**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for four of nine residents reviewed (Resident 40, R42, R61, and R63). Findings include: A review of the facility Advance Directives 10/1/24 and 1/4/24, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medial or surgical treatment. A review of the medical record indicated Resident R40 was admitted to the facility on [DATE], with diagnoses that included diabetes, anxiety and high blood pressure. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R40 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R42 was admitted to the facility on [DATE], with diagnoses that included high blood pressure, muscle weakness and repeated falls. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R42 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R61 was admitted to the facility on [DATE], with diagnoses that included dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety, high blood pressure and muscle weakness. A review of the clinical record failed to reveal an advanced directive or documentation that Resident R61 was given the opportunity to formulate an Advanced Directive. A review of the medical record indicated Resident R63 was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, high blood pressure and a history of falling. A review of the clinical record failed to reveal an advance directive or documentation that Resident R63 was given the opportunity to formulate an Advance Directive. During an interview on 10/4/24, at approximately 9:20 a.m. DON and NHA confirmed that the clinical record did not include documentation that Resident R40, R42, R61, and R63 were afforded the opportunity to formulate Advanced Directives. 28 Pa. Code: 201.29(b)(d)(j) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility investigation reports, a progress note and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of eight residents (Residents R58). Findings include: Review of the facility policy Incident/ Accident Occurrence Reporting System last reviewed on 1/27/23, indicated that the facility electronic reporting system is in place to assist staff to report incidents for tracking. All incidents are to be investigated and witness statements obtained and the licensing entities notified if required. Review of the clinical record indicated that Resident R58 most recent re-admission to the facility on 8/2/23, with diagnoses which included dementia with behaviors, psychotic disturbance, mood disturbance and anxiety. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R58's plan of care indicated use of a wheeled walker and assist of one or two staff if agitated. Review of Resident R58's current Physician orders indicated the same ambulation order as identified above. Review of a progress note dated 8/28/23, indicated that Resident R58 was ambulating with a Nurse Aide in his room and lost his balance and fell against his dresser causing abrasions to his right back and left mid back requiring a treatment. During an interview on 10/11/23, at 12:20 p.m., the DON confirmed the incident was not investigated to determine if proper assistance was utilized which could have potentially prevented incident. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interviews, it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility. Findings include: Review of the facility policy Health Center Prevention and Control of Legionella last reviewed on 1/27/23, indicated that an interdisciplinary effort will be employed to prevent and control Legionella in the health centers. The environmental services department will be responsible for maintenance of the facility water sources. They will complete random testing of at least three water supply sources twice per year unless more frequent testing is deemed necessary. Review of the facility testing provided did not include any Legionella or any other water pathogens being tested for within the last year as required. During an interview on 10/12/23, at 1:48 p.m., the Nursing Home Administrator confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and /or other potential water pathogens within the facility. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management.

Based on facility policy, observations and staff interviews, it was determined that the facility failed to provide an environment that ensured personal privacy for one of one resident during a wound care obvservation (Resident R32) and confidentiality of clinical records for residents on one of three nursing units (Pine Nursing Unit). Findings include: Review of the facility policy Confidentiality of Information and Personal Privacy last reviewed on 3/1/22, indicated that the facility will protect and safeguard personal privacy and confidentiality of all resident personal and medical records. During an observation on 11/29/22, at 8:20 a.m., the Pine medication cart was placed at nurses station with the computer screen open revealing resident personal information and two papers with resident names, room numbers and personal medical information lying on top for any passerby to see. Licensed Practical Nurse (LPN) Employee E13 was behind a curtain inside a resident room. During an interview on 11/29/22, at 8:25 a.m., LPN Employee E13 confirmed that she had left the computer screen open and her resident papers uncovered allowing resident personal and medical information for any passerby to see. During an observation on 11/29/22, at 11:31 a.m., while Registered Nurse(RN) Employee E14 was performing a dressing change on Resident R32, Nurse Aide (NA) Employee E15 knocked on closed door but did not wait for response before entering room allowing for any passerby to look into room as Resident R32's privacy curtain was not pulled. During an interview on 11/29/22, at 11:33 a.m. RN Employee E14 confirmed that NA Employee E15 should not have entered without waiting for a response and allowed any passerby to see into Resident R32's room, not allowing personal privacy. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.5(b) Clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, comfortable and homelike environment for three out of eight resident rooms (Rooms 101, 104, and SC8). Findings include: The facility Quality of Life-Homelike environment policy last reviewed on 3/1/22, indicated that residents are provided with a safe, clean, comfortable and homelike environment. During a tour on 11/28/22, at 2:30 p.m. Environmental Services Supervisor Employee E2, observations found the following: -room [ROOM NUMBER] was observed unlocked, unoccupied and with no assigned resident. room [ROOM NUMBER] had no bed, no bed frame, no television, three large boxes of incontinence supplies, four large boxes of cups, one large box of Kleenex, five large boxes of gloves, five large boxes of wipes. -room [ROOM NUMBER] was observed unlocked, unoccupied and with no assigned resident. room [ROOM NUMBER] had four oxygen concentrators, four fall mats, a linen cart, two mattresses, and three wheelchairs. During an interview on 11/29/22, at 2:39 p.m. Environmental Services Supervisor Employee E2, confirmed that the facility failed to provide a clean, comfortable and homelike environment for three out of eight resident rooms (Rooms 101, 104, and SC8). During a tour on 11/30/22, at 9:40 a.m. Licensed practical nurse (LPN) Employee E4, observations found the following: -Room SC8 was observed unlocked, unoccupied and with no assigned resident. Room SC8 had a metal bed frame with no mattress on it, a clean linen cart, five wheeled walkers, one rollator, and one wheelchair. During an interview on 11/30/22, at 9:40 a.m. LPN Employee E4, confirmed that the facility failed to provide a clean, comfortable, and homelike environment for SC8. 28 Pa. code: 207.2 (a) Administrator's Responsibility.

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to notify residents/resident representatives of their right to file anonymous grievances through postings in prominent locations throughout the facility, provide grievance forms for anonymous grievances, and provide grievance collection boxes for anonymous grievances in three of three units (Dogwood Lounge, Pine Hall and the Special Care Unit). Findings include: Review of facility policy titled Health Center Resident Grievance (Complaint) Policy last reviewed on 11/22/22, indicated the community's health center Nursing Home Administrator will assign a Grievance official who is responsible for overseeing the Grievance process. Review of facility policy titled Grievance Procedure last reviewed 3/1/22, indicated an anonymous concern/complaint can be made by completing a a form and placing it in the concern box located in the Dogwood Lounge. During an observation on 11/28/22, at 9:20 a.m. the Dogwood Unit grievance form wall bin did not contain grievance forms for filing an anonymous grievance. During an interview on 11/28/22, at 9:25 a.m. Activities staff Employee E5 confirmed grievance forms for anonymous grievances were not available in the Dogwood Lounge. During an observation on 11/30/22, at 8:55 a.m. the Pine Hall Unit did not have a grievance procedure posting, grievance forms, or a grievance collection box available to file an annoymous grievance. During an interview on 11/30/22, at 9:10 a.m. Nursing Assistant Employee E6 confirmed the Pine Hall Unit did not have a grievance procedure posting, grievance forms, or a grievance form collection box available to file an anonymous grievance. During an observation on 11/30/22, at 9:10 a.m. the Special Care Unit did not have a grievance procedure posting, grievance forms, or a grievance collection box available to file an annoymous grievance. During an interview on 11/30/22, 9:10 a.m. Licensed Practical Nurse Employee E4 confirmed the Special Care Unit did not have a grievance procedure posting, grievance forms, or a grievance form collection box available to file an anonymous grievance. During an interview on 11/30/22, at 10:00 a.m. Social Service Director and Grievance Official Employee E7 confirmed the facility failed to notify residents/resident representatives of their right to file anonymous grievances through postings in prominent locations throughout the facility, provide the grievance forms for anonymous grievances, and provide grievance collection boxes for anonymous grievances in 3 of 3 units (Dogwood Lounge, Pine Hall and the Special Care Unit). 28 Pa. Code: 201.29(i) Resident rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for two of two residents (Residents R9 and R72 ) to accurately reflect the current status of the resident. Findings include: Review of the facility policy Comprehensive Care Plan dated 3/1/22, indicated the resident care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Review of admission Record indicated Resident R72 was admitted to the facility on [DATE]. Review of Minimum Data Set (MDS -a periodic assessment of care needs) dated 10/4/22, indicated diagnoses of lumbosacral spine and pelvis fracture (a break in one or more bones of the lower back and pelvic bones), hyperlipidemia (high levels of fat in the blood), and malnutrition (lack of proper nutrition) remain current. Review of Resident R72's Physician Orders dated 9/28/22, indicated pain medication of oxycodone 5mg (milligram) tablet every six hours as needed for pain and physician order dated 10/3/22, for MiraLAX 17GM scoop (a medication used to prevent constipation). Review of Resident R72's Medication Administration Record for October 2022, indicated the pain medication oxycodone was received nine times between 10/1/22 and 10/5/22. Review of Resident R72's progress note dated 10/6/22, at 3:00 p.m. indicated patient complained of abdominal pain, tender and distended upon palpation and bowel sounds hypoactive in all four quadrants. Resident R72 was transferred to the hospital and admitted with a small bowel obstruction. Review of Resident R72's care plan failed to identify pain and or management of and potential for constipation as active problems. Review of Resident R9's clinical record indicated the resident was admitted to the facility on [DATE]. Diagnoses included disorders of dementia, fall history, artificial hip joint, hyperlipidemia (high cholesterol), hypertension (high blood pressure), and depression. Review of Resident R9's Minimum Data Set (MDS) dated [DATE], indicated the diagnoses remained current. Review of Resident R9's physician recapitulation orders dated 11/30/22, indicated on 4/21/22, Resident R9 was ordered a sliding board with the assist of one staff for transfers between the bed and wheelchair. Review of Resident R9's care plan dated 4/27/22, failed to include the use of the sliding board for transfers between the bed and wheelchair. During an interview on 12/1/22, at 11:00 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E8 confirmed the facility failed to update Resident R9's care plan to accurately reflect the current status of the resident. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and records, and staff interviews, it was determined that the facility failed to accurately monitor and assess for changes in skin condition for one of six residents reviewed (Residents R67). Findings include: Review of the facility policy Wound Care Policy, dated 3/1/22, indicated the facility follows best practices and current recommendations as set forth by the National Pressure Ulcer Advisory Panel and these guidelines are to be utilized when treating pressure injuries by all team members. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggest the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R67's admission record indicated admission to the facility on 9/16/22. Review of Resident R67's MDS dated [DATE], included diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and high blood pressure. Review of the Section C: Cognitive Patterns indicated that Resident R67's BIMS score was 3, indicating severe cognitive impairment. Review of Section H Urinary Continence indicated Resident R67 was always continent. Review of R67's initial skin evaluation dated 9/16/22, indicated no alterations in skin condition. Review of the care plan dated 9/16/22, indicated that Resident R67 had a focus of skin integrity and a goal that the skin will remain intact. Review of the Braden Scale for Predicting Pressure Sore dated 11/14/22, indicated that Resident R67 was not at risk of pressure ulcer development. Review of Resident R67's urinary continence log dated 11/2/22 through 11/16/22, indicated the following: Week 11/2/22 - 11/9/22 - one incontinent (inability to control urine) episode. Week 11/10/22 - 11/16/22 - four incontinent episodes. Week 11/17/22 - 11/23/22 - twelve incontinent episodes. Week 11/24/22 - 11/26/22 - five incontinent episodes. Review of Skin only evaluations dated 11/18/22, and 11/25/22, indicated no skin issues for Resident R67. Review of progress note dated 11/26/22, by Licensed Practical Nurse (LPN) Employee E11, indicated Resident R67 had an open area to coccyx surrounding tissue red, measures 5.0 cm (centimeter) by 5.0 cm, with wound base black and measures 2.0 cm by 1.6 cm and nurse was made aware. Review of occurrence report dated 11/26/22, indicated Registered Nurse (RN) Employee E12 received report that resident has 2.0cm by 1.6 cm black area on coccyx with 5cm by 5cm redness. There was a previous wound there that healed, using Cal zinc (protective barrier cream). During an observation of Resident R67 on 11/28/22, at 11:13 a.m. indicated resident on a regular mattress. When turned for wound care by LPN Employee E4, there was an unstageable (full thickness tissue loss where depth is undetermined due to being covered with slough or eschar in the wound bed) area to coccyx approximately a quarter size round with redness around it, Certified Registered Nurse Practitioner (CRNP) Employee E18 was also present during observation and upon interview on 11/28/22, at 11:15 a.m. confirmed the status of the wound as unstageable. During an interview on 11/28/22, at 11:30 a.m. LPN Employee E4 confirmed Resident R67's wound was not there the last day she worked a few days prior and was surprised it looked so bad. During an interview on 11/28/22, at 11:45 a.m. Nursing Assistant (NA) Employee E21 indicated when they (NA's) do their skin checks document and inform the nurse in charge at that time. During an interview on 11/28/22, at 11:45 a.m. NA Employee E22 indicated that they (NA's) check skin while giving care and if there is a mark they put in the computer on shower sheet and tell the nurse on the floor. During an interview on 11/30/22, at 3:20 p.m. RN Employee E12 indicated the wound was reported to her by Licensed Practical Nurse (LPN) Employee E11 and that it was necrotic (dead tissue). RN Employee E12 stated she knew a Stage I pressure area could turn into necrotic tissue overnight. During an interview on 11/28/22, at 11:30 a.m. the Director of Nursing confirmed the facility failed to accurately monitor and assess for changes in skin condition for Resident R67. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to monitor residents that experienced significant weight loss for two out of four residents (Residents R5 and Resident R27). Findings include: The facility Measuring weights policy last reviewed on 3/1/22, indicated that residents will be weighed to establish baseline weights and identify trends of weight loss and weight gain. The facility Activities of Daily Living (ADL) policy dated 3/1/22, indicated that residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, included assistance with mobility , hygiene, and dining. The resident's response to interventions will be monitored. Review of Resident R5's admission record indicated she was admitted on [DATE], with diagnoses that included Alzheimer's dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder and adult failure to thrive. Review of Resident R5's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 8/9/22, indicated that the diagnoses remain current upon review. Review of Resident R5's care plan dated 8/18/22, indicated to monitor and record resident meal intake. Review of Resident R5's clinical dietitian note dated 11/2/22, indicated that Resident R5 had ten percent decline in weight (from September 2022 to November 2022). Resident R5 was consuming 0-50% of her meals at most. Continued weight loss likely as resident has dementia diagnoses. Review of Resident R5's meal intake documentation for the month of November 2022 did not include documentation per shift for the following dates: 11/1, 11/2, 11/3, 11/4, 11/5, 11/6, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/16, 11/17, 11/18, 11/19, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, and 11/29/22. Review of Resident R27's admission record indicated she was originally admitted on [DATE], with diagnoses that included dysphagia(difficulty swallowing), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hypothyroidism(decrease in production of thyroid hormone). Review of Resident R27's MDS assessment dated [DATE], indicated that the diagnoses remain current upon review. Review of Resident R27's care plan dated 11/8/22, indicated to weigh resident as per protocol and as per order. Review of Resident R27's physician orders dated 11/14/22, indicated to weight Resident R27 one time a week on Monday for four weeks. Review of Resident R27's clinical dietitian note dated 11/15/22, indicated that during Resident R27 care conference held with her family, weight changes were discussed. Resident R27 was to be monitored for weight weekly for four weeks. Review of Resident R27's weight summary documentation, did not include recorded weight monitoring for 11/16/22 and 11/28/22. During an interview on 11/30/22, at 08:49 a.m. Registered Dietitian Employee E3 confirmed that the facility failed to monitor weights after a documented significant weight loss for Resident R27 as required. During an interview on 11/30/22, at 11:54 a.m. the Director of Nursing (DON) confirmed that the facility failed to monitor weights after a documented significant weight loss for Resident R5 as required 28 Pa. Code: 211.6 (b) Dietary services. 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 201.18 (b)(1) Management. 28 Pa. Code 211.12(a)(d)(1) Nursing services.

Based on a review of facility policy, observations, and staff interviews, the facility failed to make certain medications were stored in a safe and secure manner for one of three medication carts (Pine Medication cart). Findings include: Review of the facility policy Storage of Medications last reviewed on 3/1/22, indicated that all medications are stored in a safe, secure and orderly manner. Unlocked medication carts are not left unattended. Drug containers with missing, incomplete, improper or incorrect labels are returned to the pharmacy or destroyed. During an observation on 11/29/22, at 8:20 a.m., the Pine medication cart was placed at nurses station left unsecured with potential for access of any passerby. Licensed Practical Nurse (LPN) Employee E13 was behind a curtain inside a resident room. During an interview on 11/29/22, at 8:25 a.m., LPN Employee E13 confirmed that she had left the medication cart unlocked leaving access for any passerby. 28 Pa. Code: 211.9(a)(1)(2)(g)(h)(k)(l)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy, observation, and staff interview, it was determined that the facility failed to maintain infection control practices during a dressing change for one of one resident observed (Resident R32). Findings include: Review of the facility policy Dressings, Dry/Clean last reviewed on 3/1/22, indicated that the steps for the procedure included cleaning the bedside table to establish a clean field, tape a biohazard bag on the bedside stand or use waste basket below clean field for soiled items. Clean the bedside stand after use. Findings include: During an observation on 11/29/222, from 10:53 a.m. through 11:40 a.m. the following was observed: Registered Nurse (RN) Employee E14 placed dressing supplies on the bedside table next to a used urinal. The area was not cleaned. She cleaned her scissors with an alcohol wipe and placed the scissors on the table with tips inside alcohol wipe package next to the urinal. RN Employee E14 washed her hands and while exiting bathroom, touched her mask twice before donning clean gloves to begin dressing change. RN Employee E14 cleansed wound with saline then went to bathroom, placed the soiled sponges and gloves in garbage can in bathroom, washed hands touched her mask then picked up alginate pad and began to cut three small pieces of alginate with bare hands. RN Employee E14 outer dressing was applied covered the wound with lower edges open where stool could enter the dressing allowing the potential for contamination of the wound. RN Employee E14 gathered all soiled and left over clean supplies in barrier that had been placed under resident and placed them in the garbage can in the residents room. RN Employee E14 exited Resident R32's room. During an interview on 11/29/22, at 11:40 a.m. RN Employee E14 confirmed the above observations and confirmed that infection control practices were not maintained during the dressing change. 28 Pa. Code: 201.20(c) Staff development. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a facility observations and staff interview, it was determined the facility failed maintain a nursing unit refrigerator-freezer in safe operating condition on one of three units (Pine Hall). During an observation on 11/30/22, at 8:30 a.m. the resident refrigerator-freezer in the Refreshments pantry on Pine Hall had a freezer temperature of 38 degrees Fahrenheit. The freezer contained 26 ice cream cups, one pint of ice cream, six ice cream bars, and one popsicle that were soft to the touch and melting. The freezer also had condensation dripping from the seal at the front of the freezer ceiling. During an observation on 11/30/22, at 8:45 a.m. Health Center Coordinator Employee E21 demonstrated that when the refrigerator door is opened and closed, it slightly pops the freezer door allowing warm air into the freezer. During an interview on 11/30/22 at 8:47 a.m. Health Center Coordinator Employee E21 confirmed the Pine Hall resident Refreshments refrigerator-freezer malfunctions when the refrigerator door is opened and closed causing the freeze to have unsafe temperatures. 28 Pa. Code: 207.2(a) Administrator's responsibility

Based on review of facility policy, personnel records and staff interview it was determined that the facility failed to complete dementia management upon hire for one out of six personnel files (RN Employee E1). Findings include: The facility Staff development policy dated 4/1/15, last reviewed on 3/1/22, indicated that the facility is committed to providing an on-going education programs. The objective of the educational programs is to allow for the development of relative job skills as well to increase knowledge. The facility Dementia clinical protocol policy dated 3/1/22, indicated that nursing staff will receive initial training in the care of residents with dementia and related behaviors. Review of Registered Nurse (RN) Employee E1's personnel record indicated he was hired on 4/25/22. Review of Registered Nurse (RN) Employee E1's personnel record did not include dementia training or behavioral management training. During an interview on 11/29/22, at 2:22 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to complete dementia management upon hire for Registered Nurse (RN) Employee E1 as required. 28 Pa Code: 201.14 (a ) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a )(c ) Staff development.

Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate an injuries of unknown origin for three of nine residents (Resident R7, R42, and R43) and failed to investigate an actual allegation of neglect for one of nine residents (R56). Findings include: Review of the facility policy Incident Reports, last reviewed on 3/1/22, indicated that all incidents, unusual occurrences, and injuries will be documented on an incident/accident form. Review of the facility Resident Abuse/Neglect/Exploitation and Reporting Requirements, last reviewed on 3/1/22, with previous review date of 2/28/21, indicated that each resident has a right to be free from abuse, neglect and exploitation. and the facility will provide an environment free from all types of abuse, neglect and exploitation by all persons. Any reports or suspicions will be fully investigated. Indicators of abuse include cuts, lacerations, puncture wounds, bruises, welts, discolorations, any injury which has not been properly cared for, poor skin condition or hygiene, etc. All team members once reported must write a statement related to the incident, report to their immediate supervisor. Review of a progress note dated 10/29/22, indicated that Resident R7 developed a bruise of his left upper arm. During an interview on 11/28/22, at 12:24 p.m., Assistant Director of Nursing (ADON) Employee E16 confirmed that the facility failed to investigate a bruise of Resident R7's upper arm to rule out potential for abuse. Review of a progress note dated 8/2/22, indicated that Resident R42 was pulled from the dining table and developed a skin tear which required cleansing and an island dressing. A site of the injury was not clearly identified. Review of the Treatment Record dated 8/1/22 through 8/31/22 indicated a treatment to Resident R42's left arm with saline cleansing and Xeroform (petroleum embossed dressing for non-sticking) and a dry dressing until healed, this treatment was discontinued on 8/23/22, 21 days later. During an interview on 1/28/22, at 3:31 p.m., the Director of Nursing (DON) confirmed a full investigation was not completed to rule out the potential for abuse for Resident R42 while being pulled from the dining table. Review of a progress note dated 7/18/22, indicated that while Resident R43 was being showered, the Nurse Aide identified his right pinky toe was red, his big toe had a raised area and his right wrist had a bruise. During an interview on 11/28/22, at 12:18 p.m., the ADON Employee E16 confirmed that the bruise of Resident R43's wrist or the redness and swelling of Resident R43's toes was not fully investigated to rule out the potential of abuse. Review of a progress note dated 10/30/22, indicated that Resident R56's daughter had requested the resident have her morning care done very early so the resident can eat breakfast. The note indicated that Resident R56 reported that she was upset that she could not eat breakfast that day because she was wet and was told she could not be changed until trays were passed. The note indicated that the nurse aide told the LPN, who wrote the note. During an interview on 11/28/22, at 2:30 p.m. the DON confirmed that the facility failed to investigate the allegation of neglect. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management.