Every finding on record at Wecare at Mt Lebanon Rehabilitation and NRSG CTR

Based on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need for ten of 21 residents (Resident R4, R6, R7, R8, R13, R15, R18, R19, R30, R31).Findings include: Review of the facility, Staffing, Sufficient and Competent Nursing dated 1/22/25, indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. During an observation on 6/8/26, at 1:28 p.m. Resident R4's urinal was noted to be unemptied. Resident R4 had been served his noon meal a few minutes prior and the half-full urinal was on the overbed table next to Resident R4's meal. During an observation on 6/8/26, at 1:31 p.m. revealed Resident R6 to be unshaven with unkempt hair. During an observation on 6/8/26, at 1:32 p.m. revealed Resident R7 to be malodorous. During an observation on 6/8/26, at 1:34 p.m. revealed Resident R15 to be to be in a gown, in bed. Observation at this time showed what appeared to be feces smeared near Resident R15's pillow. The room had a strong odor of feces present. During a second observation at 5:50 p.m. revealed Resident R15 to still be in bed in the same gown. During an observation on 6/8/26, at 5:30 p.m. Resident R30 was noted to have tangled, unbrushed hair. During an interview on 6/8/26, at 5:19, when asked if the facility maintained sufficient staff to provide care for the residents, Resident R8 laughed and stated, No. When asked if call light response times were long, Resident R9 stated, Sometimes it takes a long time, sometimes they don't come at all. During an observation on 6/8/26, at 5:32 p.m. Resident R31 was noted to have greasy appearing hair. During an observation on 6/8/26, at 5:39 p.m. Resident R13 was noted to have greasy appearing hair and was wearing only a T-shirt and brief. During an observation on 6/8/26, at 5:46 p.m. a call light was heard to be alarming. Observation at this time revealed three staff members seated at the nurse's station. The call light alarmed for approximately three more minutes until a staff member noted the surveyor watching. At that point, the staff member answered the call light. During an interview on 6/8/26, at 5:52, when asked if the facility maintained sufficient staff to provide care for the residents, Resident R18 stated, No. They go through people like Grant went through Richmond. When asked if call light response times were long, Resident R18 stated, Yes, especially when you are in pain. Observation at this time revealed soiled linen left on Resident R18's floor. During an interview on 6/8/26, at 5:54, when asked if the facility maintained sufficient staff to provide care for the residents, Resident R19 stated, Could always use a few more bodies. Observation at this time revealed Resident R19 to have long facial hair. When asked, Resident R19 confirmed that he would like to be assisted to shave. During an interview on 6/8/26, at approximately 6:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure sufficient staffing to meet resident need for ten of 21 residents. 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 facility policies, documents, observations and resident and staff interviews it was determined that the facility failed to serve hot food products at acceptable palatable temperatures for two of two meals (lunch and dinner meal) and to ten of sixteen residents. (Residents R3, R8, R9, R10, R14, R16, R17, R21, R22, and R32).Findings include: The facility policy entitled Food Temperature Recording, dated 1/22/25, revealed all hot foods will be held and served at or above 135 (degrees Fahrenheit), and all cold foods will be held and served at or below 41 .Review of three months of Resident Council minutes (April-June 2026) revealed that on 5/7/26, the Resident Council voiced a concern related to cold food. Review of the Resident Council minutes from 6/4/26, indicated that the concern related to cold food remained unresolved.During an observation of the Main Kitchen noon meal tray line on 6/8/26, beginning at 12:35 p.m., it was noted:The facility utilized plastic plates. The plates were in the plate warming machine, but only slightly warm to the touch.Use of the facility provided thermometer revealed the plate temperature to be 90.3 .Observation of the tray assembly revealed that no bases were utilized for the plates, and a dome lid was placed over the plates on the tray.Observation of the food delivery carts confirmed that they do not have heating functionality.Observation of the tray placement on the delivery cart revealed that while the staff member who loaded the trays was unloading previously used trays, meals were left uncovered on the trays. During an observation on 6/8/26, beginning at 1:03 p.m. of the meal delivery on the First Floor unit, it was noted:The delivery cart doors were left open while two staff members delivered the trays to residents in their rooms.At 1:11 p.m. the last resident received their tray. During a resident tray assessment conducted on 6/8/26, at 1:12 p.m. it was revealed that the facility served the following food products with the following point of service temperatures that were taken by the surveyor while utilizing a facility owned thermometer, in the presence of nursing staff. Dietary staff were unavailable to witness temperature assessments.Pierogies 128.3 Creamed corn 126.0 Diced carrots 116 During resident interviews conducted during noon meal service on 6/8/26, the following was stated: -1:25 p.m. Resident R3 stated the food is often cold.-1:38 p.m. Resident R8 stated the food is frequently cold. During a resident tray assessment conducted on 6/8/26, at 5:45 p.m. it was revealed that the facility served the following food products with the following point of service temperatures that were taken by the surveyor while utilizing a facility owned thermometer, in the presence of nursing staff. Dietary staff were unavailable to witness temperature assessments.Macaroni and ground beef 113.6 During resident interviews conducted during evening meal service on 6/8/26, the following was stated: -5:19 p.m. Resident R9 stated, It's cold. It's all cold. Some of it's good, some of it's shit.-5:19 p.m. Resident R10 stated that sometimes the food is cold.-5:25 p.m. Resident R16 stated that sometimes the food is cold.-5:40 p.m. Resident R14 stated, Tell them to keep my dinner, it's cold.-5:50 p.m. Resident R17 stated the food is, pretty much always cold.-5:55 p.m. Resident R32 stated, Cold. The french fries are always cold and soggy.-5:58 p.m. Resident R21 stated the food is often cold.-6:00 p.m. Resident R22 stated the food is Sometimes not as warm as I'd like it to be, but I don't have a problem with that.During an interview on 6/8/26, at 6:30 p.m. the Nursing Home Administrator confirmed the above point of service temperatures and that facility failed to serve hot food products at acceptable palatable temperatures for two of two meals (lunch and dinner meal) and to ten of sixteen residents. 28 Pa Code: 211.6(b)(c) Dietary services

Based on a review of resident choice menu selections, and Resident Group and staff interviews, it was determined that the facility failed to provide resident selected menu items for eight of 21 residents (R1, R2, R3, R5, R10, R11, R12, and R15).Findings include: During resident interviews conducted during noon meal service on 6/8/26, the following was stated: Resident R1 did not receive the ordered Glucerna (nutrition drink with a low sugar content) as indicated on the meal ticket.Resident R2 did not receive the milk, as indicated on the meal ticket.Resident R3 did not receive the ordered Glucerna as indicated on the meal ticket. Resident R3 stated, None today. Sometimes they substitute the milk shake, but that has too much sugar.Resident R5 did not receive double portions, as indicated on the meal ticket.Resident R15 did not receive the milk, as indicated on the meal ticket. Review of the meal tickets indicated that all residents had, 6 FL OZ (fluid ounces) hot beverage of choice. Observation during the meal delivery revealed a cart with a coffee carafe and sweeteners and creamers on it. Observation of fourteen residents' trays revealed all fourteen not to have a hot beverage present. During resident interviews conducted during evening meal service on 6/8/26, the following was stated:Resident R10 did not receive the canned fruit, as indicated on the meal ticket.Resident R11 did not receive the ice cream, as indicated on the meal ticket.Resident R12 did not receive the banana or receive double portions, as indicated on the meal ticket.During an interview on 6/8/26, at 6:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide ordered and selected food items to the residents. 28 Pa Code: 211.6(a) Dietary service.

Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement an effective system of surveillance designed to identify possible tuberculosis ( TB a contagious bacterial infection that typically attacks the lungs) exposures for seven of twenty residents (R23, R24, R25, R26, R27, R28, and R29).Findings include: Review of the facility policy, Screening Residents for Tuberculosis dated 1/22/25, indicated the facility, Shall screen all residents for tuberculosis infection and disease (TB). During an interview on 6/8/26, at 2:52 p.m. the Director of Nursing confirmed that the facility's tuberculosis prevention program includes testing of all new admissions unless contraindicated. Review of the new admission orders indicated:-Tuberculin PPD (purified protein derivative or Mantoux test) Solution Inject 0.1 milliliter intradermally every day shift every 7 day(s) for monitoring for two administrations.-Read PPD 2 days after placement and record results in immunization tab every day shift every 7 day(s) for results for two administrations. Review of the clinical record indicated Resident R23 was admitted to the facility on [DATE]. Review of the April 2026 Medication Administration Record indicated that Resident R23 should have a TB skin test completed on 4/19/26, and 4/26/26, with the results to be read by nurses on 4/21/26, and 4/28/26. Review of the April 2026 MAR failed to reveal documentation that Resident R23 had tuberculosis skin tests completed on 4/19/26, and 4/26/26. Review of Resident R23's progress notes failed to reveal documentation of the reason for the omission. Review of the April 2026 MAR revealed that Resident R23's TB skin tests were read by nursing staff on 4/21/26, and 4/28/26. Review of the clinical record indicated Resident R24 was admitted to the facility on [DATE]. Review of the May 2026 MAR indicated that Resident R24 should have a TB skin test completed on 5/1/26, and 5/8/26, with the results to be read by nurses on 5/2/26, and 5/9/26. Review of the May 2026 MAR failed to reveal documentation that Resident R24 had a tuberculosis skin tests completed on 5/1/26. Review of Resident R24's progress notes failed to reveal documentation of the reason for the omission. Review of the May 2026 MAR revealed that Resident R24's TB skin tests were read by nursing staff on 5/2/26, and 5/9/26. Review of the clinical record indicated Resident R25 was admitted to the facility on [DATE]. Review of the May 2026 MAR indicated that Resident R25 should have a TB skin test completed on 5/12/26, and 5/19/26, with the results to be read by nurses on 5/14/26, and 5/21/26. Review of the May 2026 MAR failed to reveal documentation that Resident R25 had a tuberculosis skin test completed on 5/12/26. Review of Resident R25's progress notes failed to reveal documentation of the reason for the omission. Review of the May 2026 MAR revealed that Resident R25's TB skin tests were read by nursing staff on 5/14/26, and 5/21/26. Review of the clinical record indicated Resident R26 was admitted to the facility on [DATE]. Review of the May 2026 MAR indicated that Resident R26 should have a TB skin test completed on 5/14/26, and 5/21/26, with the results to be read by nurses on 5/16/26, and 5/23/26. Review of the May 2026 MAR failed to reveal documentation that Resident R26 had a tuberculosis skin test completed on 5/14/26. Review of Resident R26's progress notes failed to reveal documentation of the reason for the omission. Review of a progress note dated 5/16/26, at 11:22 a.m. indicated, resident does not recall getting a TB test, no documentation in chart under immunizations/progress note/MAR to indicate which arm TB test was given, unable to read. Review of the clinical record indicated Resident R27 was admitted to the facility on [DATE]. Review of the May 2026 MAR indicated that Resident R27 should have a TB skin test completed on 5/13/26, and 5/20/26, but the order was discontinued on 5/13/26 Review of the May 2026 MAR failed to reveal documentation that Resident R27 had a tuberculosis skin test completed on 5/13/26, or 5/20/26. Review of the May 2026 MAR revealed that Resident R27's TB skin tests were read by nursing staff on 5/15/26, and 5/22/26. Review of the clinical record indicated Resident R28 was admitted to the facility on [DATE]. Review of the June 2026 MAR indicated that Resident R28 should have a TB skin test completed on 6/3/26, and 6/10/26, with the results to be read by nurses on 6/4/26, and 6/11/26. Review of the June 2026 MAR revealed documentation that Resident R28 had refused to have a tuberculosis skin test completed on 6/3/26, and 6/4/26. Review of the June 2026 MAR revealed that Resident R28's TB skin test was read by nursing staff on 6/11/26, and documented as negative Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of the June 2026 MAR indicated that Resident R29 should have a TB skin test completed on 6/6/26, and 6/13/26, with the results to be read by nurses on 6/8/26, and 6/15/26. Review of the June 2026 MAR revealed incorrect documentation for the TB test placed on 6/13/26, indicating the body location the test was placed at as 0.1. Review of the June 2026 MAR revealed that Resident R29's revealed blank documentation for the reading of the TB test on 6/15/26. During an interview on 6/8/26, at 6:30 p.m. the Nursing Home Administrator that the facility failed to implement an effective system of surveillance designed to identify possible tuberculosis exposures for seven of twenty residents. 28 PA. Code: 201.22(a) Prevention, Control, and Surveillance of Tuberculosis

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store medications properly, for one of two medication rooms (First-floor medication room).Findings include: Review of the facility policy Storage of Medications dated 1/22/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. During an observation of the First-floor medication room on 6/826, beginning at approximately 11:08 a.m., the following was observed:(1) vial of tuberculin solution was noted to be opened, and undated.(4) aerobic blood culture bottles with an expiration date of 4/2/26.(4) anaerobic blood culture bottles with an expiration date of 5/28/26.(2) I.V. start kits with an expiration date of 4/30/26.(4) collection tubes with an expiration date of 6/2/25.(94) collection tubes with an expiration date of 2/28/26.(24) urine collection tubes with an expiration date of 3/31/26. During an interview on 6/8/26, at approximately 11:20 a.m. Registered Nurse Employee E1 confirmed the above observations. During an interview on 6/8/26, at approximately 6:30 p.m. the Nursing Home Administrator confirmed that the facility failed to store medications properly for one of two medication rooms. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k) Pharmacy Services.

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision during transfers for one of three residents (Resident R1). This was identified as past-noncompliance.Findings include:Review of facility Safety and Supervision of Residents dated 1/22/25, indicated that the facility takes an initialized resident centered approach to resident safety including implementing interventions with adequate supervision.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 9/12/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), arthritis (inflammation of one or more joints, causing pain and stiffness), and physical debility. Review of Section G: indicated that Resident R1 required substantial/maximal assistance to transfer to and from a chair or bed.Review of Resident R1's plan of care for Functional Decline in ADLs (activities of daily living) initiated 8/29/22, revised on 8/13/25, indicated, Transfer resident with Ax2 (assist of two people).Review of Resident R1's Kardex (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) utilized by nurse aide staff dated 10/8/25, indicated that Resident R1 as Transfer resident with Ax2.Review of a progress note dated 10/8/25, at 12:15 p.m. indicated, [Provider] notified of residents left foot and ankle is swollen, warm to touch and tender. Orders received for 2 view xray.Review of a progress note dated 10/9/25, at 9:06 a.m. indicated, X-ray positive for left ankle fracture. [Provider] in facility and aware. Investigation into fracture in process. Could be related to disease process. Family notified by MD (doctor of medicine).Review of facility submitted information dated 10/9/25, indicated, [Resident R1] had an X-Ray of the left ankle due to swelling. Results positive for left ankle fracture. Resident has a BIMS of 0 and unable to state what occurred. Investigation started. Upon conclusion of investigation it was determined that the residents plan of care was not followed on 10/6/2025 with [Nurse Aide Employee E1] as resident was transferred with an assist x1 and her plan of care is assist x2. This happened due to census sheets at nurses' station having the incorrect transfer status.Review of an employee statement written by NA Employee E1 dated 10/9/25, indicated, I got [Resident R1] up on Monday and she stayed up all day until I put her back at 2 pm. This is my usual routine with her. When I put her back or got her up, there was nothing that I observed about her injury. She did not moan or scream. I had her in bed at 2 pm and that was the last time I saw her until this morning. I have always transferred her by myself because that is what is on the census sheet. I never looked at PCC [electronic charting system].Review of a facility submitted Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 10/9/25, included the information, Neglect substantiated due to CNA (nurse aide) not following the plan of care. CNA immediately educated to find all transfer statuses in PCC under the Kardex and to follow the plan of care.On 10/9/25, the facility initiated a plan of correction that included:-Residents' representative aware. -Census sheets on the units updated to remove transfer statuses.-Therapy evaluated resident and noted that Broda chair has a metal bar footrest and padding was applied. -Physician notified and POLST (Physician Orders for Life-Sustaining Treatment, set of medical orders signed by both the patient and their healthcare provider, which allows emergency medical personnel to follow the patient's specific preferences) will continue comfort measures only in house and MD to conduct a medication review for pain meds/comfort. -Whole house audit of residents to ensure accuracy of transfer status. -Whole house education to obtain transfer status in PCC by reviewing the Kardex and following each resident's plan of care.-All incidents are reviewed by the IDCP team and QAPI committee.During observations of the census sheets for use by staff confirmed that the transfer status was not included. During interviews completed on 11/6/25, six staff interviewed confirmed they had received education on the appropriate way checking a resident ' s transfer status and demonstrated how to navigate to the appropriate area in the electronic medical record system. Facility in compliance as of 11/6/25.During an interview on 11/6/25, at approximately 5:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision during transfers that resulted in the actual harm of an ankle fracture one of three residents. This was identified as past-noncompliance.

Based on facility document review and staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department.Findings include: Review of documents provided to the survey team on 9/14/25, indicated an educational degree for Dietary Manager Employee E4. During an interview with Registered Dietician (RD) Employee E5 on 9/18/25, at 11:06 a.m. she confirmed that while employed full-time by the facility corporation, she works in two separate facilities. RD Employee E2 further confirmed that she does not take an active role in the daily operations of the dietary department. During an interview on 9/18/25, at approximately 12:00 p.m., the Nursing Home Administrator confirmed that Dietary Manager Employee E4 is not a Certified Dietary Manager. During an interview on 9/18/25, at approximately 12:30 p.m., the Nursing Home Administrator confirmed that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department. Pa Code: 201.18(e)(6) Management.

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen and one of two nursing unit nutrition rooms (Ground floor nursing units). Findings include: Review of the Dietary Services policy, Sanitation dated 1/22/25, indicated All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.During an observation of the Main Kitchen on 9/14/25, at 10:30 a.m. revealed the following:-Unused disposable cup lids, visibly soiled.-(9) 4-ounce milk carton with a best-by date of 9/12/25.-Slicer uncovered, not currently in use. -Mixer uncovered, not currently in use. During a second observation of the Main Kitchen on 9/16/25, at 12:48 p.m. the following was observed:-Staff member loading scraping the soiled dishes and loading them into the dishwasher also removing the clean dishes and storing them for use. No hand hygiene, wearing of an apron, or any other way to remove contamination after handling the soiled dishes was observed prior to the staff member handling the clean dishes. -Slicer uncovered, not currently in use. -Mixer uncovered, not currently in use. -Two-compartment sink in the food preparation area was noted to have approximately 2-3 inches of standing water in the right compartment, with a large amount of black sediment collecting in the garbage disposal drain and floating in the standing water.During an interview at this time, Dietary Manager Employee E4 confirmed that garbage disposal is not operable. Dietary Manager Employee E4 stated that staff place a large baking sheet over the inoperable sink area to have a food preparation area. During an observation of the Ground Floor nutrition room on 9/16/25, at 10:14 a.m. revealed the following:-(1) gallon sized jug of a red liquid, not dated. -(1) staff member lunch bag. -(1) peanut-butter and jelly sandwich in a zippered storage bag, without a name or date. -(1) prepackaged chicken wrap, without a name.-(1) container of sliced watermelon, without a name or date. -(1) grocery store bag containing an open package of pretzels, an open package of pistachios, an open package of tortillas, and a container with an unknown food inside of it, without a name or date. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen and one of two nursing unit nutrition rooms. 28 Pa. Code: 211.6(c) Dietary services.

Based on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months (October 2024 through August 2025).Finding include:Review of the facility policy Legionella Water Management Program dated 1/22/25, previously dated 1/18/24, indicated Specific actions should be taken for prevention of Legionella and for investigation should a case occur. Core Elements of the Water Management Plan are:1. Establish Water Management Plan team.2. Describe Center's water system using text and flow diagram.3. Risk assessment with control methods and corrective actions.4. Monitoring control measures.5. Corrective actions.6. Verification and validation.7. Documentation and communication.Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 7/6/18, revealed, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals (CAHs) and Long-Term Care (LTC). However, this policy memorandum is also intended to provide general awareness for all healthcare organizations. Facilities must have water management plans and documentation that, at minimum, ensure each facility:-Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Nontuberculous Mycobacteria, Burkholderia, Stenotrophomonas, and fungi) could grow and spread in the facility water system.-Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit.-Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.-Maintains compliance with other applicable Federal, State, and local requirements.Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine-dioxide, copper-silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50-3.00 ppm (part per million).Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold-water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. Review of the Water Management Program Preventive Maintenance did not contain logs for flushing of all hot water and storage tanks monthly, minimum water temperature testing in all tanks. During an interview on 9/16/25, at approximately 11:30 a.m. the Nursing Home Administrator confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on observations and staff interviews, it was determined that the facility failed to make certain that equipment was maintained in operating condition in the Main Kitchen. Findings include: During an observation of the Main Kitchen on 9/16/25, at 12:48 p.m. the two-compartment sink in the food preparation area was noted to have approximately 2-3 inches of standing water in the right compartment, with a large amount of black sediment collecting in the garbage disposal drain and floating in the standing water. During an interview at this time, Dietary Manager Employee E4 confirmed that garbage disposal is not operable. Dietary Manager Employee E4 stated that staff place a large baking sheet over the inoperable sink area to have a food preparation area. Dietary Manager Employee E4 confirmed that the maintenance department is aware. During an interview on 9/16/25, at approximately 1:30 p.m. the Nursing Home Administrator (NHA) confirmed that she was made aware of the garbage disposal not being operable during a walk-through completed with Maintenance Director Employee E8 and members of the corporate staff. Review of an electronic communication dated 8/28/25, at 5:16 p.m. confirmed the walk-through and listed in the items of needing repaired or replaced was the two-compartment sink and garbage disposal. When asked about the corporate management response to the need for repaired/replaced garbage disposal, the NHA was unable to provide an answer. During an interview on 9/16/25, at approximately 2:15 p.m. Maintenance Director Employee E8 confirmed that he had been made aware of the need to repair/replace the garbage disposal. When asked for evidence when the initial request for repair was made, the Maintenance Director was unable to provide the initial maintenance request. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that equipment was maintained in operating condition in the Main Kitchen. 28 Pa. Code: 207.2(a) Administrator's responsibility.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for five of twelve residents (Resident R2, R5, R53, R66, and R82).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments (MDS - periodic assessment of care needs) dated October 2024, indicated that 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 1, and the BIMS assessment should be completed 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 R2 had an MDS completed on 8/12/25. Review of Section P: Restraints and alarms, Question P0100 indicated that Resident R2 used a limb restraint less than daily when in a chair or out of bed. Review of Resident R2's clinical records revealed Resident R2 did not have orders from a provider or other documentation indicating the utilization of a restraint or that a restraint could/should be utilized for Residents R2's care. During an interview on 9/15/25 at approximately 1:30 p.m. Resident R2 was unaware of any plan for restraint utilization with her care. Resident R5 had an MDS completed on 6/18/25. Review of Section N: Medications, Question N0415 indicated that Resident R5 received an anticoagulant medication within the seven days previous 6/18/25. Review of Resident R5's Medication Administration Record indicated Resident R5 did not receive an anticoagulant medication during 6/11/25, through 6/18/25. Resident R53 had an MDS completed on 7/24/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R53 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R8 is rarely understood, and the BIMS assessment was not completed. Resident R66 had an MDS completed on 7/3/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R66 is sometimes understood. Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R8 is rarely understood, and the BIMS assessment was not completed. Review of Section D: Mood, Question C0100 indicated that Resident R66 is rarely understood, and the Resident Mood Interview assessment was not completed. Resident R82 had an MDS completed on 6/10/25. Review of Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R82 is understood. Review of Sections C: Cognitive Patterns, Question C0100 indicated the BIMS assessment should be completed. All further questions were documented as Not Assessed. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for five of twelve residents. 28 Pa. Code: 211.5(f) Clinical records.

Based on review of facility policy, observation, resident, and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for thirteen of twenty residents (R2, R10, R13, R77, R500, R501, R502, R503, R504, R505, R506, R507, R508, and 509) on two of two nursing units (ground floor G wing and first floor 1 wing).Findings included: Review of the facility policy Homelike Environment dated 1/22/25, indicated in part The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean bed and bath linens that are in good condition. During an observation on 9/15/25, at approximately 10:55 a.m. of Resident R77's room revealed the bed linen to be extremely worn, with areas thin enough to make the blue mattress visible beneath it. During a group interview, on 9/15/25, at approximately 11:00 a.m., consensus from the group, Residents R500, R501, R502, R503, R504, R505, R506, R507, R508 and R509 verbalized frustration with the lack of linen and frequency of bed linen changes at the facility at the facility. Residents stated in the past they would get their bed linen changed on shower days or more often if needed. Now you may have the same bed linen for a week or two. If you don't ask for clean sheets, you're not going to get them unless you had an accident in bed. The sheets here are old, they are so thin, they have a lot of holes in them. They just don't have enough bed linen here. During an observation on 9/15/25, at 1:40 p.m. Resident R2 bed linen had holes. During an observation on 9/15/25, at 2:00 p.m. Resident R10 bed linen had holes. During an interview on 9/15/25, at approximately 1:30 p.m. Resident R13 stated they don't change the sheets often. The surveyor observed there were holes in his bed linen. Resident R13 was re-interviewed again on 9/18/25 at approximately 8:30 a.m., the surveyor observed holes in the bed linen as observed on the prior interview. During an observation on 9/16/25, at approximately 2:00 p.m. of the Ground Floor nursing unit, within a closet on the nursing unit the following items were stored together on the shelves: an employee lunch bag, toilet seat raiser, powdered drink thickener, disposable cup lids, medical supplies, clothing, and a toolbox. During an interview on 9/18/25, at approximately 8:40 a.m. Employee E3 confirmed the holes in the Resident R13's bed linen. During an interview on 9/18/25, at approximately 8:50 a.m. Employee E1 confirmed the facility has been short of bed linen and there are holes in some of the linen they have available to use. During an interview on 9/18/25, at approximately 9:00 a.m. Employee E2 confirmed the facility has been low on bed sheets and there are holes in some of the linen they have available to use. During an interview on 9/18/25, at approximately 9:30 p.m., the Nursing Home Administrator (NHA) and DON confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment for fourteen of twenty residents on two of two nursing units (ground floor G wing and first floor 1 wing). 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 201.29(k) Resident rights.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization (Resident R5 and R12).Findings Include: Review of the facility policy Bed-Holds and Returns dated 1/22/25, indicated, All residents/ representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents are provided written information about these policies at least twice: Well in advance of any transfer (e.g. in the admission packet); and At the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R5's minimum data set (MDS - periodic assessment of resident care needs) dated 6/15/25, included diagnoses of cirrhosis of the liver and muscle wasting. Review of Section C: Cognitive Patterns indicated Resident R5 had severe cognitive impairment. Review of documents attached to Resident R5's clinical record court documents dated 9/24/25, that indicated that Resident R5 was adjudged to be an incapacitated person and had a legal guardian appointed by the court on that date. Review of a progress note dated 12/6/24, at 9:59 a.m. indicated, Called to resident bedside by assigned LPN (licensed practical nurse), resident was alert but non-responsive. Left sided facial drooping was observed. Resident not responding to verbal stimuli. Review of the Transfer/Discharge/Bed Hold Form Notice dated 12/6/24, revealed that the bed hold policy was understood, and the facility was requested to hold the bed. The signature box that indicated who agreed to this (resident or responsible party) was blank. The facility representative signature box was blank. Review of a progress note dated 6/8/25, at 8:41 p.m. indicated, At about 1912 (7:12 p.m.) today, resident was sent out to [hospital] by two EMS (emergency services) personnel because of low hemoglobin (iron-containing protein in the blood).Review of the Transfer/Discharge/Bed Hold Form Notice dated 6/8/25, revealed that Resident R5 was provided a copy of the Transfer/Discharge/Bed Hold Notice in person and that Resident R5 understands the bed hold policy and requests the facility to hold the bed. Left blank was the option of, Resident cognitively impaired. The resident representative/guardian/HCP (healthcare proxy) was provided a written copy of the Transfer/Discharge/Bed Hold Notice. Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R12's MDS dated [DATE], included diagnoses of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior) and history of a stroke. Review of Resident R12's demographic information in the electronic medical record indicated Resident R12's daughter was documented as his Power of Attorney. Review of a progress note dated 5/13/25, at 11:31 a.m. indicated, Pt. (patient) transferred at this time via ambulance to [hospital]. Review of the Transfer/Discharge/Bed Hold Form Notice dated 5/13/25, revealed that Resident R12 was provided a copy of the Transfer/Discharge/Bed Hold Notice in person. The options that the resident holds or releases the bed were not documented. Additionally left blank were the options of: The resident representative/guardian/HCP was notified via phone of the Transfer/ Discharge/ Bed Hold. The resident representative/guardian/HCP understands the bed hold policy and requests that the facility hold the bed. The resident representative/guardian/HCP understands the bed hold policy and requests that the facility hold the bed. Review of the paper copy uploaded to Resident R12's electronic medical record of the Notification of Bed Hold Policy Upon Transfer dated 5/13/25, revealed the section for Person Notified to be blank. Additionally, both the option to hold the bed and release the bed were blank. The signature line for the Resident/Responsible Party was blank. During an interview on 9/19/25, at approximately 12:305 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of four residents reviewed for hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of the facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic review of advance directive instructions, for two of eight residents reviewed (Resident R13, and R85).Findings Include: A review of the facility policy Advance Directives last reviewed 1/22/25, indicated it's the policy of this facility that each resident has the right to formulate an Advance Directive. The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/3/25, indicated diagnoses of Parkinson's disease (brain disorder that affects movement), bipolar disorder (extreme mood swings), and anxiety, a BIMS of 13. Review of the clinical record failed to reveal evidence of periodic advanced directive review, as part of the comprehensive care planning process, the existing care instructions and whether resident R13 or designated surrogate's wishes to change or continue these instructions. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of cerebrovascular disease (stroke), thyroid disorder (impacts thyroid hormone production levels), and depression, a BIMS of 15. Review of the clinical record failed to reveal evidence of periodic advanced directive review, as part of the comprehensive care planning process, the existing care instructions and whether resident R5's or designated surrogate's wishes to change or continue these instructions. During an interview on 9/16/25 at 1:30 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the opportunity to formulate an advance directive (written instructions for when the individual is incapacitated) or conduct periodic reviews of advance directive instructions, for two of eight residents reviewed (Resident R13, and R85). 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

Based on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for four of sixteen residents (Resident R5, R13, R71, and R97).Findings include: Review of facility policy Activities of Daily Living (ADL), Supporting reviewed 1/22/25, indicated resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact8 - 12: moderately impaired0 - 7: severe impairment Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R5's minimum data set (MDS - periodic assessment of resident care needs) dated 6/15/25, included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and muscle wasting. Review of a physician order dated 9/9/25, indicated Cleanse abdominal wound with NSS (normal saline solution), apply collagen sheet, cover w/island dressing daily every day shift every Mon, Thu for Wound Treatment AND as needed for displacement/drainage. Review of Resident R3's plan of care for edema/excess fluid volume reviewed 6/12/23, failed to include the intervention of ACE wraps. During an observation on 9/14/25, at 1:47 p.m. Resident R5 was observed in bed with his brief and bed linen saturated with urine. Observation of Resident R5's abdominal wound dressing revealed it to be saturated in urine also. During an interview on 9/14/25, at 1:50 p.m. Registered Nurse (RN) Employee E13 confirmed that Resident R5's dressing was soiled and should have been changed, as needed. Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE]. Review of Resident R13's MDS dated [DATE], indicated diagnoses of Parkinson's disease (brain disorder that affects movement), bipolar disorder (extreme mood swings), anxiety, and a BIMS of 13. Section GG 130 personal hygiene indicated resident required setup or clean up assistance (helper sets up or cleans up). During an interview on 9/15/25, at approximately 1:30 p.m. Resident R13 was observed with unkept facial hair. When asked, the resident stated he would like to have his facial hair shaved, he stated has asked several times last week and is still waiting to be shaved. Resident R13 was re-interviewed again on 9/18/25 at approximately 8:30 a.m., was observed unshaven and he confirmed he still wants to have his facial hair shaved. During an interview on 9/18/25 at approximately 8:40 a.m. with Employee E3 and Resident 13, Employee E3 confirmed the resident was unshaved and had been requesting to be shaved. Review of the clinical record indicated Resident R71 was readmitted to the facility on [DATE]. Review of Resident R71's MDS dated [DATE], included diagnoses of hemiplegia, a seizure disorder, and a BIMS of 14. During an interview and observation on 9/16/25, at 1:05 p.m. Resident R71 was noted to have an untrimmed beard. When asked if he preferred to have facial hair or be clean-shaven, Resident R71 stated that he wants to be shaved, I never get shaved. Review of the clinical record indicated Resident R97 was readmitted to the facility on [DATE]. Review of Resident R97's MDS dated [DATE], included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of facility submitted information indicated that on 7/18/25, Resident R97 stated to RN Employee E14 that she needed to go to the bathroom. RN Employee E14 told Resident R97 that, you can do it in your diaper. Review of facility provided investigation information confirmed that RN Employee E14 refused to provide ADL assistance to Resident R97. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that necessary care and services were provided for four of sixteen residents. 28 Pa. Code: 211.12(1) Nursing services.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on a review of observations and resident and staff interviews, it was determined that the facility failed to follow physician's orders for five of eight residents (Resident R4, R5, R10, R37, and R77). Findings include: Review of Resident R37's admission record indicated he was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/30/25, included diagnoses of anoxic brain injury (injury to the brain caused by a complete lack of oxygen) and chronic hepatitis (inflammation of the liver caused by viruses). Review of Resident R37's plan of care dated 4/27/25, indicated Resident R37 has a skin integrity impairment on the left lower extremity related to the history of abscess and non-healing wound. Included in the interventions for this care plan were to administer treatments as ordered. Review of a physician's order dated 8/18/25, indicated to cleanse Resident R37's left lower leg wounds with Dakins (disinfectant solution) 0.25. Apply calcium alginate to small wound beds, cut to size. Cover both (wounds) with border dressing. DO NOT let scab over. Will inhibit discharge of purulent drainage. Every evening shift. During an observation on 9/14/25, at 1:10 p.m. two dressings were observed on Resident R37's left lower leg. Both dressings were very soiled, with dried exudate having dripped and dried on Resident R37's leg. Both dressings were dated 9/9/25. During an interview and observation on 9/14/25, at approximately 1:27 p.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed that Resident R37's dressing was dated 9/9/25, and was extremely soiled. Review of Resident R37's Treatment Administration Record (TAR) indicated: 9/10/25 - Dressing change completed by Licensed Practical Nurse (LPN) Employee E9.9/11/25 - Dressing change completed by Registered Nurse (RN) Employee E10.9/12/25 - Dressing change completed by the Assistant Director of Nursing.9/13/25 - Dressing change completed by RN Employee E11. Further review of Resident R37's clinical record failed to reveal any documented refusals of care for his dressing changes between 9/10/25, through 9/14/25. Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R5's MDS dated [DATE], included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and muscle wasting. Review of a physician order dated 9/9/25, indicated Cleanse abdominal wound with NSS (normal saline solution), apply collagen sheet, cover w/island dressing daily every day shift every Mon, Thu for Wound Treatment AND as needed for displacement/drainage. Review of Resident R3's plan of care for edema/excess fluid volume reviewed 6/12/23, failed to include the intervention of ACE wraps. During an observation on 9/14/25, at 1:47 p.m. Resident R5 was observed in bed with his brief and bed linen saturated with urine. Observation of Resident R5's abdominal wound dressing revealed it to saturated in urine also. During an interview on 9/14/25, at 1:50 p.m. Registered Nurse Employee E13 confirmed that Resident R5's dressing was soiled and should have been changed, as needed. Review of Resident R4's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R4's plan of care dated 1/14/25, for altered cardiovascular status included the intervention of ACE wraps on BLE (bilateral lower extremities). On in AM off in PM. During an observation on 9/15/25, at 11:17 a.m. Resident R4 was observed in her wheelchair, with her ACE wraps on, wrapped in the direction from the knee to foot. During an interview and observation on 9/17/25, at 11:14 a.m. Resident R4 was observed without her ACE wraps on. Resident R4 stated that staff often apply the wraps incorrectly. When asked if she had refused the ACE wraps this morning, she stated that staff never mentioned them to me. During an observation on 9/18/25, at 10:20 a.m. Resident R4 was observed without her ACE wraps on. Resident R4's lower legs were visibly swollen, with the elastic at the top of her socks creating an indentation in her legs. Review of Resident R10's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of dementia (a group of symptoms that affect memory, thinking and interferes with daily life) and high blood pressure. Review of Resident R10's plan of care updated 5/31/25, for cellulitis (bacterial skin infection) and lower extremity swelling included the intervention ted hose (compression socks) on in the morning; off at HS (hour of sleep) Review of an active physician order dated 5/31/25, indicated Resident R10 should have [NAME] stockings to bilateral legs - on in the am/off in the pm. During an observation on 9/15/25, at 11:39 a.m. Resident R10 was observed without her [NAME] hose on. Review of Resident R10's TAR for 9/15/25, indicated that the [NAME] hose were held due to physician's order. Further review of Resident R10's clinical record failed to reveal an order to hold the [NAME] hose. During an observation on 9/17/25, at 11:19 a.m. Resident R10 was observed without her [NAME] hose on. Review of Resident R10's TAR for 9/17/25, indicated that the [NAME] hose were applied by LPN Employee E6. During an observation on 9/18/25, at 10:11 a.m. Resident R10 was observed without her [NAME] hose on. Review of Resident R10's TAR for 9/18/25, indicated that the [NAME] hose were applied by LPN Employee E12. Review of Resident R77's admission record indicated she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of a seizure disorder and history of a stroke. Review of Resident R77's plan of care updated 8/7/25, failed to include goals and interventions related to the use of [NAME] hose. Review of an active physician order dated 2/9/24, indicated compression stockings on in the am off in the pm for edema. During an observation on 9/15/25, at 11:45 a.m. Resident R77 was observed without her [NAME] hose on. Review of Resident R77's TAR for 9/15/25, indicated that the [NAME] hose were held due to physician's order. Further review of Resident R77's clinical record failed to reveal an order to hold the [NAME] hose. During an observation on 9/18/25, at 10:09 a.m. Resident R77 was observed without her [NAME] hose on. Resident R77 was noted to have visible swelling, with the elastic top of the socks constricting Resident R77's lower leg. Review of Resident R77's TAR for 9/18/25, indicated that the [NAME] hose were applied by LPN Employee E12. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to follow physician's orders for five of eight residents.

Based on observations and staff interviews, it was determined that the facility failed to provide a safe environment for residents on two of two nursing units (Ground Floor and First Floor).Findings include: During an observation of the Ground Floor Soiled Utility Room on 9/14/25, at 2:03 p.m. the door was noted to be unsecured, with sharps containers and biohazardous waste containers accessible to residents. During an observation of the Ground Floor Soiled Utility/Trash Room on 9/14/25, at 2:03 p.m. the door was noted to be unsecured, with refuse and soiled linen accessible to residents. During an observation on 9/16/25, at approximately 1:00 p.m. a facility maintenance room on the Ground Floor was noted to be unsecured, with circuit breaker boxes accessible to residents. During an observation on 9/16/25, at approximately 1:00 p.m. a facility maintenance room on the First Floor was noted to be unsecured, with circuit breaker boxes accessible to residents. During an observation on 9/17/25, at 1:36 p.m. of the outdoor smoking area revealed a propane grill, with propane tank attached to the grill, to be present in the smoking area. Observation of the propane tank revealed labels affixed to the tank that stated, Danger and instruction to prevent flames from being near the tank. During an interview on 9/17/25, at 1:43 p.m. the Maintenance Director E8 confirmed the presence of the propane tank accessible to residents in the smoking area and further confirmed the danger of having a propane tank near possible sparks or flames. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents on two of two nursing units.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 resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for nineteen of twenty-four residents (Residents R5, R11, R13, R48, R62, R64, R71, R77, R79, R81, R500, R501, R502, R503, R504, R505, R506, R507, R508, and R509). Findings include: During an interview on 9/14/25, at 12:15 p.m. when asked if he felt the facility maintained sufficient staff to care for resident needs, Resident R11 stated, No! Review of the clinical record indicated Resident R5 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident R5's minimum data set (MDS, periodic assessment of resident care needs) dated 6/15/25, included diagnoses of cirrhosis (chronic damage leading to scarring and failure) of the liver and muscle wasting. Review of a physician order dated 9/9/25, indicated Cleanse abdominal wound with NSS (normal saline solution), apply collagen sheet, cover w/island dressing daily every day shift every Mon, Thu for Wound Treatment AND as needed for displacement/drainage. Review of Resident R3's plan of care for edema/excess fluid volume reviewed 6/12/23, failed to include the intervention of ACE wraps. During an observation on 9/14/25, at 1:47 p.m. Resident R5 was observed in bed with his brief and bed linen saturated with urine. Observation of Resident R5's abdominal wound dressing revealed it to be saturated in urine also. During an interview on 9/14/25, at 1:50 p.m. Registered Nurse (RN) Employee E13 confirmed that Resident R5's dressing was soiled and should have been changed, as needed. During a group interview, on 9/15/25 at approximately 11:00 a.m., when asked if he felt the facility maintained enough staff to care for resident needs and answer call lights, consensus from the group was no. Residents R500, R501, R502, 503, 504, 505, 506, 507, 508 and 509 verbalized frustrations with the lack of aides in the building, stating they seem to always be short of staff, some days are worse than others. Residents stated the staff will tell them if they are short of nursing assistants no shower today we are too short of staff. - Resident R500 reported call light wait times of 40 minutes to 50 minutes is fair to say.- Resident R501 reported call light wait times of 60 minutes occurred a few times.- Resident R502 reported call light wait times of 30 minutes consistently.- Resident R506 reported call light wait times of 40 minutes is not uncommon.- Resident R509 reported call light wait times of 30 minutes to 60 minutes. During an interview on 9/15/25, at approximately 1:30 p.m. Resident R13 was observed with unkept facial hair. When asked, the resident stated he would like to have his facial hair shaved, he stated has asked staff several times last week and is still waiting to be shaved. Resident R13 was re-interviewed again on 9/18/25 at approximately 8:30 a.m., was observed unshaven and he confirmed he still wants to have his facial hair shaved. Resident R13 stated they are busy there is not enough staff to help everyone. During an interview on 9/16/25, at 1:00 p.m. when asked if she felt the facility maintained sufficient staff to care for resident needs, Resident R62 stated, No and further stated that she has waited up to an hour for call light response. During an interview and observation on 9/16/25, at 1:05 p.m. Resident R71 when asked if he felt the facility maintained sufficient staff to care for resident needs, Resident R71 stated, No way and stated that call light times depend on if there is enough staff working. Resident R71 was noted to have an untrimmed beard. When asked if he preferred to have facial hair or be clean-shaven, Resident R71 stated that he wants to be shaved, I never get shaved. During an interview on 9/18/25 at approximately 8:40 a.m. with Employee E3 and Resident R13, Employee E3 confirmed the resident was unshaved and had been requesting to be shaved. During an observation on 9/18/24, at 10:14 a.m. the call lights for Residents R48's room and Residents R79 and R81's room were illuminated and alarming at the nurse's station. Observation at this time revealed NA Employee E2 to be on what appeared to be her personal phone at the nurses' station and NA Employee E15 to be leaned back in her chair, with her head reclined back on her hands. Upon the surveyor entering the nurses' station, NA Employees E2 and E15 left the nurses' station, and the call lights were answered. During a confidential staff interview on the first-floor unit 1, when asked if the staff member felt there was sufficient staff to care for resident needs, the staff member stated really, we don't, we don't have the number of nurse aides most days. During a confidential staff interview on the ground floor unit G, when asked if the staff member felt there was sufficient staff to care for resident needs, the staff member stated there hasn't been for some time. Review of a grievance filed on behalf of Resident R64, dated 4/16/25, revealed concerns documented for incontinence care. Review of a grievance filed on behalf of Resident R500, dated 5/1/25, revealed concerns documented for call light wait times. Review of a grievance filed on behalf of Resident R77, dated 5/26/25, revealed concerns documented for wait time for incontinence care. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for nineteen of twenty-four residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medical supplies were properly stored and/or disposed of in two of two nursing units (Ground Floor and First Floor) and one of four medication carts (First Floor, high hall). Findings include:Review of the facility policy Storage of Medications dated 1/22/25, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Unlocked medication carts are not left unattended. During an observation of the Ground Floor Soiled Utility Room on 9/14/25, at 2:03 p.m. a large box of vacutainer one-use holders (plastic sheath for blood-collecting tubes). During an observation of the First Floor Soiled Utility Room on 9/15/25, at 11:48 a.m. the following clean items were observed:-Blood-collecting sets.-Vacutainers, greater than 100.-Gauze-Aerobic blood culture bottle, with an expiration date of 7/26/25.-Anaerobic blood culture bottle, with an expiration date of 5/29/25.-Bandages, multiple boxes-Alcohol wipes-(2)Urine collection kits, with an expiration date of 4/4/24.(49) eswabs (sterile collection and transport system for samples), with an expiration date of 10/31/23.(31) Covid swabsticks, with an expiration date of 6/30/23. During an interview on 9/15/25, at approximately 11:55 a.m. Licensed Practical Nurse Employee E6 confirmed the above observations.During an observation of the First Floor, high end medication cart on 9/15/25, at 12:24 p.m. the cart was noted to be unlocked. No staff were present in the vicinity. During an interview on 9/15/25, at 12:26 p.m. Registered Nurse Employee E7 confirmed she had left her medication cart unsecured. During an interview on 9/18/25, at approximately 12:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to make certain that medical supplies were properly stored and/or disposed of in two of two nursing units and one of four medication carts.28 Pa. Code: 201.14 (a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1)(e)(1) Management.28 Pa. Code: 211.9 (a)(1) Pharmacy 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 certain, residents who voice grievances can do so without fear of discrimination or reprisal for ten of seventeen residents (R86, R500, R501, R502, R503, R504, R505, R506, R507, and R508) and failed to display written information on the grievance procedure and grievance official contact information in the building (main lobby, ground floor G wing and first floor 1 wing).Findings include: The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number. A review of the facility policy Skilled Nursing Facility Grievance Policy last reviewed 1/22/25, indicated to ensure all residents, representatives, and responsible parties in the Skilled Nursing Facility (SNF) have the right to voice concerns, file grievances, and receive a prompt, thorough and impartial response without fear of retaliation, as required under CMS SOM Appendix PP, F585 and Pennsylvania Department of Health (DOH) regulations. Postings of grievance procedures, contact for the grievance official, Ombudsman, and DOH hotline shall be visible throughout the facility. During a group interview, on 9/15/25 at approximately 11:00 a.m., consensus from the group Residents R86, R500, R501, R502, 503, 504, 505, 506, 507, and 508, revealed the residents have a fear of reprisal if they complain or file a grievance. The residents stated they fear they will be blackballed or get on a hitlist if they complain. During an observation by the survey team on 9/15/25 at approximately 3:00 p.m. Resident R86 was verbally engaged with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Resident R86 appeared upset and verbalized that an employee made comments to Resident R86 regarding a complaint she had made earlier this date in a confidential setting. During an interview on 9/16/25 at approximately 10:30 a.m. The NHA and DON confirmed the verbal engagement Resident R86 had and that R86 was upset, that an employee confronted her about the complaint Resident R86 had made. During an interview on 9/18/25 at approximately 7:40 a.m. Resident R86 confirmed that she verbally engaged with the NHA and DON and that she was upset with an employee confronting her regarding the complaint she had made that was to be confidential. Resident R86 stated this is the fear here that we have if we complain, the staff finds out, and you get treated differently. I just need to watch what I say. During rounds and an interview, on 9/18/25, at approximately 9:00 a.m., with the Nursing Home Administrator (NHA), the (NHA) confirmed the facility failed to make certain, residents who voice grievances can do so without fear of discrimination or reprisal for ten of seventeen residents (R86, R500, R501, R502, R503, R504, R505, R506, R507, and R508) and failed to display written information on the grievance procedure and grievance official contact information in the building (main lobby, ground floor G wing and first floor 1 wing). 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights.

Based on review of facility provided policies and documentation, clinical records, and resident, family, and staff interviews, it was determined that the facility failed to protect residents from staff initiated sexual abuse. This failure resulted in a staff member receiving oral sex from a resident, a staff member sexually touching a resident's genitalia to two of four residents, and this failure created an Immediate Jeopardy for two of 96 residents (Resident R1 and R2). Findings include: Review of facility policy Abuse: Protection from Abuse, reviewed 3/2022, revealed that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Review of abuse education provided to facility staff defined sexual abuse as non-consensual sexual contact of any type with a resident; any forced, coerced, or extorted sexual activity with a resident, is sexual abuse. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS), 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 A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/23, included diagnoses of high blood pressure, diabetes (an impairment in the way the body regulates and uses sugar), and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 15, cognitively intact. A review of documentation submitted by the facility on 1/20/23, revealed that Resident R1 performed oral sex on Nurse Aide (NA) Employee E1 on an unknown date, in Resident R1's bathroom. A review of documentation submitted by the facility on 1/20/23, revealed that on 1/20/23, Resident R1 told Physical Therapy Assistant (PTA) Employee E3 that NA Employee E1 let him give him head in his bathroom in his room During an interview on 2/15/23, at 2:46 p.m. Resident R1 confirmed that the above did occur. Resident R1 also stated that I wish I didn't tell anyone because people are avoiding talking to me. During an interview on 2/21/23, at 3:05 p.m., Resident R1's family member stated that Resident R1 has an intelligence level of a [AGE] year-old, and that he can be swayed very easily. It was also stated that prior to this incident he has been the most balanced he has ever been and has now become more manic since the situation and has had his medication upped. During an interview on 2/21/23, at 3:09 p.m. Psychiatric Nurse Practitioner (PNP) Employee E6 stated that Resident R1 is diagnosed with schizoaffective disorder and that while a person is in a manic state, they often become hypersexual, and may be easily persuaded into sexual activity. PNP Employee E6 stated that Resident R1 would not be able, while during a manic state, of making a rational decision to consent to sexual activity. Review of medical records indicated that Resident R1 had been on olanzapine (an antipsychotic medication used to treat schizophrenia and bipolar disorder) 5 milligram (mg) once per day from 12/21/21, until it was increased on 2/10/23 to 10 mg twice per day. Resident R1 had also been on lamotrigine (a medication used to stabilize mood in bipolar disorder) 100 mg twice per day from 12/22/21 to 2/9/23, when it was increased to 100 mg daily and 125 mg daily. On 2/13/23, lorazepam (a medication used to treat anxiety) 0.5 mg take every eight hours as needed, was added. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 2/6/23, included diagnoses of high blood pressure, anxiety, and depression. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 15, cognitively intact. A review of documentation submitted by the facility on 2/4/23, indicated Resident R2 reported that NA Employee E1 touched her inappropriately during routine care by rubbing her clitoris and inserting a finger into her rectum. A review of documentation submitted by the facility on 2/4/23, revealed that Resident R2 reported that the incident occurred about a year ago. And that she reported it via text message to NA Employee E2, but that nothing was ever done. During an interview on 2/15/23, at 2:30 p.m., Resident R2 confirmed the above statements and stated that it occurred sometime in 2022 and that NA Employee E1 had manipulated her clitoris and placed his finger in her rectum. Resident R2 stated she reported this, via text message about an hour after the occurrence to NA Employee E2. Resident R2 stated that she elected to tell NA Employee E2 about that incident as she wasn't sure what to do and that he had been my aide for years and he took good care of me, and I didn't realize he wouldn't tell anyone, and I trusted him. She elaborated that it appeared that NA Employee E2 might have told NA Employee E1 that she reported this to NA Employee E2 as NA Employee E1 acted different towards me after that. Resident R2 elaborated that once she realized that no one was going to ask her anything about the incident she decided to not pursue it anymore as she had already told someone that she trusted. Review of records revealed that Resident R2 is seen regularly by psychiatry. During an interview on 2/15/23, at 2:40 p.m., Resident R2 stated that she never discussed the incident with psychiatry as I didn't want to stir anything up. She stated that once the story broke about Resident R1 and NA Employee E1 on the local news channel, she felt safe to report the incident as she was not the only victim. Review of Resident R2's medical record revealed that Ativan 0.5 mg every eight hours as needed was added on 2/9/23. Review of an employee statement written by NA Employee E2, dated 2/4/23, indicated I recall her texting me about that issue. During an interview on 2/16/23, at 10:15 a.m., NA Employee E4 stated that she was surprised to know of the incidents involving NA Employee E1 and Residents R1 and R2 and that she was unaware that NA Employee E2 was aware of the incident involving Resident R2. During an interview on 2/17/23, at 9:15 a.m., Licensed Practical Nurse (LPN) Employee E5 stated that if you see abuse or hear about it, you have to report it to the supervisor During an interview on 2/21/23, at 9:40 a.m., Law Enforcement Personnel confirmed that NA Employee E1 admitted to law enforcement that he participated in a sex act with Resident R1 and that Employee E2 had admitted to receiving a text message from Resident R2 regarding sexual abuse by NA Employee E1 which was unreported. Review of NA Employee E1's file revealed that abuse education was completed on 6/22/22. Review of NA Employee E2's file revealed that abuse education was completed on 3/28/22. On 3/2/23, at 4:05 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for two of 96 residents, and the Immediate Jeopardy template was provided to facility administration. On 3/2/23, at 8:33 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -Before reporting for his next scheduled shift, on 1/23/23, NA Employee E1 was interviewed by the NHA. He was escorted out of the building. Police were then notified as well as Adult Protective services. NA Employee E1 was placed on Do Not Return list 1/23/23. His staffing agency was informed of the allegation and pending investigation. -Resident R1 was immediately offered psych services. He has been seen by psych several times since. -When Resident R2 disclosed on 02/04/23, that she was inappropriately touched by NA Employee E1 , he was already placed on the Do not return list from facility. Law enforcement and Adult Protective Services were notified on 02/04/23. NA Employee E2 was suspended pending investigation on 02/04/23. Resident R2 was offered to be transported to hospital on 02/04/2,3 and resident refused transport. Resident R2 was immediately offered psych services. She has been seen by psych several times since. -All staff currently working in the building were educated on the abuse policy on 03/02/23, by 6:00 p.m. -Incoming staff will be educated by the RN Supervisor at the start of their shift today. Current employees who are not presently at work will be educated by phone on the abuse policy by 12:00 p.m. on 03/03/23. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. -Social Worker will audit all grievances for the past three months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. Grievances will continue to be audited monthly at QAPI. -Psychotropic medications for Resident R1 and R2 will be audited monthly for three months, and then quarterly and as needed. -In-house and agency staff will be educated on abuse reporting monthly for three months, then yearly. New hires and new agency staff will be educated upon orientation. -Social Worker will interview residents monthly for three months. During staff interviews conducted on 3/3/23, between 9:00 a.m. and 11:30 p.m. 17 staff members confirmed they received education on abuse prevention. During resident interviews conducted on 3/3/23, between 9:00 a.m. and 11:30 p.m. 12 residents confirmed they had been re-interviewed to learn if they had any concerns about staff abusing them. The Immediate Jeopardy was lifted on 3/3/23, at 12:40 p.m., when the action plan implementation was verified. During an interview on 3/3/23, at 12:45 p.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from staff initiated sexual abuse. This failure resulted in a staff member receiving oral sex from a resident, a staff member sexually touching a resident's genitalia to two of four residents, and this failure created an Immediate Jeopardy for two of 96 residents (Resident R1 and R2). 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 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 resident and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion of staff to resident sexual abuse for one of four residents reviewed (Resident R2), which resulted in the previously accused staff member engaging in a sexual act with one of four residents reviewed (Resident R1). This failure created an Immediate Jeopardy for two of 96 residents (Resident R1 and R2). 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. If the suspected abuse is sexual abuse, serious physical injury, serious bodily injury, or suspicious death, the law requires additional reporting to the Department of Aging and local law enforcement. Review of the facility's policy Abuse Reporting and Investigation dated 3/22, indicated anyone who witnesses an incident of suspected resident abuse is to intervene immediately and stop the abuse. They are to report it to the charge nurse or supervisor immediately. Review of abuse education provided to facility staff defined sexual abuse as non-consensual sexual contact of any type with a resident; any forced, coerced, or extorted sexual activity with a resident, is considered to be sexual abuse. 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 clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 2/6/23, included diagnoses of high blood pressure, anxiety, and depression. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 15, cognitively intact. A review of documentation submitted by the facility on 2/4/23, Resident R2 reported that Nurse Aide (NA) Employee E1 touched her inappropriately during routine care by rubbing her clitoris and inserting a finger into her rectum. A review of documentation submitted by the facility on 2/4/23, revealed that Resident R 2 reported that the incident occurred about a year ago. And that she reported it via text message to NA Employee E2, but that nothing was ever done. During an interview on 2/15/23, at 2:30 p.m., Resident R2 confirmed the above statements and stated that it occurred sometime in 2022 and that NA Employee E1 had manipulated her clitoris and placed his finger in her rectum. Resident R2 stated she reported this, via text message about an hour after the occurrence to NA Employee E2. Resident R2 stated that she elected to tell NA Employee E2 about that incident as she wasn't sure what to do and that he had been my aide for years and he took good care of me, and I didn't realize he wouldn't tell anyone, and I trusted him. She elaborated that it appeared that NA Employee E2 might have told NA Employee E1 that she reported this to NA Employee E2 as NA Employee E1 acted different towards me after that. Resident R2 elaborated that once she realized that no one was going to ask her anything else about the incident she decided to not pursue it anymore as she had already told someone that she trusted. Review of records revealed that Resident R2 is seen regularly by psychiatry. During an interview on 2/15/23, at 2:40 p.m., Resident R2 stated that she never discussed the incident with psychiatry as I didn't want to stir anything up. She stated that once the story broke about Resident R1 and NA Employee E1on the local news channel, she felt safe to report the incident as she was not the only victim. Review of an employee statement written by NA Employee E2, dated 2/4/23, indicated I recall her texting me about that issue. During an interview on 2/17/23, at 9:15 a.m., Licensed Practical Nurse (LPN) Employee E5 stated that if you see abuse or hear about it, you have to report it to the supervisor During an interview on 2/21/23, at 9:40 a.m., Law Enforcement Personnel confirmed that Employee E2 had admitted to receiving a text message from Resident R2 regarding sexual abuse by NA Employee E1 which was unreported. Review of education rosters dated 3/28/22, revealed NA Employee E2 received facility provided inservice education on abuse. A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/2/23, included diagnoses of high blood pressure, diabetes (an impairment in the way the body regulates and uses sugar), and schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 15, cognitively intact. A review of documentation submitted by the facility on 1/20/23, revealed that Resident R1 performed oral sex on Nurse Aide (NA) Employee E1 on an unknown date, in Resident R1's bathroom. A review of documentation submitted by the facility on 1/20/23, revealed that on 1/20/23, Resident R1 told Physical Therapy Assistant (PTA) Employee E3 that NA Employee E1 let him give him head in his bathroom in his room During an interview on 2/15/23, at 2:46 p.m. Resident R1 confirmed that the above did occur. Resident R1 also stated that I wish I didn't tell anyone because people are avoiding talking to me. On 3/2/23, at 4:05 p.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for two of 96 residents, and the Immediate Jeopardy template was provided to facility administration. On 3/2/23, at 8:33 p.m. an acceptable Corrective Action Plan was received which included the following interventions: -NA Employee E2 was suspended on 2/4/23, pending investigation of allegation failure to report abuse. NHA notified police on 2/4/23 and they immediately came to the facility. Resident R2 was offered to go to the hospital for evaluation, she declined. Adult protective services were notified also on 2/4/23. -NA Employee E2's employment was then terminated on 2/7/23, due to failure to report abuse. -All staff currently working in the building were educated on the abuse policy specifically as it applies to reporting abuse on 03/02/23 by 6:00 p.m. -Incoming staff will be educated by the RN Supervisor at the start of their shift today. Current employees who are not presently at work will be educated by phone on the abuse policy by 12:00 p.m. on 03/03/23. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. -Resident R2 has been receiving psych services. She is care planned for two female caregivers for all care. -Social Services and Activity Director conducted interviews with current residents to determine if any abuse had happened on 03/02/23. No other allegations of abuse occurring has been reported from interviews. -Social Worker will audit all grievances for the past three months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. Grievances will continue to be audited monthly at QAPI. -Psychotropic medications for Resident R2 will be audited monthly for three months, and then quartely and as needed. -In-house and agency staff will be educated on abuse reporting monthly for three months, then yearly. New hires and new agency staff will be educated upon orientation. -Social Worker will interview residents monthly for three months. During staff interviews conducted on 3/3/23, between 9:00 a.m. and 11:30 p.m. 17 staff members confirmed they received education on abuse prevention. During resident interviews conducted on 3/3/23, between 9:00 a.m. and 11:30 p.m. 12 residents confirmed they had been reinterviewed to learn if they had any concerns about staff abusing them. The Immediate Jeopardy was lifted on 3/3/23, at 12:40 p.m. when the action plan implementation was verified. During an interview on 2/22/23, at 12:40 p.m. the Nursing Home Administrator confirmed that facility staff failed to implement policies and procedures for covered individuals to report to local law enforcement, the suspicion of staff to resident sexual abuse for one of four residents, which resulted in a resident providing oral sex to a previously accused staff member for one of four residents. This failure created an Immediate Jeopardy for two of 96 residents. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policy and documentation, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision for the transfer and bed mobility needs of two of six residents (Resident R3 and R4), resulting in the actual harm of fractures and/or lacerations. Findings include: Review of facility policy Fall Protocols dated 3/22, indicated Residents' will be assessed for fall risk upon admission, readmission, quarterly, and with a significant change in medical condition. In the event of an actual fall, an attempt will be made to eliminate causal factors and prevent further falls. Review of Resident R3's admission record indicated she was originally admitted to the facility on [DATE], and readmitted [DATE]. Review of Resident R3's Minimum Data Set (MDS, mandated assessment of a resident's abilities and care needs) dated 11/7/22, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hemiplegia (paralysis on one side of the body), osteogenesis imperfecta (genetic disorder characterized by fragile bones that break easily). Review of Resident R3's admission, quarterly, and annual MDS assessments completed since admission (8/7/19, 8/9/19, 11/9/19, 2/9/20, 5/11/20, 8/2/20, 11/2/20, 2/2/21, 2/11/21, 5/14/21, 8/3/21, 11/3/21, 2/3/22, 5/6/22, and 8/4/22) indicated in Section G - Functional Status, Questions G0110B, ADL Assistance for Transfers, all indicated that Resident R3 required extensive assistance of two or more staff members. Review of Resident R3's plan of care initiated on 8/7/19, updated on 7/14/22, indicated Resident R3 required Transfer resident with Hoyer (mechanical lift) and assist x2 staff. Review of the Care Record report (a printable version of the resident's assigned interventions and/or tasks) indicated that Resident R3 was Transfer status: Transfer resident with assist of one. Review of a physician's order dated 8/11/22, indicated transfer resident with assist of one. Review of a progress note dated 9/3/22, at 9:03 a.m. stated Called to room by (nurse aide) saying that she was transferring resident from bed to wheelchair. During transfer, (nurse aide) says that she was losing her hold on resident and put her back onto the bed. Resident c/o (complained of) severe right knee pain. Right knee flexed approximately 90 degrees. Resident says that she isn't able to move her leg without severe pain. No redness noted, skin intact. Resident is agreeable to x-rays or whatever treatment that she can have here. Doesn't want to go to ER. Call to (provider). Review of a progress note dated 9/3/22, at 9:56 a.m. stated (Resident R3) decided the pain was too severe and requested to be transferred to the ER. Review of hospital paperwork dated 9/7/22, at 11:22 a.m. indicated that Resident R3 was admitted on [DATE], and treated for a closed fracture of the distal end of the right femur (a break in the bottom end of the upper leg bone, that did not break through the skin). Review of the facility provided Fall Investigation dated 9/3/22, indicated that Resident R3 required one assist to transfer, that one aide was present at the time of the fall, and that the Hoyer lift was not used. Review of Resident R4's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms), and adult failure to thrive (seen in older adults with multiple medical conditions resulting in downward spiral of poor nutrition, weight loss, inactivity, depression and decrease in functional abilities). Review of Section G - Functional Status, Questions G0110A, ADL Assistance for Bed Mobility, indicated that Resident R4 required extensive assistance of two or more staff members. Review of Resident R4's plan of care for functional decline in ADLs initiated on 8/4/21, failed to include information on bed mobility assistance needed. Review of the nurse aide task list for Resident R4 for bed mobility did not provide any indication of the assistance level. Review of Resident R4's physicians orders since admission failed to reveal an order for the bed mobility assistance level. Review of a progress note dated 2/13/23, at 11:30 p.m. indicated a nurse and nurse aide were providing care to Resident R4. Resident was rolled on her right side and stated she was cold and thrust herself towards the right which made aide and nurse slip and resident fell to the ground. Bed was in an elevated position for staff while doing dressing change. Resident hit her head off the ground. open area to top of forehead noted. actively bleeding. Resident never lost consciousness and remained alert. Resident understood she hit her head. Pressure applied while staff waited on EMTs (emergency medical technicians). Review of a progress note dated 2/14/23, at 6:09 a.m. indicated that Resident R4 had been admitted to the hospital Intensive Care Unit (ICU). Review of a progress note dated 2/16/23, at 8:25 p.m. indicated that Resident R4 was readmitted to the facility. Review of a progress note dated 2/16/23, at 10:27 p.m. indicated that Resident R4 is required to wear a c-collar (neck brace) for 6 weeks, and has five staples at the top of her scalp. Review of hospital paperwork dated 2/16/23, at 11:12 a.m. that Resident R4 was seen on 2/14/23, after a fall from her bed at the skilled nursing facility while staff was attempting to roll her. Review of multiple CT scans (a series of X-ray images taken from different angles to create cross-sectional images) of the head, cervical spine (neck region), CAP (chest, abdomen, pelvis), and T/L (thoracolumbar - area of the back from approximately shoulder level to waist) indicated the following: -Small subarachnoid hemorrhage (bleeding in the space that surrounds the brain). -Large frontal scalp hematoma and laceration (solid swelling of clotted blood within the tissues, and deep cut or tear in skin or flesh). -Comminuted acute fracture (bone that is broken in at least two places) of the C1 (first vertebra, which supports the head). -Nondisplaced (not out of alignment) acute fracture of the C2 (second vertebra of the spine). -Prevertebral (in front of) soft tissue swelling/hematoma at T3-T4 (tenth and eleventh vertebra of the spine) -Likely acute compression (break caused by pressure) fracture of the T3. -Acute compression burst (the vertebra is crushed in all directions) fracture of the T2 (ninth vertebra of the spine) and T3. During a telephone inteview on 2/18/23, at 11:44 a.m. Licensed Practical Nurse (LPN) Employee E7 clarified that Nurse Aide (NA) Employee E8 was positioned between Resident R4's bed and the wall, and that she (LPN Employee E7) was positioned between Resident R4's bed and the roommate bed. LPN Employee E7 stated she was changing the wound dressing on Resident R4's back. Resident kept stating she was cold, and began to get irritated. LPN Employee E7 stated Nurse Aide (NA) Employee E8 turned her body slightly to the left (but did not step away) to get a brief and wipes from the bedside night stand, and Resident R4 rolled off of the bed, on the side of NA Employee E8. During an interview on 2/22/23, at 10:10 a.m. the Nursing Home Administrator confirmed that facility failed to provide adequate supervision for the bed mobility and transfer needs of two of six residents, which resulted in fractures and or lacerations. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.14(c)(d)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code: 211.10(a) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies and clinical records, staff interviews and written statements, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide adequate supervision of a two person transfer to prevent an avoidable accident which resulted in actual harm of a resident causing a left intertrochanteric femur fracture (breaking of the upper part of the leg bone between the bony prominence near to the hip muscles attachments) for one of eight residents (Resident R58). Findings include: Review of the facility policy Abuse Protection last reviewed 3/22/22, indicated that neglect is defined as the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R58's Minimum Data Set (MDS - periodic review of care needs) dated 5/20/22, indicated she was admitted to the facility on [DATE], Section C Cognitive Patterns, Brief Interview for Mental Status (test of cognitive status) score is 15 (cognitively intact), and her current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R58's MDS dated [DATE], Section G - Functional Status, Questions G0110b, ADL (activities of daily living) Assistance for Transfer Status, indicated she required an extensive assistance of two or more staff members when transferring from one surface to another. Review of a physician order dated 3/24/22, instructed staff to transfer resident with a sit to stand (a type of mechanical lift) and assist times 2 staff. Review of facility employee witness statement dated 3/27/22, not timed, completed by Nurse Aide (NA) Employee E1 indicated that on 3/26/22, when transferring Resident R58, from her chair with the sit to stand. I noticed her head fall to the right and her body start go limp. We (the roommate's daughter) lowered her to the floor. I called the nurse. She came in and Resident R58 was not responding. After a few times of calling her name, she said she wanted to get up she said her leg was feeling pain, and we covered her up, and sent her to the hospital emergency room . Review of facility Witness Statement dated 3/26/22, at 4:30 p.m. completed by Registered Nurse (RN) Employee E2, indicated she was alerted to Resident R58's room by NA Employee E1. Upon entering the room, resident was laying on her back in the supine position (laying on back face up). Resident did respond when her name was called upon assessment the resident began to scream my leg, my leg while guarding her left leg. As staff began to elevate head because she complained of I can't breathe, she yelled louder in extreme pain. This staff instructed staff to keep her as she was lying, not to attempt to move her in anyway, while this nurse called for a transfer to the hospital. That NA Employee E1 stated resident loss consciousness and began to slide out of lift. During a phone interview on 7/13/22, at 3:15 p.m. NA Employee E1 stated on 3/26/22, she was transferring Resident R58 from her wheelchair to her bed by herself, NA Employee E1 stated that she knew Resident R58 should have had two staff to assist her with the transfer and did the transfer by herself, that the resident passed out on the lift, and the roommates daughter helped her lower the resident to the floor. During an interview on 7/13/22, at 3:24 p.m. Resident R58 stated she broke her hip in March of 2022, that it hurt at the time, and she cannot remember the incident. During an interview on 7/14/22, at 11:30 a.m. that on 3/26/22, RN Employee E2 stated that she heard NA Employee E1 yelling and that she went into the room and Resident R58 was lying on the floor, that during her assessment resident screamed out in pain, and was guarding her leg, which was rotated out, and the resident could not move it. That Resident R58 was ordered a sit to stand with an assist of two staff, and NA Employee E1 moved her by herself. During a phone interview on 7/15/22, at 9:51 a.m. NA Employee E1 stated that she was aware of Resident R58's orders for a two person assist using a sit to stand and completed the lift by herself. During a phone interview on 7/15/22, at 10:50 a.m. the facility Wound Care RN Employee E3 stated, I was outside the room on 3/26/22, I heard a scream, so I ran and Resident R58 was on the floor screaming in pain. That she was transferred with one assist in a sit to stand lift by the NA Employee E1, when she was ordered a two assist in a sit to stand lift. Review of Resident R58's hospital documents Orthopedics Consult Note dated 3/27/22, indicated she fell in the nursing home, orthopedics was consulted for left intertrochanteric femur fracture. Reports stated patient was dropped on her left side during a transfer using a sit to stand lift. Patient stated she does not recall incident. Imaging notes indicated the resident has a slightly displaced (break where bones are not in alignment) left intertrochanteric femur fracture. Review of Resident R58's facility physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/15/22, at 11 a.m. and 7/18/22, at 1:38 p.m. The Nursing Home Administrator and Director of Nursing (DON) confirmed, that the facility had not provided Resident R58 the correct two person assist with a transfer resulting in actual harm of a left intertrochanteric femur fracture. 28. Pa Code 201.14(a) Responsibility of licensee. Previously cited 10/6/21, 5/19/21, 4/1/21 and 10/8/20. 28. Pa Code 201.18(b)(1) Management. Previously cited 5/18/21, 4/1/2 and 9/1/20. 28. Pa Code 201.18(e)(1) Management. Previously cited 5/18/21 and 4/1/21. 28. Pa. Code 211.12(d)(1) Nursing services. Previously cited: 5/5/22, 10/6/21, 5/19/21, 4/1/21, 1/27/21 and 9/1/20. 28. Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/5/22, 5/19/21, 4/1/21, and 1/27/21. 28. Pa Code 201.18(b)(1)(e)(1) Management. Previously cited: 10/6/21, 5/18/21, 4/1/21, 9/1/20.

Based on review of facility policies and clinical records, staff interviews and written statements, it was determined that the facility failed to make certain that a resident received adequate supervision and was provided a safe transfer resulting in actual harm when resident fell during a transfer causing resident to sustain a left intertrochanteric femur fracture (breaking of the upper part of the leg bone between the bony prominence near to the hip muscles attachments) for one of eight residents (Resident R58), and failed to adequately maintain equipment to prevent incident for one of eight residents (Resident R70). Findings include: Review of the facility policy Abuse Protection last reviewed 3/22/22, indicated that Neglect is defined as the failure to provide the goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to nutrition, medication, therapies, and activities of daily living. Review of Resident R58's Minimum Data Set (MDS - periodic review of care needs) dated 5/20/22, indicated she was admitted to the facility on [DATE], Section C Cognitive Patterns, Brief Interview for Mental Status (test of cognitive status) score is 15 (cognitively intact), and her current diagnosis included high blood pressure, diabetes, and left femur fracture. Review of Resident R58's MDS dated [DATE], Section G - Functional Status, Questions G0110b, ADL (activities of daily living) Assistance for Transfer Status, indicated she required an extensive assistance of two or more staff members when transferring from one surface to another. Review of Resident R58's physician order dated 3/24/22, instructed staff to transfer resident with a sit to stand (a type of mechanical lift) and assist times 2 staff. Review of facility employee witness statement dated 3/27/22, not timed, completed by Nurse Aide (NA) Employee E1 indicated that on 3/26/22, when transferring Resident R58, from her chair with the sit to stand. I noticed her head fall to the right and her body start to go limp. We (the roommate's daughter) lowered her to the floor. I called the nurse. She came in and Resident R58 was not responding. After a few times of calling her name she said she wanted to get up she said her leg was feeling pain, and we covered her up, and sent her to the hospital emergency room . Review of facility employee Witness Statement dated 3/26/22, at 4:30 p.m. completed by Registered Nurse (RN) Employee E2, indicated she was alerted to Resident R58's room by NA Employee E1. Upon entering the room resident, she was laying on her back in the supine position (laying on back face up). Resident did respond when her name was called upon assessment the resident began to scream my leg, my leg while guarding her left leg. As staff began to elevate head because she complained of I can't breathe, she yelled louder in extreme pain. This staff instructed staff to keep her as she was lying, not to attempt to move her in anyway, while this nurse called for a transfer to the hospital. That NA Employee E1 stated resident loss consciousness and began to slide out of lift. During a phone interview on 7/13/22, at 3:15 p.m. NA Employee E1 stated on 3/26/22, she was transferring Resident R58 from her wheelchair to her bed by herself, NA Employee E1 stated that she knew Resident R58 was to have two staff to assist her with the transfer and did the transfer by herself, and Resident R58 passed out on the lift, and the roommates daughter helped her lower the resident to the floor. During an interview on 7/13/22, at 3:24 p.m. Resident R58, stated she broke her hip in March of 2022, that it hurt at the time, and she cannot remember the incident. During an interview on 7/14/22, at 11:30 a.m. that on 3/26/22, RN Employee E2 stated that she heard NA Employee E1 yelling and she went into Resident R58's room and was laying on the floor, during her assessment resident was screaming in pain, and was guarding her leg, which was rotated out, and the resident could not move it. RN Employee E2 stated that Resident R58 was ordered a sit to stand with an assist of two staff, and NA Employee E1 moved her by herself. During a phone interview on 7/15/22, at 10:50 a.m. the facility Wound Care RN Employee E3 stated, I was outside the room on 3/26/22, I heard a screaming and went to Resident R58's room and resident was on the floor screaming in pain. Wound Care RN Employee E3 stated that Resident R58 was transferred with one assist in a sit to stand lift by the NA Employee E1, and the physician orders were assist of two while using a sit to stand lift. Review of Resident R58's hospital documents Orthopedics Consult Note dated 3/27/22, indicated she fell in the nursing home, orthopedics was consulted for left intertrochanteric femur fracture. Reports stated patient was dropped on her left side during a transfer using a sit to stand lift. Patient stated she does not recall incident. Imaging notes indicated the resident has a slightly displaced (break where bones are not in alignment) left intertrochanteric femur fracture. Review of Resident R58's facility physician progress notes dated 4/19/22, indicated the resident was recently admitted to the hospital with left hip fracture, was not a surgical candidate and returned to the facility as a hospice resident (end of life care focusing on symptom management). During an interview on 7/15/22, at 11:00 a.m. and 7/18/22, at 1:38 p.m. The Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to provide Resident R58 the correct two person assist with a transfer resulting in a preventable accident and causing accrual harm to Resident R58 resulting in a left intertrochanteric femur fracture. Review of the clinical record indicated that Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's MDS assessments dated 12/3/21, and 5/24/22, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section G - Functional Status indicated that Resident R70 required physical assistance of two or more persons with bed mobility and transferring. Review of a facility incident report dated 1/26/22, indicated that Resident R70 was being assisted out of bed, and began to slide on the mattress. Resident R70 was lowered to the floor. Review of the witness statement written by LPN Employee E34 stated that Resident R70 was in bed and wanted to get up into wheelchair. He was sitting on side of his bed waiting for the lift to help get him to stand up and get into wheelchair. The bed frame is not the right size for the mattress. The mattress belongs to a bari (bariatric) bed and the mattress is on a small single frame. The mattress had no support or frame under the mattress, so the mattress tilted and he was sliding with the mattress to the floor of his room. Review of the fall investigation dated 1/26/22, indicated the intervention to be implemented after the fall was for maintenance to service the bed. During an interview on 7/18/22, at 10:45 a.m. the DON confirmed the facility failed to provide an appropriately sized mattress for Resident R70 causing a fall. During an interview on 7/18/22, at 2:30 p.m. the NHA and DON confirmed that the facility does not have a written policy for resident transfers and the facility failed to ensure that resident was free from preventable accident by failing to provide the adequate supervision of a two person transfer resulting in actual harm of Resident R58 causing a femur fracture and failed to provide the proper sized mattress to prevent an incident for one of eight Resident R70. 28. Pa Code 201.14(a) Responsibility of licensee. Previously cited 10/6/21, 5/19/21, 4/1/21 and 10/8/20. 28. Pa Code 201.18(b)(1) Management. Previously cited 5/18/21, 4/1/2 and 9/1/20. 28. Pa Code 201.18(e)(1) Management. Previously cited 5/18/21 and 4/1/21. 28. Pa. Code 211.12(d)(1) Nursing services. Previously cited 5/5/22, 10/6/21, 5/19/21, 4/1/21, 1/27/21 and 9/1/20. 28. Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/5/22, 5/19/21, 4/1/21, and 1/27/21. 28. Pa Code 201.18(b)(1)(e)(1) Management. Previously cited 5/18/21, 4/1/21.

Based on review of facility policy, review of clinical records and staff interview, it was determined that the facility failed to properly maintain an assistive device (AD - enclosed framed wheeled walker with a posterior seat) and failed to provide adequate monitoring and supervision to prevent a fall which resulted in harm for one of three residents reviewed (Resident R1). Findings include: A review of the facility, Merry Walker policy dated 3/24/15, indicated the IPU (Innovative Products Unlimited) walker is a wheeled ambulating assistance device and residents performance in the walker must continue to be assessed on an ongoing basis. A review of Resident R1's quarterly Minimum Data Set assessment (MDS, a periodic assessment of care needs) dated 4/9/15, revealed a [DIAGNOSES REDACTED]. A review of Resident R1's physician's orders [REDACTED]. A review of Resident R1's, At Risk for Falls/Related to wandering, vision impairment and lack of safety awareness care plan updated 5/5/15, indicated, ambulation utilizing Merry Walker with supervision. A review of Resident R1's Therapy Screen Form dated 5/5/15, indicated, resident experienced a fall while utilizing AD (Merry Walker) as the resident slid off of the walker seat, the resident was screened for ambulation and transfers and was able to complete functional ambulation and sit to stand transfers safely. Will reassess per nursing request in the future. A review of Resident R1's nursing progress note dated 6/19/15, at 11:13 a.m., indicated that the resident was observed lying on the floor while still in the Merry Walker with his/her face on the floor and guarding (to protect) the right upper extremity with movement. A review of Resident R1's, Therapy Screen Form dated 6/19/15, included comments: resident experienced a fall due to a modified AD resulting in injury. The AD was examined and found that it had been modified with inappropriate wheels and anti-tippers (used to prevent a patient from tipping over their chair) that caused the device to sit lower to the ground. For this reason the AD did not clear a doorway transition strip and resulted in a fall. Discussed with the Executive Director (Nursing Home Administrator) and the Director of Nursing Services and found that modifications were made by/at request of the resident's family member, to make the AD move better. Recommend replacement of components. Return AD components to original for proper function and safety. Modifications were not cleared by the Rehabilitation Department. A review of Resident R1's physician's orders [REDACTED]. A review of Resident R1's physician's progress notes dated 6/25/15, indicated that as a result of the fall the resident experienced a right humerus (upper arm bone) fracture and a laceration (deep cut) over the left upper eyebrow and swelling on his/her right wrist with bruising. During an interview on 7/2/15, at 10:15 a.m., the Director of Nursing (DON) confirmed that Resident R1's family member had purchased larger wheels for the resident's AD and on 6/3/15, the DON changed the wheels and anti-tippers. During an interview on 7/2/15, at 3:15 p.m., the Director of Nursing confirmed that the facility failed to properly maintain the AD and failed to provide adequate monitoring and supervision to prevent a fall which resulted in a major injury for Resident R1. During an interview on 7/6/15, at 10:30 a.m., the Licensed Physical Therapist, Employee E1 confirmed that the facility's specialized rehabilitation services were not made aware of the wheel and anti-tipper modifications that were made to Resident R1's AD on 6/3/15. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 5/14/15.

Based on review of facility policy, clinical and facility records, and staff interviews, it was determined that the facility failed to provide the necessary staff assistance as ordered for a resident transfer, which resulted in an injury to one of two residents (Resident R1). Findings include: Review of the facility policy "Transfer Orders Policy and Procedure" dated 5/6/11, indicates that each resident has a specific physician transfer order that must always be followed "with absolutely no exceptions". The resident's transfer order is on the focus sheet (a paper on the back of the resident's wardrobe door containing physician transfer order specific to each resident) , in the ADL (activity of daily living) book, and in the nurses Medication Administration Record (MAR). Nursing assistants doing a resident transfer are to refer to the focus sheet on back of the resident's wardrobe door. The Minimum Data Set (MDS, a periodic assessment of resident care needs) assessment dated [DATE], indicated that Resident R1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS indicated that Resident R1 required the extensive assistance of two plus persons for all transfers. The MDS also indicated that Resident R1's balance when moving from a seated to standing position or from surface to surface, was not steady and was only able to be stabilized with assistance. Review of the physician's orders dated 5/27/11, indicated that Resident R1 was to be transferred with the assistance of two "every shift everyday." Review of a reportable event dated 6/4/11, indicated that on 6/3/11, Nurse Aide (NA), Employee E1, transferred Resident R1 alone from the weight chair (a chair used to obtain a weight) to a wheelchair and reported hearing a "popping" sound. Review of Verification of Investigation dated 6/4/11, indicated that Resident R1 was returned to bed with an assist of two, a pain assessment done at the time of the incident indicated that on a scale of one to ten, Resident R1's pain was two, the physician was notified and an Xray was ordered. Review of a Radiology Report dated 6/3/11, indicated that Resident R1 had a left humeral (upper arm bone) fracture. Review of NA, Employee E1's employee file revealed that NA Employee E1 wrote in an undated statement, that he was, "never taught on focus sheets". Review of "Verification of Investigation" dated 6/3/11, indicated that during an interview with the Director of Nursing, NA Employee E1 indicated not being aware of the order for a two person assist and always transferred Resident R1 with an assist of one. During an interview on 8/10/11, at 11:30 p.m., the Director of Nursing confirmed that the facility did not provide instruction to NA Employee E1 regarding the location of the transfer orders specific to each resident. During an interview on 8/11/11, at 1:30 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that NA Employee E1 performed an unsafe transfer without two staff members present, contrary to the physician's orders on 6/3/11, resulting in an injury to Resident R1. Refer to F226. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 5/13/11. 28 Pa. Code: 201.29(a)(c)(d) Residents rights. 28 Pa. Code: 211.12(d) (1) (5) Nursing services. Previously cited 5/13/11.