Every finding on record at Wyncote Care Center

Based on review of facility policy, review of clinical records, observation, and staff interviews, it was determined the facility failed to ensure that residents were free from abuse for two of 2 residents reviewed related physical and verbal abuse allegations (Resident R1, Resident R2).Findings include: Review of facility policy titled Abuse, Neglect and Exploitation Policy dated May 1, 2025, revealed Wyncote Care Center maintains zero tolerance for abuse, neglect, exploitation, involuntary seclusion and misappropriation of resident property. All residents have to the right to be free from such conduct. Review of Facility Education titled Annual in-service training: abuse, neglect and exploitation, undated, Abuse: The willful infliction of injury, intimidation punishment, or deprivation that leads to harm or the risk of harm. This encompasses physical, emotional, sexual, and verbal abuse. Review of Resident R1's clinical record revealed resident was admitted to the facility on [DATE], with a diagnosis of dementia (progressive disease of the brain resulting in loss of reality). Review of Resident R1's quarterly MDS (Minimum Data Set- assessment of resident's care needs), dated January 1, 2026, revealed resident's BIMS (Brief interview for Mental Status) of 15, indicating resident cognitively intact. Review of facility investigation dated February 19, 2026, at 11:10 p.m., revealed resident statement A couple nights ago there were 2 people who came to change me. A black man maybe in his 50's and a kind of heavy-set black woman. I told them I didn't want to get changed but they went ahead and turned me violently. In fact, the man hit me- maybe I slugged first. There is no excuse for violence. It was late at night in the evening at about 10:30 p.m. They refused to listen to me, and they insisted in a violent way to change me. Every time they tried to turn me, I resisted. He gripped me with a very strong grip, but I couldn't break him. I never gave in, but they continued to. There was a lot of swearing by me and him, she has a bad temper too. I don't know his name, but I recognize him. He was in charge, but she went along. The woman is the person who took care of me tonight (Employee E3). Further review of facility investigation revealed statement from Employee E5, Nursing Supervisor, Resident R1 denies any pain or injury related to this event. No visible bruising noted. Also, the male nursing assistant [Resident R1] was referring to is [Nurse aide, Employee E4], identified by [Employee E3]. Interview with Employee E2, Director of Nursing on April 14, 2026, revealed [Nurse aide Employee E3] was terminated based on multiple allegations and refused to provide a statement and [Nurse aide, Employee E4] was not terminated because he provided a statement and since he had no other allegations, they did not terminate employment. Review of information reported to the State Survey Agency revealed Upon investigation, the male nursing assistant (Employee E4) did not appear to be involved in the incident. The allegation against the female nursing assistant (Employee E3) was substantiated and she was subsequently terminated. Review of Resident R2's clinical record revealed resident was admitted to the facility on [DATE], with diagnosis of cerebral infarction (disrupted blood flow to the brain). Review of Resident R2's Significant Change MDS (Minimum data set) dated December 23, 2023, revealed resident's BIMS (Brief interview for mental status) score of 9, indicating moderately cognitively impaired. Review of facility investigation dated February 19, 2026, revealed Resident R2's statement, dated February 19, 2026, at 11:10 p.m., She hit me (referring to Employee E3, Nursing aide), she slapped my wrist three times and then she grabbed my glasses. It just happened. Review of documentation submitted to the State Survey Agency for Employee E3, Nursing assistant, revealed Based on the Resident's statement and demonstration of the incident, there is sufficient concern regarding inappropriate physical interaction. The allegation was taken seriously and reported according to facility policy. Findings: substantiated. Review of facility reported incident, dated February 19, 2026, at 11:10 p.m., revealed Allegation is substantiated. Interview with Employee E1, Nursing Home Administrator on April 14, 2026, at 12:13 p.m., confirmed all findings. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.29(d) Resident Rights

Based on staff interviews, review of facility documentation and the review of clinical records, it was determined that the facility failed to ensure that a complete and through investigation was completed related to abuse allegations for 2 out of 3 residents reviewed (Resident R1 and Resident R3).Findings include: Review of facility policy titled Abuse, Neglect and Exploitation Policy dated May 1, 2025, revealed Wyncote Care Center maintains zero tolerance for abuse, neglect, exploitation, involuntary seclusion and misappropriation of resident property. All residents have to the right to be free from such conduct. Review of Facility Education titled Annual in-service training: abuse, neglect and exploitation, undated, Abuse: The willful infliction of injury, intimidation punishment, or deprivation that leads to harm or the risk of harm. This encompasses physical, emotional, sexual, and verbal abuse. Further review revealed Protocol for responding to abuse: Documentation must be objective and factual, including details of who, what, when, where and witness statements. Review of Resident R1 clinical record revealed resident was admitted to the facility on [DATE], with a diagnosis of dementia (progressive disease of the brain). Review of Resident R1's Quarterly MDS (Minimum Data Set), dated January 1, 2026, revealed resident's BIMS (Brief interview for Mental Status) of 15, indicating resident cognitively intact. Review of facility investigation dated February 19, 2026, at 11:10 p.m., revealed resident statement A couple nights ago there were 2 people who came to change me. A black man maybe in his 50's and a kind of heavy-set black woman. I told them I didn't want to get changed but they went ahead and turned me violently. In fact, the man hit me- maybe I slugged first. There is no excuse for violence. It was late at night in the evening at about 10:30 p.m. They refused to listen to me, and they insisted in a violent way to change me. Every time they tried to turn me, I resisted. He gripped me with a very strong grip, but I couldn't break him. I never gave in, but they continued to. There was a lot of swearing by me and him, she has a bad temper too. I don't know his name, but I recognize him. He was in charge, but she went along. The woman is the person who took care of me tonight (Nurse aide, Employee E3). Further review of facility investigation revealed statement from Employee E5, Nursing Supervisor, Resident R1 denies any pain or injury related to this event. No visible bruising noted. Also, the male nursing assistant resident R1 was referring to is Employee E4, nursing assistant identified by Employee E3, nursing assistant. Further review of facility investigation revealed no documented evidence of statements from other staff or other residents on the unit regarding concerns of abuse or incident. Interview with Employee E2, Director of Nursing on April 14, 2026, at 11:30 a.m. confirmed no interviews with other staff or residents completed after the reported incident. Review of Resident R3's clinical record revealed resident was admitted to the facility on [DATE] with diagnosis of fracture to left fibula (broken leg). Review of Resident R3's admission MDS (Minimum Data Set), dated February 8, 2026, revealed resident's BIMS (Brief interview for Mental Status) of 15, indicating resident cognitively intact. Review of Resident R3's Comprehensive Care Plan, date initiated April 6, 2026, Resident exhibits behavioral concerns, including verbal aggression such as cursing at other residents and staff. The resident demonstrates inappropriate verbal behavior, including cursing directed toward other residents and staff. Interventions include: Staff will monitor and document all episodes of verbal aggression, including triggers and frequency. Provide redirection and verbal cues when inappropriate language begins. Encourage the resident to use appropriate words to express needs and feelings. Maintain a calm, non-confrontational approach when responding to the resident. Review of facility grievance, dated March 11, 2026, revealed that Resident R3 States Nurse (Employee E6, registered nurse) was being unprofessional said he cursed at him. Resident became very upset and began to yell at Employee E6. Resident said he was talking to another resident and Employee E6 chimed in. States he had no reason to speak to him, and he shouldn't be around people if he is going to be unprofessional. Further review of facility grievance revealed resolution of grievance/complaint: Complaint investigated by ADON (Assistant Director of Nursing) and administration. Findings confirmed inappropriate and unprofessional communication by employees toward resident. The facility employee was terminated in accordance with facility policy. Resident informed that the concern was addressed and corrective action taken. Review of facility investigation revealed statement from Employee E7, Assistant Director of Nursing, revealed I was in my office when I heard a commotion coming from the hallway near the nursing station. Upon listening, I heard a staff nurse, you heard me, boy, while walking away down the hallway from the resident. The resident was positioned near the nursing station in the hallway at the time. Following the statement, I heard the resident respond, What you call me? No physical contact observed. My observation was limited to what I heard and positioning of the individuals in the hallway. Further review of facility investigation revealed statement from Employee E8, Social Worker, revealed I came upstairs for my rounds. In the mist of my rounds, I heard a loud commotion between Resident R3 and Employee E6, Registered Nurse. I heard the Registered Nurse (Employee E6) call Resident R3 a boy. I then took the resident into the rehab room to calm him down. Further review of facility investigation revealed no documented evidence of statement from Resident R3 or other residents on the nursing unit regarding concerns of abuse or incident. Interview with Employee E2, Director of Nursing on April 14, 2026, at 11:30 a.m. confirmed no interviews were conducted with other residents or Resident R3 after the reported incident. Upon request for investigation, Employee E2, Director of Nursing stated, well I have to run around and collect all the pieces of information from everyone because it's not all together some of it is with the social worker, some of it is with the ADON (Assistant Director of Nursing) and some of it is in my office in piles that I have to sift through. 28 Pa. Code:201.18(a)(1)(3) Management28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for three of the six residents reviewed. (Resident R2, Resident R3, and Resident R4).Findings include: Review of the facility policy titled Enhanced Barrier Precautions, August 2022, revealed: Enhanced barrier precautions are utilized to prevent the spread of multi -drug resistant organisms (MDRO's to residents. Under policy Implementation: EBP's (Enhanced Barrier Precautions) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis retention of urine and benign prostatic hyperplasia without lower urinary tract symptoms (enlargement of the prostate gland). Review of Resident R2's physician's order dated March 17, 2026, revealed an order for foley catheter and enhanced barrier precautions for multidrug-resistant organism (MDRO) risk. Review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of sepsis (infection of the blood). A physician order dated March 27, 2026, included Transmission-Based Precautions for contact precautions due to an Methicillin-Resistant Staphylococcus aureus (MRSA) wound on the resident's right lower extremity (RLE). Review of Resident R4's clinical record revealed that the resident was admitted to the facility on [DATE]. According to the Director of Nursing, Resident R4 had an open pelvic drain and was placed on enhanced barrier precautions. On April 1, 2026, at 9:36 a.m., an interview was conducted in Resident R3's room, where a sign indicated Enhanced Barrier Precautions rather than Transmission-Based Precautions. When asked if the employee who provided direct morning care that day was wearing a gown and appropriate PPE, Resident R3 responded, No, staff only wore gloves. Observation conducted on April 1, 2026, at 9:51 a.m. revealed that nursing aide Employee E3 was providing direct morning care to Resident R2 without wearing required personal protective equipment (PPE), specifically a gown. This observation was confirmed by the Director of Nursing, Employee E2. Employee E2 educated Employee E3 and assisted them in putting on the gown during the direct care activity. On April 1, 2026, at 9:51 a.m., an observation revealed that licensed nurse Employee E4 was administering medication to Resident R4 without wearing enhanced barrier precautions. An interview conducted after the medication administration revealed that Employee E4 was applying a clonidine patch, which had direct contact with the resident's skin and required the use of EBP PPE. When questioned about why Resident R4 was on EBP, Employee E4 was unable to provide an answer. This was confirmed by the Director of Nursing, Employee E1, who educated Employee E4 that Resident R4 had an open pelvic drain and that EBP was required. On April 1, 2026, at 10:08 a.m., an observation and interview were conducted with the Director of Nursing, Employee E2, in the laundry room. During the observation, Laundry Director Employee E6 was folding clean laundry with housekeeping staff Employee E7. When questioned about whether both staff should be wearing PPE, Employee E6 retrieved a reusable apron and gloves from the soiled laundry room and gave them to Employee E7. Employee E6 ensured the PPE provided was clean. When asked about PPE requirements for folding laundry, the Laundry Director could not provide a clear answer. The Director of Nursing was also unsure of Infection Control practices. During the observation, Employee E7 attempted to wear the gown incorrectly, as one would a jacket, rather than over the front of the body. The Director of Nursing provided assistance and redirected Employee E7 on the proper way to wear the gown. On April 1, 2026, at 10:43 a.m., an interview with the Director of Nursing, Employee E2, who also serves as the facility's Infection Preventionist, revealed that the facility did not have a tracking system for antibiotic surveillance forms. The facility had new ownership as of May 2025, and Employee E2 became the Director of Nursing and Infection Preventionist in September 2025. It was reported that all infections were being reported to the Patient Safety Authority on a case-by-case basis. Employee E2 retains all infection information and is familiar with the cases from memory; there were no surveillance forms readily available for review. Following this, Employee E2 created a Nosocomial Infection Tracking Log for the past three months: January, February, and March 2026. On April 1, 2026, at approximately 1:30 p.m., Resident R3's clinical record was reviewed with the Director of Nursing (DON) to clarify why the physician order indicated that Resident R3 was on Transmission-Based Precautions (TBP), while the sign outside the resident's door indicated Enhanced Barrier Precautions (EBP). The DON confirmed that the TBP order needed to be updated and that Resident R3 should be on EBP, as TBP was no longer required. During this review, the DON confirmed that surveillance tracking was not available. For MRSA. Surveillance data was not readily available for periods prior to January 2026. Additionally, a current listing of residents requiring EBP and TBP was not readily available. Review of facility IPCP documents revealed that there were no Infection Control Committee (ICC) meeting minutes for review. There was no evidence of input from the required ICC members. There was no evidence of reporting surveillance data, HAI rates, or infection control compliance metrics to the ICC. There was no evidence an annual infection control risk assessment or the development of annual goals and performance measures. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for 10 of 10 months (May 2025 -March 2026).Findings include: Review of the Facility policy titled Antibiotic Stewardship revised December 2016, revealed Antibiotic will be prescribed and administered to resident under guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of the Facility policy titled Antibiotic Stewardship- Review and Surveillance of antibiotic use and outcomes, last revised December 2016 revealed Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decision for improvement of individual resident antibiotic prescribing practices and faculty - wide antibiotic stewardship. The information will include: resident name and medical record number; unit and room number; date symptoms appeared; name of antibiotic, start date of antibiotic, pathogen identified; site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. On April 1, 2026, at 10:43 a.m., an interview with the Director of Nursing, Employee E2, who also serves as the facility's Infection Preventionist, revealed that the facility did not have a tracking system for antibiotic surveillance forms. The facility had new ownership as of May 2025, and Employee E2 became the Director of Nursing and Infection Preventionist in September 2025. It was reported that all infections were being reported to the Patient Safety Authority on a case-by-case basis. Employee E2 retains all infection information and is familiar with the cases from memory; there were no surveillance forms readily available for review. Following this, Employee E2 created a Nosocomial Infection Tracking Log for the past three months: January, February, and March 2026. Facility Nosocomial Infection Tracking Logs for the months of January, February and March 2026, were reviewed. Nosocomial is defined as an infection does not present on admission, also referred to as healthcare-associated infections. Review of the January 2026 tracking log revealed that one infection was recorded. The recorded infection did not include a resident name or room number; location of infection; symptoms of the infection; any diagnostic testing obtained; the dose, route, frequency and duration of the prescribed antibiotic; or an evaluation of the treatment effectiveness. Review of the February 2026 tracking log revealed that three infections were recorded. The recorded infections did not include the location of infections; symptoms of the infections; any diagnostic testing obtained; the dose, route, frequency and duration of the prescribed antibiotic; or an evaluation of the treatment effectiveness. Further review of the February 2026 tracking log revealed that one resident had an upper respiratory infection. There was no evidence that the resident was tested for current disease threats, including influenza, RSV (Respiratory syncytial virus) and COVID-19. Review of the March 2026 tracking log revealed that six infections were recorded. Two of the infections did not include the location of infections; three did not include any diagnostic testing obtained; and non of the recorded infections included the dose, route, frequency and duration of the prescribed antibiotic; or an evaluation of the treatment effectiveness. Further review of the March 2026 tracking log revealed that two residents had an upper respiratory infection. There was no evidence that the resident was tested for current disease threats, including influenza, RSV (Respiratory syncytial virus) and COVID-19. Continued review of infection control data revealed that there were no tracking logs provided that monitored community acquired infections (infections that were present upon admission or re-admission) and no tracking of any antibiotics that were prescribed to treat those infections. Further review of infection control data revealed no evidence of the facility's antibiotic use protocol(s) that guide antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of the antibiotic; review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted; an infection assessment tool or management algorithm for use when prescribing) and a system to monitor antibiotic use (i.e., antibiotic use reports provided by the pharmacy and lab, antibiotic resistance reports). 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on a review of select facility policies and staff interviews, it was determined that the facility failed to ensure that the Infection Preventionist fulfilled the required duties and responsibilities of the position.Findings include: Review of facility policy, Antibiotic Stewardship - Staff and Clinician Training and Roles dated December 2016, revealed, under the responsibilities of Director of Nursing (DON) and Infection Preventionist (IP), Administrative and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on: the facility's antibiotic program; the rationale for judicious use of antibiotics; common clinical conditions and associated pathogens treated at the facility; how to access the current facility antibiogram; how to access the list of antimicrobial agents available through the pharmacy formulary; how to use surveillance tools to monitor infectious rates, antibiotic usage patterns and outcomes; how and when to gather to present to the infection prevention and control committee for scheduled meetings; and individual roles and responsibilities in maintaining antibiotic stewardship. On April 1, 2026, at 10:43 a.m., an interview with the Director of Nursing (DON), Employee E2, who also serves as the facility's Infection Preventionist (IP), revealed and confirmed that she is a full-time DON and a part-time IP. The facility has currently hired an Assistant Director of Nursing who is undergoing training to become an IP. Review of the facility 2026 - Infection Control Plan dated March 31, 2026, revealed, The Infection Preventionist (IP), who is the ADON, in collaboration with the Infection Control Committee (ICC), conducts an annual Infection Control Program Risk Assessment. Continued review revealed that The Risk Assessment is used to: Identify potential risks for acquiring and/or transmitting infections; Evaluate and prioritize risks based on likelihood and impact; and Develop strategies to mitigate or eliminate identified risks. Continued review of the facility 2026 - Infection Control Plan revealed that duties of the Infection preventionist include: Development, implementation, monitoring, and enforcement of the evidence-based infection control plan, program, policies, and practices; Performance of an annual risk assessment with input from the ICC; Development of annual goal set points using prioritized risks from the risk assessment; Maintenance of IPCP data for tracking, trending, and reporting to committees and leadership; Performance of an annual IPCP evaluation and reporting outcomes to the ICC, and Implementation of necessary precautions and containment strategies in response to infectious disease threats. Further review of the facility 2026 - Infection Control Plan revealed, The Infection Control Committee (ICC) is a multidisciplinary group responsible for oversight of the IPCP. Membership of the ICC includes: Medical staff, Administration, Nursing staff, Infection Preventionist (ADON), Laboratory personnel, Pharmacy staff, Physical therapy /maintenance personnel, and A community member who is not an employee, agent, or contractor of the facility. Responsibilities of the ICC include: Reviewing and approving the Infection Control Plan, Risk Assessment, and infection control policies at least annually; Reviewing surveillance data, HAI rates, and infection control compliance metrics; Recommending and monitoring quality improvement initiatives; Addressing issues related to emerging pathogens and communicable diseases; and Reviewing and approving cleaning, disinfection, and sterilization products and practices used within the facility. Review of the facility assessment, dated last review December 12, 2025, revealed that the facility had one infection control nurse/preventionist and that the infection preventionist was also the Director of Nursing. There was no information included in the assessment regarding the amount of time required to fulfill the responsibilities and duties specifically for the role of the infection preventionist, or any determination of the resources it needs for its IPCP (Infection Prevention and Control Program), and ensure that those resources are provided for the IPCP to be effective. Review of facility IPCP documents revealed that infection surveillance data was not readily available and that no data was available prior to January 2026. Continued review revealed that a listing of residents requiring Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) was not readily available. There was no evidence of staff oversight to ensure that practices, such as hand hygiene and adherence to use of Personal Protective Equipment (PPE) was implemented. Refer to F880. Review of facility infection tracking logs revealed that they failed to contain location of infections; symptoms of the infections; any diagnostic testing obtained; the dose, route, frequency and duration of the prescribed antibiotics; or an evaluation of the treatment effectiveness. Review of infection control data revealed no evidence of: the facility's antibiotic use protocol(s) that guide antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of the antibiotic; review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted; an infection assessment tool or management algorithm for use when prescribing) and a system to monitor antibiotic use (i.e., antibiotic use reports provided by the pharmacy and lab, antibiotic resistance reports). Refer to F881. There was no evidence that the facility has any systems or protocols in place to monitor for current disease threats, including influenza, RSV (Respiratory syncytial virus) and COVID-19. Review of facility IPCP documents revealed that there were no Infection Control Committee (ICC) meeting minutes for review. There was no evidence of input from the required ICC members. There was no evidence of reporting surveillance data, HAI rates, or infection control compliance metrics to the ICC. There was no evidence an annual infection control risk assessment or the development of annual goals and performance measures. The facility failed to ensure that the Infection Preventionist had the necessary time and resources provided to fulfill the responsibilities and duties of the position. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1)(e)(1) Management.28 Pa. Code: 201.19(3) Personnel records.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, clinical record review, and staff interviews, it was determined that the facility failed to ensure that, before offering the influenza immunization, each resident or the resident's representative received education regarding the benefits and potential side effects of the immunization for five of five records reviewed (R1, R2, R3, R4, R5).Findings include: Review of the facility policy titled Influenza, Prevention and Control of Seasonal, undated, revealed that this facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Under the Vaccination section, bullet 3 further stated, Systematic strategies to improve staff vaccination rates may include: providing incentives, providing vaccine at no cost to staff, improving access (offering vaccination at work and during work hours), requiring personnel to sign a declaration form to acknowledge that they have been educated about the benefits and risks of vaccination, and mandating influenza vaccination for staff without contraindication. Review of consents forms for the influenza vaccines and review of clinical record for Resident R1, R2, R3, R4, R5), revealed no documented evidence that that Resident R1, R2, R3, R4, R5)., were provided with education on influenzas vaccines prior to the administration or refusing of the vaccine. The form constrained a check box declaring that Vaccination Information Sheets (VIS) has been received; however, when requested to see a copy of the VIS sheet. DON confirmed that there is no VIS sheet available for review. Interview with the Director of Nursing, Employee E2, conducted on April 1, 2026, at 10:43 a.m., confirmed that the consent form contained a check box stating that Vaccination Information Sheets (VIS) have been received. However, when requested, a copy of the VIS sheet was not available for review. The DON confirmed that no VIS sheet was available, which indicated there was no evidence of education provided to residents regarding influenza vaccines prior to administration for Residents R1, R2, R3, R4, and R5. 28 Pa. Code 201.18(e)(1) Residents rights

Based on observation and interviews with staff, it was determined that the facility failed to maintain a safe, sanitary, and comfortable environment for residents in the facility, related with safe maintenance of two of two dryers.Findings include:On January 2, 2026, at 1:44 p.m., during observational tour of the Laundry room, it was detected that the lint of the two dryers was not removed from the lint compartment; and the lint layer was thick. There was no lint removal log available for review. At the time of the finding the same was confirmed with the Supervisor of Housekeeping, and the Administrator of the facility. 28 Pa Code 201.18(b)(1)(3) Management

Based on record review and interview with staff, it was determined that the facility failed to ensure that MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment was completed accurately for one of twenty-one residents reviewed. (Resident R9) Findings include:Review of CMS's RAI Version 3.0 Manual revealed that CH 3: MDS Items [O] October 2025 Page O-1 SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. Under Item Rationale Health-related Quality of Life The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life. Planning for Care Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. Review of Resident R9's clinical record revealed that Resident R9 was admitted to the facility on [DATE], with diagnosis of but not limited to Malignant Neoplasm of the Breast, Cerebral Infraction, Non-Hodskins's Lymphoma. Further review of Resident R9's clinical record revealed a physician's order for: Hospice consultation and treatment dated September 8, 2025. Review of Hospice contract revealed that the contract was signed by daughter who was the POA (Power of Attorney) on September 10, 2026. Review of significant change MDS (minimum data set, a federally required resident assessment completed at a specific interval) dated September 16, 2025, revealed that Section O - Special Treatments, Procedures, and Programs, K1. Hospice care was coded No (not on hospice) Interview with RNAC (Registered Nurse Assessment Coordinator) Employee E3 conducted on January 2, 2025, at 11:23AM revealed that Resident R9's Hospice contract was signed on September 10, 2025, and that hospice services started on the day the contract was signed. Further interview with Employee E3 confirmed that when she completed Resident R9's significant change MDS dated [DATE], she coded No on Section O - Special Treatments, Procedures, and Programs, K1. Hospice care. 28 Pa. Code 211.10(a) Resident assessment

Based observation, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to develop a person-centered care plan related to skin breakdown for two of twenty-one residents reviewed. (Resident R7 and Resident R8) Findings include: Review of facility policy on Care Planning revealed that under section Purpose: To ensure that each resident at Wyncote Care Center receives individualized person-centered gear through the development implementation and ongoing review of an interdisciplinary care plan in compliance with CMS and Pennsylvania Department of Health requirements. Under section Policy statement: Wyncote Care Center shall develop and maintain a comprehensive resident centered care plan for each resident care plans are based on assessments resident goals and preferences physician orders and ongoing clinical evaluation Care planning is an interdisciplinary process and care plans must be actively implemented and followed by all staff. Review of Resident R8's clinical record revealed that Resident R8 was admitted to the facility on with diagnosis of End Stage Renal Disease, Dependent on Dialysis. Review of Resident R8's oral health assessment dated [DATE], revealed that Resident R8 had four or more decayed or broken teeth/roots. Further review of Resident R8's clinical record revealed that there was no care plan developed to address Resident R8's missing teeth. Observation on Resident R8 conducted on December 29, 2025, at 1:23PM revealed that Resident R8 had one visible front tooth. Interview with Resident R8 conducted at the time of the observation revealed that he only has three teeth. Further Resident R8 also revealed that he was not able to chew the food that he likes because he does not have teeth. Interview with Director of Nursing Employee E2, conducted on December 31, 2025, at 10:46AM confirmed that there oral/dental care plan was not developed for Resident R8. Review of Resident R7's clinical record revealed that Resident R7 was admitted to the facility on [DATE], with diagnoses of but not limited to Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy (failure of the body to produce insulin), and Disorder of Arteries. Review of Resident R7's progress note dated December 3, 2025, revealed that CNA (nurse aide) staff asked RN (registered nurse) supervisor to assess the resident's right top of foot area, as there is redness on the left aspect of the red foot area that was not seen there last Monday (12/1/2025) when she was with the resident. RN assessed the area: -localized redness, size of quarter, tender to touch, pain (3/10 as per pt). No broken skin observed. Further review of Resident R7's clinical record revealed that there was no care plan addressing Resident R7's potential for skin breakdown on the top of Resident R7's right foot. Observation on Resident R7's right foot conducted with DON (Director of Nursing) Employee E2 conducted on December 31, 2025, at 10:50 AM revealed a skin breakdown with a round dark reddish-brown scab over it, the size of a quarter on top of Resident R7's right foot. Interview of the Director of Nursing, Employee E2 conducted at the time of the observation confirmed that Resident R7 had a skin breakdown on top of Resident R7's right foot. Follow-up interview with Director of Nursing, Employee E2 conducted on December 31, 2025, at 11:46AM confirmed that there was no care plan addressing Resident R7's skin breakdown on top of his right foot. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and staff interviews, it was determined that the facility failed to revise the care plan for enteral nutrition for one out of 16 residents reviewed. (Resident R26) Findings include:Review of clinical records revealed that Resident R26 was admitted in the facility on December 1, 2025. R26 had diagnoses that included Dysphagia (difficulty swallowing food or liquids, making it hard for them to move from the mouth through the throat and into the stomach), Anemia (a condition where the blood lacks enough healthy red blood cells or hemoglobin, impairing oxygen transport, leading to fatigue, weakness, pale skin, and shortness of breath, often caused by iron deficiency, blood loss, or inherited disorders) and ,Gastrostomy Status (Gastrostomy status means a person has a surgically created opening (a stoma) into their stomach, usually to place a feeding tube (G-tube) for nutrition, fluids, or medication when they can't eat by mouth. It's a coded medical status, indicating the presence of this artificial opening for long-term access, requiring specific care for the site). Review of physician order dated December 1, 2025, for Resident R26 revealed an order to administer Tube Feed formula of Glucerna 1.2, at 45mls/hour, continuous every shift, until Osmolite is available. Review of physician order dated December 9, 2025, for Resident R26 revealed an order to administer Osmolite 1.5, 45mls/hour, Continuous, every shift Review of physician order dated December 18, 2025, for R26 revealed an order to administer Osmolite 1.5 45mls/hour, every shift, continuous; Ok (Agreed) to substitute Jevity 1.5 if Osmolite is not available. Review of physician order dated December 29, 2025, for Resident R26 revealed an order to administer two times a day Osmolite 1.5, at 55mls/hour for 12 hours overnight or until total volume infused; up at 1900, off at 0700; total volume to be infused: 660ml Review of Resident R265's care plan revealed under its focus area: The resident has a swallowing problem related to dysphagia, H/O (history of) PD, Peg tube placement on prior hospital-admission; Date Initiated: 12/02/2025; Revision on: 12/07/2025. Continued review of the resident's care plan revealed under its goal area: The resident will maintain weight and nutritional balance through the review date. Date Initiated: 12/02/2025, Target Date: 03/22/2026. The resident will have clear Lungs, no signs and symptoms of aspiration through the review date. Date Initiated: 12/02/2025; Revision on: 12/07/2025. The interventions stated to achieve the goal were All staff to be informed of resident's special dietary and safety needs. Date Initiated: 12/02/2025; Monitor for shortness of breath, choking, labored respirations, lung congestion; Date Initiated: 12/02/2025. Refer to Speech therapist for Swallowing Evaluation, Date Initiated: 12/02/2025 On January 5, 2026, at 11:52 a.m., review of the care plan of Resident R26, revealed that no care plan revision was made to the Peg tube-related focus, goals, and interventions based on different orders to administer different tube feedings, dated December 1, 2025; December 9, 2025; and December 18, 2025, respectively. At the time of the findings, interview with the Director of Nursing confirmed the same.28 Pa Code 211.10 (d) Resident care policies

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provided assistance with toileting for one of 21 residents reviewed. (Resident R23) Findings include:Review of Resident R23's clinical record revealed that Resident R23 was admitted to the facility on [DATE], with diagnosis of but not limited to Hemiplegia/Hemiparesis (paralysis/weakness to one side of the body). Review of Resident R23's MDS (Minimum Data Set, a federally required resident assessment completed at a specific interval) dated October 2, 2025, Section C - Cognitive Pattern C0500 BIMS (brief interview for mental status) summary score was coded 11 indicating that Resident R23 was moderately impaired of cognition; Section GG - Functional Abilities, GG0130. Self-Care C. Toileting hygiene: The ability to maintainperineal hygiene, adjust clothes before and after voiding or having a bowel movement was coded 04. Supervision or touching assistance, Section H - Bladder and Bowel, H0300. Urinary Continence was coded 2. Frequently incontinent, H0400. Bowel Continence was coded 2. Frequently incontinent. Review of Resident R23's care plan for incontinence of bowel and bladder at times related to Impaired Mobility. Further review of the care plan revealed that the resident requires assistance with ADLs (activities of daily living) r/t (related to) impaired mobility Date Initiated: 07/18/2024. The goal was for ADL care needs will be met through next review date and intervention included to: Provide assistance as required for completion of ADL tasks. Date Initiated: 07/18/2024. Observation of Resident R23's room conducted on December 29, 2025, at 11:44 AM together with Director of Nursing (DON) Employee E2 revealed that Resident R23's was in his room sitting on his bed, in street clothes. Further observation revealed a strong odor of urine coming from resident's room. Interview with Employee E2 conducted at the time of the observation confirmed that there was strong odor of urine in Resident R23. Further, Employee E2 revealed that Resident R23 tries to go to the bathroom on his own but sometimes doesn't make it to the bathroom. 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(5) Nursing services

Based on the review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect the confidentiality of medical records for one of three records reviewed. (Resident R1) This was cited as past non-compliance.Findings Include:Review of an undated facility policy Medical Records Policy revealed that Wyncote Care Center maintains accurate and confidential medical records for all residents in compliance with federal and state regulations. The facility ensures secure storage, proper retention, and lawful release of medical records in accordance with CMS (Centers for Medicare & Medicaid Services).3. Release of Information:- Medical records will be released only in accordance with applicable federal and state privacy laws (e.g., HIPAA).- Records may be released to:- The resident.- The resident's legally authorized representative (e.g., Power of Attorney, legal guardian).- Healthcare providers involved in the resident's care.- Regulatory agencies and authorities as required by law.- Other parties only with a valid, signed authorization from the resident or their legalrepresentative.- All requests for records must be submitted in writing and will be processed in a timelymanner.-A fee may be charged for record copies in accordance with facility policy and state law.- Documentation of all record releases will be maintained, including the request,authorization (if applicable), date of release, and recipient details. Review of facility reported incident dated August 1, 2025, revealed that Facility made aware that another family received the wrong medical records, causing a HIPAA breach.Further review of the facility reported incident revealed that NHA notified POA of the HIPAA breach, and assistance was extended for any identification protection measures. In addition, the family member who was accidentally given wrong record is scheduled to return the document for proper management.Interview with the Administrator on September 2, 2025, at 12:30 p.m. revealed that the staff provided the wrong record, record of Resident R1, to Resident R2's representative. Facility could not find out what information was provided; however, it was informed by Resident R2's representative that information such as social security number and date of birth was part of the privacy breach. The administrator also confirmed that the facility medical record request process was not followed. This deficiency was cited as past non-compliance. Review of facility Action plan/Follow up documentation revealed the following information. 1. Facility administrator notified the affected resident's (R1) POA(power of attorney) of the possible HIPAA breach, and extended assistance or resources as a result of the breach. In addition, R2 POA (the family who received R1's medical information) was asked to return the documents back to the facility, so it can be properly discarded.2. The Concierge program was utilized in order to monitor other potential breaches of medical information. Since the facility was unable to determine who provided the record, facility administration had to ensure that facility is quick to identify anyone else, if effected. Facility did not identify others effected, and this was an isolated incident. 3. Training was provided for staff on proper Medical Record Request policy and process. Forms were made available for future medical records requests.4. Monthly QAPI and weekly concierge discussions review any medical records requests. NHA is made aware of all medical record requests, in order to prevent future breaches. Facility date of compliance was August 29, 2025.A review was conducted of clinical records, facility documentation, staff education, and documentation of audits conducted by the facility. Interview with staff revealed that the staff was knowledgeable about facility medical record request practices and HIPAA compliance. It was determined that the plan of correction was implemented, and identified as past non-compliance. 28. Pa Code: 201.29(a) Resident Rights28 Pa. Code 211.5(b) Medical Records

Based on interviews with staff, residents, and family members, review of clinical records, it was determined that the facility did not implement appropriate interventions to prevent and support the healing of pressure ulcers for one of four residents reviewed (Resident R1).Findings include:Review of Resident R1 ' s clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Dementia, muscle weakness.Review of Resident R1 ' s clinical record revealed physician order, dated January 31, 2025, for Prevention Devices check every shift. Pressure reducing devices to bed and wheelchair, offload heels on pillows in bed, turn and reposition frequently in bed.Review of Resident R1 ' s MDS (Minimum Data Set) State Optional dated May 3, 2025, under section M1200, dated May 3, 2025, revealed Resident R1 is not enrolled in a turning and repositioning program.Further review of Resident R1 ' s MDS (Minimum Data Set) State Optional dated May 3, 2025, under section G0110, revealed Resident R1 is Total dependence (full staff performance every time during entire shift) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed).Review of Resident R1 ' s Care Plan date-initiated January 28, 2025, revealed that Resident R1 has a potential for alteration in skin integrity r/t incontinence.Review of Resident R1 ' s clinical record revealed progress notes written by Employee E3, Licensed Practical Nurse dated April 7, 2025, While CNA was giving care an open area noted on resident ' s sacrum and CNA reported that to the charge nurse. Charge assessed area and measured it 2 cm x 1.75 cm.Review of Resident R1 ' s clinical record revealed nursing progress note dated April 10, 2025, Seen by wound doctor, see wound consult for more information.Interview with Employee E1, Administrator on 6/24/2025 at 2:30pm revealed that wound consult documentation unavailable to view, A lot of stuff is missing from the switch over.Review of Resident R1 ' s clinical record revealed Wound Evaluation and Management Summary by Wound Physician dated April 17, 2025, Wound with significant deterioration over the past week, not eating per nursing, may be beginning of end stage skin failure. Wound Size measuring 3.2 x 3.2 x not measurable (depth is unmeasurable due to presence of nonviable tissue and necrosis). General recommendations include off-Load wound, reposition per facility protocol, turn side to side in bed.No documented evidence of care plan initiated for facility acquired pressure ulcer. Confirmed by Employee E2, Director of Nursing on June 24, 2025 at 2:05pm. 28 Pa Code 211.10(c) Resident care policies28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of clinical record, facility documentation, and interviews with staff, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to perform weekly skin assessments as ordered by the physician for one of six residents reviewed. (Resident R1) Findings include: Review of facility policy titled Skin Check Policy, effective 2025, stated the facility will perform comprehensive skin checks on all residents as prescribed in their care plan, and at a minimum frequency consistent with the physician's orders (e.g., weekly, biweekly, monthly). The goal is to promptly identify changes in skin integrity and initiate appropriate interventions. Findings must be recorded in the resident's clinical record immediately after completion. Any new or worsening skin condition must be documented and reported to the attending physician and Director of Nursing immediately. Clinical record review revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus (when the body doesn't use insulin properly, resulting in unusual blood sugar levels), bilateral primary of osteoarthritis of knee (condition that affects both knee joints with cartilage damage and inflammation), and dementia. Review of physician's order, dated April 18, 2025, revealed an order for Skin care: skin and nail checks weekly, every day shift, every Tuesday. Nursing progress note, dated May 13, 2025, stated Resident R1's skin check was done after (his/her) bed bath, Resident R1 abdominal fold looks irritated and red. Further review of Resident R1's progress notes revealed no further skin assessments and no indication of skin issues noted. Review of Resident R1's clinical record revealed on May 30, 2025 Resident R1 was transferred to the hospital due to change in mental status and abnormal vital signs. Review of Resident R1's hospital documentation, dated May 31, 2025, revealed Resident R1 had an admitting diagnosis of sepsis with acute renal failure (Sepsis is a life-threatening condition caused by an intense response of your immune system to an infection. Sepsis triggers inflammation throughout your body that can result in multiple organ failure. Sepsis is the most common risk factor of acute kidney failure. Acute kidney failure, or acute kidney injury, is a sudden loss of kidney function). Review of Resident R1's hospital documentation, dated June 02, 2025, revealed a physician's note that stated Resident R1 says ouch when examining abdomen and left lower extremity however more severe pain when examining right lower extremity. Right lower extremity with lower leg swelling, wound of lateral lower leg without parlance/drainage. Physician note, dated June 03, 2025, revealed right knee fluid gram stain positive for gram positive cocci (strong indicator of septic arthritis). Right ankle fluid clotted. Plan for OR today for right knee irrigation and debridement with possible right ankle irrigation and debridement (surgical procedure that involves washing out and cleaning a wound, by removing debris and dead or damaged tissue). Interview with on June 04, 2025 at 12:17 p.m. with Director of Nursing, Employee E1, revealed not being aware of any skin issues on Resident R1. Interview on June 04, 2025 at 2:05 p.m. with Registered Nurse, Employee E2, revealed that she was Resident R1's nurse on May 30, 2025, the day Resident R1 was transported to the hospital. Registered Nurse, Employee E2, was unaware of swelling or skin issues on Resident R1's right lower extremity and no nurse aides reported any concerns. Interview with Administrator, Employee E2, confirmed the facility was unable to find evidence that there was a wound present on Resident R1's right lower extremity and weekly skin assessment was not performed as ordered. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on the review of clinical record, facility investigation, policies and procedures interview with staff, it was determined that the facility failed to ensure resident environment was free of accident hazard related to providing appropriate technique during resident care which resulted in resident falling from the bed during care for one of five residents reviewed (Resident R1) Findings Include: Review of facility policy Fall Management Program dated December 17, 2024, revealed that The community will maintain systems designed and implemented to identify hazards and individual resident risk; evaluate hazards and risks; implement interventions to reduce hazards and risks; and monitor the effectiveness of measures implemented in an attempt to eliminate or reduce the risk of accidents as much as possible. Review of Resident R1's clinical record revealed the diagnoses of lack of coordination, unsteadiness on the feet, obesity and muscle weakness. Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident care needs) dated January 28, 2025, revealed that the resident required partial/moderate assistance on bed mobility and required substantial/maximum assistance on transfers to and from bed to chair. MDS also revealed that substantial/maximum assistance status coding indicated helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Partial/moderate assistance status coding indicated helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of care plan for Resident R1 dated July 22, 2024, revealed that Resident R1 required assistance with ADL's (Activities of Daily Living- bed mobility/transfers/eating/dressing/bathing and hygiene) Review of facility investigation dated March 30, 2025, revealed that the nursing supervisor heard Resident R1 cry out then the Nurse Aide, Employee E3, called out that she needed help. Upon arrival resident's bed was in high position and the resident was laying on her right side with her head towards the top of the bed, she was complaining of severe right-side pain, resident stated from my shoulder to my hip. Nurse Aide, Employee E3 was in the room at the time of the incident performing morning care. Nurse Aide, Employee E3 stated she resident was holding on the half side rail used for turning and repositioning her hands slipped off the rail rolling to the floor. Further review of the investigation indicated that resident was an assist of one for bed mobility. Nurse Aide, Employee E3 stated after giving resident a bed bath, she was in the process of changing residents sheets while the resident was in the bed, she rolled resident away from her to roll over the sheets, while she was changing the sheet, the resident rolled over the sheets and fell away from her. Review of progress note fir Resident R1 dated March 30, 2025, revealed that resident fell from bed and complained of severe right arm and shoulder pain. Resident was transported to the hospital via for further evaluation. Further review of the progress note revealed that the resident returned from the hospital without any new orders. Resident complained of some discomfort to the right shoulder in the evening shift. Review of a statement from Nurse aide, Employee E3 dated March 30, 2025, revealed that attempting to do my final round changing the patient, she was holding on, she fell landing on her right side complain of right shoulder pain. Another statement obtained from the same employee revealed that she was doing a complete bed change on Resident R1, she was turned towards the door (left side) with side rails up, Before she could turn her over the folded linen, she fell out of bed. Interview with Director of Nursing, Employee E2 on April 22, 2025, at 12:00 p.m. stated on March 30, 2025, Employee E3 was providing morning care for Resident R1. After morning care, she decided to change resident's bed linen while resident was in the bed. Nurse Aide turned resident away from her, folded the linen towards the resident. Before resident rolling back over to the other side, while the resident was on sheet, Employee E3 pulled the sheet out and resident fell to the floor. Employee E2 stated if residents get linen change while they are in the bed, they should complete it with appropriate technique. Employee E2 stated the appropriate technique was staff should turn resident safely to one side, fold the linen, roll the resident to the other side over the folded linen, once the resident was off the sheet, staff should pull the sheet. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to review and revise a care plan related to feeding assistance for one of 12 residents reviewed (Resident R34). Findings Include: Review of facility policy Interdisciplinary Care Planning revised 12/16/2024 revealed it is the responsibility of each discipline to add, revise, and discontinue care plan problems, goals, and interventions as needed. Review of Resident R34's comprehensive care plan revised December 13, 2024, revealed the resident had potential for alteration in nutrition status related, but not limited to, dementia, varied meal completion, and decline in self-feeding with need for adaptive feeding devices. Intervention dated February 12, 2024, and March 22, 2024, revealed to provide Resident R34 with a Kennedy cup for beverages and inner lip plate for food items with all meals. Observations in the dining room on December 18, 2024, at 12:00 p.m. revealed Resident R34 was not provided with adaptive equipment for the lunch meal service and was instead being fed by nurse aide, Employee E5. Interview on December 18, 2024, at 12:00 p.m. with Nurse Aide, Employee E5, revealed Resident R34 had a decline in self-feeding capabilities and was no longer able to use the adaptive equipment at meals. Further interview with nurse aide, Employee E5, revealed Resident R34 required 1:1 feeding assistance with meals. Review of Resident R34's comprehensive care plan revealed no evidence interventions were revised related to self-feeding capabilities. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing services

Based on review of clinical record, facility policy, observations, and interviews with staff, it was determined that the facility failed to exercise proper infection control techniques and wear personal protective equipment (PPE) during a dressing change for one of one resident observed (Residents R32). Findings include: Review facility policy titled Transmission Based Precautions- Infection Control revised May 28, 2024, revealed precautions should be maintained as long as necessary to prevent the transmission of the infection. Further review of policy under section Enhanced Barrier Precautions (EBP) revealed that gloves and gowns are to be used when providing high contact resident care. High contact resident care activities include wound care. EBP are implemented for any resident with a wound. Review of Resident R32's clinical record revealed that Resident R32 was admitted to the facility on [DATE] with a diagnoses hydrocephalus (excess fluid in the brain ventricles), edema (swelling caused by too much fluid trapped in the body's tissues), and lack of coordination. Review of physician orders revealed an order dated November 11, 2024, that stated cleanse left buttock with normal saline, apply anasept gel (prevent and treat skin and tissue infections), calcium alginate (type of wound dressing), and cover with boarder gauze daily and prn (as needed). Wound care observation on Resident R32 conducted on December 18, 2024, at approximately 10:00 a.m. with licensed nurses Employee E3 and Employee E4 revealed that Employee E3 and Employee E4 donned gloves prior to performing Resident R32's dressing change. Further, observation revealed that licensed nurse, Employee E4 started performing wound dressing change on Resident R32 without donning a gown. Interview with Licensed nurse, Employee E4, conducted December 18, 2024, at approximately 11:20 a.m. revealed proper PPE, which includes donning gloves and gown during high contact resident care, is to be worn for residents on enhanced barrier precautions when providing care. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based facility policy, observation, and interviews, it was determined that facility failed to secure residents privacy relating to confidential medical records for 5 out of 42 residents reviewed. (Residents; R14, R28, R37, R11, and R1) Findings include: Review of the center for Disease Control and Prevention (CDC), Public health law titled the Health Insurance Portability and Accountability Act of 1996 (HIPAA) revealed that HIPAA is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule which is a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Privacy Rule standards address the use and disclosure of individuals' health information-called protected health information. Review of the facility policy titled Transmission-based Precautions last revised June 20, 2023, revealed that the Infection preventionist will identify the type of transmission-based precautions and notification will be placed on the residents doors to which transmission based precaution is implemented, the selection and use of personal protective equipment (PPE), and the clinical conditions for which specific PPE should be used. Observation of the facility Second floor nursing unit on February 27, 2023 at 10:40 a.m. revealed residents rooms: 404, 419, 420, 422, and 428 with a red colored sign hanging on the outside of the doors for everyone to see, which revealed the residents occupying those rooms were identified as being covid positive. Interview with Licensed nurse, Employee E18, at time of observation above, confirmed that the signs on these doors declared the residents diagnosis of covid positive. 28 Pa. Code 210.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on observations of the daily meal preparation and delivery from the Food and Nutrition Department to the nursing unit for 41 of 46 residents reviewed and interviews with staff, it was determined that the facility failed to ensure that essential resident care equipment, for the food service operation was maintained in safe operating condition. Findings include: Observations on February 27, 2024 during the noon meal service revealed that the dietary staff was not using the plate warmer according to manufacturer's recommendations. There were no lids in place above the lowerator wells. The every day china plates were stacked above the food service equipment's warming mechanism; preventing proper heating of the dishware. Observations on February 27 and March 1, 2024 during the plating of foods and beverages and assembly of meal trays; revealed that dietary staff were using opened slotted carts and opened push carts to deliver meals throughout the hallways on the nursing units and into each resident room. Observations on February 27 and March 1, 2024 of the food service equipment being used to deliver the breakfast, lunch and dinner meals for the residents eating inside their rooms, revealed that the entire thermal set of food service equipment for plating, transporting and delivery of hot foods was not available for use. There were no metal pellets as specified by the equipment manufacturer for the dietary services. Interview with the Director of Dietary, Employee E11 at 11:30 a.m., on February 27, 2024 and the dietary staff, Employees E5, E6 and E7 confirmed that the thermal heating equipment (pellets) manufactured to keep foods hot and safe during plating, transportation and delivery to each resident's room for breakfast lunch and dinner, were not being used according to manufacturer's recommendations and standards of the food service operation to ensure food service safety. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Based on clinical record reviews, interviews with staff, facility documentation, policy and procedure reviews and interviews with family members, it was determined that the facility failed to notify the resident's representative of a need to alter treatment significantly and failed to notify the resident's physician of an accident requiring physician intervention for two of 23 residents reviewed. (Residents R96 and R97) Findings include: A review of the facility policy titled Notification of Changes revealed that it was the responsibility of the facility to immediately inform each resident and/or resident representative of accidents that have the potential for physician intervention or significant changes in condition. The policy also indicated that it was the facility's responsibility to ensure that the physician was immediately notified of an accident that had the potential for requiring physician intervention. The policy said that the physician was to be notified immediately of a significant change in physical, mental and psychosocial status of the resident. Clinical record review for Resident R96 revealed that this resident was admitted to the facility on [DATE]. The nursing progress note indicated that Resident R96 had poor cognitive status. The nurse indicated that the resident's diagnosis upon admisssion was CVA (cerebral vasculer accident) with right sisded weakness and aphasia (a loss or impairment of one's capacity to use or comprehend language, which is most commonly caused by injury to a specific area in the brain). Clinical record review on February 13, 2024 indicated that Resident R96 received testing for the virus that causes COVID-19 and the test results were positive. The nursing progress note on February 13, 2024 indicated that interventions were significantly changed for Resident R96 to include taking transmission based precaustions when providing care or visiting this resident. The nursing progress note dated February 15, 2024 indicated that Resident R96 had a persistent cough. Interview with Resident R96's responsible party/family member at 1:00 p.m., on February 27, 2024, revealed that the family member was not notified of the need to alter Resident R96's treatment and care due to the fact that Resident R96 was diagnosed as being positive for the virus that causes COVID-19 on February 13, 2024. The family member reported visiting the facility on February 14, 2024 and having to ask nursing staff, the medical status of Resident R96. Interview with Employee E2, the Director of Nursing, at 9:00 on February 28, 2024 confirmed that the facility had no documentation to indicate that the responsible party for Resident R96 was notified of a significant change (postive results for COVID-19 testing) or change in medical status on February 13, 2024. Clinical record documentation for Resident R97 indicated that this resident was admitted to the facility on [DATE] and had diagnoses of osteoporosis (brittle bones), rheumatoid arthritis(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm). Clinical record review for Resident R97 revealed that the resident reported to the Licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024, at approximately 6:00 p.m. The nursing assistant responsible for this resident reported that she was clearing a path or clearing the room to the resident's bed, when she saw the resident fall in the bathroom. Review of facility's investigation of alleged abuse, neglect and misappropriation of property dated February 8, 2024 indicated that the nursing assistant assigned to provide care to Resident R97 failed to report to the licensed nurse that Resident R97 experienced a fall on February 7, 2024. The fall occurred in the bathroom on February 7, 2024 for Resident R97. After the fall occurred, the nursing assistant responsible for Resident R97 asked another nursing assistant to assist the resident from the floor and they placed Resident R97 into the wheelchair and into bed on February 7, 2024. Continued review of the faciltiy's investigation revealed that the resident's incident/accident was consequently not reported to the physician, by the licensed nurse, on February 7, 2024, for required intervention post fall. The investigation report form indicated that the facility was not aware of any incident/accident for Resident R97 until the resident reported the incident on February 8, 2024. Interview with the Director of Nursing, Employee E2, on February 29, 2024 confirmed that lack of notification of the physician of an incident/accident (fall) involving Resident R97 on February 7, 2024. Employee E2, Director of Nursing also confirmed that the lack of notification of the physician, resulted in a delay of assessment, monitoring and potential treatment for Resident R97. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review, staff interview, review of facility policies, and review of facility documentation, it was determined that the facility failed to ensure that Resident R29 was free from neglect related to a Registered Nurse failing to immediately assess the resident after being notified of a fall sustained by the resident. Facility staff transferred the resident off the ground to the bed without an assessment from a Registered Nurse for possible injuries, causing the resident to scream with pain. The facility ' s failure to complete a timely assessment for Resident R29, resulted in harm, when the resident experienced pain and a delay in treatment for one of 17 residents reviewed. (Resident R29) Findings include: Review of facility policy, Abuse Policy - Prevention, Investigation, Reporting dated March 29, 2022, revealed that, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials. Review of facility policy Fall Management Program last revised My 13, 2022, revealed: Definition of a Fall per the RAI Manual: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (i.e. onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Review of facility documentation reported to the Department of Health on February 27, 2023, revealed: . resident had a fall on 2/26/2023 at around 0500am . Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had a history of falls/injury and was unaware of safety needs. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing) supervisor made aware. Review of the next available nursing note dated February 26, 2023, at 1:02 p.m. revealed Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l (bilateral) knees, R. (right) L (left), no bruising or erythema noted. Resident medicated for pain. The resident's physician was contacted and orders were obtained for X-ray to bilateral knees and left hip. Review of a Nursing note dated February 26, 2023 at 1:02 p.m. revealed: Resident moaning, pointing to left inner thigh, stating it hurts. Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l knees, R>L, no bruising or erythema noted. Resident medicated for pain asper PRN order an lidocaine patches placed to b/l knee with some relief noted. Call out to [Doctor's Office], spoke with on call physician . Order given, readback and verified for X-Ray to B/L knee and Left hip. Resident resting comfortably in chair, will continue to monitor. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcaptial left femoral (hip) neck. Orders were obtained for the resident to be transferred to the local hospital for evaluation. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was readmitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Review of a witness statement, by Nurse aide, Employee E11, dated February 27, 2023, revealed I was doing my rounds and I heard someone screaming and I stopped to listen I didn't hear anything so I kept on to the next room so when I came out the room I heard screaming again but this time the nurse was out in the hall and I asked her did she hear so we start looking for where the noise was coming from so the nurse went into [Resident R29] room . she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said of the nurse walk out the room told the nurse supervisor so I got [Resident R29] back in bed. Interview on April 21, 2023, 1:45 p.m. with nurse aide, Employee E11, confirmed that she was a nurse aide assigned to Resident 29 and that she found Resident R29 wrapped up in a blanket rolled over her floor mattress and screaming for help. The resident bed was in low position, Resident R29 complaint of her pain in her leg, there was no bleeding, bruising. I told the nurse we need to send her out. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Interview on April 21, 2023, at 10:04 a.m. with Licensed Practical Nurse, Employee E9, confirmed that she was a nurse assigned to Resident 29 on night shift of February 25, 2023. Employee E9 confirmed Resident R29 was laying on stomach, and away from the floor mat on the bare floor. That she did a brief assessment and went to Registered Nurse, Supervisor, Employee R15. I advised her that Resident R29 was found on the floor. The RN, Supervisor, Employee E15 told me that we're not doing an incident report. I went back to ROM of upper extremity/lower extremity arms and leg and lifted her up to standings position and transferred her to bed. I cannot give an explanation why there's no documentation in the resident's clinical record. I did not notify the coming nurse of the possible unwitnessed fall. Review of a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms. On April 20, 2023, at 2:23 p.m. an interview was held with Nursing Home Administrator (NHA) and Director of Nursing (DON) who reported that based on the video footage, Registered Nurse Supervisor, Employee E15 did not go into the resident's room to assess the resident and failed to report the incident, investigated the allegation, and make any documentation in the clinical report of Resident 29. Interview on March 15, 2023, at 9:15 a.m. the Nursing Home Administrator (NHA) confirmed that RN Supervisor, Employee E15, was terminated for neglect related to not reporting and investigating an unwitnessed fall for Resident R29. The facility failed to ensure that Resident R29 was free of neglect following an unwitnessed fall. This failure resulted in Resident R29 not being assessed for injuries by a Registered Nurse following the report of a fall, which resulted in Resident R29 not receiving timely medical treatment and subsequently requiring transfer to the hospital and diagnosed with a left femoral neck fracture. Refer to F684 and F658 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, review of personnel files, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that a Licensed Practical Nurse and a Registered Nurse, maintained professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards. This failure resulted in actual harm to a resident related to a lack of a timely nursing assessment and a delay of medical care to a resident who sustained a fall which resulted in fracture of left hip which required medical intervention for one of 17 residents reviewed (Resident R29). Findings include: Review of the Pennsylvania Code Title 49, Professional and Vocational Standards, State Board of Nursing 21.11(a)(1)(2)(4) indicated that the Registered Nurse was responsible for collect complete and ongoing data to determine nursignc are needs, analyze the health status of individuals and comare the datat with the norm norm when determining care needs and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. Review of the Pennsylvania Code Title 49, Professional and Vocational Standards, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) revealed, The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. Continued review revealed, An LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when . the patient's condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable, or the patient needs immediate assistance. Review of Licensed Practical Nurse, Employee E9's personnel file revealed a Licensed Practical Nurse Position Description signed and dated by the Employee E9 on June 4, 2021, which indicated that essential job duties included ensuring that documents resident's progress, deterioration, changes in condition etc., as necessary Continued review revealed that, abides by both institutional and State Board of Nursing Examiners requirements in the performing of all duties. Review of Registered Nurse, Employee E15's personnel file revealed a Registered Nurse Shift Supervisor job description, signed and dated by the Registered Nurse Supervisor, Employee E15 on March 31, 2023, which indicated that essential job duties included, Investigates all incidents of unknown origin and other incidents and monitors nursing care for accurate assessment and appropriate interventions; supervises the care given to residents on assigned shift. Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had a history of falls/injury and was unaware of safety need. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing)_ supervisor made aware. Review of the next available nursing note dated February 26, 2023, at 1:02 p.m. revealed Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l (bilateral) knees, R. (right) L (left), no bruising or erythema noted. Resident medicated for pain. The resident's physician was contacted and orders were obtained for X-ray to bilateral knees and left hip. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcaptial left femoral (hip) neck. Orders were obtained for the resident to be transferred to the local hospital for evaluation. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was readmitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Review of a witness statement, by Nurse aide, Employee E11, dated February 27, 2023, revealed I was doing my rounds and I heard someone screaming and I stopped to listen I didn't hear anything so I kept on to the next room so when I came out the room I heard screaming again but this time the nurse was out in the hall and I asked her did she hear so we start looking for where the noise was coming from so the nurse went into [Resident R29] room . she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said of the nurse walk out the room told the nurse supervisor so I got [Resident R29] back in bed. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM (range of motion) of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Review a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms.' On April 20, 2023, at 2:23 p.m. an interview was held with Nursing Home Administrator (NHA) and Director of Nursing (DON) who reported that based on the video footage, RN Supervisor Employee E15 did not go into the resident's room to assess the resident and failed to report the incident, investigate the allegation, and make any documentation in the clinical report of Resident R29. Registered Nurse, Supervisor, Employee E15 was terminated. Review of documentation by the facility, revealed that Licensed nurse, Employee E9 and CNA, Employee E11 found Resident R29 on her floor on February 26, 2023, approximately at 5:00 a.m. Based on the facility investigation the unwitnessed fall was communicated to the RN, Supervisor Employee E15 who failed to assess the resident, failed to investigate, and document the incident. Resident R29 fell and sustained significant injury of an acute fracture of the sub capital left femoral beck with proximal migration of the distal fragment with no dislocation which required a medical intervention a surgery. Licensed nurse, Employee E9 and Registered Nurse, Supervisor Employee E15 failed to document an unwitnessed fall, investigate the incident which delayed medical treatment from 5:00 a.m. to 1:00 p.m. on February 26, 2023, which resulted in Resident R29 being neglected. Therefore, allegation of neglect is substantiated against Licensed nurse, Employee E9 and Registered Nurse, Supervisor Employee E15 Interview on March 15, 2023, at 9:15 a.m. the Nursing Home Administrator (NHA) confirmed that RN Supervisor, Employee E15 was terminated for neglect related to not reporting and investigating an unwitnessed fall for Resident R29. Licensed Practical Nurse, Employee E9, failed to maintain professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members when Resident R29 had a unwitnessed fall as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards. which resulted in harm to the resident related to a lack of a timely nursing assessment and a delay of medical care to the resident. Registered Nurse Supervisor, Employee E15 failed to maintain professional standards of quality care, established by essential job requirements, to completed an assessment of Resident R29 after receiving a report of an unwitnessed, investigate the accident, and changes in resident condition as set forth by Chapter 21.1 Practice of professional nursing. This failure resulted in actual harm to Resident R29 related to a lack of timely nursing assesment and a delay on medical care to the resident. Refer to F600 and F684. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Based on clinical record review, review of personnel files, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that a Licensed Practical Nurse and a Registered Nurse, maintained professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards. This failure resulted in actual harm to a resident who sustained a fall in which the facility failed to provide a timely nursing assessment causing undue pain and delay in medical care for a left hip fracture for one of 17 residents reviewed (Resident R29).

Based on clinical record review, staff interview and review of facility documentation, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not having a Registered Nurse assess Resident R29 following an unwitnessed fall causing undue pain and a delay in care and treatment. Resident R29 did not have an x-ray report read until 23 hours and 10 minutes from the initial fall for one of 20 residents reviewed. The lack of assessment caused actual harm, undue pain and delay in care to Resident R29 who was diagnosed with a left femoral neck fracture, for one of 17 residents reviewed. (Resident R29) Findings include: Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had history of falls/injury and was unaware of safety need. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing)_ supervisor made aware. Review of the next available nursing note dated February 26, 2023, at 1:02 p.m. revealed Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l (bilateral) knees, R.L, no bruising or erythema noted. Resident medicated for pain. The resident's physician was contacted and orders were obtained for X-ray to bilateral knees and left hip. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcapital left femoral (hip) neck. Orders were obtained for the resident to be transfer to the local hospital for evaluation. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was readmitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Review of a witness statement, by Nurse aide, Employee E11, dated February 27, 2023, revealed I was doing my rounds and I heard someone screaming and I stopped to listen I didn't hear anything so I kept on to the next room so when I came out the room I heard screaming again but this time the nurse was out in the hall and I asked her did she hear so we start looking for where the noise was coming from so the nurse went into [Resident R29] room . she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said of the nurse walk out the room told the nurse supervisor so I got [Resident R29] back in bed. Interview on April 21, 2023, 1:45 p.m. with nurse aide, Employee E11, confirmed that she was a nurse aide assigned to Resident R29 and that she found Resident R29 wrapped up in a blanket rolled over her floor mattress and screaming for help. The resident bed was in low position, Resident R29 complaint of her pain in her leg, there was no bleeding, bruising. I told the nurse we need to send her out. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Interview on April 21, 2023, at 10:04 a.m. with Licensed Practical Nurse, Employee E9, confirmed that she was a nurse assigned to Resident 29 on night shift of February 25, 2023. Employee E9 confirmed Resident R29 was laying on stomach, and away from the floor mat on the bare floor. That she did a brief assessment and went to Registered Nurse, Supervisor, Employee R15. I advised her that Resident R29 was found on the floor. The RN Supervisor, Employee E15 told me that we're not doing an incident report. I went back to ROM of upper extremity/lower extremity arms and leg and lifted her up to standings position and transferred her to bed. I cannot give an explanation why there's no documentation in the resident's clinical record. I did not notify the coming nurse of the possible unwitnessed fall. Review a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms. The facility failed to properly assess Resident R29 following a an unwitnessed fall. This failure resulted in actual harm to Resident R29 who did not receive medical treatment for a period of 8 hours (5:00 a.m. to 1:00 p.m.) on February 26, 2023, required transfer to the hospital and was diagnosed with a left femoral neck fracture. Refer to F600 and F658. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records and facility documentation, observations and interviews with staff, it was determined that the facility failed to provide adequate supervision for two of 22 residents reviewed which resulted in actual harm, for two residents, in the form of a subarachnoid hemorrhage to one resident (Resident R1) and a fractured arm to another resident (Resident R32). Findings include: A review of Resident R1's clinical record revealed that the resident was admitted to the facility on (MONTH) 20, (YEAR), with diagnoses, including but not limited to, abnormalities of gait and mobility, [MEDICATION NAME] degeneration ([MEDICAL CONDITION] disorder of the retina resulting in progressive loss of vision) and dementia (irreversible, progressive [MEDICAL CONDITION] disease of the brain, resulting in loss of reality contact and functioning ability). The clinical record further indicated that the resident is [AGE] years old, severely impaired in decision making skills and propels around the facility in a wheelchair. Review of nurse's notes dated (MONTH) 4, 2019 revealed that Resident R1 was observed removing a small bingo chip from her mouth. Staff were advised to observe the resident more closely. Review of a follow-up nurse's note dated (MONTH) 5, 2019 stated resident observed, no concerns. No other documentation related to resident observations was noted. Continued review of the clinical record for Resident R1 revealed nurse's notes dated (MONTH) 24, 2019, which revealed that at 9:00 a.m. Resident R1 was found on the floor in the main dining room. Clinical documentation indicated that staff stated they did not see the fall just heard the fall. The resident was found lying on her face, slightly to the right side, the wheelchair was behind her. The resident was unable to state what occurred. The resident had an abrasion/skin tear to the center of her forehead measuring 2 centimeters by 3 centimeters, and a bruise to left shin. Review of facility documentation regarding Resident R1's fall of (MONTH) 24, 2019, revealed an intervention for staff to monitor the resident while in the dining room more closely related to the resident picking up things off the floor that she believes are there. Review of a progress note dated (MONTH) 28, 2019 revealed that the resident sustained [REDACTED]. Continued review of facility documentation revealed that on (MONTH) 15, 2019 at 3:30 p.m. Resident R1 had been participating in activities in the clubhouse room (activities room) down the hall from the nurse's station. At 4:40 p.m. the resident was found face down in front of her wheelchair in the clubhouse room by a nurse's aide. Facility documentation further indicated that the resident was rolled over and found to have a laceration and a hematoma (a swelling of blood that forms as the result of a broken vessel) on the right side of her forehead which was bleeding. The resident complained of pain. The physician was notified and ordered that the resident be sent to the hospital. Further review of facility documentation titled fall incident, dated (MONTH) 15, 2019 revealed that following the fall, the resident complained of left ankle pain, right hip pain and head pain when touched. 9-1-1 was called. A review of nurse's note dated (MONTH) 16, 2019 revealed that the resident returned from the hospital, post fall, with a [DIAGNOSES REDACTED]. A review of a witness statement by Employee E6, nursing assistant, revealed that on (MONTH) 15, 2019, at 4:45 p.m. she and another nursing assistant entered the activity room to assist residents to the dining room for dinner. They saw that Resident R1 was face down on the floor and called the nurse immediately. A review of staff witness statements regarding Resident R1's fall on (MONTH) 15, 2019, revealed a statement from Employee E5, activity aide, dated (MONTH) 16, 2019, which indicated that the employee had started the activity program approximately 2:00 p.m The program include: music, sensory, memory game and a discussion about the fire in Paris. The program ended at approximately 3:45 p.m.-3:50 p.m Employee E5 further indicated that when the activity was over all the residents were left in the clubhouse room with music and aroma therapy. Interview with Employee E5, activity aide, on (MONTH) 30, 2019 at 11:00 a.m. confirmed that she left seven residents (Residents R1, R2, R5, R15, R20, R30, and R31) alone in the clubhouse room (activity room) on (MONTH) 15, 2019, following an activity. She stated that no one informed her that Resident R1 was a fall risk and she stated that she always leaves the residents in the activity room with music and aroma therapy. Interview with Employee E8, Director of Activities, on (MONTH) 30, 2019 at 11:30 a.m. further confirmed that seven residents had been left unattended in the clubhouse after an activity was over. A review of clinical records for Residents R2, R5, R15, R20, R30 and R31 revealed that all six residents who had been left alone in the activity room on (MONTH) 15, 2019, had been identified with severe cognitive impairments. Further review of the clinical records for residents R2, R5, R15, R20, R30 and R31 revealed that all six of the residents had been identified with symptoms of confusion and/or poor balance and an unsteady gait. Interview with the Director of Nursing on (MONTH) 30, 201 at 1:00 p.m. confirmed that the facility did leave Resident R1 unsupervised in the activity room which resulted in the resident sustaining a traumatic subarachnoid hemorrhage from a fall. A review of Resident R32's clinical record revealed that the resident was admitted to the facility on (MONTH) 13, (YEAR), with diagnoses, including but not limited to, difficulty walking, lack of coordination and muscle weakness. Additionally, the resident has [MEDICAL CONDITION] ([MEDICAL CONDITION]-difficulty breathing) and uses oxygen via a nasal cannula (nasal prongs). The resident is independent in decision making skills. A review of the Resident R32's care plan titled potential for falls, date revised on (MONTH) 28, (YEAR), revealed that the resident was identified as at risk for falls related to respiratory disease, poor balance, attached oxygen tubing and impaired vision. Interventions to reduce the risk of falling to the resident included, but were not limited to, bathroom assistance, appropriate foot wear, call bell within reach, and environment free of clutter. A review of a fall risk assessment for Resident R32 dated (MONTH) 13, (YEAR) revealed that the resident has poor balance and unsteady gait, uses a wheelchair and equipment such as oxygen. The resident also has impaired vision and hearing. Are fall interventions recommended? Yes. Describe fall interventions: bed in low position, call bell with in reach and the resident is encouraged to wait for assistance. A review of nurse's notes date (MONTH) 30, (YEAR) revealed that the resident was found on the floor, lying on her back. The resident stated she was at the sink bushing her hair and must have tripped on the oxygen cord. Resident complained of pain (did not state where) and was sent to the hospital. The resident returned from the hospital the same day with a fracture (broken bone) of the right proximal humerus (right upper arm). Immobilizer in place. A review of facility documentation titled fall incident, dated (MONTH) 30, (YEAR), stated, indicate causative factors related to fall: the residents oxygen tubing was the causative factor as stated by the resident as to why she fell . Indicate any new care plan interventions: resident sent to the hospital. Observation of Resident R32 on (MONTH) 26, 2019 at 9:00 a.m. revealed the resident sitting in her wheelchair in her room. Continued observation of Resident R32 revealed the oxygen tubing around her ankles. The resident observed this also and removed the tubing from around her ankles. Interview with Employee E9, Director of Rehabilitation, on (MONTH) 30, 2019 at 9:05 p.m. and Employee E12, occupational therapist, confirmed that the oxygen tubing had not been updated in the care plan. Employee E12 further stated that she did verbally tell staff working with Resident R32 to use a shorter oxygen tubing when the resident was using an oxygen tank. The facility failed to provide adequate supervision and monitoring of two residents which resulted in actual harm to the residents. Resident R1 sustained a subarachnoid hemorrhage and Resident R32 sustained a fractured arm. 42 CFR 483.25 (d)(1)(2) Free of accident hazards/supervision/devices. Previously cited 3/12/18. 28 Pa. Code:211.10(d) Resident care policies. Previously cited 3/12/18 28 Pa. Code:211.12 (d)(1)(5) Nursing services.