**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select investigation reports and staff interviews, it was determined that the facility failed to provide necessary supervision, and implement effective individualized safety measures for a resident with known unsafe behaviors to prevent multiple falls for one resident (Resident 13) and a serious burn, to one resident (Resident 27) out of 19 residents sampled. Findings include: A review of Resident 27's clinical record revealed that the resident was admitted to the facility April 14, 2023, with diagnoses to include hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side. (Hemiparesis, also called unilateral paresis, is the weakness of one entire side of the body. Hemiplegia, in its most severe form, is the complete paralysis of one entire side of the body). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 15, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 6 (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The resident required supervision and the assistance of one staff person when eating according to the MDS assessment. The resident had a current physician order, initially dated January 23, 2024, for the use of a Kennedy cup (a lightweight spill proof drinking cup that is used with a straw) at all meals and for the use of Divided scoop dish and built up utensils to max his ability to engage in self-feeding tasks dated November 27, 2023. An Occupational Therapy treatment encounter note dated December 14, 2023, the last encounter the resident had with Occupational Therapy, prior to an incident that occurred while the resident was eating on July 14, 2024, indicated that the resident required precautions due to the resident's left sided hemiplegia (paralysis on one side of the body). The resident was able to drink from a Kennedy cup and utilize built-up utensils and scoop dish with moderate staff assistance to manage eating with these assistive devices. Review of documentation in Resident 27's clinical record revealed the resident had multiple falls since the resident's admission to the facility on April 14, 2024, through the time of the survey ending July 25, 2025, with progress note documentation revealing that the resident displayed frequent behaviors of restlessness and impulsivity. A nurses note dated July 14, 2024, indicated that at approximately 4:00 PM Resident 27 accidentally spilled soup on his LLQ (left lower quadrant) and left groin during evening meal. Area from lower abdomen to groin erythematous with bright coloration and shiny appearance. One (1 cm) blister noted on center of LLQ area. Resident c/o pain and was medicated per order. At time of event, resident was sitting in chair at dining table, soup was placed in center of table out of exact reach, staff were present in dining room serving other residents, clothing protector was in place for protection. Resident over estimated ability to handle soup bowl independently. Resident diagnosed with left hemiplegia/hemiparesis post cerebral infarct as well as lack of coordination. Following event, nurse immediately removed source of heat and rushed [Resident 27] to wash area where clothing was removed, area soaked in cool running tap water. SSD applied. Call out to on-call provider. A review of the incident report completed by the facility Director of Nursing, dated July 15, 2024, revealed that Resident 27 sustained a burn while reaching for his soup, which staff placed on the table in a reachable distance from the resident, when staff turned to get an ice cube to cool the resident's soup per his preference. The incident report revealed that the dietary staff had taken the temperature of the soup in the kitchen, prior to point of service to the resident, and noted the temperature 179 degrees fahrenheit at that time. The facility staff did not obtain the temperature of the soup after it was brought to the dining room steam table, the point of service to residents, as per facility policy. Review of a witness statement from Employee 3, LPN, dated July 14, 2024, revealed that at dinner time, she delivered Resident 27's soup from the steam table in the dining room and set him up at the dining table to eat, thinking the soup was out of the resident's reach. Employee 3 stated she turned around to get the resident an ice cube per his preference and the resident was able to reach his soup and it spilled in his lap. Resident 27's clinical record revealed resident sustained a 12 cm x 15-centimeter reddened area on his left lower stomach with a 1-centimeter blister noted. A physician order dated July 15, 2024, was noted to cleanse the blister on the resident's left lower abdomen with NSS, apply Silvadene cream, non-stick dressing and optifoam daily and prn soilage/displacement. An Occupational Therapy consult dated July 16, 2024, after the resident sustained the burn on July 14, 2024, revealed that the resident had a decline in ability to feed himself even with the use of built up utensils, and now required moderate staff assistance during eating. The consult noted that the resident's poor safety awareness contributed to his spillage of soup and subsequent burn. The facility failed to consistently provide the resident with the necessary staff supervision at meals, based on the resident's known restlessness and impulsivity, to prevent a serious injury to the resident. Interview with the NHA and DON on July 25, 2024, at approximately 12:00 PM revealed that the facility was unable to provide evidence that staff supervised Resident 27 while eating to prevent the resident from spilling hot soup on himself sustaining painful burns. Clinical record review revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following a stroke affecting left non-dominant side, bipolar disorder, and anxiety. Review of Resident 13's transfer paperwork the facility received from a prior skilled nursing facility revealed that the resident was at high risk for falls. The sending [NAME] nursing facility provided this current facility with the resident's plan of care, which included all interventions implemented for safety. These interventions included to encourage the resident to be out of bed for all meals, placement of a fall mat to left side of bed while resident in bed, low bed- keep in lowest position (bed controls out of resident's reach), offer to adjust temperature when placed in bed, offer toileting between 1:30 PM and 2:30 PM and change (incontinence care) if needed, pad alarm to bed hung behind headboard [control box] to alert staff of self-transfers and check functioning and placement every shift, resident request is to be in bed between 7:30 PM and 8 PM, resident to be out of bed in wheelchair with rearward tilt of wheelchair seat, thicker fall mat to window side (left) side of bed when resident in bed and check every shift, keep frequently used items in reach, and high risk for falls. Resident 13's transfer documentation also revealed that she had a self-releasing seat belt with alarm to alert staff of attempts to self transfer initiated October 19, 2023, and had experienced a recent fall on May 24, 2024. An admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 12, 2024, revealed that the resident was cognitively intact with a BIMS score of 15 (a score of 13 to 15 indicates no cognitive impairment). A Fall Morse Scale evaluation dated June 5, 2024, revealed that the resident was identified as a Moderate Fall Risk. Interventions implemented upon admission included to have call bell in reach, pain evaluation, non-skid socks, and a therapy screen. A review of Resident 13's baseline care plan dated June 5, 2024, revealed that interventions implemented upon admission on [DATE], were to anticipate and meet resident's needs, encourage resident to use call bell for assistance as needed, and for room to be free from spills and/or clutter with adequate light. An incident report investigation dated June 18, 2024, revealed that at 1:45 PM, Resident 13 fell to the floor in her room while attempting to self-transfer to wheelchair from standard chair. The resident was found on the floor, lying on her left side, after the resident's roommate rang the call bell for staff assistance. According to investigation, Resident 13's roommate witnessed the fall, and Resident 13 did not sustain any injuries. Safety interventions implemented after fall included to apply dycem (non-skid material) beneath cushion. Review of care plan revealed that interventions added June 20, 2024, included a sensor pad to both the resident's bed and chair. An incident report investigation dated June 25, 2024, revealed that at 11:35 AM, staff again found the resident on the left side of her bed on the floor. She sustained a bump on the back of her head. According to the investigation, the resident stated that she was attempting to get out of bed to go out the door. The physical therapy assistant found the resident on the floor when she had returned Resident 13's roommate to their room. There was no evidence according to incident report and witness statement, that bed or chair alarms were sounding/functioning to alert staff that Resident 13 had self-transferred and on the floor. The incident report indicated that a low-bed and a medication review were to be implemented, and orders received for ice to be applied to bump on the back of resident's head, and neuro checks were initiated. Review of documentation dated June 25, 2024, at 2:27 PM revealed that the resident complained of dizziness and nausea. Neuro check within normal limits with the exception of the new nausea and dizziness. Orders were received from the physician to send the resident to the emergency room for an evaluation. Review of emergency room evaluation dated June 25, 2024, the resident was seen after falling backwards in her bathroom, hitting the back of her head on the tile. En route to the ED [emergency department], patient offered complaints of HA [headache] accompanied by blurry vision, nausea, and dizziness. No injuries were identified and based on urinalysis, the resident returned to the facility on antibiotic for possible urinary tract infection. An incident report investigation dated June 29, 2024, revealed that at 6:45 AM, staff again found the resident on the floor to the left side of the resident's bed. The bed alarm was sounding and the resident's call bell within reach. According to the investigation, the resident rolled out of bed. Resident 13 then complained of left knee and left hip pain and x-rays were ordered by the physician. No fractures/injuries were identified and floor mats were to added to both sides of the resident's bed when the resident in bed (an intervention that had been in place when the resident resided at the prior skilled nursing facility and noted on the transfer form, with a thicker fall matt on the left side). Review of an incident report investigation dated July 7, 2024, revealed that at 10:45 AM, Resident 13's roommate rang the call bell to alert staff that Resident 13 was ambulating unassisted. Staff found Resident 13 sitting on the floor, on the left side, in front of wheelchair. According to the investigation, Resident 13 stated that she went to get my sneakers, I didn't ring because I'm stupid. The investigation's conclusion indicated that the resident self-removed chair alarm and attempted to ambulate across the room to retrieve item, and overestimates functional abilities and has poor safety recall. The alarm was replaced, and a therapy screen was submitted for further recommendations. An incident report investigation dated July 11, 2024, revealed that at 6 AM, the resident had an unwitnessed fall while attempting to self-transfer out of bed. The resident was found on window side of the bed with alarm sounding, fall mats were noted to be in place, call bell within reach, and non-skid socks in place. The resident stated she wanted to get up. According to the report, the resident had been tended to approximately 30 minutes prior to fall. Additional intervention included application of a perimeter/raised edge mattress to the resident's bed to enhance safety awareness of bed perimeter. A incident report investigation dated July 16, 2024, revealed that at 10:45 AM, staff found Resident 13 on the floor in the bathroom of the resident's room, sitting next to the toilet. According to the investigation, the resident stated that she transferred herself from the toilet to the wheelchair and slid to the floor. The investigation's conclusion, revealed that resident did not ask for assistance, requires assist of 2 staff members with rollator walker for transfers, is non-ambulatory, forgets to ask for assistance, and self-removed alarm. The resident did not sustain any injuries. The resident's risk for falls and need for multiple safety and fall prevention measures was included in the resident's transfer documentation upon the resident's admission to the facility. The facility failed to timely address the resident's high risk for falls and promptly implement sufficient safety and fall prevention interventions, individualized to the resident's habits and behaviors identified in the resident's transfer documentation, to prevent repeated falls, which increased the resident's risk for serious injury. Interview with the NHA and DON on July 25, 2024, at 11:30 AM confirmed that the facility was unable to demonstrate the implementation of necessary individualized fall prevention measures, and sufficient staff supervision at the level and frequency required, to prevent Resident 13's repeated falls. 28 Pa Code 211.12 (d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and interview with staff it was determined that the facility neglected to provide the care and services necessary to avoid physical harm and maintain physical health for one resident out of five residents sampled (Resident 2). Findings include: A review of the facility's Resident Abuse policy, last revised January 2023, revealed that the facility will provide each resident with the highest practicable physical, mental, and psychological services to meet their individual needs and to promote or maintain the resident at their highest level of well-being. This includes the protection of Resident's Rights. Each resident has the right to privacy, dignity and confidentiality for all aspects of care and services. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], 2022, with diagnoses, which included dementia, muscle weakness and the need for assistance with personal care A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 20, 2023, indicated that the resident required the assistance of staff for activities of daily living and and utilized a sit to stand lift for transfers. A review of the resident's current plan of care, initially dated July 8, 2023, revealed a care plan in place for ADL (activities of daily living) self-care performance deficit. Planned interventions were that upon admission the resident needed to utilize a sit to stand lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). A review of a facility investigation report dated December 19, 2023, at 9:55 PM revealed that Employee 3, an agency nurse aide, and Employee 4, an agency nurse aide, were transferring Resident 2 from the wheelchair to the bed via a sit to stand lift. The nurse aides placed the resident into the lift and had her hovering {in the lift sling} over her bed. Employee 3, an agency nurse aide, left the room to get a clean brief. At the same time, Employee 4, an agency nurse aide, left the resident in the lift to get a washcloth from the bathroom sink. When Employee 4 looked back from the bathroom, she observed Resident 2 opening the velcro ties to the sling (on the lift), falling onto the bed, and then onto the floor, hitting her buttocks and back. The RN supervisor assessed the resident. The Physician was contacted. No injuries were noted. An interview with the Nursing Home Administrator and Director of Nursing on January 31, 2024, at approximately 2 PM confirmed that Employees 3 and 4 were aware that the resident's transfer was to performed with two people, utilizing a sit to stand lift, but both employees left the resident unattended in the lift sling resulting in the resident's fall. 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services