Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that residents were free from neglect which resulted in harm as evidenced by a fall with fracture for one of five residents reviewed (Resident 3). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated January 16, 2025, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. The care plan for Resident 3, dated June 2, 2023, for a self-care performance deficit related to limited mobility included interventions for two assist with bed mobility. An occupational therapy note for Resident 3, dated for the certification period of May 2 to May 31, 2025, indicated that Resident 3 was dependent and in need of two assist for toileting hygiene. A nursing note for Resident 3, dated May 6, 2025, at 6:49 a.m., revealed that Registered Nurse 1 was called to the room where the resident was found on the floor between the beds. She was face down moaning in pain and was rolled onto her back with the support of three staff. A registered nurse assessment at that time revealed that there was bleeding and bruising to the nose and right side of the face, as well as skin tears to the right elbow and right shin. The resident was sent to the emergency room for evaluation. An emergency room X-ray report for Resident 3, dated May 6, 2025, at 10:59 a.m., revealed a nondisplaced fracture of the third digit of the right hand. An incident report for Resident 3, dated May 6, 2025, at 5:52 a.m. revealed that Nurse Aide 2 was in the resident's room providing incontinent care when the resident shifted her weight causing her to slip through the aide's arms and roll onto the floor between the beds. Nurse Aide 2 performed care by herself and did use a two person assist. A witness statement, dated May 6, 2025 at 5:52 a.m., revealed that the Nurse Aide 2 was removing Resident 3 from the bedpan when the resident shifted her weight and slid through her hands and off the bed. She indicated that the RN and other aide were in another room attending to a resident at that time. She went on to say that she was trying to get Resident 3 settled in time for the other aide to leave at 6:30 a.m., because at that time she would be by herself. In addition, she indicated that the resident was wanting to get off the bedpan as soon as possible. A fall investigation form, dated May 6, 2025, submitted at 3:24 p.m., indicated that one staff person was providing care at the time of the fall. Interview with the Director of Therapy on May 29, 2025, at 3:15 p.m. indicated that at the time of Resident 3's fall, she was a maximum assist of two for bed mobility. She went on to say that during the facility's morning meeting on the day of the fall, the Director of Nursing indicated that Resident 3 was to be an assist of two while removing the bedpan and not one. Interview with Resident 3 on May 29, 2025, at 3:25 p.m. indicated that on the day of the fall, the aide tilted her and she went off the bed. Additionally, she indicated that the there is usually two staff in the room assisting with her care. Interview with the Director of Nursing on May 29, 2025, at 6:14 p.m. confirmed that there should have been two nursing assistants providing care to Resident 3 while removing her from the bedpan. Nurse Aide 2 did not follow the resident's plan of care for a two person assist resutling in a fall from bed and a fracture. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, staff interviews, and investigation reports, it was determined that the facility failed to ensure that a safe environment was provided for one of five residents reviewed (Resident 3) resulting in a fall with fracture. Findings include: The facility's policy regarding fall prevention, dated January 16, 2025, revealed that the facility was to provide an environment that is free from accident hazards over which the facility has control, and provide supervision to prevent avoidable accidents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 16, 2025, indicated that the resident was cognitively intact, could understand and was understood. Nurse aide documentation revealed that Resident 3 was an extensive assist of two for bed mobility and toileting at the time of the fall. The care plan for Resident 3, dated June 2, 2023, for a self-care performance deficit related to limited mobility included interventions for two assist with bed mobility. An occupational therapy note for Resident 3, dated for the certification period of May 2 to May 31, 2025, indicated that Resident 3 was dependent and in need of two assist for toileting hygiene. A nursing note for Resident 3, dated May 6, 2025, at 6:49 a.m., revealed that Registerd Nurse 1 called to the room where the resident was found on the floor between the beds. She was face down moaning in pain and was rolled onto her back with the support of three staff. A registered nurse assessment at that time revealed that there was bleeding and bruising to the nose and right side of the face, as well as skin tears to the right elbow and right shin. The resident was sent to the emergency room for evaluation. An emergency room X-ray report for Resident 3, dated May 6, 2025, at 10:59 a.m., revealed a nondisplaced fracture of the third digit of the right hand. An incident report for Resident 3, dated May 6, 2025, at 5:52 a.m. revealed that Nurse Aide 2 was in the resident's room providing incontinent care when the resident shifted her weight causing her to slip through the aide's arms and roll onto the floor between the beds. A witness statement, dated May 6, 2025 at 5:52 a.m., revealed that Nurse Aide 2 was removing Resident 3 from the bedpan when the resident shifted her weight and slid through her hands and off the bed. She indicated that the RN and other aide were attending to another resident at that time. A fall investigation form, dated May 6, 2025, submitted at 3:24 p.m., indicated that one staff person was providing care at the time of the fall. Interview with the Director of Therapy on May 29, 2025, at 3:15 p.m. indicated that at the time of Resident 3's fall, she was a maximum assist of two for bed mobility. She went on to say that during the facility's morning meeting on the day of the fall, the Director of Nursing indicated that Resident 3 was to be an assist of two while removing the bedpan and not one. Interview with Resident 3 on May 29, 2025, at 3:25 p.m. indicated that on the day of the fall, the aide tilted her and she went off the bed. Additionally, she indicated that the there is usually two staff in the room assisting with her care. Interview with the Director of Nursing on May 29, 2025, at 6:14 p.m. confirmed that there should have been two nursing assistants providing care to Resident 3 while removing her from the bedpan. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's physician orders to prevent worsening of a non-pressure skin condition for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, was dependent on staff for transfers, and needed assistance of two staff members for daily care needs. Resident 2 had diagnoses of kyphosis, cervical region (spine curves toward the front of the body) and general muscle weakness. Physician's orders for Resident 2, dated July 19, 2023, indicated to thoroughly cleanse MASD (moisture-associated skin damage) to the right clavicle (collar bone) and right neck/chest excoriation (scraped or abraded) with soap and water, dry well, apply DermaCol/Ag (a wound care dressing made of collagen and sodium alginate) to wound, and moisten wound bed with sterile water if needed to begin healing process. Cover the wound with optifoam gentle (a soft foam dressing that can be easily removed) and apply and an old pillow case length wise around the neck to separate every evening shift. Due to the location on the right clavicle area of the MASD, Resident 2's saliva and drool would accumulate causing the moisture. A non-pressure skin assessment was completed on July 24, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.0 x 2.0 x 0.1 cm in size. The surrounding skin was intact and a small amount of serous red/pink drainage with an odor was noted to be present. A nursing note for Resident 2, dated July 25, 2023, at 5:30 a.m. revealed that Resident 2 complained to the CNA that her neck was very sore and stinky. The nurse went to the room and ask the resident what was wrong. The resident stated that her neck had not been done for three days. The nurse removed the old dressing from her neck, which was dated from Friday, July 21, 2023. There was a cottage cheese-like exudate under the neck fold with a foul odor and the wound dressing was dried to the wound bed on her collar bone. The treatment was performed per orders. The treatment was signed as administered for July 22, 23, and 24, 2023. The dressing that was dried to the wound was dated July 21, 2023. The Director of Nursing was made aware via paper statement and provided with the old dressing for viewing. The physician and responsible party were made aware and the registered nurse completed a non-pressure skin assessment. A non-pressure skin assessment was completed on July 25, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.0 x 3.0 cm in size. The surrounding skin was intact with redness noted and a small amount of serous sanguineous drainage (a thin water fluid that is pink in color due to small amounts of red blood cells) with an odor was noted. A nursing note for Resident 2, dated July 26, 2023, at 9:17 p.m., revealed that there was a small to moderate amount of bleeding noted at dressing change. The resident had pain at the site, which is not her normal. Resident 2 was medicated for pain with positive effect and registered nurse was made aware. A nursing note for Resident 2, dated July 26, 2023, at 11:25 p.m., reveled that the registered nurse was made aware of the bleeding during dressing change and that the resident was medicated for pain with positive effect. Resident 2's vital signs were within normal limits. However, the resident was noted to have slight confusion during the shift. She was unable to recall recent events and who her care takers were. The resident was not in acute distress, and the Certified Registered Nurse Practioner (CRNP) was notified. A non-pressure skin assessment was completed on July 27, 2023, and indicated that Resident 2's non-pressure area on the right clavicle measured 2.5 x 3.5 cm in size. The surrounding skin was intact with redness and increased drainage. A nursing note for Resident 2, dated July 28, 2023, at 1:37 p.m., revealed that Resident 2's MASD was noted to be larger with increased drainage (odor is fungal in nature), and the wound nurse was consulted via live streaming video for recommendation. The wound nurse recommended to cleanse daily with soap and water, apply silver alginate to the wound bed, and cover with optifoam to absorb moisture. All parties were made aware of change and CRNP the approved changes. The facility's investigation determined that Licensed Practical Nurse 1 gave a verbal statement to the Director of Nursing on July 25, 2023. She stated that she forgot to do Resident 2's treatment on July 24, 2023. She stated that the hall is crazy and she had trouble remembering. She stated that it only happened on July 24, 2023. She did not give an explanation for the other two nights of missing the treatment. She stated that she writes her treatments down and then clicks them off before doing them. She stated that she knows that is not the proper procedure for administration of treatments. She also stated that she thought the treatment was twice a day. Licensed Practical Nurse 1 did not want to write down her statement. After giving a verbal statement to the Director of Nursing, Licensed Practical Nurse 1 was escorted out of the building after notification of her suspension. Interview with the Director of Nursing on August 2, 2023, at 3:30 p.m. confirmed that Licensed Practical Nurse 1 failed to administer Resident 2's treatment to right clavicle as ordered on July 22, 23, and 24, 2023, and documented that she did. Resident 2's non-pressure wound did increase in size and neglect was substantiated. Licensed Practical Nurse 1 was terminated for negligence and falsifying documentation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that two of 39 residents reviewed (Residents 22, 67) were free from sexual abuse perpetrated by another resident (Resident 296). Findings include: The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated February 9, 2023, revealed that each resident was afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Sexual abuse was non-consensual sexual contact of any type with a resident. Sexual abuse includes unwanted intimate touching of any kind especially of breast and perineal area and forced observation of masturbation. Sexual contact was non-consensual when the resident lacks the cognitive ability to consent or does not want the contact to occur. A nursing note for Resident 296, dated March 1, 2023, at 10:25 p.m. revealed that the resident made multiple sexual comments towards nursing staff during the evening shift. Nursing staff attempted to redirect the resident and inform him that this kind of language and comments are not necessary and are inappropriate. Redirection was unsuccessful. A social services progress note for Resident 296, dated March 2, 2023, at 11:31 a.m. revealed there was an attempt to follow up with the resident about the comments that he made to nursing staff last night and if he said anything inappropriate, and he denied any such comments. A behavior care plan for Resident 296 was developed on March 2, 2023, and included interventions to discuss the resident's behavior. If he is reasonable, explain/reinforce why the behavior is inappropriate and/or unacceptable to the resident, redirect resident to positive conversation when he starts to make inappropriate comments, and remind the resident to use appropriate language if he starts swearing. The care plan was updated on March 6, 2023, to include frequent visualization of the resident. A nursing note for Resident 296, dated March 6, 2023, at 1:44 p.m. revealed that he had been using sexually explicit and violently motivated language. The medical doctor was notified and orders were requested. A social service note for Resident 296, dated March 7, 2023, at 6:69 a.m. (as a late entry note for March 3, 2023) revealed that Resident 296 had been in the hallway saying/yelling that he was looking for his [NAME] 45 to kill people because they were trying to steal his truck. He stated he was tired of people taking advantage of him. Resident 296 was able to be redirected and was taken to his room because he did not have socks or shoes on. Resident 296 laid on the bed while he was assisted with putting socks and gripper socks on. The resident fell asleep after his socks were put on. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated January 3, 2023, revealed that the resident was cognitively impaired; was understood; could understand; and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A nursing note for Resident 67, dated March 7, 2023, revealed that at approximately 3:20 a.m. Resident 296 forcefully asserted himself (was sexually aggressive) toward Resident 67 while she was sleeping. A social services note, dated March 10, 2023, revealed that Resident 67 was seen as a follow up to the recent event with another resident. Resident 67 indicated that she felt down and was unsure why she felt that way but did not accept any assistance from the social worker. Interview with Resident 67 on March 28, 2023, revealed that she did not know the resident that came into her room, but he climbed on top of her and fondled her. She said it was scary, and she told him to get off of her or she was going to kick him in the face. A quarterly MDS for Resident 22, dated February 27, 2023, revealed diagnoses that included dementia, anxiety and major depressive disorder; was confused; required assistance for care; and used a walker as a mobility device. A nursing note for Resident 22, dated March 7, 2023, revealed that at approximately 3:20 a.m. a resident forcefully asserted himself towards the resident while she was sitting by the nursing station. Interview with Nurse Aide 2 on March 28, 2023, at 11:08 p.m. revealed that she remembered the event on March 7, 2023. Nurse Aide 2 said that she heard someone calling for help and entered Resident 67's room and found Resident 296 lying half way on top of the resident. Resident 296 stated, I am going to f**k you. Nurse Aide 2 said she had to physically remove Resident 296 from on top of Resident 67, assisted him to his room where she toileted him, and put him in bed. Then she went to the nurse's station to report the incident to Nurse Supervisor 3. At that time, Resident 296 came out of his room, of his own accord, to the nurse's station where Resident 22 was sitting and the second incident occurred, but Nurse Aide 2 was not in direct sight to say what occurred. The prior shift reported that he had aggressive and agitated behaviors. Interview with the Nurse Supervisor 3 on March 28, 2023, at 11:17 p.m. revealed that Resident 296 was housed on the 100 Hall. After receiving a report of the incident, she assessed Resident 67, who was rattled and upset. When she returned to the nurse's station Resident 296 was there. Nurse Supervisor 3 considered Resident 269 a one-to-one observation, because he would carry out violent threats and harm other staff or residents. While on one-to-one, Resident 296 approached Resident 22, pulled down his pants, and started fondling himself. Resident 296 was redirected away from the resident and then directed to his room, where he remained until the ambulance arrived. Resident 296 was yelling, cursing and swearing the entire night. Information reported to the Department of Health on March 7, 2023, indicated that Resident 296 was immediately removed from the room and brought to the nurse's station. A discharge MDS for Resident 296, dated March 8, 2023, revealed that the resident was cognitively impaired and required extensive assistance with daily care activities. Resident 296 had diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrolled), cognitive communication deficit, and intellectual disabilities. The resident's care plan, dated March 2, 2023, revealed that he had behaviors related to inappropriate comments, cursing and swearing towards staff. Information reported to the Department of Health by the facility on March 7, 2023, at 3:30 a.m. revealed that Resident 296 was found in bed with Resident 67 and stated, I am going to f**k you. Both residents were clothed and Resident 296 was immediately removed from the room and taken to the nurse's station to monitor behavior. An event report, dated March 7, 2023, at 3:35 a.m., revealed that Resident 296 exposed his genitals to Resident 22 after being found on top of Resident 67. A nursing note, dated March 7, 2023, at 7:46 a.m., revealed that at approximately 3:20 a.m. Resident 296 forcefully self-asserted himself towards Residents 22 and 67, and that no injuries were noted. Resident 296 stated that he was going to shoot on-duty staff. 9-1-1 was called and resident was transported to the hospital for evaluation. There was no documented evidence in Resident 296's clinical record to indicate that new interventions were implemented to prevent further incidents of sexual abuse toward other residents and that there was no documented evidence that frequent visualizations of the resident were completed as care planned on March 6, 2023. Interviews with the Nursing Home Administrator and Director of Nursing on March 30, 2023, at 4:19 p.m. confirmed that there was no documented evidence that frequent visualizations of Resident 296 were done or that other interventions were implemented to prevent further incidents. 42 CFR 483.13 Resident Behavior and Facility Practices, 10-1-1998 Edition. 28 Pa. Code 211.12(d)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, by failing to develop and implement new interventions for fall/injury prevention for one of 39 residents reviewed (Resident 44) who had a history of falls, which resulted in a fracture; by failing to develop and implement new interventions for fall/injury prevention for one of 39 residents reviewed (Resident 56) who had a history of falls; by failing to complete a thorough investigation and assessment of falls to determine the possible cause and/or if care-planned interventions were in place at the time of the falls for one of 39 residents reviewed (Resident 68); by failing to ensure that residents were transported in a safe manner for one of 39 residents reviewed (Resident 74); and by failing to ensure that fall prevention interventions were in place as care planned for one of 39 residents reviewed (Resident 87). Findings include: The facility's policy regarding fall management, dated February 9, 2023, revealed post-fall strategies that the resident will be evaluated and post-fall care provided, will re-evaluate fall risk utilizing the Post-Fall Evaluation, will update care plan and nurse aide [NAME] (a desktop file system that gives a brief overview of each patient) with intervention(s), the interdisciplinary team will review fall documentation and complete a root cause analysis, and review fall trends monthly during QAPI. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 44, dated February 27, 2023, revealed that the resident was understood, could understand, required assistance for care, was occasionally incontinent of bowel and bladder and had diagnoses that included Alzheimer's disease, stroke, and dementia. A care plan for the resident, dated November 3, 2022, revealed that the resident had a self-care deficit. Staff was to encourage the resident with walking to and from the bathroom with a wheeled walker and a moderate assist of one and required limited assist of one staff for toileting. A care plan, dated January 12, 2023, revealed that the resident had behavior problems related to refusal of care and was non-compliant with sensor alarms to his bed and chair (will turn them off or place objects on them so the alarm will not sound or will stop sounding). Staff were to anticipate the resident's needs. A care plan, dated February 27, 2023, revealed that the resident was at risk for falls related to deconditioning, muscle weakness, and fatigue. Staff will anticipate the resident's needs, be sure the resident's call light is within reach, and encourage the resident to use it for assistance as needed. Encourage the resident to use the call bell and wait for assistance when needed. Ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in his wheelchair. Staff were to offer toileting frequently and were to have multiple urinals placed in the resident's room for the resident to have easy access for usage. A nursing note for Resident 44, dated July 3, 2022 at 8:45 p.m. revealed that at approximately 7:04 p.m. a falling star (an announcement used by the facility to inform staff when a resident has fallen) was announced to room [ROOM NUMBER]. Upon entering the resident's room the resident was sitting on his buttocks in his bathroom with his bilateral knees flexed upwards. The resident was alert and oriented to person, but otherwise confused as per his norm. The resident stated that he ambulated himself to the bathroom without the assistance of his quad cane to urinate. The resident is independent for transfers. The resident stated that he did urinate a small amount on the floor. When he attempted to ambulate back to his bed, he slipped in the urine and fell. A nursing note for Resident 44, dated August 12, 2022, at 2:50 p.m. revealed that the resident expressed increased weakness to bilateral lower extremities and was requesting assistance from staff for transfers. The resident is currently an independent transfer status. The assigned nurse aides were educated to ensure the resident has assistance when needed. A nursing note for Resident 44, dated August 19, 2022, at 3:15 p.m. revealed that a falling star was called. The resident was found kneeling on his right knee. The resident had been to the bathroom and toileted himself and reported that his right knee gave out. A therapy referral was made; however, there were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated October 19, 2022, 3:15 p.m. revealed that a falling star was called to the resident's room. He was found kneeling on his right knee. Resident 44 had been up to bathroom and toileted himself, and he reported that his right knee gave out causing him to fall. There were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated November 19, 2022, at 11:40 p.m. revealed that the resident was found sitting on the floor outside of the bathroom. The resident stated that his legs gave out and he went to his knees while ambulating to the bathroom. The care plan was updated to include verify the alarms. A nursing note for Resident 44, dated November 28, 2022, at 8:11 a.m. revealed that the resident was found lying on the floor in front of the restroom door. The resident stated that he had to use the restroom and got up unassisted. The resident's alarm did not sound. Staff made sure the alarm sounded before leaving the room. The care plan was updated to include make frequent offers to toilet. A nursing note for Resident 44, dated December 9, 2022, at 12:45 a.m. revealed that at approximately 11:00 p.m. on December 8, 2022, the nurse aide walked by the resident's room and noted that the resident was not in bed and was found sitting on the floor. The resident stated that he was walking and lost his balance. The resident was given new footwear. A nursing note for Resident 44, dated January 17, 2023, at 7:11 p.m. revealed that the resident had a unwitnessed fall in his room during shift change at 7:00 p.m. Staff heard a bang in the resident's room and responded finding the resident sitting on his buttocks beside his bed. The resident reported that he hit his head during the fall. The resident stated he had to piss. There was a urinal on the other side of his bed. The alarm on his wheelchair was turned off. The resident has a long history of non-compliance and turning alarms off and not waiting or calling for assistance. The wheelchair alarm was turned back on and another urinal was provided. The care plan was updated to include for the resident to have multiple urinals. A nursing note for Resident 44, dated February 27, 2023, at 9:42 p.m. revealed that at approximately 8:30 p.m., upon entering the room, the resident was found lying on the floor near the walkway. The resident stated that he lost his balance and fell to the floor. The resident did not have his walker by his side. The resident did not ring his call bell. A bowel and bladder program was to be evaluated for appropriateness. However, there was no documented evidence that the bowel and bladder evaluation was started until March 10, 2023. A nursing note for Resident 44, dated March 10, 2023, at 6:02 p.m. revealed that at approximately 5:50 p.m. the resident had a unwitnessed fall in the restroom. The resident ambulated unassisted to restroom and did not use a cane or wheelchair. The call bell was not on. The resident had non-skid socks in place. However, there were no new interventions put into place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated March 12, 2023, at 11:50 a.m. revealed that the nurse aide entered the resident's room to assist him with toileting and discovered him lying on the floor on his back between the bed and the window. The bed was in the low position and the call bell was in reach. The resident did not have gripper socks on. He reports that he was going to the restroom and was incontinent of bowel and bladder. No injuries were found; however, there were no new interventions put in place to prevent the resident from transferring unassisted. A nursing note for Resident 44, dated March 12, 2023, at 1:40 p.m. revealed that staff notified the registered nurse that the resident had a second fall. Nurse aides heard his plate crash to the floor. He was sitting on the floor between his bed and the window. He was complaining of severe pain to left hip and leg. The resident was sent to the hospital. A nursing note for Resident 44, dated March 13, 2023, at 10:16 a.m. revealed that the resident returned from the hospital at 7:00 p.m. on March 12, 2023. All scans were negative and no fractures noted. A nursing note for Resident 44, dated March 13, 2023, at 5:53 p.m. revealed that the resident was having extreme pain to left hip and leg. The physician was notified, and his reply was that he saw his x-rays and he has a fractured hip. The facility's investigation, dated March 12, 2023, revealed that Resident 44 did not ring for help and attempted to ambulate himself to the bathroom. Interview with the Director of Nursing on March 29, 2023, at 9:10 a.m. confirmed that she could not find any new interventions implemented to prevent Resident 44 from repeatedly transferring unassisted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 8, 2023, revealed that the resident was cognitively impaired, was understood and could understand, required extensive assistance with care, and had a history of falls. A care plan for Resident 56, dated April 27, 2021, revealed that the resident was at risk for falls related to deconditioning, gait balance problems, unawareness of safety needs, and non-adherence to recommendations. Staff were to anticipate and meet the resident's needs and ensure that the resident was wearing appropriate footwear and non-skid socks when ambulating or mobilizing in wheelchair. A fall investigation form, dated April 30, 2022, indicated that Resident 56 had a witnessed fall in the hallway. Resident 56's sweater was caught in the wheel of her wheelchair. The clothing got stuck and she attempted to remove it; however, the resident ended up on the floor. As a result, the intervention was to provide education to Resident 56 to ask for assistance and staff education about removing extraneous items on the wheelchair. The care plan was updated to have staff inspect the wheelchair for extraneous items on the seat or handlebars and remove any items that may pose a risk to the resident while in motion. A fall investigation form date May 28, 2022, indicated that Resident 56 had an unwitnessed fall in the bathroom. Resident 56 was found on the floor in front of the toilet. The resident said she was leaning over to clean up urine on the floor and fell from the toilet. The resident used the call bell after the fall to alert staff. As a result the intervention to provide two-hour checks at night to offer assistance to the bathroom. There was no documented evidence that two-hour checks were implemented or documented. The care plan was updated for staff to check the resident through the night and offer toileting as needed. A fall investigation form, dated June 28, 2022, indicated that Resident 56 had an unwitnessed fall in her room. She transferred herself out of bed without assistance. The investigation revealed that the grippers on her socks were worn down. The care plan was updated to include new gripper socks and to check them to ensure proper grip and replace if the grips were worn. A fall investigation form, dated July 4, 2022, indicated that Resident 56 had an unwitnessed fall in the bathroom. Resident 56 utilized the bathroom call bell and staff responded and found her on the floor. The investigation determined that the resident was non-compliant with asking staff for assistance for toileting and transfers for toilet use. An intervention to have a bathroom door alarm was added to prevent further falls. The care plan was not updated with the new intervention. Observations and interview with Licenced Practical Nurse 1 on March 29, 2023, at 2:56 p.m., revealed that there was no alarm on Resident 56's bathroom door and has not been for a while. There was no documented evidence that a bathroom alarm was added following the fall. A fall investigation form, dated October 21, 2022, indicated that Resident 56 had an unwitnessed fall in her room. Resident 56 self-transferred out of her wheelchair to her bed without assistance. The investigation revealed that she was not wearing gripper socks. As a result, staff were to provide new gripper socks. The care plan was updated to include gripper socks were to be changed daily during a.m. care. A fall investigation form, dated March 5, 2023, indicated that Resident 56 had an unwitnessed fall out of her wheelchair in her room. Upon investigation, the resident's wheelchair had items around and under the cushion of the wheelchair elevating the back of the cushion and causing a forward slope of the chair. The care plan was updated to include an intervention to remove excess items from wheelchair for safety. A fall investigation form, dated March 19, 2023, indicated that Resident 56 had an unwitnessed fall out of her wheelchair in her room. An employee statement revealed that the resident's door was closed and that the resident had closed it to open the bathroom door. An assessment revealed that the resident had on regular socks without grippers and multiple items piled up on the back of the wheelchair and seat (clothing and napkins). Staff removed excess items from the wheelchair seat for safety. Interview with the Director of Nursing on March 30, 2023, at 1:44 p.m. confirmed that the interventions of removing excess items on the wheelchair and having adequate gripper socks on were repetitive, and also confirmed that there was no evidence the bathroom door alarm was ever implemented, and no evidence that two-hour checks for toileting were implemented or documented. A quarterly MDS assessment for Resident 68, dated July 5, 2022, indicated that the resident was able to understand and be understood by others; however, he was moderately cognitively impaired and required extensive assistance from staff for his daily care tasks including with walking. The resident's care plan, dated August 12, 2022, indicated that the resident was at risk for falls related to deconditioning. Interventions on the care plan included to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, bed in low position, bilateral fall mats while in bed, bilateral pool noodles while in bed, encourage resident to ask for assistance when reaching out of bed for items, encourage resident to keep remote control within reach, ensure that the resident is wearing appropriate footwear/nonskid socks when ambulating or mobilizing in wheelchair daily, frequent visualizations related to falls, monitor for malfunctioning sensor alarm, offer nutrition at bedtime, offer the resident to be out of bed to chair when restless, offer tactile objects in an attempt to decrease agitation, use a sensor chair/bed electronic alarm, and check placement and function every shift. A nursing note for Resident 68, dated July 25, 2022, at 3:30 p.m. revealed that staff was called to the resident's room and found the resident lying on his left side on the floor in front of his bathroom door. He had socks on, but no pants or brief. The resident reported that he was trying to take himself to the bathroom. His wheelchair was in the bathroom beside the toilet and the brief was on the toilet. Resident 68's left elbow had a skin tear and the back of his head was noted to have a laceration approximately 1.5 centimeter (cm). Orders were received to send him to the hospital. There was no documented evidence that Resident 68's fall was investigated. A nursing note for Resident 68, dated August 17, 2022 at 3:20 p.m. revealed that the resident had an unwitnessed fall at 3:20 p.m. The resident was found lying on his right side in front of the bathroom door with his chair in the bathroom. The resident was visualized by staff five minutes prior in his wheelchair in the hallway self-propelling without any complaints. Staff had entered another resident's room to provide care when the fall occurred. The wheelchair alarm was on and working and non-skid socks were in place. The resident reported that he took himself to the bathroom and urinated and when he was getting back into his chair he just fell. There were no other witness statements obtained from other staff involved in the residents care that afternoon in an attempt to determine what may have caused the resident to self-transfer to the bathroom. A nursing note for Resident 68, dated October 12, 2022, at 10:05 a.m. revealed that the resident was found by the social services assistant sitting between his bed and the bathroom. He had appropriate footwear on, the call bell was in place, and the bed was in a low position, but the bed alarm was not on. The resident stated that he was trying to go to the bathroom. His bed alarm was turned off and his fall mats were not in place on the floor. There were no other statements obtained from staff who were involved in the resident's care to determine if the bed alarm was on and if the fall mats were in place. A nursing note for Resident 68, dated February 1, 2023, at 3:50 p.m. revealed that the resident had an unwitnessed fall in his room out of his bed. Staff were in another resident's room when they heard the bed alarm sound. Staff entered his room and found him on his knees beside his bed. However, the investigation did not included to see if the fall mats were in place at the time of the fall. Interview with the Director of Nursing on March 30, 2023, at 12:45 p.m. confirmed that there was no documented evidence that Resident 68's fall on July 25, 2022, was investigated and that no additional statements were obtained regarding Resident 68's falls on August 17, 2022; August 28, 2022; and October 12, 2022, and that additional statements should have been obtained from all caregivers involved in the resident's care to include when the resident was last toileted. The Director of Nursing also confirmed that the investigations were not thoroughly investigated to include if all care-planned interventions were in place at the time of the falls. A quarterly MDS assessment for Resident 74, dated February 16, 2023, indicated that the resident was severely cognitively impaired and required extensive assistance from staff for bed mobility, transfers, and locomotion on the unit. Resident 74's care plan, dated May 17, 2022, indicated that he had a deficit with self-care performance related to activity intolerance, impaired balance, limited mobility, and limited range of motion A visual/bedside [NAME] report for Resident 74, current as of March 8, 2023, revealed that bilateral leg rests were to be used on the wheelchair to provide assistance for staff with propelling. Observations of Resident 74 on March 27, 2023, at 10:46 a.m., revealed that he was sitting in his wheelchair holding on to the ice cart. At 11:20 a.m., the resident had fallen asleep and let go of the ice cart. Licenced Practical Nurse 1 proceeded to push the wheelchair from outside of room [ROOM NUMBER] to room [ROOM NUMBER] while the resident was asleep and both of the resident's feet were sliding on the ground. An interview with Licenced Practical Nurse 1 on March 27, 2023, at 11:23 a.m. revealed that Resident 74's foot rests were forgotten and he had not thought about putting the footrests on, but will make sure they were in place next time, as they should be in place for transport. Interview with the Director of Nursing on March 28, 2023, at 10:30 a.m. confirmed that footrests should have been in place before assistance was provided when a resident was unable to self-propel. An admission MDS for Resident 87, dated January 28, 2023, indicated that he was confused, required extensive assistance of two for bed mobility, extensive assist of one for transfers, limited assistance of two for ambulation in his room, and he had a history of falls. A diagnosis record for Resident 87, dated March 7, 2023, included repeated falls, unsteadiness on his feet, vascular dementia, and anxiety. A nursing note for Resident 87, dated February 23, 2023, indicated that at 12:05 a.m. he was found on the floor beside the right side of his bed and that he had rolled out of his bed. A measure to prevent future falls included fall mats to bilateral sides of the bed to be used when he was in bed. A nursing note, dated February 23, 2023, indicated that at approximately 2:30 a.m. Resident 87's alarm sounded, and he was found on the floor beside his bed. A nursing note, dated February 24, 2023, indicated that at approximately 3:35 a.m. the resident was found on the floor beside his bed and a measure to prevent further falls was to use pool noodles at the sides of the resident's bed. The plan of care for Resident 87, dated February 23, 2023, indicated that he was to have fall mats to bilateral sides of the bed. The task record for nurse aides, dated February 24, 2023, indicated that pool noodles were to be utilized at the sides of Resident 87's bed. Observations of Resident 87 while in bed on March 27, 2023, at 10:16 a.m. and March 28, 2023, at 3:45 p.m. revealed that there was a fall mat on the floor on the left side of the bed only. Observations of Resident 87 on March 29, 2023, at 10:3 a.m. revealed that he was in bed lying on his right side and there were no pool noodles noted on the sides/surface of his bed. Interview with Nurse Aide 7 on March 27, 2023, at 12:02 p.m. revealed that the resident was only to have the fall mat on the left side of the bed. Interview with Registered Nurse 8 on March 28, 2023, at 3:50 p.m. revealed that the resident was to have a fall mat on each side of the bed. Interview with the Director of Nursing on March 29, 2023 at 11:50 a.m. indicated that bilateral fall mats and pool noodles should be in place when the resident is in bed. 28 Pa. Code 211.12(d)(3)(5) Nursing services.