.- Previous Experience in food service, preparation, and management.- Previous experience in institutional food service preferred During an interview on 2/4/26, at 8:35 a.m. Dietary Manager Employee E2 stated she completed her SERV Safe certification. she did not complete a Certified Dietary Manager (CDM) course. She started the current position on 12/28/25. She stated that she currently did not have her CDM (Certified Dietary Manager) and was not currently enrolled in the program.Review of the facility employee files indicated the following:- Employee E3 was hired 8/10/18, as a cook. Employee E3 accepted the position of Dietary Supervisor 11/7/23. His employee file did not include proof that he was qualified for the position, or a signed job description. Employee E3 left the facility's employ on 6/9/25.- Employee E5 was offered the Certified Dietary Manager position on 5/27/25. Employee E5 employee file failed to reveal proof she was qualified for the position as CDM or was enrolled in a CDM course. Employee E5 left the facility's employ on 7/30/25.- Employee E2 was offered the Certified Dietary Manager position on 8/25/25. Employee E2 employee file failed to reveal proof she was qualified for the position of CDM or was enrolled in a CDM course.During an interview on 2/4/26, at 9:20 a.m. Registered Dietician Employee E1 stated she is shared between two facilities. She works at the facility three days a week, and at a different facility two days a week. She confirmed she provides part-time services to the residents.During an interview on 2/4/26, at 2:00 p.m. the Nursing Home Administrator confirmed there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of three residents reviewed (Resident R7).Findings include: Review of the facility policy, Trauma Informed Care dated 1/7/26 with a prior review date of 1/31/25, indicated that A trauma-informed approach to care delivery recognized the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plan, policies, procedures and practices to avoid re-traumatization. Review of the facility policy, Care Plans, Comprehensive Person-Centered dated 1/7/26 with a prior review date of 1/31/25, indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, and functional needs is developed and implemented for each resident. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/1/25, indicated the diagnoses of post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anxiety. Section I6100 indicated PTSD is present. Review of Resident R7's facility diagnosis list indicated that the diagnosis of PTSD was added on 10/16/24. Review of Resident R7's care plan reveals a trauma care plan was not initiated until 2/2/26 during the full health survey. During an interview on 2/2/26, at 10:30 a.m. Resident R7 verbalized his history of being sexually victimized by predators for multiple years as a youth, while living in a group home. During an interview on 2/5/26, at approximately 10:45 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder. 28 Pa Code 201.24(e)(4) admission Policy.28 Pa Code 211.12(a)(d)(3)(5) Nursing Services.28 Pa. Code 211.16(a) Social Services.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of two residents reviewed (Resident R89).Findings include:Review of the facility policy Abuse, Neglect and Exploitation reviewed on 1/31/25 and 1/7/26, indicated an immediate investigation is warranted when suspicion, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD caused by swelling and irritation in the airways that limit air going in and out of the lungs), other schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves), and generalized edema (excessive accumulation of fluid in the interstitial spaces throughout the body).Review of a facility reported incident dated 12/10/25, revealed Resident R89 reported Nurse Aid (NA) for being rough and causing pain.Review of the facility investigation revealed the residents interviewed did not sign or time the statements. The facility staff witness statements failed to include signatures or times.During an interview on 2/3/26, at 1:30 p.m. Nursing Home Administrator (NHA) stated he conducted the staff interviews over the telephone and forgot to get the staff to sign when they returned to work. He stated he was not aware the residents had not signed their statements. The NHA confirmed the facility failed to conduct and document a thorough investigation in regard to Resident R89's incident. 28 Pa. Code: 201.149(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management

Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews it was determined that the facility failed to make certain comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were accurate and fully completed for one of eight residents (Resident R21).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2025, indicated:Section B: Hearing, Speech and Vision, Question B0700: Makes Self Understood: Ability to express ideas and wants (consider both verbal and non-verbal expression) should be coded as 0 Understood, 1 Usually understood (difficulty communicating some words or finding thoughts but is able if prompted or given time), 2 Sometimes understood (ability is limited to making concrete requests), 3 Rarely/never understood. Section C: Cognitive Patterns, Question C0100: Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, or it should be coded as 1 Repetition of 3 words meaning the assessment should be completed (Questions C0200-C0500) if the resident is at least sometimes understood. Section D: Mood, Question D0100 Should Resident Mood Interview Be Conducted? should be coded as 0 if the resident is rarely/never understood, and or it should be coded 1, and the assessment should be completed if the resident is at least sometimes understood. Resident R21 had a MDS completed on 4/21/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R21 is coded as 1 repetition of 3 words, BIMS assessment was completed as Resident R21 scored 00, meaning the resident has severe cognitive decline. Review of Section D: Mood, Question D0100 indicated that Resident R21 is understood and the Resident Mood Interview assessment was not completed. Resident R21 had a MDS completed on 8/15/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated the Resident R21 is rarely/never understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R21 is rarely understood and the Resident Mood Interview assessment was not completed. Resident R21 had a MDS completed on 11/15/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is usually understood. Review of Section C: Cognitive Patterns, Question C0100 indicated the Resident R21 is rarely/never understood and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R21 is understood and the Resident Mood Interview assessment was not completed. During an interview on 2/5/26, at 9:55 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed. During an interview on 2/5/26, at 10:55 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for one of eight residents (Resident R21). 28 Pa. Code: 211.5(f) Clinical Records.

Based on review of facility documents, clinical record review, and resident and staff interview, it was determined that the facility failed to complete a significant change on the Minimum Data Set (MDS - core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) for one of three residents (Resident R9).Findings include:Review of facility policy Coordination of Hospice Services reviewed 1/31/25 and 1/7/26, indicated when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice.Review of the clinical record revealed Resident R9 was admitted to the facility on [DATE], with diagnoses that included cancer, high blood pressure, and depression.A review of a physician's order dated 5/21/21, indicated that Resident R18 was admitted to hospice services. Review of a physician's order dated 9/26/25, indicated admit to hospice.Review of the MDS dated [DATE], failed to indicate Resident R9 was receiving hospice care and services.A review of the communication between the facility and the hospice service, failed to reveal any documentation of nurse or home health aide visits to Resident R18. A review of the care plan dated 9/27/25, indicated the hospice Resident R9 was receiving hospice care and services.During an interview on 2/5/25, at 9:20 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed the MDS dated [DATE], failed to indicate Resident R9 was receiving hospice care and services and confirmed the facility failed to ensure provision of ordered hospice services for two residents. 28 PA Code: 211.10(c) Resident Care Policies28 PA Code: 211.10(d) Resident Care Policies28 PA Code: 201.18 (b)(1)(e)(1) Management. 28 PA Code: 211.12 (d)(2) Nursing Services. 28 PA Code: 211.12 (d)(1)(3)(5) Nursing Services.

Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (A and C Wings) and across from the social service department. Findings include: A review of the facility policy Resident and Family Grievances reviewed 1/31/25, support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The Centers for Medicare & Medicaid Services (CMS) does not specify exact height requirements for grievance boxes in skilled nursing facilities. However, CMS mandates that grievance procedures be accessible to all residents, including those with disabilities, in compliance with the Americans with Disabilities Act (ADA). In Pennsylvania, the Department of Health incorporates by reference the federal requirements outlined in 42 CFR Part 483, Subpart B, which pertain to long-term care facilities. These regulations emphasize the importance of accessibility but do not provide additional specifications regarding grievance box placement. To ensure accessibility, the ADA Standards for Accessible Design recommend that operable parts, such as slots on grievance boxes, be mounted between 15 and 48 inches above the floor. This range accommodates individuals using wheelchairs and ensures usability for a broad range of residents. During an observation on 3/19/25, at 11:25 a.m., the grievance box were not accessible on nursing units (A and C Wings) and across from the social service department. The grievance boxes had been mounted at approximately 57 inches above the floor, out of the reach of residents in wheelchairs. During rounds on 3/19/25, at 12:40 p.m. the Nursing Home Administrator and surveyor measured the height of the grievance boxes on nursing units (A and C Wings) and across from the social service department and confirmed the grievance boxes had been mounted at approximately 57 inches above the floor, out of the reach of residents in wheelchairs. During an interview on 3/19/25, at 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents on three of three locations, nursing units (A and C Wings) and across from the social service department. 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for 10 of 11 months from April 2024 through February 2025. (April, May, June, July, August, September, October, November, December 2024 and January 2025). Findings include: Review of the facility policy Transfer or Discharge Documentation dated 1/31/25, indicated that when a resident is transferred appropriate notice will be provided to the resident and/or legal representative and others as appropriate or necessary. Review of Title 42 Code of Federal Regulations §483.15(c)(3) Notice Before Transfer: indicates, before a facility transfers or discharges a resident, the facility must (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Federal Regulations further define emergency transfers as, When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer. During an interview on 3/21/24 at 12:45 p.m., the Nursing Home Administrator confirmed the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division from April 2024 through January 2025. 28 Pa. Code 201.18(b)(3)(e)(2) Management.

Based on observations and staff interview, it was determined that the facility failed to provide a safe environment for residents in four areas of the facility (Beauty Shop, Lift Rom, Shower Room, and Boiler Rom). Findings include: During an observation on 3/17/25, at 2:25 p.m. the Beauty Shop was observed unlocked. The door was noted to have a locking mechanism. Within the Beauty Shop were observed scissors, hair dryers, curling irons, and disinfecting solution. During an observation on 3/17/25, at 2:29 p.m. the Lift Room door was noted to have a sign reading, Keep door closed at all times posted on it. The door was noted to have a locking mechanism, but the door was not closed. Within the Lift Room was noted exhaust fan panels, circuit breaker boards, charging stations for the lift batteries, and three needles used to draw blood. During an observation on 3/17/25, at 2:35 p.m. the Shower Room cabinet was observed to have a disengaged padlock on it. Within the cabinet was observed a spray bottle without a front label describing the contents, and the back label provided directions on how the use the contents as a virucide (any physical or chemical agent that deactivates or destroys viruses). During an interview on 3/17/25, at 2:40 p.m. Registered Nurse (RN) Employee E1 confirmed the above observations. During the interview (which took place at the Beauty Shop door) Beautician Employee E2 approached RN Employee E1, who asked why the door was open. Beautician Employee E2 stated that the visiting dentist had used it last Friday (3/14/25), and it must have been open since then. During an observation on 3/18/25, at 11:21 a.m. the Boiler Room door was noted to be unlocked. Signage on the door indicated authorized personnel only. Additional to the boilers in the room, were noted various tools, degreasers, personal drinks. Upon walking through the boiler room, the rear door to the room was open all the way, allowing access to the grassy area behind the building. During an interview on 3/18/25, at 11:30 a.m. the Director of Nursing confirmed Boiler Room door was open, allowing residents to access an unsafe area. During an interview on 3/21/25, at approximately 12:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for two of three residents. (Resident R11 and R38). Findings include: Review of the facility policy, Antipsychotic Medication Use dated 1/31/25, indicated; Residents will not receive medications that are not clinically indicated to treat a specific condition. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. Review of Resident R11's admission record indicated he was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R11's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). No psychotic diagnoses were present on the MDS. Review of Section N: Medications revealed Resident R11 received antipsychotic medications in the seven days prior to the assessment. Review of a physician order dated 1/30/25, indicated Resident R11 received Rexulti (an anti-psychotic medication) 0.5 mg daily for dementia without behavioral disturbance. This order was discontinued on 3/5/25. Review of a physician order dated 3/5/25, indicated Resident R11 received Rexulti 1.0 mg daily for dementia, mild, with agitation. Review of Resident R11's care plan for the use of antipsychotic medications and for behavioral disturbances, updated 2/19/25, failed to include goals and interventions for monitoring behaviors, except when a new medication is started or dosage change. Review of behavior monitoring documentation indicated that only symptoms of anxiety and depression were being monitored. Review of the documentation for, 12/1/24, through 3/17/24, failed to reveal any documented behaviors. Review of a nurse practitioner note created 10/20/24, at 8:38 p.m. indicated, Does not have significant dementia. Review of a psychiatric evaluation on 1/23/25, indicated the provider documented that Per nursing collateral recent and frequent verbal agitation, physical aggression. Review of progress notes from 12/1/24, through 3/17/25, failed to reveal documentation of any behaviors. Review of Resident R38's admission record indicated he was initially admitted to the facility on [DATE]. Review of Resident R38's MDS assessment dated [DATE], included diagnoses of dementia, cancer, and a seizure disorder. Review of Section N: Medications revealed Resident R38 received antipsychotic medications in the seven days prior to the assessment. Review of a physician order dated 12/31/24, indicated Resident R38 received Quetiapine (an anti-psychotic medication) 25 mg twice daily for emotional lability. This order was discontinued on 1/28/25. Review of a physician order dated 1/28/25, indicated Resident R38 received Quetiapine 50 mg twice daily for dementia, unspecified severity, with agitation. Review of Resident R35's care plan for the use of psychotropic medications and for behavioral disturbances, updated 2/24/25, failed to include goals and interventions for monitoring behaviors, except when a new medication is started or dosage change. Review of behavior monitoring documentation indicated that only symptoms of anxiety and depression were being monitored. Review of the documentation for, 1/1/25, through 3/17/24, failed to reveal any documented behaviors. Review of a psychiatric evaluation on 1/28/25, indicated the provider documented that the patient reported paranoia. Review of progress notes from 1/1/25, through 3/17/25, revealed one progress note on 3/4/25, that Resident R38 had one episode of being agitated. During an interview 3/21/25, at approximately 12:45 p.m. Nursing Home Administrator confirmed the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for two of three residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.2(a)(c) Physician services. 28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services. 28 Pa. Code: 211.12(c)(d)(5) Nursing services.

Based on review of facility policies, facility provided documentation, clinical records and staff interview, it was determined that the facility failed to make certain a resident was free from abuse/neglect for two of five residents(Residents R1 and R2). Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 1/31/25, with a previous review date of 1/31/24, indicated that the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Potential employees will be screened for a history of abuse, etc. New employees will be educated on abuse, neglect, etc. The facility will have ongoing training for facility personnel as to he requirements of the facility's policies and procedures for assuring resident safety. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included dementia, difficulty walking, cognitive communication disorder and heart failure. A Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 1/14/25, indicated the diagnoses remained current. Section C0500 (Brief Interview for Mental Status - BIMS) indicated a score of 15; which indicated the resident was cognitively intact. Review of the facility provided information dated 1/15/25, indicated that Resident R1 had been identified as being neglected by Nurse Aide Employee E1 when she put on her call light for assistance. The Housekeeper who submitted the allegation indicated that NA Employee E1 stated It was not her job to care for Resident R1 that the floater would do it. The information submitted indicated that NA Employee E1 confirmed that she refused to provide Resident R1 assistance. Review of the Alleged Neglect report dated 1/15/25, indicated that Resident R1 was interviewed by the Director of Nursing and Resident R1 stated she put on her call bell to use the bathroom, and she waited more than usual time to be provided assistance (30- 40 minutes). Review of a phone interview with NA Employee E1 dated 1/15/25, indicated that she was scheduled to be the NA on the wing where Resident R1 resides and that she refused to respond to Resident R1's request for assistance. Review of the statement submitted by the Housekeeper Employee E2 indicated that at approximately 3:30 a.m., Resident R1's call light was illuminated and NA Employee E1 walked past the room. At approximately 4:10 a.m., NA Employee E1 walked up to another housekeeper and Housekeeper Employee E2 and said I am not getting that resident, it is ot my job. we have a floater who can do it. The stated indicated that Resident R1's call light was still on at 5:00 a.m. and NA Employee E1 was sitting in a chair in the hall on her phone. Review of Resident R1's Documentation Survey Report (an electronic report showing the care provided to a resident by the Nurse Aide's) did not include documented care for Resident R1 on 1/15/25, for the 11-7 shift. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], with diagnoses which included lung disease, bipolar disorder (a mental condition marked by alternating elation and depression), morbid obesity, anxiety and psychosis. A MDS dated [DATE], indicated the diagnoses remained current. Section C0500 (Brief interview for mental status) indicated a score of 15; which indicated the resident was cognitively intact. Review of the facility provided documentation dated 1/15/25, indicated that Resident R2 had indicated that on 1/6/25, LPN Employee E3 had questioned the resident why he was going to call the DOH and why. The report indicated that Resident R2 went to he Nursing Home Administrator with the concern who then went to LPN Employee E3 to speak to her. The report indicated that after that LPN Employee E3 went back to Resident R2 and asked him why he went to the NHA about her. Review of a statement dated 1/6/25 submitted by the NHA indicated that LPN Employee E3 made Resident R2 anxious about it. Review of the statement submitted by the DON after interviewing Resident R2 indicated that the LPN contacted he resident on Facebook and med him feel uncomfortable. During an interview on 2/11/25, at 2:35 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to make certain a resident was free from abuse/neglect for two of five residents reviewed (Resident R1 and R2). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observation of life equipment, and staff interviews, it was determined that the facility failed to maintain patient care equipment in a safe operating condition to keep mechanical lift in safe operating condition for one of four mechanical lifts reviewed ). Findings include: Review of the facility policy, Safe Lifting and Movement of Residents dated 1/31/24, indicated the maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure it remains in good working order. Review of the Manufacturer Instructions Preventive Maintenance Schedule for the Maxi Move Arjo dated 9/6/2023. Staff should visually inspect the unit prior to use and yearly inspections to be conducted by a qualified service technician. Review of the facility Preventive Maintenance documents for 9/9/24 and 10/7/24, revealed internal checks of the lift equipment is completed and maintained in a logbook. Review of the facility Preventive Maintenance documents for the lifts, revealed their contracted vendor ISS Solutions inspects the lift equipment. The most recent ISS inspection was completed on 9/20/24. Lift Serial number SEE0613041 was deemed ok for use. Review of the four of twenty-four residents utilizing lift equipment 12/3/24, no lift related incidents. Resident R3, Resident R8, Resident R9, and Resident R10. During an observation on 12/3/24, at 12:10 p.m. two of the three lifts were observed in the lift equipment room. The third lift was in use. During an interview on 12/3/23 at 12:00 p.m. Employee E1 reported the lift was visually checked prior to lifting Resident R1, with no observed issues, green pad utilized and two staff performed lift per policy. During an interview on 12/3/24, at 12:30 p.m. Employee interviews conducted with Employee E1, E2, E3, E4 and E5 who confirmed locations of lifts, the number of lifts available and visual check is done prior to use. During an Interview on 12/3/23 at 12:50 p.m. Employee interviews conducted with Employee E1, E2, E3, E4 and E5 who confirmed receiving education on lifts upon hire and additional education after the fall of Resident R1. During an interview on 12/3/24, at 1:15 p.m. the Director of Nursing confirmed the malfunction lift was sequestered and removed from service as was the lift pad after the fall of Resident R1. During an interview on 12/03/24, at approximately 1:20 p.m. the Interim Nursing Home Administrator and Director of Nursing confirmed the equipment malfunction for one of four lifts. 28 Pa Code 201.14 (a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1) Management.

Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for nine of the sixteen residents reviewed (Resident R14, R18, R48, R84, R86, R96, R98, R99, R108). Findings Include: A review of the facility policy Advanced Directives reviewed 3/1/2023 and 1/31/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R14 was admitted to the facility on [DATE], with diagnoses that included Parkinson ' s disease (affects movement of muscles often seen with tremors, shaking), diabetes, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R14 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R18 was readmitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and paraplegia (no movement of lower body or legs). A review of the clinical record failed to reveal an advance directive or documentation that Resident R18 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R43 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, gastro-esophageal reflux disease (GERD-severe indigestion), gastro-intestinal bleed (bleeding from either the stomach or the intestines). A review of the clinical record failed to reveal an advance directive or documentation that Resident R43 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R84 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity (severely overweight) and foot drop of both feet (unable to lift the foot into a normal position to allow you to walk). A review of the clinical record failed to reveal an advance directive or documentation that Resident R84 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R87 was re- admitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and GERD. A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R96 was readmitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, left leg below knee amputation. A review of the clinical record failed to reveal an advance directive or documentation that Resident R96 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R98 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, chronic pain, and cancer. A review of the clinical record failed to reveal an advance directive or documentation that Resident R98 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R99 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD-tightening of the airways making it difficult to breath), stroke (an interruption of the blood flow within your brain that causes the death of brain cells), and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R99 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R108 was admitted to the facility on [DATE], with diagnoses that include dysphagia (difficulty swallowing), difficulty walking and muscle weakness. A review of the clinical record failed to reveal an advance directive or documentation that Resident R108 was given the opportunity to formulate an Advance Directive. During an interview on 3/13/2024, at 2:28 p.m. the Social Worker Employee E1 and Medical Records Employee E2 stated she confused the POLST with Advance Directives, confirming Residents (Resident R14, R18, R43, R84, R87, R96, R98, R99, R108), were not afforded the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility job description, resident record review, and staff interview, it was determined that the facility failed to follow professional standards of practice for to three of four residents reviewed (Resident R1, R2, and R3). Review of the facility Licensed Practical Nurse job description, effective 9/1/23, indicated the Licensed Practice Nurse (LPN) is responsible for rendering nursing care in terms of individualized resident needs based on the scope of practical nursing. The job description further stated the LPN performs delegated nursing functions using established procedures, policies, guidelines and standards. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 1/15/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and hypertension (high blood pressure in the arteries). Review of Resident R1's January 2024 vital sign record revealed LPN Employee E1 documented blood pressures (BP) and heart rates (HR) on Resident R1 on nine separate shifts, which revealed the following: -1/12/24, at 12:00 a.m.: LPN Employee E1 documented BP 152/88 and HR 80, a duplicate of the previous BP/HR completed on 1/11/24, at 9:07 p.m., approximately three hours prior. -1/16/24, at 12:31 a.m.: LPN Employee E1 documented BP 133/72 and HR 77, a duplicate of the previous BP completed on 1/15/24, at 10:56 p.m., approximately one and a half hours prior. -1/16/24, at 11:33 p.m.: LPN Employee E1 documented BP 137/85 and HR 71, a duplicate of the previous BP/HR completed on 1/16/24, at 10:36 p.m., approximately one hour prior. -1/18/24, at 12:15 a.m.: LPN Employee E1 documented BP 126/75 and HR 72, a duplicate of the previous BP/HR completed on 1/17/24, at 6:57 p.m., approximately five hours prior. -1/20/24, at 12:57 a.m.: LPN Employee E1 documented BP 163/78 and HR 70, a duplicate of the previous BP/HR completed on 1/19/24, at 6:22 p.m., approximately six hours prior. -1/21/24, at 11:55 p.m.: LPN Employee E1 documented BP 168/88 and HR 80, a duplicate of the previous BP/HR completed on 1/21/24, at 6:30 p.m., approximately five and a half hours prior. -1/26/24, at 1:06 a.m.: LPN Employee E1 documented BP 141/86 and HR 72, a duplicate of the previous BP/HR completed on 1/25/24, at 3:26 p.m., approximately eight and a half hours prior. -1/27/24, at 12:04 a.m.: LPN Employee E1 documented BP 137/68 and HR 73, a duplicate of the previous BP/HR completed on 1/25/24, at 4:56 p.m., approximately seven hours prior. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) and hypertension. Review of Resident R2's January 2024 vital sign record revealed Licensed Practical Nurse (LPN) Employee E1 documented BPs on Resident R2 on ten separate shifts, which revealed the following: -1/04/24, at 12:20 a.m.: LPN Employee E1 documented BP 125/74, a duplicate of the previous BP/HR completed on 1/3/24, at 8:28 p.m., approximately four hours prior. -1/08/24, at 12:18 a.m.: LPN Employee E1 documented BP 132/74, a duplicate of the previous BP/HR completed on 1/7/24, at 6:01 p.m., approximately six hours prior. -1/09/24, at 12:14 a.m.: LPN Employee E1 documented BP 137/65, a duplicate of the previous BP/HR completed on 1/8/24, at 9:54 p.m., approximately two hours prior. -1/12/24, at 11:49 p.m.: LPN Employee E1 documented BP 100/60, a duplicate of the previous BP/HR completed on 1/12/24, at 7:55 p.m., approximately four hours prior. -1/16/24, at 12:41 a.m.: LPN Employee E1 documented BP 102/67, a duplicate of the previous BP/HR completed on 1/15/24, at 10:58 p.m., approximately three hours prior. -1/18/24, at 12:07 a.m.: LPN Employee E1 documented BP 106/68 and HR 80, a duplicate of the previous BP/HR completed on 1/17/24, at 6:54 p.m., approximately five hours prior. -1/20/24, at 12:53 a.m.: LPN Employee E1 documented BP 118/56 and HR 72, a duplicate of the previous BP/HR completed on 1/19/24, at 10:27 p.m., approximately two and a half hours prior. -1/21/24, at 11:52 p.m.: LPN Employee E1 documented BP 126/66 and HR 73, a duplicate of the previous BP/HR completed on 1/21/24, at 6:33 p.m., approximately five hours prior. Review of the clinical record indicated that Resident R3 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and muscle weakness. Review of Resident R3's January 2024 vital sign record revealed Licensed Practical Nurse (LPN) Employee E1 documented BPs and HRs on Resident R3 on nine separate shifts, which revealed the following: -1/2/24, at 12:15 a.m.: LPN Employee E1 documented BP 108/72 and HR 76, a duplicate of the previous BP/HR completed on 1/1/24, at 10:29 p.m., approximately one hour prior. -1/8/24, at 11:55 p.m.: LPN Employee E1 documented BP 108/64 and HR 72, a duplicate of the previous BP/HR completed on 1/8/24, at 10:53 p.m., approximately one hour prior. -1/11/24, at 1:04 a.m.: LPN Employee E1 documented BP 109/69 and HR 73, a duplicate of the previous BP/HR completed on 1/10/24, at 9:53 p.m., approximately three hours prior. -1/12/24, at 2:00 a.m.: LPN Employee E1 documented BP 130/72 and HR 60, a duplicate of the previous BP/HR completed on 1/11/24, at 8:48 p.m., approximately five hours prior. -1/13/24, at 12:30 a.m.: LPN Employee E1 documented BP 124/70 and HR 75, a duplicate of the previous BP/HR completed on 1/11/24, at 7:57 p.m., approximately four and a half hours prior. -1/18/24, at 12:13 a.m.: LPN Employee E1 documented BP 104/68 and HR 68, a duplicate of the previous BP/HR completed on 1/17/24, at 6:58 p.m., approximately five hours prior. -1/20/24, at 12:44 a.m.: LPN Employee E1 documented BP 114/68 and HR 70, a duplicate of the previous BP/HR completed on 1/19/24, at 10:42 p.m., approximately two hours prior. -1/21/24, at 11:46 p.m.: LPN Employee E1 documented BP 116/64 and HR 64, a duplicate of the previous BP/HR completed on 1/21/24, at 6:46 p.m., five hours prior. During an interview on 2/3/24, at approximately 12:30 p.m. the Director of Nursing confirmed that Licensed Practical Nurse Employee E1 appeared to consistently duplicate prior blood pressure and heart rate assessments in place of completing them herself. During an interview on 2/3/24, at approximately 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to follow professional standards of practice for to three of four residents reviewed. 28 PA. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of the Activity Calendars for two months (December 2023 and January 2024), and resident and staff interview, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for five of eleven residents. Findings include: Review of Activities Calendar for December 2023, and January 2024, revealed: -No activities scheduled after 2:00 p.m. -55 of 59 days had Bible Study as an activity, daily at 10:00 a.m. -On Sundays, only three activities over the period of both months, were not religious or one-on-one visits. During an interview on 2/2/24, at 1:43 p.m. Resident R4, when asked about activities, stated, I'm bored as hell. During an interview on 2/2/24, at 2:15 p.m. Resident R5, when asked about activities, stated, Not much. Half and half. During an interview on 2/2/24, at 2:18 p.m. Resident R6, when asked about activities, stated he is Bored as shit. During an interview on 2/3/24, at 12:55 p.m. Resident R7, when asked about activities, stated There's not much to do I watch TV. During an interview on 2/3/24, at 1:01 p.m. Resident R8, when asked about activities, stated I watch television mostly. Eat. During an interview on 2/3/24, at approximately 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide an ongoing program of activities to meet based on the designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for five of eleven residents. 28 Pa. Code: 201. 18(b)(3) Management. 28 Pa. Code: 207.2(a) Administrators Responsibility.

Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for one of four residents reviewed (Resident R8). Findings include: Review of the facility policy Assistive Devices and Equipment dated 3/1/23 indicated the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Review of the Nurse Aide (NA) Job Description dated 3/1/23, indicated the nurse aide will attend to the individual needs of the resident, which may include assistance with transferring and ambulation. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 8/12/23, revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and morbid obesity (chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions). Section G: Functional Status indicated Resident R8 utilized a wheelchair for mobility. Review of a physician's order dated 8/31/23, indicated for physical therapy to evaluate Resident R8 to address muscle weakness and, contracture, and balance. Review of facility provided documentation dated 9/2/23, indicated an incident that involved Resident R8. Nurse Aide (NA) Employee E3 had assisted Resident R8 by pushing the wheelchair without leg rests, Resident R8 was unable to keep legs elevated during this transport; the legs were lowered to the floor during this transport which caused a pop being heard. Xrays were obtained which showed a fracture. Review of a physician's note signed 9/3/23, at 1:00 a.m. indicated Resident R8 was evaluated for knee pain. The note stated, the patient presents with a chief complaint of right knee pain after an incident involving their foot getting caught underneath a wheelchair while returning from the dining hall. The patient reports feeling and hearing a pop during the incident. The patient experiences pain below the knee and has limited mobility in their legs. The note further indicated that x-ray results were pending. Review of a progress note dated 9/5/23, at 12:43 p.m. indicated Resident is to have CT scan of right knee due to knee popping incident on 9/3/23. On 9/3/23, resident had x-ray or right knee. Impression: No acute bony injury. MD notified. Due to appointment being unable to be made within a timely manner, resident was sent to the hospital emergency room so the imaging could be completed. Review of a progress noted dated 9/5/23, at 11:02 p.m. indicated Resident R8 returned from the hospital. Review of hospital discharge paperwork dated 9/5/23, indicated Resident R8 was treated for a closed fracture of right tibial plateau (an injury that fractured the bone and injure the cartilage that covers the top end of the bottom part of your knee). Review of a physician's note created 9/6/23, at 1:08:23 p.m. indicated Resident R8 is currently experiencing pain and swelling around the knee area. Resident R8 is using an immobilizer and has been advised to remain non-weight bearing for the next six weeks. His pain medication has been changed to Lortab (a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication. Acetaminophen, also called Tylenol, is a less potent pain reliever that increases the effects of hydrocodone. Lortab is used to relieve moderate to severe pain.) to be taken three times a day. Review of physician's orders indicated from 4/14/22, through 9/5/23, Resident R8 received Tramadol (a narcotic to treat mild to moderate pain) 50 mg (milligrams), with orders varying from every four to every eight hours. Review of physician's orders dated 9/5/23, indicated Resident R8 was to receive Lortab 7.5 mg - 325 mg every six hours as needed for pain. During an interview on 9/9/23, at 11:25 a.m. Resident R8 stated I was down in the cafeteria, and I ran out of oxygen. I asked the nurse to push me back to my room. I was holding my feet up, but I was having a hard time. My foot went down too far and it hit the floor. It wrapped up right underneath me. Review of facility provided documents confirmed that NA Employee E3 failed to follow the facility's wheelchair policy while transporting a resident. Attempts to further interview this employee went unanswered. During staff interviews conducted on 9/9/23, between 12:30 p.m. and 1:15 p.m. the following was indicated: -Registered Nurse Employee E7 indicated that he was currently providing education to all licensed nurses and nurse aides regarding the need to always utilize leg rests when pushing a resident in a wheelchair. This education began after the issue with the leg rests but was not yet completed. -NA Employees E8, E9, E10, and E11 confirmed that the wheelchairs should always utilize leg rests when pushing a resident in a wheelchair. -Helping Hand (Hospitality Aide) Employee E12 confirmed that he was recently hired. When asked if he should push a wheelchair without leg rests, he confirmed that he should not. -Licensed Practical Nurses (LPN) Employees E13 and E14 confirmed that they are aware that leg rests are always required when pushing a resident in a wheelchair. During an interview on 9/9/23, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a leg fracture for one of four residents. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from emotional trauma for two of six residents (Residents R2 and R5) and neglect to provide goods and services of changing a brief to one of three residents (Resident R7). Findings include: Review of the facility Abuse Policy dated 3/1/23, indicated residents have the right to be free of abuse and neglect. The policy defined verbal abuse as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, within hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. The policy defined neglect as the failure of the facility, its employees or service providers, to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Nurse Aide (NA) Job Description dated 3/1/23, indicated the nurse aide will attend to the individual needs of the resident, which may include assistance with transferring and ambulation. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS)assessment is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment 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's care needs) dated 6/7/23, revealed diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), a seizure disorder, and psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality). Section C: Cognitive Patterns indicated that a BIMS assessment was unable to be performed due to Resident R1 being rarely/never understood. Review of Resident R1's care plan for cognitive loss initiated 12/24/19, indicated for staff to approach/speak in a calm, positive/reassuring manner. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), diabetes, and high blood pressure. Section C: Cognitive Patterns indicated that a BIMS score of 15. Review of facility submitted documentation dated 8/1/23, indicated that Resident R2 reported to facility staff that Nurse Aide (NA) Employee E1 was verbally inappropriate while providing care to Resident R1. Resident R2 stated that NA Employee E1 would get upset and yell, I'm not f****** with you today! This documentation further indicated that During investigatory process, it was discovered that more than one resident was negatively impacted by NA Employee E1's inappropriate behavior. Resident R2 indicated that this employee should not work with sick people, and Resident R2 spoke up to bring attention to her behavior. Resident R1 is unable to verbalize this information. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of diabetes, hemiplegia (paralysis on one side of the body), and systemic lupus erythematosus (SLE, an autoimmune disease where the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). Section C: Cognitive Patterns indicated a BIMS score of 15. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), coronary artery disease (damage or disease in the heart's major blood vessels), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Section C: Cognitive Patterns indicated that a BIMS assessment was unable to be performed due to Resident R4 being rarely/never understood. Review of Resident R4's care plan for activities initiated 9/26/22, indicated staff will promote socialization with peers. Review of facility provided investigation documents dated 8/1/23, indicated facility staff interviewed Resident R3 to learn if she had issues with any staff. Resident R3 stated: Yes, (NA Employee E1) on 2-10. Resident R3 stated she is rude, often comes to work angry, and takes it out on residents. Resident R3 stated, A lot of people have issues with her. She reported that she slams the trays down on the tray tables and she shuts (Resident R4) in and closes the door because she yells. Resident R3 reported that NA Employee E1 told another staff to put (Resident R4) in her room with the door closed if she is loud. Review of an employee statement written by Admissions Director Employee E2 on 8/1/23, stated A few weeks back I was working in activities as an activities aide, a CNA (nurse aide) by the name of (NA Employee E1's first name) brought a resident into activities by the name of (Resident R4). She was very upset about being out of her room but her roommate had just ceased to breathe therefore EMS (emergency medical services) was taking her out. I occupied her as long as I could without keeping her there against her will before taking her back to her room. When I took her back I advised (NA Employee E1) that Resident R4 would like to lay down. She replied she is always wanting something/or always yelling just put her in there and shut the door. I of course did not do those things and just proceeded with my day. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:25 a.m Admissions Director Employee E2 stated that she did not feel it was appropriate to seclude Resident R4 in her room, and took her back to the activities area with her. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of COPD, diabetes, and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior). Section C: Cognitive Patterns indicated a BIMS score of 13. Review of Resident R5's care plan for Activities of Daily Living Assistance related to physical limitations initiated 9/15/21, indicated that Resident R5 was dependent on extensive assistance of two staff members to transfer in and out of bed. Review of facility submitted documentation dated 9/1/23, indicated that Maintenance Director Employee E4 heard NA Employee E5 mock Resident R5 while he was complaining of back pain, saying, Oh oh oh my back hurts and Stop whining (Resident R5's first name). Immediately after, NA Employee E5 was heard, by Maintenance Director Employee E4, saying to Resident R5, I'm so tired of you. It was further documented that NA Employee E5 then went into the hallway, stating loudly, It's too f****** hot in here. Review of facility provided investigation documents dated 9/1/23, revealed a transcribed interview with Resident R5 dated 9/1/23, at 3:30 p.m. Resident R5 was asked how his care was today (9/1/23). He said it was fine, but the girl with the dark hair always comes in with an attitude. I wanted to go to bed because my back was hurting and she told me to wait. When asked if he felt safe in the facility, Resident R5 stated, Yes, really, I have no choice because I have nowhere else to go, but I feel safe. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed diagnoses of hemiplegia, psychotic disorder, and history of a stroke. Section C: Cognitive Patterns indicated a BIMS score of 05. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's facility diagnosis list revealed diagnoses of hemiplegia, spinal stenosis (a narrowing of the spaces within the spine, which causes pain and weakness), and history of a stroke. Review of Resident R7's Admission Evaluation completed on 8/24/23, at 8:31 p.m. indicated Resident R7 used a urinary pad or brief. Review of a BIMS assessment completed 9/4/23, indicated a BIMS score of 08. Review of facility provided investigation documents dated 9/1/23, revealed an interview was attempted with Resident R6, but was unable to be completed due to Resident R6's cognitive status. At the time, Resident R6's roommate, Resident R7's daughter reported a concern that her mom was not changed all day and the diaper she had on fell apart when she removed it, and she reported, however the aide said she was changed. She said, you know how I know she wasn't changed? The brief that I removed was the one brief I placed on her before I left last night. We bring one of our own supplies get her ready for bed and place our own briefs on her because she is a heavy wetter, and we do not leave any here. This is why we stay here through the day and night. The nurse aide in question was NA Employee E5. This information was determined at the time of investigation into NA Employee E5 and with the statement from Maintenance Director Employee E4. Further review of investigative documents relating to issues of emotional trauma revealed the following written statement: Review of an undated employee statement written by NA Employee E3 stated I have witnessed (NA Employee E1) cuss and scream and be very nasty toward the residents. Review of the facility Report Form for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property dated 8/4/23, indicated the facility substantiated the allegation of abuse, and terminated NA Employee E1. Attempts to interview NA Employee E5 went unanswered as this employee no longer works at the facility. During staff interviews conducted on 9/9/23, between 12:30 p.m. and 1:15 p.m. the following was indicated: -On 9/2/23, Registered Nurse Employee E7 indicated began providing re-education to all licensed nurses, nurse aides, and ancillary staff regarding verbal and emotional abuse, and neglect of services. This education began after identification of the abuse and was to include all staff working at the facility but was not yet completed. -NA Employees E8, E9, E10, and E11 confirmed that they had received facility provided education on types and examples of verbal and emotional abuse, and further confirmed that not providing needed services, such as leg rests when pushing a wheelchair, is neglect. -Helping Hand (Hospitality Aide) Employee E12 confirmed that he was recently hired, and was provided education on abuse and neglect. When asked if he should push a wheelchair without leg rests, he confirmed that he should not. -Licensed Practical Nurses (LPN) Employees E13 and E14 confirmed that they are aware of what constitutes verbal and emotional abuse, and that not using leg rests when pushing a resident in a wheelchair is neglect. During an interview on 9/12/23, at 8:53 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain residents were free from emotional trauma two of six and neglect to provide goods and services of changing a brief. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa. Code 201.29(a)(c)(d) Resident rights.

Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of four residents reviewed (Resident R4 and R7). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's Abuse Policy dated 3/1/23, indicated employees must immediately report any suspected abuse or suspected incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. This policy further indicated that allegations of abuse and/or neglect will be reported to the State Survey Agency within 24 hours when no serious bodily injury has occurred. Review of an employee statement written by Admission Director Employee E2 on 8/1/23, stated A few weeks back I was working in activities as an activities aide, a CNA (nurse aide) by the name of (NA Employee E1's first name) brought a resident into activities by the name of (Resident R4). She was very upset about being out of her room but her roommate had just ceased to breathe therefore EMS (emergency medical services) was taking her out. I occupied her as long as I could without keeping her there against her will before taking her back to her room. When I took her back, I advised (NA Employee E1) that Resident R4 would like to lay down. She replied she is always wanting something/ or always yelling just put her in there and shut the door. I of course did not do those things and just proceeded with my day. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:25 a.m Admissions Director Employee E2 stated that she did not seclude Resident R4 in her room, but took her back to the activities area with her. Admissions Director Employee E2 stated that while she did not immediately report the attempted seclusion of Resident R4, she did explain the situation when asked about it later that day. Review of an undated employee statement written by NA Employee E3 stated I have witnessed (NA Employee E1) cuss and scream and be very nasty toward the residents. During a follow-up, clarification telephone interview completed on 9/13/23, at 10:38 a.m NA Employee E3 confirmed that she had frequently heard NA Employee E1 being disrespectful toward the residents, and confirmed that she reported her concerns to the Registered Nurse Supervisor on duty. Review of facility provided investigation documents revealed an interview completed on 9/2/23, at 3:45 p.m with Resident R7's daughter. During this interview, Resident R7's daughter's reported a concern that her mom was not changed all day and the diaper she had on fell apart when she removed it, and she reported, however the aide said she was changed. She said, you know how I know she wasn't changed? The brief that I removed was the one brief I placed on her before I left last night. We bring one of our own supplies get her ready for bed and place our own briefs on her because she is a heavy wetter, and we do no leave any here. This is why we stay here through the day and night. Review of facility submitted information as of 9/10/23, failed to reveal that the allegation of neglect of Resident R7 was reported to the state survey agency. During an interview on 9/12/23, at 8:53 a.m. the Nursing Home Administrator confirmed that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse or neglect for two of four residents reviewed.

Based on staff interview and a review of employee credentials, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. Findings include: During an interview on 3/24/23, at 9:15 a.m. Registered Dietician (RD) Employee E12, confirmed that she is not a full-time employee, and works usually one to two days in the facility. RD Employee E12 further confirmed that she is not involved in the management of the facility food service program. During an interview on 3/24/23, at 10:00 a.m. Culinary Manager Employee E13 revealed that she was not a CDM (Certified Dietary Manager), but had a bachelor's degree in hospitality. Employee E12 further confirmed that the facility During an interview on 3/24/23, at 1:30 p.m., the Nursing Home Administrator confirmed that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. 28 Pa. Code 211.6(c) Dietary services. 28 Pa Code 201.18(e)(1)(6) Management.

Based on a group resident interview, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen. Findings include: Review of facility document Department Staffing dated October 2019, provided by the contracted culinary service provider, indicated the Dining Services department employs sufficient staff, with the appropriate competencies and skills sets to carry out the functions of food and nutrition services in a manner that is safe and effective. During a confidential resident group interview on 3/21/23, at 10:30 a.m. seven of seven residents unanimously agreed that all areas of food service are terrible (quality, taste, temperature). During an interview on 3/24/23, at 10:00 a.m., Culinary Manager Employee E13 stated: -There is not enough kitchen staff to effectively run the kitchen. -The always available menu for residents is not always prepared due to a lack of staffing. -That between meal deliveries to the units, there is not enough staff to complete the other kitchen duties. -Due to not enough staff during meal deliveries, one staff member has to leave the line to bring the carts to the floor, and the tray line stops until that person returns, as they had tray line duties also. -That three dietary aides and one cook are needed to provide effective dining, and there are only two dietary aides, with usually Culinary Manager Employee E13 working as one of those dietary aides, not in addition to them. During an interview on 3/24/23, at 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to have sufficient dietary staff to perform essential kitchen duties in the Main Kitchen 28 Pa. Code: 211.6 (c) Dietary services.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function and provided appropriate post-fall care for seven of eleven residents (R8, R19, R20, R33, R37, R53 and R90). Findings include: A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the facility policy, Bowel Regimen Protocol dated 3/1/23, indicated the purpose of the protocol is to provide a guideline for bowel intervention in the absence of a bowel movement every third day/ every nine shifts. bowel movements are to be recorded by nursing staff in the electronic healthcare record. If there is no bowel movement by the completion of the third day/ ninth shift: a dose of milk of magnesia (MOM, a medication to treat constipation) will be given per physician order. If there is no bowel movement within 24 hours following administration of the milk of magnesia, A bisacodyl (a medication to treat constipation) suppository will be given per physician order. If there is no bowel movement by the end of next shift following the administration of the bisacodyl suppository, a sodium phosphate. (Fleets) enema (solution introduced into the rectum to promote evacuation of feces) will be given. If there is no bowel movement following the administration of the phosphate. (Fleets) enema, a GI (gastrointestinal) evaluation will be completed and the physician notified for further orders/ recommendations. Review of the facility policy, Assessing Falls and Their Causes dated 3/1/23, indicated that after a fall, staff should obtain a set of vital signs as soon as it is safe to do so, observe for delayed complications of a fall for approximately 48 hours and document findings in the medical record. Review of the facility Falls Management Play Book: Post-Fall Considerations dated 4/27/22, indicated to compare vital signs to baseline readings, changes in mental status and completion of a neurological evaluation may indicate an acute change in status, and neurological evaluations should be completed whenever there is a witnessed fall when a resident has hit their head or following an unwitnessed fall. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) for Resident R20 dated 12/9/22, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and history of a stroke. Review of Question C0500 revealed Resident R20's score to be 06, severe impairment. Question G0110 1 indicated Resident R20 was totally dependent on the physical assistance of one person, H0400 indicated that Resident R20 was frequently incontinent of bowel. Review of Resident R20's facility diagnosis list included a diagnosis of constipation, created on 2/18/21. Review of the physician orders active in March 2023, indicated that Resident R20 had orders for: -Milk of magnesia, give 30 milliliters (ml) as needed for constipation. Administer if no BM by the third day/9 shifts Document effectiveness. -Bisacodyl suppository, Insert 10 mg rectally as needed for Constipation For no Bowel movement within 24 hours after administration of Milk of Magnesia. -Fleet enema, Insert 1 applicatorful rectally as needed for Constipation For no bowel movement by the end of the following shift after administration of suppository. Notify MD if ineffective. Review of Resident R20's plan of care updated 3/11/23, failed to include a care plan for bowel elimination or constipation. Review of Resident R20's bowel record, dated 3/13/23 - 3/18/23 did not include documentation of a bowel movement. The March 2023, medication administration record failed to reveal any administrations of milk of magnesia, bisacodyl suppository, or a fleets enema. Review of the clinical record indicated Resident R33 was admitted to the facility on [DATE]. Review of the MDS for Resident R33 dated 2/10/23, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Question C0500 revealed Resident R33's score to be 14, cognitively intact. Question G0110 1 indicated Resident R33 required physical assistance of one person, H0400 indicated that Resident R33 was always continent of bowel. Review of the physician orders active in March 2023, indicated that Resident R33 had orders for: -Polyethylene Glycol 3350 Powder (Miralax, a powdered medication used to prevent and treat constipation) Give 17 gram by mouth every 24 hours as needed for constipation -Milk of magnesia, give 30 milliliters (ml) as needed for constipation. Administer if no BM by the third day/9 shifts Document effectiveness. -Bisacodyl suppository, Insert 10 mg rectally as needed for Constipation For no Bowel movement within 24 hours after administration of Milk of Magnesia. -Fleet enema, Insert 1 applicatorful rectally as needed for Constipation For no bowel movement by the end of the following shift after administration of suppository. Notify MD if ineffective. Review of Resident R33's plan of care for risk for bowel elimination alteration: constipation related to lack of exercise, medications initiated 6/24/22, indicated for staff to administer medications per physician order. Review of Resident R33's bowel record, dated 3/1/23 - 3/5/23, and 3/9/23 - 3/14/23 did not include documentation of a bowel movement. The March 2023, medication administration record failed to reveal any administrations of Miralax, milk of magnesia, bisacodyl suppository, or a fleets enema. Review of the clinical record indicated Resident R53 was admitted to the facility on [DATE]. Review of the MDS for Resident R53 dated 2/8/23, included the primary medical condition as a non-displaced fracture of the left radial styloid process (a break in the end of one of the forearm bones), with additional diagnoses of muscle weakness and glaucoma (a group of eye conditions that can cause blindness). Review of Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed Resident R53's score to be 10, moderately impaired. Section G: Function Status, Question G0110 I, Activities of Daily Living (ADL) Assistance, Toilet Use indicated Resident R53 required extensive assistance of two or more persons physical assistance. Section H Bladder and Bowel, Question H0400 Bowel Incontinence indicated that Resident R53 was always continent of bowel. Review of the physician orders active in March 2023, indicated that Resident R53 had orders for: -Milk of magnesia, give 30 milliliters (ml) as needed for constipation. Administer if no BM by the third day/9 shifts Document effectiveness. -Bisacodyl suppository, Insert 10 mg rectally as needed for Constipation For no Bowel movement within 24 hours after administration of Milk of Magnesia. -Fleet enema, Insert 1 applicatorful rectally as needed for Constipation For no bowel movement by the end of the following shift after administration of suppository. Notify MD if ineffective. Review of Resident R53's plan of care for Requires assistance /Potential to restore function for toileting initiated 2/8/23, failed to include any interventions related to constipation. Review of Resident R53's bowel record, dated 3/3/23, through 3/9/23, indicated one bowel movement, and for 3/12/23, through 3/17/23, did not include documentation of a bowel movement. The March 2023, medication administration record failed to reveal any administrations of. milk of magnesia, bisacodyl suppository, or a fleets enema. Review of a nurse's progress note dated 3/8/22, at 12:09 p.m. indicated Resident awake, will answer questions, but slow to respond. Abdomen soft, Palpable, bowel sounds hypoactive. Resident appetite decreased, refusing breakfast. Resident does complain of upset stomach. Review of a nurse's progress note dated 3/11/22, at 12:09 p.m. indicated Resident R53's abdominal X-ray showed possible constipation. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of the MDS for Resident R8 dated 2/1/23, included diagnoses of hemiplegia (paralysis on one side of the body) and history of a stroke. Review of Question C0500 revealed Resident R8's score to be 07, severe impairment. Review of an incident report dated 3/15/23, at 9:20 p.m. indicated Resident found by the side of the bed by staff. Resident seen by staff five minutes prior to her fall, propelling self in her room in the wheelchair. No injuries noted. Review of the post-fall Alert Charting progress notes dated from 3/15/23, at 10:18 p.m. through 3/20/23, at 2:00 p.m. all utilized blood pressures, heart rates, and respiratory rates documented on 3/15/23. Furthermore, no alert charting was completed on 3/18/23, and 3/19/23. Review of the incident report documentation failed to include neurological assessments completed on Resident R8. During an interview 3/24/23, at 10:30 a.m. the Assistant Director of Nursing (ADON) Employee E11 confirmed that the alert charting for Resident R8 was incomplete and inaccurate, and confirmed that neurological checks should have been completed on the unwitnessed fall. Review of the clinical record indicated Resident R19 was admitted to the facility on [DATE]. Review of the MDS for Resident R19 dated 2/22/23, included diagnoses of COPD, high blood pressure, and muscle weakness. Review of an incident report dated 3/17/23, at 1:54 a.m. indicated A resident came down the hall, telling us there was a man on the floor. We went in and sat patient up. He was laying on his side. I checked the chest back and abdomen. No marks or wounds. We got him back in bed and I found zero wounds anywhere. Patient changed and put back to bed. No pain at this time. Review of the post-fall Alert Charting progress notes included only one note dated 3/18/23, at 4:16 a.m. During an interview 3/24/23, at 10:30 a.m. the ADON Employee E11 confirmed that the alert charting for Resident R19 was incomplete. Review of the clinical record indicated Resident R20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS for Resident R20 dated 12/9/22, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and history of a stroke. Review of an incident report dated 3/11/23, at 4:00 p.m. indicated Notified by activity aide that resident had slid out of his wheelchair onto the floor in front of it. No injuries noted. Review of a nurse ' s progress note dated 3/11/23, at 8:12 p.m. indicated that neurological checks were started. Review of the post-fall Alert Charting progress notes dated from 3/11/23, at 5:24 p.m. through 3/15/23, at 3:33 a.m. all utilized blood pressures, heart rates, and respiratory rates documented on 3/4/23, seven days prior to the fall. Furthermore, no alert charting was completed on 3/12/23. Review of the incident report documentation failed to include neurological assessments completed on Resident R20, as stated in the progress note. During an interview 3/24/23, at 10:30 a.m. the ADON Employee E11 confirmed that the alert charting for Resident R20 was incomplete and inaccurate, and confirmed that neurological checks were not available for Resident R20. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of the MDS for Resident R37 dated 2/13/23, included diagnoses of COPD, diabetes, and Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior). Review of an incident report dated 3/16/23, at 7:28 a.m. indicated Resident ' s roommate reported that resident fell from the wheelchair last night. Resident could not confirm this neither did staff who worked on that shift. The roommate reported that someone put resident back in bed. Resident could not confirm, just stated her back and butt hurt. Review of the post-fall Alert Charting progress notes dated from 3/16/23, at 2:59 p.m. through 3/20/23, at 11:28 a.m. all utilized blood pressures, heart rates, and respiratory rates documented on 3/3/23, 13 days prior to the fall. Furthermore, no alert charting was completed on 3/19/23. During an interview 3/24/23, at 10:30 a.m. the ADON Employee E11 confirmed that the alert charting for Resident R37 was incomplete. Review of the Neurological Flow Sheet dated 3/16/23, through 3/17/23, documented that Resident R37 had fixed pupils (when the pupil does not react to light, often caused by trauma to the brain, and indicates an emergency situation). At the bottom of the Neurological Flow Sheet was printed Notify MD (Doctor of Medicine): IMMEDIATELY of signs and symptoms of intracranial pressure!!! During an interview 3/24/23, at 10:30 a.m. the ADON Employee E11 confirmed that the alert charting for Resident R20 was incomplete and inaccurate, confirmed that R20 ' s pupils were inaccurately documented as fixed, and if Resident R20 had fixed pupils, the provider should have been notified, as a sign of intracranial pressure. Review of the clinical record indicated Resident R90 was admitted to the facility on [DATE]. Review of the MDS for Resident R90 dated 2/1/23, included diagnoses of heart failure and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of an incident report dated 3/19/23, at 5:54 p.m. indicated Resident was found on the floor on the left side of the bed during evening med pass. Resident unable to give a description. Review of the post-fall Alert Charting progress notes dated from 3/20/23, at 11:09 a.m. through 3/24/23, at 6:37 a.m. all utilized blood pressures, heart rates, and respiratory rates documented on 3/19/23. Furthermore, no alert charting was completed on 3/21/23, and 3/22/23. Review of the Neurological Flow Sheet dated 3/19/23, through 3/20/23, documented that Resident R90 ' s level of consciousness was obtunded (dulled or reduced level of alertness or consciousness). At the bottom of the Neurological Flow Sheet was printed Notify MD (Doctor of Medicine): IMMEDIATELY of signs and symptoms of intracranial pressure!!! Review of Resident R90 ' s nurse aide documentation for 3/19/23, through 3/20/23, revealed that Resident R90, consumed meals and snacks, was assisted to dress and was provided hygiene care at her baseline level of assistance, was documented as actively participating in one-on-one activities, and spent leisure time in the lounge. During an interview 3/24/23, at 10:30 a.m. the ADON Employee E11 confirmed that the alert charting for Resident R20 was incomplete and inaccurate, confirmed that R20 ' s level of consciousness was inaccurately documented as obtunded, and if Resident R20 had been obtunded for time period of the neurological flow sheet, the provider should have been notified, as a sign of intracranial pressure. During an interview of 3/24/23, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and services to maintain bowel function and provided appropriate post-fall care for seven of eleven residents.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for [CONDITION(S)] (high blood glucose) and [CONDITION(S)] (low blood glucose), and failed to educate staff on facility policies related to [CONDITION(S)] and [CONDITION(S)] for 6 of 9 Residents (Residents R10, R17, R58, R64, R67, and R86), resulting in immediate jeopardy and harm which resulted in two residents transferred to the hospital (Residents R17 and R64). Findings include: The Centers for Disease Control (CDC) defines diabetes as: Diabetes Mellitus is a chronic (long-[MEDICATION(S)]) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. [CONDITION(S)] is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, [CONDITION(S)] may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. [CONDITION(S)], or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. [CONDITION(S)] is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have [CONDITION(S)] and it's untreated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Diabetes - Clinical Protocol reviewed 10/31/21, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management, the staff will incorporate the parameters in the medication administration record (MAR) and resident care plan. Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus reviewed 10/31/21, indicated the purpose of the guidelines are to prevent [CONDITION(S)]/[CONDITION(S)], and to recognize, manage, and document the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation should reflect the carefully assessed diabetic resident and should include vital signs, level of consciousness, skin assessment, and symptoms Review of the facility policy Change in Resident's Condition or Status reviewed 10/31/21, indicated the facility will promptly notify the resident, the physician, and resident representative of changes in the resident's medical/mental condition, and the nurse will notify the physician when there has been a significant change in the resident's condition, when there is a need to alter the resident's medical treatment, and specific instruction to notify the physician of changes in the resident's condition. Further review revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of a clinical record indicated Resident R10 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 1/7/22, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400. Further review of the physician orders revealed the following orders: - Insulin [MEDICATION(S)] (short-acting form of insulin) Solution Pen-injector 100 UNIT/milliliter (ML) Inject as per sliding scale: if 70 - 130 = 0; 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units If finger stick glucose is above 400 notify physician; 301 - 350 = 8 units; 351 - 400 = 10 units >400 give 12 units, call MD, subcutaneously (under the skin) before meals and at bedtime. Order start date 1/7/22. - [MEDICATION(S)] FlexTouch Solution Pen-injector 100 UNIT/ML (Insulin Detemir) Inject 55 unit subcutaneously at bedtime. Order start date 1/25/22. A review of Resident R10's Medication Admission Record (MAR) revealed that the resident's CBG's were as follows: - 2/1/22, at 8:19 p.m., CBG was noted to be 457. - 2/20/22, at 4:30 p.m. CBG was noted as NA A review of the MAR and clinical progress notes indicated for the above listed dates that Resident R10 was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. A review of a eMAR - Order Administration Note dated 2/1/22, at 8:19 p.m. specified Resident R10 was given 10 units of insulin and would be monitored, MD was not notified. Resident R10 should have received 12 units per physician order. A review of an eMAR - Order Administration Note dated 2/1/22, at 8:19 p.m. indicated Resident R10's CBG was 457, and she received 10 units of insulin and resident will be monitored for [CONDITION(S)] (MD not notified, wrong medication dose administered, no assessment or recheck completed). Further review revealed an eMAR - Order Administration Note on 2/20/22, at 4:29 p.m. indicated Resident R10's CBG was 422, MD was notified, no assessment or recheck was completed. The CBG value was entered as NA in the vitals documentation. A review of the MAR for February failed to reveal a CBG entered for 2/20/22. A review of the care plan indicated there were not interventions in place at the tie of the incident. A review of a clinical record indicated Resident R17 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician orders dated 7/10/21, indicated that Resident R17 had orders to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400. Further review of physician orders revealed: - Insulin [MEDICATION(S)] (short-acting form of insulin) Solution Pen-injector 100 UNIT/milliliter (ML) Inject as per sliding scale: if 70 - 130 = 0; 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units If finger stick glucose is above 400 notify physician; 301 - 350 = 8 units; 351 - 400 = 10 units >400 give 12 units, call MD, subcutaneously (under the skin) before meals and at bedtime. Order start date 7/10/21. - [MEDICATION(S)] (long-acting insulin) FlexTouch Solution Pen injector 100 UNIT/ML (Insulin Detemir) Inject 30 unit subcutaneously two times a day. Order start date 1/15/22. - [MEDICATION(S)] (injectable diabetes medicine that helps control blood sugar levels) Solution Pen-injector 3 MG/0.5 ML ([MEDICATION(S)]) Inject 1.5 mg subcutaneously one time a day every Friday. Order start date 11/12/21. - [CONDITION(S)] protocol: If blood sugar <60 then 1.) give resident glucoburst (glucose) 15 gm if alert and conscious 2.) if resident cannot take PO, give 25 ml of D50 as intravenous (IV) push [MEDICATION(S)] 1 mg intra-muscular (IM -into the muscle) if no IV access 3) Check blood sugar every 15 minutes and repeat above IF blood sugar <80 4) Call MD to consider adjusting diabetic regimen, depending on circumstances. As needed for Blood sugars AC + HS start date 7/10/21. A review of the MAR revealed that Resident R17's CBG's were as follows: - 12/27/21, at 1:28 p.m., CBG was 435. Physician notified. - 01/01/22, at 6:24 p.m., CBG was documented as 400 (actual result was 450 per MAR note). - 1/1/22, at 9:29 p.m., CBG was documented as 400 (actual result was 427 per MAR note). - 1/3/22, at 1:06 p.m., CBG was 441. - 1/5/22, at 1:21 p.m., CBG was 414. - 1/10/22, at 12:29 p.m., CBG was 407. - 1/11/22, at 7:40 a.m., CBG was 415. Physician notified. - 1/11/22, at 1:20 p.m., CBG was 451. A review of the MAR and clinical progress notes for the above listed dates Resident R17 was not assessed for symptoms of [CONDITION(S)], and the physician was not notified unless otherwise noted. A review of the clinical record progress notes dated 1/13/22, at 2:52 p.m. indicated that Resident R17 was found slumped in his/her wheelchair, difficult to wake up, unable to speak, sweating, and drooling. CBG 352. A review of the clinical record progress notes dated 1/14/22, at 3:28 a.m. Resident R17 was admitted to the hospital for [CONDITION(S)] and dehydration. A review of the care plan dated 3/14/19, indicated to administer medications per physician orders, and report signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. A review of a clinical record indicated Resident R58 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 3/19/22, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400, no protocol for [CONDITION(S)] order noted. A review of Resident R58's MAR revealed that the resident's CBG's were as follows: - 4/1/22, at 5:20 p.m., CBG was noted to be 17. - A review of Resident R58's eMAR - Order Administration Note and clinical progress notes indicated for the above listed date the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. A review of the clinical record failed to reveal an assessment was completed. A review of a progress note dated 4/4/22, at 2:38 p.m. indicated Resident R58 was found on the floor, the assessment did not include a CBG to rule out hyper/[CONDITION(S)]. A review of the care plan dated 5/3/21, indicated to administer medications per physician orders, and report signs and symptoms of [CONDITION(S)] and [CONDITION(S)], and on 3/18/22, indicated to obtain glucometer readings and report abnormalities as ordered. A review of a clinical record indicated Resident R64 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 3/14/22, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400. Further review of the physician orders indicated the following orders: - Insulin [MEDICATION(S)] (synthetic insulin with a very rapid onset and short duration of action) Solution. Inject per sliding scale: if 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units OVER 400 GIVE 12 UNITS subcutaneously four times a day. Order start date 3/24/22. - [CONDITION(S)] Protocol: If finger stick blood sugar <60 then 1.) Give resident Glucoburst 15 gm if resident is alert and conscious 2.) If resident cannot take PO, Give 25 ml of D50 IV push. [MEDICATION(S)] 1 mg IM if no IV access 3.) Check blood sugar every 15 minutes and repeat above IF blood sugar <80 4.) Call MD to consider adjusting diabetic regimen, depending on circumstances as needed. Order start date 3/24/22. - [MEDICATION(S)] (long-acting man made insulin) Kwik Pen 100 unit, inject 30 units subcutaneously two times a day. Order start date 4/5/22. A review of a progress notes dated 3/21/22, at 6:50 p.m. revealed was notified by nurse on floor at the time that resident was slurring speech and not making sense when usually is AOx3 (alert and oriented to person, place, and time). Resident was moaning making sounds but could not verbalize anything to nurse. Resident had tongue hanging out of mouth and would not swallow or do anything but moan. Unable to answer questions. Senior Life nurse notified and said to wait for call from the on-call MD. A review of a progress notes dated 3/21/22, 8:03 p.m. revealed Resident found unresponsive by staff, speech garbled and slurred. BS 47, [MEDICATION(S)] gel administered under residents' tongue along with orange juice mixture provided. Glucose level remained extremely low after several attempts to increase; 1mg [MEDICATION(S)] IM injection given BS raised to 117. A review of Resident R64 CBG were as follows: - 3/21/22 at 4:14 p.m. was 81. - 3/21/22, at 8:32 p.m. was 208. A review of a progress note dated 3/21/22, at 10:26 p.m. when EMS arrived in facility resident was fully AOx3 and back to baseline, resident verbalized he did not see a reason to be sent out and felt fine to stay in the facility. Residents blood sugar was then checked and was at 102, MD would be notified of resident staying in facility. The facility failed to follow facility protocol for Resident R64 on 3/21/22, resident was not AOx3, not able to take medication by the mouth so should have been given the [MEDICATION(S)] 1mg IM per protocol and failed to complete fifteen-minute blood sugar checks. A review of a progress note dated 3/22/22, at 08:01 a.m. indicated Resident BG this a.m. was 49 IM [MEDICATION(S)] given 15 min later BG was only 51, unresponsive at this time, [NAME] Life notified and orders to be sent to hospital obtained. A review of a progress note dated 3/22/22, at 12:53 p.m. resident was admitted to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a clinical record indicated Resident R67 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 10/13/20, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400. Further review of the physician orders revealed: - [CONDITION(S)] Protocol: If finger stick blood sugar <60 then 1.) Give resident Glucoburst 15 gm if resident is alert and conscious 2.) If resident cannot take PO, Give 25 ml of D50 IV push. [MEDICATION(S)] 1 mg IM if no IV access 3.) Check blood sugar every 15 minutes and repeat above IF blood sugar <80 4.) Call MD to consider adjusting diabetic regimen, depending on circumstances as needed. Order start date 10/15/20. - [MEDICATION(S)] FlexTouch Pen-Injector 100 unit/ml. Inject 55 units subcutaneously at bedtime. Order start date 10/15/20. - [MEDICATION(S)] (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) [MEDICATION(S)] Pen-Injector 100 unit/ml. Inject per sliding scale: if 70-180 + 0; 181-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 = 12 units; >400 CALL MD, subcutaneously before meals. Order start date 10/16/20. - [MEDICATION(S)] Solution Pen-Injector 0.75 MG/0.5 ml. Inject 0.75 mg subcutaneously one time a day every Thursday. Order start date 11/24/20. A review of an eMAR - Order Administration Note dated 11/28/21, at 5:11 p.m. revealed the blood sugar was 522, but the nurse stated she entered 400 for blood glucose due to not being able to enter a higher number; MD was not notified, no assessment or recheck was completed. A review of Resident R67's MAR revealed that the resident's CBG's were as follows: - 11/28/21, at 5:16 p.m., CBG was noted to be 400 (MAR note states actual CBG was 522). - 12/11/21, at 4:29 p.m., CBG was 426. MD notified. - 12/13/21, 8:38 p.m., CBG was 421. - 12/18/21, at 12:31 p.m., CBG was 412. - 12/20/21, at 12:31 p.m., CBG was 431. - 12/27/21, at 1:48 p.m., CBG was 420. - 1/5/22, at 1:32 p.m., CBG was 409. - 3/1/22, at 4:52 p.m., CBG was 476. A review of Resident R67's MAR and clinical progress notes indicated, for the above listed dates, the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified unless otherwise noted. A review of the care plan dated 10/1/19, indicated to administer medications per physician orders, and report signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. A review of a clinical record indicated Resident R86 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order dated 10/16/20, indicated to check CBG four times daily with sliding scale coverage of insulin with instructions to call the physician with CBG over 400. Further review of the physician orders revealed the following orders: - [CONDITION(S)] Protocol: If finger stick blood sugar <60 then 1.) Give resident Glucoburst 15 gm if resident is alert and conscious 2.) If resident cannot take PO, Give 25 ml of D50 IV push. [MEDICATION(S)] 1 mg IM if no IV access 3.) Check blood sugar every 15 minutes and repeat above IF blood sugar <80 4.) Call MD to consider adjusting diabetic regimen, depending on circumstances as needed. Order start date 10/15/20. - [MEDICATION(S)] FlexTouch Pen-Injector 100 units/ml. Inject 55 units subcutaneously at bedtime. Order start date 10/15/20 - [MEDICATION(S)] [MEDICATION(S)] Pen-Injector 100 unit/ml. Inject per sliding scale: if 70-180 + 0; 181-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 = 12 units; >400 CALL MD, subcutaneously before meals. Order start date 10/16/20. - [MEDICATION(S)] Solution Pen-Injector 0.75 MG/0.5 ml. Inject 0.75 mg subcutaneously one time a day every Thursday. Order start date 11/24/20. A review of Resident R86's MAR revealed that the resident's CBG's were as follows: - 1/3/22, at 1:14 p.m., CBG was 461. - 1/4/22, at 12:36 p.m. CBG was 585. MD notified, re-check CBG ordered. A review of Resident R86's MAR and clinical progress notes indicated on 1/3/22, the MD was not notified, and was not assessed or rechecked. Further review revealed on 1/4/22, a recheck was not completed. A review of the care plan dated 10/15/20, indicated to administer medications per physician orders, and report signs and symptoms of [CONDITION(S)] and [CONDITION(S)]. During an interview on 4/14/22, at 9:22 a.m. Licensed Nurse Employee E7 stated if there were increased or decreased blood sugar results, the protocol would be followed for each resident as ordered by the doctor. Rechecks are done and documented in the chart. A review of the residents' clinical record revealed Licensed Nurse Employee E7 had 10 instances of elevated blood sugars and did not notify the physician. During an interview on 4/14/22, at 9:28 a.m. Licensed Nurse Employee E8 stated if there were increased or decreased blood sugar results, the physician would be notified and protocol would be followed for each resident as ordered by the doctor, rechecks are completed and documented in the chart. During an interview on 4/14/22, at 9:30 a.m. Licensed Nurse Employee E9 stated if there were increased or decreased blood sugar results the protocol would be followed and the doctor notified. The protocol would depend on the resident's order. During an interview on 4/14/22, at 9:32 a.m. Licensed Nurse Employee E10 stated if there were increased, or decreased blood sugar results the doctor would be notified if that was the policy and documented. During an interview on 4/14/22, at 9:35 a.m. Licensed Nurse Employee E11 stated if there were increased or decreased blood sugar results a recheck would be done with a different glucose machine to verify results and protocol would be followed, the doctor would be notified, and documentation would be completed. A review of the residents' clinical record revealed Licensed Nurse Employee E11 had 2 instances of elevated blood sugars and did not notify the physician. During an interview on 4/14/22, at 2:35 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON) confirmed the facility failed to notify the physician of resident's change in condition, correctly document blood glucose results, complete resident assessments with a change in condition, and to monitor resident's condition to ensure interventions to be effective. The NHA and DON were made aware that Immediate Jeopardy existed due to the failure of the facility to monitor, evaluate and /or revise the residents' response to intervention which placed the residents at risk when the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person- centered policy. The facility failed to follow the policy Guidelines for notifying Physicians of Clinical problems: Appendix B: guidelines for reporting abnormal test results to physicians which states glucose >300 in diabetic with signs/symptoms; >430 or high on glucose monitor in anyone. The facility failed to assess and document for signs and symptoms of [CONDITION(S)] and [CONDITION(S)] and notify physician of acute condition changes on six of nine residents (R10, R17, R58, R64, R67, and R86) resulting in immediate jeopardy and harm which resulted in resulting in two (R17 and R64) of those residents transferred to the hospital emergency department in critical condition on 4/14/22 at 4:00 p.m. and a corrective action plan was requested and the Immediate Jeopardy template was provided. On 4/15/22, at 11:00 a.m. an acceptable Immediate Action Plan was approved which included the following interventions: - Residents identified to be affected R10, R17, R58, R64, R67, and R86 were assessed for signs and symptoms of [CONDITION(S)]/[CONDITION(S)] with current accuchecks. Residents within current diabetic parameters and physician notified. - Facility residents with sliding scales for diabetes were reviewed and a 24 hour look back of residents with orders for blood glucose check to ensure MD orders/parameters were followed and MD notified if warranted. - Care plan audit completed of current residents with Diabetes Mellitus to ensure care plan in place with appropriate interventions. - Audit completed of residents utilizing sliding scales; Audit entailed if resident identified are ordered blood glucose check and parameters. - Education on 4/14/22, with licensed staff and MD on Blood Glucose parameters which includes MD notification, assessment of a resident [CONDITION(S)]/[CONDITION(S)], completion of care plan related to diabetes mellitus. Education included the following: Nursing Care of Residents with DM, Guidelines for Notifying Physician of Clinical Problems, Change in Residents Condition or Status, Charting and Documentation, Diabetes Clinical Protocol, and Resident Assessment. - All audits will be reviewed as part of the monthly QAPI process The Immediate Jeopardy was removed on 4/15/22, at 11:00 a.m. when the action plan was verified. During an interview on 4/15/22, at 10:58 a.m. the Nursing Home Administrator confirmed the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person- centered policy. The facility failed to assess and document for signs and symptoms of [CONDITION(S)] and [CONDITION(S)] and notify physician of acute condition changes on six (R10, R17, R58, R64, R67, and R86) of nine residents resulting in immediate jeopardy and harm which resulted in resulting in two (R17 and R64) of those residents transferred to the hospital emergency department in critical condition. 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.

Based on a review of clinical records, facility documents, an event report submitted to the State Survey Agency, the medical examiner's report and staff interviews, it was determined that the facility failed to assure that the physician's orders [REDACTED]. Findings include: A review of the admission record indicated that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident CR1's most recent quarterly Minimum Data Set assessment (MDS - a periodic review of care needs) dated [DATE], indicated that these [DIAGNOSES REDACTED]. The review of the quarterly MDS assessment also indicated that Resident CR1 had a mental status score of "00" (indicating that the resident had severe cognitive impairment), was unable to ambulate independently and required extensive assistance of two persons to transfer between surfaces. A review of Resident CR1's most recent facility side rail assessment, dated [DATE], indicated that Resident CR1 had an alteration in safety awareness due to cognitive decline, was not able to get in or out of bed unassisted and based on the assessment findings, Resident CR1 was not to utilize side rails. A review of Resident CR1's progress note dated [DATE], written by the Alzheimer Care Director, indicated that Resident CR1 was transferred that day from the secure dementia unit at the facility, where she had been residing since [DATE], to the "C" Wing of the facility, per the family's request. During an interview on [DATE] at 12:45 p.m., Physician Employee E5 stated that Resident CR1's family member requested that Resident CR1 be transferred from the secure dementia unit to another facility unit, because the family member did not feel that Resident CR1 had adequate activity and socialization opportunities on the secure dementia unit. A review of Resident CR1's monthly physician recapitulation orders (a monthly summary of the current physician's orders [REDACTED]. to alert staff when an unassisted exit from the bed occurs). The review also indicated that Resident CR1 did not have a physician's orders [REDACTED]. A review of an event report submitted by the facility on [DATE], to the State Survey Agency, indicated that Resident CR1 was found nonresponsive on [DATE], at 5:45 a.m. CPR (Cardio-Pulmonary Resuscitation) was started immediately and the 911 emergency system was called. Resident CR1 was pronounced deceased at the facility on [DATE], at 6:19 a.m. A review of a facility witness statement dated [DATE], indicated that Nurse Aide (NA) Employee E1 stated, "Resident CR1 was checked at about 5:40 a.m. She was asleep and awoke when I checked her. She had an alarm on. I don't remember bolsters." A review of Resident CR1's nursing progress note dated [DATE], at 7:52 a.m., indicated that Nursing Supervisor Employee E2 found Resident CR1 on [DATE], at 5:45 a.m., with her head trapped in the bed side rail and in a nonresponsive state. CPR was initiated, including application of an Automated External Defibrillator (AED - a machine with electrodes that attach to the chest to deliver shocks to the heart) and the 911 emergency system was activated. The review of the nursing progress note also indicated that the emergency medical service personnel arrived at the facility on [DATE], at 5:58 a.m., and continued CPR and subsequently contacted their medical command, who pronounced Resident CR1 deceased on [DATE], at 6:19 a.m. The review of the facility witness statements dated [DATE], indicated that Nurse Aide (NA) Employee E3 stated, "She had alarms. She did not have bolsters on her bed." and NA Employee E4 stated, "There weren't any bolsters on the bed. I know she had an alarm on." During an interview on [DATE], at 9:40 a.m., Nursing Supervisor Employee E2 stated, "There were no bolsters on her bed. She did have the alarm cord clipped on her shoulder, but it had become detached from the alarm on the head of the bed." A review of a facility witness statement dated [DATE], indicated that Nursing Supervisor Employee E2 stated "I had gone into Room C11 at 5:45 a.m. Upon entering, I noticed Resident CR1 sitting on the floor facing the door with her chin in between the bottom two bars of the siderail." During an observation on [DATE], at 1:00 p.m., of Resident CR1's bed, with Maintenance Director Employee E6, revealed that the bed had two metal siderails applied to the right and left top of the bed frame. Each siderail was 26.5 inches in length and 11 ,[DATE] inches in height. Each siderail had three horizontal rails, with 4 inches of space between the top and middle rail and 4 inches of space between the middle and bottom rail. During interviews on [DATE], with the Director of Nursing (DON) at 9:20 a.m., and the Nursing Home Administrator (NHA) at 10:15 a.m., the DON and NHA both confirmed that Resident CR1 did not have a physician's orders [REDACTED]. A review of the preliminary report from the Greene County Coroner's office dated [DATE], stated that the official cause of Resident CR1's death was accidental asphyxiation due to compression. The facility failed to follow the physician's orders [REDACTED]. 28 Pa Code 201.14(a) Responsibility of licensee. Previously cited [DATE]. 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE]. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services.