Timber Ridge Health Center

F-F600

28 Pa. Code 201.14 (a)(c) Responsibility of licensee

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29 (a)(c) Resident Rights

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 28 Pa. Code 211.12 (c)Nursing Services

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738 potential for actual harm Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it Residents Affected - Few was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 27 sampled (Residents 2, 40, and 47).

Findings included:

A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow).

A current physician order initially dated January 28, 2025, noted an order for Warfarin Sodium (an anticoagulant medication also known as a blood thinner) 4 mg via PEG-tube (percutaneous endoscopic gastrostomy- feeding tube placed directly into the stomach through the abdominal wall to provide liquid nutrition, medications, and fluids into the stomach) at bedtime for diagnosis of atrial fibrillation.

A review of Resident 2's February 2025 Medication Administration Record revealed Apixaban 5 mg (anticoagulant) was administered daily as ordered by the physician.

A review of Resident 2's quarterly MDS assessment dated [DATE REDACTED], indicated the resident did not receive an anticoagulant (blood thinner) medication during the 7-day look-back period.

An interview with the RNAC (registered nurse assessment coordinator) on April 23, 2025, at approximately 1:30 PM confirmed Resident 2's MDS assessment was not accurate.

A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

A review of Resident 40's annual MDS assessment dated [DATE REDACTED], Section I active diagnoses, infection in the past seven days, indicated infections of MDRO (multi-drug resistant organism is a germ that is resistant to many antibiotics) and pneumonia (infection that affects one or both lungs, which makes it difficult to breathe and can cause a fever and cough). However, review of the clinical record revealed no documented evidence

the resident had an MDRO infection or pneumonia.

An interview with the RNAC on April 23, 2025, at approximately 1:45 PM confirmed that Resident 40 did not have an MDRO infection or pneumonia during the seven-day look-back period of the MDS assessment. The RNAC confirmed that Resident 40's MDS assessment was not accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 A clinical record review revealed Resident 47 was admitted to the facility on [DATE REDACTED], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or Level of Harm - Minimal harm or when the body cannot effectively use the insulin it produces). potential for actual harm

A review of a 5-day MDS assessment dated [DATE REDACTED], Section N0350. Insulin: Resident 47 did not receive any Residents Affected - Few insulin injections during the seven-day look-back period. However, a review of Resident 47's Medication Administration Record dated February 2025 revealed Resident 47 received a Lantus 100 unit/ml solution pen injector (insulin) on five occasions from February 7, 2025, through February 11, 2025.

During an interview on April 24, 2025, at approximately 1:30 PM, the RNAC confirmed Resident 47's February 11, 2025, MDS, Section N0350. Insulin was not accurate.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738 potential for actual harm Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed Residents Affected - Few to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of intravenous medication via a peripheral IV (thin, flexible plastic tube inserted into a peripheral vein to allow for the administration of fluids, medications, and other therapies into the bloodstream and used for short-term intravenous therapy) for one of 27 residents reviewed (Resident 101).

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following:

The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

Chapter 21.145b. IV therapy curriculum requirements;

(f) An LPN may perform only the IV therapy functions for which the LPN

possesses the knowledge, skill and ability to perform in a safe manner, except as

limited under S 21.145a (relating to prohibited acts), and only under supervision

as required under paragraph (1).

(1) An LPN may initiate and maintain IV therapy only under the direction

and supervision of a licensed professional nurse or health care provider authorized

to issue orders for medical therapeutic or corrective measures (such as a

CRNP, physician, physician assistant, podiatrist or dentist).

(g) An LPN who has met the education and training requirements of S 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145a and only under supervision as required under subsection (f):

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 (1) Adjustment of the flow rate on IV infusions.

Level of Harm - Minimal harm or (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration potential for actual harm and initiation of appropriate interventions.

Residents Affected - Few (3) Administration of IV fluids and medications.

(4) Observation of the IV insertion site and performance of insertion site care.

(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.

(6) Discontinuance of a medication or fluid infusion, including infusion devices.

(7) Conversion of a continuous infusion to an intermittent infusion.

(8) Insertion or removal of a peripheral short catheter.

(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.

(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.

(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.

(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.

(13) Collection of blood specimens from an IV access device.

A review of the facility Continuous Administration of IV Fluids by Pump Policy dated January 22, 2025, indicated that continuous infusions of IV fluids or medications in volumes greater than 250 ml may be controlled via electronic pump. Further review of the policy failed to include which licensed nursing staff (RN or LPN) would be responsible for the infusion of physician ordered IV fluids or medications.

Interview with the administrator (NHA) and director of nursing (DON) on April 24, 2025, at approximately 10:00 AM confirmed the facility did not have a written policy or protocols to allow LPNs to administer IV fluids or medications. The NHA and DON failed to provide written evidence that LPNs employed at the facility had completed a Board approved educational program to start and discontinue an intravenous infusion and administer and withdraw intravenous fluids and medications with a physician's order. The NHA and DON also failed to provide documented evidence that a yearly in-service on administration of IV fluids and medications was provided to LPNs who have completed the Board certified educational program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Clinical record review revealed that Resident 101 was admitted to the facility on [DATE REDACTED], with diagnoses which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or Level of Harm - Minimal harm or injury and marked by memory disorders, personality changes, and impaired reasoning). potential for actual harm

A physician order dated April 16, 2025, noted an order for Meropenem-Sodium Chloride Intravenous Solution Residents Affected - Few (an antibiotic) reconstituted 500 MG/50ML use 500MG intravenously every 8 hours for urinary tract infection for seven days.

An IV therapy note dated April 16, 2025, noted that a peripheral IV was placed in the right forearm.

Review of the Resident 101's April 2025 Medication Administration Record (MAR) revealed that between April 16 through April 22, 2025, Employee 1 (LPN), Employee 2 (LPN), Employee 3 (LPN), Employee 4 (LPN), and Employee 5 (LPN) signed the MAR as administering the IV antibiotic medication to the resident through the peripheral IV.

Interview on April 24, 2025, at approximately 11:00 AM with Employee 1 (LPN), stated she never administered medications through residents' intravenous lines at the facility based on facility policy. She confirmed that she did sign out on April 16, 2025, at 2:00 PM that she had administered the medication even though the RN was the one who had administered the IV medication through the resident's peripheral IV. Employee 1 (LPN) indicated she was never educated at the facility on the administration of intravenous medications.

There was no documented evidence of any education or supervision regarding IV administration for any LPNs working at the facility.

During an interview on April 25, 2025, at approximately 9:00 AM the DON failed to provide documented evidence that LPNs in the facility received education regarding the administration of intravenous medications. The DON further confirmed that facility policy indicated the nurse administering the medications are to sign the MAR indicating it was administered.

28 Pa. Code 201.20(a) Staff Development.

28 Pa Code 211.12 (d)(5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 21738 potential for actual harm Based on observation, clinical record review, and staff interview it was determined the facility failed to ensure Residents Affected - Some respiratory care including tracheostomy (surgical procedure where a hole is created in the neck and a tube is inserted into the trachea or windpipe to help a person breathe) care was provided in accordance with physician orders for one of three sampled residents (Resident 2).

Findings include:

Review of the clinical record revealed Resident 2 had diagnoses which included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy and cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).

A physician order dated February 3, 2025, was noted for a Pulmonary Consult on February 17, 2025.

Review of the Pulmonary Consult dated February 17, 2025, revealed that Resident 2 was weaned to room air (normal air without supplemental oxygen) during the appointment. The plan/medical decision making/recommendations included to use oxygen as needed to maintain O2 level (oxygen saturation- the amount of oxygen carried by red blood cells in blood) was greater than 89%. Maintain humidification (process of adding moisture to the air a person with a tracheostomy breathes, without humidification the air can dry out secretions, making them thick and difficult to clear) via trach even if on room air. Start vest (SmartVest- provides high frequency chest wall oscillation to simulate repetitive mini-coughs to shear mucus away from the walls of the lung's airways and reduce the viscosity [thickness] of secretions) twice daily as tolerated for airway clearance. Use Albuterol (bronchodilator which works by relaxing and opening the air passages to the lungs to make breathing easier) twice daily with vest. Follow-up with pulmonary medicine in three months for evaluation.

A physician order following the Pulmonary Consult dated February 17, 2025, noted to use oxygen as need to keep O2 level greater than 89%. Use humidification for trach. Start vest therapy twice daily to assist with mucous clearance if the resident tolerates. Use Albuterol nebulizer twice daily with vest therapy.

Observation of Resident 2 on April 24, 2025, at 1:25 PM revealed the resident was in bed. Further

observation revealed the resident was not receiving oxygen or humidification via the resident's tracheostomy. There was no evidence of a SmartVest in the resident's room.

Interview with Employee 8 (RN) on April 24, 2025, at approximately 1:40 PM confirmed that humidification was not being used for the resident when the resident is on room air. Employee 8 (RN) confirmed the resident had not yet received a SmartVest.

Further review of the clinical record revealed no documented evidence that arrangements had been made to obtain a SmartVest for the resident based on the physician order dated February 17, 2025, for vest therapy twice daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Upon surveyor inquiry on April 24, 2025, the facility clarified recommendations from the resident's pulmonary consult on February 17, 2025. Level of Harm - Minimal harm or potential for actual harm A telephone encounter note dated April 25, 2025, confirmed the resident should be receiving humification when on room air to keep secretions moist and easier for the resident to cough the secretions out or be Residents Affected - Some suctioned. A phone number to obtain a SmartVest was also provided.

Interview with the director of nursing on April 25, 2025, at 12:23 PM failed to provide documented evidence that physician orders related to respiratory and tracheostomy care for Resident 2 were timely implemented.

28 Pa. Code 211.5 (f)(i) Medical records.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51726 potential for actual harm Based on a review of clinical records, resident, and staff interviews, it was determined the facility failed to Residents Affected - Few develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 27 residents reviewed (Resident 55).

Findings include:

A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by

an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event).

A review of the clinical record also revealed a physician's order dated March 12, 2025, for Prazosin HCL (a medication that decreases levels of norepinephrine in the central nervous system thereby reducing nightmares related to PTSD), with instructions to administer 1 mg tablet by mouth at bedtime for nightmares.

During an interview conducted on April 23, 2025, at approximately 12:45 PM, Resident 55 indicated he served two tours in Vietnam and had nightmares every night prior to the initiation of the Prazosin.

The resident's current care plan, in effect at the time of review on April 25, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet

the resident's needs for minimizing triggers and/or re-traumatization.

The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety.

Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 8:50 AM, confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.

28 Pa Code 211.12 (d)(3)(5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 potential for actual harm Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility Residents Affected - Few failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 27 residents sampled (Resident 47).

Findings included:

A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy indicates when a resident is admitted from an emergency department, the admitting nurse will review discharge and transfer paperwork for current antibiotic and anti-infective orders. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

A clinical record review revealed Resident 47 was admitted to the facility on [DATE REDACTED], with diagnoses that include epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures).

A progress note dated March 24, 2025, at 2:06 PM revealed Resident 47 was sent to the community emergency department related to lethargy and a change in mental status.

A progress note dated March 24, 2025, at 10:49 PM, indicated that Resident 47 returned to the facility from a community emergency department visit. The note documented the physician to verify new medications from

the hospital, including Cephalexin 500 mg (an antibiotic medication), and instructed that all hospital-prescribed medications be continued. The note further indicated that the physician planned to evaluate the resident in person the following day. Resident 47's vital signs at the time were assessed to be within normal limits.

A physician's order initiated on March 25, 2025, at 10:30 PM directed administration of Cephalexin oral capsule 500 mg by mouth four times daily for a urinary tract infection (UTI), with a stop date of April 1, 2025.

Laboratory review revealed a urine culture (method to grow and identify bacteria that may be in the urine) and quantitative report dated March 26, 2025, at 7:35 AM. The results showed no significant growth, indicating the absence of detectable bacteria or other microorganisms in the urine. A concurrent urinalysis noted an elevated white blood cell (WBC) count at 30-49 per high-powered field (normal range: 0-2/HPF), but no clinical documentation correlated this laboratory result with active symptoms of a urinary tract infection.

A review of the Medication Administration Record (MAR) for March 2025 revealed that Resident 47 was administered a total of 25 doses of Cephalexin 500 mg from March 24, 2025, through April 1, 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 A comprehensive review of the clinical record failed to reveal documentation of any clinical signs or symptoms of a UTI from March 24, 2025, through April 1, 2025, including but not limited to, acute dysuria Level of Harm - Minimal harm or (painful urination), elevated temperature, increased urinary urgency, suprapubic pain, increased urinary potential for actual harm incontinence, or gross hematuria.

Residents Affected - Few During an interview on April 24, 2025, at approximately 1:30 PM, the facility's Infection Preventionist (IP) confirmed that the clinical record did not contain documentation of a clinical rationale supporting the continued use of Cephalexin for Resident 47 during the noted period.

In an interview conducted on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) was unable to provide documentation of a clinical rationale for the administration of Cephalexin oral capsule 500 mg. The NHA acknowledged it is the facility's responsibility to ensure that each resident's drug regimen remains free from unnecessary antibiotics.

28 Pa. Code 211.2(d)(3)(5) Medical Director

28 Pa. Code 211.12(d)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 potential for actual harm Based on observations, a review of select facility policies, the facility's infection control log, and staff Residents Affected - Many interviews, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program and failed to implement transmission-based precautions to mitigate the spread of infectious disease for one out of the 27 residents sampled (Resident 56).

Findings included:

A review of a facility policy titled Respiratory Syncytial Virus (RSV) Prevention, last reviewed by the facility on January 22, 2025, revealed it is the facility policy to ensure that residents diagnosed with RSV are placed on contact precautions for the duration of the illness.

A review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, last reviewed by

the facility on January 22, 2025, revealed that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to wear gloves (clean-nonsterile) and a disposable gown when entering the room and remove

before leaving the room and to avoid touching potentially contaminated surfaces with clothing after gown is removed.

A clinical record review revealed Resident 56 was admitted to the facility on [DATE REDACTED], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).

A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 56 dated February 03, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment).

A review of Resident 56's clinical record for the laboratory of a respiratory panel, which resulted on April 22, 2025, at 11:11 AM, revealed abnormal results of positive RSV.

A review of Resident 56's clinical record revealed a laboratory result from a respiratory panel collected April 22, 2025, at 11:11 AM, indicated the resident tested positive for Respiratory Syncytial Virus (RSV), an infectious viral illness that requires implementation of transmission-based precautions.

A physician's order dated April 22, 2025, at 12:17 PM, directed that contact precautions 9 prevent the spread of bacteria or viruses by the use of gowns, gloves and masks) be initiated for Resident 56 due to the positive RSV result, to remain in place through May 2, 2025.

However, an observation conducted on April 22, 2025, at 1:30 PM revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 No signage was posted outside Resident 56's room indicating that contact precautions were in effect.

Level of Harm - Minimal harm or No personal protective equipment (PPE), such as gloves or gowns, were available outside the resident's potential for actual harm room for staff use.

Residents Affected - Many An interview conducted at the time of observation with Employee 6, Licensed Practical Nurse (LPN), confirmed that Resident 56 required contact precautions due to the RSV diagnosis.

A second observation conducted at 2:20 PM on April 22, 2025, again revealed the continued absence of contact precaution signage and PPE outside the resident's room.

A third observation conducted on April 23, 2025, at 8:10 AM continued to show no signage or PPE readily available for use.

An interview with Employee 7, LPN, conducted during the April 23, 2025, observation, revealed that the nurse was unaware that Resident 56 required contact precautions.

An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 23, 2025, at 9:40 AM confirmed the contact precautions ordered for Resident 56 were not implemented as directed by the physician. The NHA further confirmed that the contact precautions were not initiated until approximately 11:00 AM on April 23, 2025, one day after the observation after the order was issued, and only following surveyor inquiry. The NHA confirmed the facility is responsible for ensuring full implementation of infection control procedures, including contact precautions, in accordance with facility policy and nationally recognized infection control guidelines.

A review of a select facility policy titled Infection Prevention and Control Program, last reviewed by the facility

on January 22, 2025, revealed it is the facility's policy to establish an infection prevention and control program (IPCP) to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.

The policy indicates surveillance data and reporting information are used to inform the infection prevention and control committee of potential issues and trends. Data gathered during surveillance is used to oversee infections and spot trends. The policy indicates the infection Preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility- or community-acquired), and records the absolute numbers of infections.

A review of the facility's infection control data revealed the facility's infection control program failed to implement an operational system to monitor and investigate causes of infection and manner of spread from November 2024 through April 2025. The facility's surveillance and data analysis system of infectious disease data failed to identify clusters of infection, track changes in prevalent organisms, or identify increases in infection rates in a timely manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on April 25, 2025, at approximately 9:00 AM, the infection Preventionist indicated that

she has not been able to keep up with infection control data analysis. She provided handwritten infection Level of Harm - Minimal harm or surveillance logs from November 1, 2024, through March 18, 2025, that indicated the resident's name, potential for actual harm prescribed medication, date range of administered medications, and an incomplete listing of infectious disease category (e.g., urinary tract infection, rash, wound). Residents Affected - Many

The Infection Preventionist, explained that she was behind on her data analysis and surveillance of facility infectious disease. She indicated the last time she was able to fully analyze infectious disease was October 2024.

Additionally, review of the logs from November 2024 through April 2025 indicated the facility failed to consistently document critical infection-related details such as:

Resident room numbers or location in the facility

Identification of organisms as applicable

Indication of whether infections were facility- or community-acquired

Symptoms experienced by residents

Date of infection onset

During an interview on April 25, 2025, at approximately 10:00 AM, the NHA confirmed the facility is responsible for implementing a comprehensive infection control program that includes effective surveillance and timely analysis of infectious disease trends. The NHA was unable to provide documentation demonstrating that the facility had a functional surveillance system capable of tracking infection clusters or analyzing changes in prevalent organisms from November 2024 through April 2025.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 395148

F-F610

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident Rights

28 Pa. Code 211.12 (d)(5) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52053 potential for actual harm Based on observation, clinical record review, review of facility policy, investigative documentation, and staff Residents Affected - Few and resident interviews, it was determined the facility failed to thoroughly investigate an incident involving a fall with minor injury to determine whether neglect occurred and failed to identify that planned fall interventions were not in place for one of 27 sampled residents (Resident 57).

The findings include:

A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents.

Further review of the facility policy revealed the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and will investigate and report any allegations within time frames required by federal requirements.

A review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE REDACTED], with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of the lower extremities.

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2024, revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).

Additionally, the MDS indicated the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was indicated to be dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair).

The most current review of a quarterly MDS, dated [DATE REDACTED], revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact).

Resident 57's comprehensive person-centered plan of care initiated on November 23, 2024, indicated the resident required the assistance of two staff members with transfers. The care plan was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 A review of Resident 57's clinical record revealed physician's orders dated December 6, 2024, to utilize a mechanical lift for all transfers and bed mobility with the assistance of two staff members. Level of Harm - Minimal harm or potential for actual harm A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) initiated on December 8, 2024, revealed that Resident 57 was an assist of two staff Residents Affected - Few members via the mechanical lift for transferring.

A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide, was transferring Resident 57 and experienced a fall during the transfer.

A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer.

A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in

the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on

the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used.

A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm.

After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident.

A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor.

The facility investigation failed to obtain a resident statement from Resident 57 at the time of the incident.

During the survey, the Nursing Home Administrator (NHA) was unable to explain the omission of the resident's statement. When interviewed on April 24, 2025, at 8:40 AM, Resident 57 stated that he had informed Employee 14 he required a mechanical lift with two-person assistance, but the aide proceeded to transfer him manually. The resident believed the aide

in a hurry to get the transfer done faster.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 25 395148 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395148 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

River View Nursing and Rehabilitation Center 1555 East End Boulevard Plains Twp Wilkes Barre, PA 18711

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 A nurse's progress note dated December 14, 2024, at 10:37 AM documented complaints of rib pain, and a subsequent x-ray was ordered. Although the December 17, 2024, radiology report showed no fracture, a Level of Harm - Minimal harm or physician's note dated December 19, 2024, noted that Resident 57 was likely to have a right rib contusion potential for actual harm (bruise), as x-ray findings were negative, and the resident was experiencing pain.

Residents Affected - Few The resident required Tylenol for rib pain on multiple occasions between December 14-20, 2024, with reported pain scores ranging from 3 to 8 (pain scale of 1 to 10 1 being no pain and 10 being the worst pain).

The facility investigation lacked evidence the facility evaluated whether the plan of care for Resident 57 was implemented as directed. There was no documentation identifying the resident was transferred by only one staff member or that the mechanical lift was not used. The facility failed to identify or document the deviation from the care plan.

Furthermore, attempts to re-contact Employee 14 during the on-site survey were unsuccessful. The NHA was unable to provide documentation or rationale for the staff member's departure from the facility. Employee 15, interviewed on April 24, 2025, stated he did not know why the aide was transferring the resident alone.

A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident.

Despite this documented training and acknowledgment of competency, review of Resident 57's clinical

record confirmed that Employee 14 failed to adhere to established protocols by not using the required mechanical lift to transfer Resident 57 along with another staff member on December 13, 2024.

The facility failed to implement its established procedures in response to a fall with minor injury by failing to conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment of the resident as a potential cause of the fall with minor injury. There was no indication the facility identified at the time of the incident that there was only one nurse aide, Employee 14, and no use of a mechanical lift for transfers.

During an interview conducted on April 24, 2025, at 1:30 PM, the NHA confirmed that the facility could not provide documented evidence the facility fully investigated to rule out potential neglect following Resident 10's fall with minor injury. The facility failed to identify that planned interventions were not in place and/or implemented in a manner to ensure the resident's safety to prevent the fall and prevent future reoccurrence to the extent possible and implement appropriate corrective actions to prevent recurrence.

Refer