Every finding on record at Abbeyville Skilled Nursing and Rehabilitation Cent

Based on review of clinical records and interview with staff, it was determined that the facility failed to notify the office of the state long term care ombudsman of emergency transfers for 10 of 31 residents reviewed (Residents 1, 10, 14, 20, 46, 84, 91, 126, 134, and 165).Findings include:Finding include Review of Resident 1's clinical record revealed Resident 1 was transferred to the hospital on March 11, 2026, due to abnormal vitals. Further review of Resident 1's clinical record revealed Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 1's transfer and admission to the hospital. Review of Resident 10's progress note of December 27, 2025, revealed that resident's power of attorney requested that resident be sent to the hospital for respiratory distress. Further review of the clinical record revealed that the resident was readmitted to the facility on [DATE]. Review of Resident 10's progress note of January 24, 2026, revealed that resident was sent to the emergency department for an unwitnessed fall. Additional note of January 24, 2026, revealed that Resident 10 was admitted for hypotension (low blood pressure) and syncope (fainting). Resident 10 was readmitted to the facility on [DATE], Review of Resident 10's progress note of March 19, 2026, revealed that resident was sent to the emergency department for evaluation and treatment. Further review of the clinical record revealed that resident was admitted for dyspnea (shortness of breath) and readmitted to the facility on [DATE]. Review of Resident 10's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 10's transfer and admission to the hospital. Review of Resident 14's clinical record revealed Resident 14 was transferred to the hospital on October 31, 2025, for worsening discoloration of toes. Further review of Resident 14's clinical record revealed Resident 14 was readmitted to the facility on [DATE]. Review of Resident 14's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 14's transfer and admission to the hospital. Review of Resident 20's clinical record revealed Resident 20 was transferred to the hospital on December 30, 2025, for a fall resulting in a right femur fraction. Further review of Resident 20's clinical record revealed Resident 20 was readmitted to the facility on [DATE]. Review of Resident 20's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 20's transfer and admission to the hospital. Interview with the Nursing Home Administrator on April 2, 2026, at 12:50 p.m. confirmed that notification of Resident 1, Resident 14 and Resident 20's transfer and admission to the hospital was not sent to the State Ombudsman's office as required Review of Resident 46's progress note of February 22, 2026, revealed that the resident was sent to the emergency department. Additional progress note of February 22, 2026, revealed that resident was admitted to the hospital for hypoxia (low oxygen levels). Resident 46 was readmitted to the facility on [DATE]. Review of Resident 84's clinical record revealed a nursing progress note dated February 7, 2027 indicating the resident was transferred to the local hospital with a diagnosis of Emphysematous cystitis. Further review of Resident 84's clinical record revealed that Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident 84's transfer and admission to the hospital. Review of Resident 91's clinical record revealed Resident 91 was transferred to the hospital on March 8, 2026, with a diagnosis of sepsis. Further review of Resident 91's clinical record revealed Resident 91 was readmitted to the facility on [DATE]. Review of Resident 91's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 91's transfer and admission to the hospital. Interview with the Nursing Home Administrator on April 2, 2026, at 12:50 p.m. confirmed that notification of Resident 91's transfer and admission to the hospital was not sent to the State Ombudsman's office as required. Review of Resident 126's progress note of December 1, 2025, revealed that the resident was admitted to the hospital for constipation and an urinary tract infection. Review of Resident 126's progress note of February 7, 2026, revealed that the resident was sent to the hospital for pain. Resident was readmitted to the facility on [DATE]. Review of Resident 126's progress note of March 14, 2026, revealed that Resident 126 was transferred to the hospital per the resident's request. Progress notes of March 15, 2026, indicated that the resident was admitted to the hospital for a pulmonary embolism (blockage in a lung artery). An additional note revealed that the resident was readmitted to the facility on [DATE]. Interview with the Nursing Home Administrator on April 2, 2026, at 10:35 a.m. confirmed that the office of the state long term care ombudsman's office was not being notified of resident 126's transferred to the hospital. Review of Resident 134's clinical record revealed Resident 134 was transferred to the hospital on January 2, 2026, after sustaining a fall at the facility. Further review of Resident 134's clinical record revealed Resident 134 was readmitted to the facility on [DATE]. Review of Resident 134's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 134's transfer and admission to the hospital. Interview with the Nursing Home Administrator on April 2, 2026, at 12:50 p.m. confirmed that notification of Resident 134's transfer and admission to the hospital was not sent to the State Ombudsman's office as required. Review of Resident 165's clinical record revealed a nursing progress note dated January 11, 2026, indicating the resident was transferred to the local hospital for evaluation after the resident was found with intractable vomiting and abdominal pain. Review of Resident 165's clinical record revealed a nursing progress note dated January 13, 2026, indicating that the resident had passed away at the hospital on January 13, 2026. Review of Resident 165's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident 165's transfer to the hospital. An interview with the NHA on April 2, 2026, at approximately 11:35AM revealed the Office of the State Long Term Care Ombudsman was not made aware of resident 84's or resident 165's hospital transfer. 483.15 Admission, Transfer, and DischargePreviously cited 2/7/25

Based on facility record reviews and interviews, it was determined that the facility failed to ensure monthly Medication Regimen Reviews (MMR) were completed as required for two of seven residents reviewed (Resident 6 and Resident 12).Findings include: Review of the facility's policy titled Medication Regimen Review (MRR) or Drug Regimen Review (DRR) indicated that the MMR includes review of the medical record in order to prevent, identify, report, and resolved medication-related problems, medication errors, or other irregularities. The MMR also involves collaborating with other members of the interdisciplinary team (IDT), including the resident, their family, and/or resident representative. Review of Resident 6's Medication Regimen Reviews between March 29, 2025 and March 8, 2026, revealed pharmacist recommendations documented in the progress notes tab of the resident's clinical chart under Medication Regimen Review on the following dates: March 29, 2025, May 29, 2025, June 28, 2025, July 26, 2025, September 29, 2025, October 25, 2025, November 17, 2025, and December 17, 2025. The facility was unable to provide a record of the pharmacist's recommendations for June 28, 2026, July 26, 2025, September 29, 2025, October 25, 2025, November 17, 2025, or December 17, 2025. Interview with the Nursing Home Administrator on April 2, 2026, at approximately 12:36PM confirmed that the recommendations from those reviews were not available. Review of facility documentation revealed MRR's for Resident 12 were completed for January 2026, February 2026, and March 2026. Further review of facility documents failed to reveal evidence of completed MMR's for any additional months. Interview conducted on April 02,2026, with the Nursing Homes Administrator (NHA) at approximately 12:00 p.m., when the above was presented the NHA confirmed that the MRR's were not available. 28 Pa Code 211.5(f) Clinical Records 28 Pa Code 211.12(d)(3) Nursing Services

Based on a resident interview and review of the clinical record, it was determined that the facility failed to ensure that the resident or resident's representative was included in the resident's comprehensive care plan for one of 31 residents reviewed (Resident 3).Findings include:Interview with Resident 3 on March 30, 2026, at 1:00 p.m. revealed that the resident had not been invited to a care plan conference. Review of Resident 3's clinical record revealed that a quarterly MDS (Minimum Data Set - periodic assessment of resident needs) had been completed on February 17, 2026. Further review of the clinical record revealed no evidence that a care plan meeting was held or that the resident was invited to the meeting. Interview with the Nursing Home Administrator on April 2, 2025, at 10:37 a.m. confirmed that there was no evidence that a care plan meeting was held or that the resident was invited. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to follow physicians' orders in regard to weights and medication administration for two of 31 residents review (Resident 95 and Resident 133).Findings include:Review of Resident 95 face sheet revealed medical diagnoses that includes but not limited to; HEART FAILURE (a chronic condition where the heart is unable to pump enough blood), HYPOMAGNESEMIA (a low concentration of magnesium in the blood), UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION (insufficient intake of both protein and calories), and ADULT FAILURE TO THRIVE (significant decline in physical mental and functional health).Review of Resident 95's physician order revealed an order for weekly weights dated February 23, 2026 noting Weekly weight. Please obtain a weekly weight EVERY Wednesday. Weigh every day shift every Wednesday for Weekly weight. Start date: February 25, 2026Review of Resident 95's weight summary revealed on February 25, 2026, March 11, 2026, March 18, 2026, and March 25, 2026, Resident 95's weight was not obtained.Further review of Resident 95's weight summary revealed that on March 1, 2026, the resident weighed 87 pounds, and on March 4, 2026, weighed 87.2 pounds, indicating a 0.2 pound weight gain over 3 days, representing approximately a 0.23% increase.Review of Resident 95's clinical record failed to reveal evidence that weekly Wednesday weights were consistently obtained as ordered.Interview with the Nursing Home Administrator (NHA) on April 2, 2026, at approximately 10:15AM when the above was presented the NHA confirmed physician orders for weekly Wednesday weights were not being followed.Review of Resident 133's diagnosis list revealed diagnoses including orthostatic hypotension (low blood pressure caused by changes in body position) and coronary artery disease (narrowing of blood vessels which supply the heart with blood and oxygen).Review of Resident 133's March physician orders revealed an order for Midodrine (medication used to treat hypotension) Tablet 2.5 milligrams (mg) to be administered by mouth three times per day and give if SBP (systolic blood pressure) is equal or less than 100 mmHg.Review of Resident 133's March Medication Administration Record (MAR) revealed that Midodrine 2.5 mg was administered on the following days when Resident 133's SBP was greater than 100 mmHg: March 1, 2026 - 109/62, 114/67, 128/64; March 2, 2026 - 110/47; March 3, 2026 - 108/53, 101/54; March 4, 2026 - 124/63; March 6, 2026 - 109/69, 114/64, 110/50; March 7, 2026 - 108/53; March 8, 2026 - 107/54; March 9, 2026 - 132/55; March 14, 2026 - 103/67; March 15, 2026 - 110/60, 127/80, 119/81 and March 25, 2026 - 103/53.Interview with the Nursing Home Administrator on April 2, 2026, at 12:45 p.m. confirmed that the above medication was not administered according to physician's orders. 28 Pa. Code 211.12(c)(d)(1) Nursing ServicesPreviously cited 2/7/2025, 8/19/2025

Based upon clinical record review and interview, it was determined that the facility failed to conduct a baseline care plan meeting for one of 31 residents reviewed (Resident 4).Findings include:Review of Resident 4's clinical record revealed Resident 4 was admitted to the facility on [DATE], with a diagnosis of vascular dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).Interview with Resident 4's representative on March 30, 2026, at 1:00 p.m. revealed that Resident 4 and Resident 4's representative had not had a care plan meeting to establish a baseline care plan since admission.Review of Resident 4's clinical record revealed a social services progress note dated March 11, 2026, which revealed an attempt had been made to schedule a meeting with Resident 4 but Resident 4 was sleeping. Interview with the Nursing Home Administrator on April 3, 2026, at 10:00 a.m. confirmed that no further contact had been made with Resident 4 or Resident 4's representative to schedule a baseline care plan meeting. 28 Pa. Code 211.16(a) Social ServicesPreviously cited 2/7/2025

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area in four of five nursing units (Arcadia, [NAME], Roosevelt, and [NAME] nursing units).Findings include: Review of the facility policy Call Lights dated 10/20/24, indicated, Patients will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow patients to call for assistance when unattended. Staff will respond to call lights and communication devices promptly. During an observation on 8/4/25, at 9:49 a.m. the call light was activated for room [ROOM NUMBER]. The light above the door illuminated, but the panel at the nurses' station ([NAME]) did not activate. During an interview on 8/4/25, at 9:49 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the call light panel at the nurses' station ([NAME]) did not activate. During an observation on 8/4/25, at 9:54 a.m. staff were asked to activate the call lights in rooms [ROOM NUMBER]. At this time, Nurse Aide (NA) Employee E4 confirmed that the call light panel at the nurses' station ([NAME]) did not activate. During an interview on 8/4/25, at 9:59 a.m. Unit Manager (UM) Employee E3 was asked if the call light panel was operable. UM Employee E3 motioned to the light fixture at the hallway intersection and stated, That one's not working. During an observation on 8/4/25, at 10:00 a.m. UM Employee E3 was asked to activate the call light in room [ROOM NUMBER]. The light above the door illuminated, but the panel at the nurses' station ([NAME]) did not activate. When asked how long the call light panels at the nursing stations had not been operating, UM Employee E3 stated, No idea. Review of the Nurse Call System Inspection Log indicated on 5/5/25, that the call light system on the [NAME] nursing unit was down. Review of the Nurse Call System Inspection Log indicated on 6/2/25, that the call light system on the [NAME] nursing unit still not working. This old system don't have part for this system. Review of the Nurse Call System Inspection Log indicated on 7/16/25, that the call light system on the [NAME] nursing unit not working. During an interview on 8/4/25, at 10:28 a.m. the Director of Nursing and Maintenance Employee E5 confirmed that the call light panel on the [NAME] nursing unit, the [NAME] nursing unit, and the call light panel shared nursing station for Roosevelt and Arcadia did not activated at the centralized location, and further confirmed that the facility did not utilize any communication devices that would alert staff members directly of a call light activation. During an interview on 8/4/25, at 10:30 a.m. the Director of Nursing confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area in four of five nursing units. 28 Pa Code 207.2(a) Administrators responsibility 28 Pa Code 205.28 (c)(1)(4) Nurses station

Based on review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the wounds for four of six residents (Resident R2, R3, R4, and R5).Findings include: Review of the facility policy, Skin Integrity and Wound Management dated 10/20/24, indicated the facility will provide safe and effective care to promote optimal skin health. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 7/24/25, included diagnoses of high blood pressure, presence of a hip fracture, and need for assistance with personal care. Review of a progress note dated 7/17/25, at 3:35 p.m. indicated, Res (resident) admitted to room - res arrived to the facility on a litter- res transferred from litter to bed with 4 assist- res has 2 drains (a tube placed near a surgical incision or wound to remove excess fluid, blood, or pus, preventing it from accumulating in the body) and a Prevana wound vac (a medical device that uses negative pressure to help wounds heal) in place. Review of Resident R2's clinical admission assessment dated [DATE], indicated Resident R2 was admitted with a left medial calf pressure wound. The admission assessment indicated Resident R2 did not have a drain or a surgical wound, and no information was present to indicate the presence of a wound vac. Review of Resident R2's care plan for, risk for skin breakdown related to decreased mobility and has vascular wound LLE (left lower extremity) and R (right) hip surgical incision initiated 7/18/25, indicated Weekly wound assessment to include measurements and description of wound status. Further review of the care plan failed to reveal specific interventions related to Resident R2's surgical and vascular wounds. Review of a wound note dated 7/18/25, at 1:40 p.m. indicated Resident R2 had a left calf venous ulcer (chronic wound that is caused by poor blood flow in the veins) and a right hip Prevan dressing with hemovac (a surgical tool used to remove excess fluid, like blood and other fluids, from under the skin after surgery) x2. Prevena dressing and drains present and intact, and functioning properly. Will eval upon d/c (discontinuation) of dressing for R hip and weekly+ prn for L venous ulcer. Review of a progress note dated 7/25/25, at 1:34 p.m. indicated Resident R2 had the Prevana vac and drains removed. Review of Resident R2's physician's order dated 7/26/25, indicated, L posterior calf wound- cleanse with Vashe (liquid skin cleanser). Gently Dry. Apply thin layer of Xeroform (fine mesh gauze) to wound bed followed by abd pad (highly absorbent dressing that provides padding and protection for large wounds). Wrap with Kling wrap (absorbent rolled bandage). Review of Resident R2's physician's order dated 7/26/25, indicated, R Hip area/ drain site- cleanse incision with NSS (normal saline solution), dry well and apply dressing to area. During an interview and observation on 5/31/248/4/25 at 10:53 a.m., Resident R2 was noted to have a gauze dressing on his lower left leg. The dressing was had a large amount of drainage visible. When asked if he received a dressing change every day, Resident R2 stated, They didn't get to it this weekend. Review of Resident R2's Treatment Administration Record (TAR) for August 2025, failed to reveal documentation that wound care was completed for Resident R2's left lower leg wound or the right hip area/drain site for 8/2/25, and 8/3/25. Review of Resident R2's progress notes failed to reveal a documented reason for the lack of wound care on 8/2/25, and 8/3/25. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and acquired absence of right leg below the knee. Review of Resident R3's care plan for actual skin breakdown initiated on 7/5/25, indicated for staff to provide wound treatment as ordered. Review of a physician's order dated 7/26/25, indicated that Resident R3 left foot wound was to be cleansed with Vashe, pat dry, apply Therahoney (medical-grade honey) and covered with bordered gauze. Review of Resident R3's TAR for August 2025, failed to reveal documentation that wound care was completed for Resident R3's left foot wound on 8/2/25. Review of Resident R3's progress notes failed to reveal a documented reason for the lack of wound care on 8/2/25. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of the facility diagnosis list on 8/4/25, revealed diagnoses of heart failure, peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and acquired absence of other right toes. Review of Resident R4's care plan for at risk for skin breakdown related to decreased mobility- has R anterior foot amputation and Coccyx (base of the spinal column) area initiated on 7/30/25, failed to include any goals or interventions related to Resident R4's actual skin breakdown. Review of a physician's order dated 7/30/25, indicated that Resident R4 R Foot amputation site- cleanse incisions with nss, apply perform and cover with a dry dressing and kling every day shift for incision care. Review of a physician's order dated 7/31/25, indicated that Resident R4 NSS. Gently dry. Apply sm (small) amt zinc-oxide barrier cream and cover with bordered foam. every day shift for wound care. Review of Resident R4's TAR for August 2025, failed to reveal documentation that wound care was completed for Resident R4's right foot wound or coccyx on 8/2/25. Review of Resident R4's progress notes failed to reveal a documented reason for the lack of wound care on 8/2/25. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of leukemia (type of cancer that affects the blood and bone marrow), deep vein thrombosis (DVT, is a blood clot that forms in a deep vein, usually in the leg or pelvis), and syncope (fainting or passing out). Review of Resident R5's care plan for at risk for skin breakdown initiated on 7/28/25, indicated for staff to observed Resident R5's skin for signs/symptoms of skin breakdown. Review of a physician's order dated 8/1/25, indicated that Resident R5 R Foot amputation site- cleanse incisions with nss, apply perform and cover with a dry dressing and kling every day shift for incision care. Review of a physician's order dated 7/31/25, indicated that for Resident R5's Bilateral shin abrasions- cleanse with NSS. Gently dry. Apply single layer, small piece of Xeroform to wound bed and cover with bordered gauze. Review of Resident R5's TAR for August 2025, failed to reveal documentation that wound care was completed for Resident R5's leg wounds on 8/3/25. Review of Resident R5's progress notes failed to reveal a documented reason for the lack of wound care on 8/3/25. During an interview on 8/4/25, at approximately 4:00 p.m. the Director of Nursing confirmed the facility failed to provide prescribed treatment and services related to the wounds for four of six residents. 28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of clinical record was determined that the facility failed to develop a person-centered care plan related to discharge for five of five residents (Residents R1, R6, R7, R8, and R15).Findings include: Review of the facility policy, Discharge Planning Process dated 10/20/24, indicated the facility must develop and implement an effective discharge planning process. Discharge planning will begin upon admission and be completed as part of the Person-Centered Care Plan process. Review of the facility policy, Person Centered Care Plan dated 10/20/24, indicated, Care plan includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments for newly admitted patients. The interdisciplinary team, in conjunction with the patient and or patient representatives as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency and duration of care, and any other factors related to the effectiveness of care. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's full care plan including revision history, from admission [DATE]) through discharge (7/1/25) failed to include a plan of care developed for discharge. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's full care plan including revision history, from admission [DATE]) through discharge (7/16/25) failed to include a plan of care developed for discharge. Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's full care plan including revision history, from admission [DATE]) through discharge (7/17/25) failed to include a plan of care developed for discharge. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's full care plan including revision history, from admission [DATE]) through discharge (7/24/25) failed to include a plan of care developed for discharge. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's full care plan including revision history, from admission [DATE]) through discharge (7/16/25) failed to include a plan of care developed for discharge. During an interview on 8/7/25, at approximately 2:30 p.m. the Nursing Home Administrator confirmed the facility failed to develop a person-centered care plan related to discharge for five of five residents. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of seven residents (Resident R1 and R14).Findings include: Review of CMS guidelines, Medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage, (SNF ABN) must be issued to Medicare Fee -for-Service (original Medicare) beneficiaries who are receiving care in a Skilled Nursing Facility (SNF) when: Medicare is expected to deny coverage and when the SNF wants to charge the beneficiary for the non-covered services. Review of the clinical record indicated Resident R1 was discharged from skilled services and discharged from the facility on 7/1/25. Review of the electronic medical record failed to reveal a NOMNC or progress notes that indicated communication of the information contained in a NOMNC to Resident R1's family member, who is responsible for Resident R1's billing statement. Review of Resident R1's paper chart failed to reveal a NOMNC for Resident R1. Review of the clinical record indicated Resident R14 was discharged from skilled services and discharged from the facility on 8/1/25. Review of the electronic medical record failed to reveal a NOMNC or progress notes that indicated communication of the information contained in a NOMNC to Resident R14. During an interview on 8/4/25, at 1:17 p.m. Director of Social Services Employee E8 confirmed that the facility was not able to provide evidence that a NOMNC was issued to the resident or resident representative for Residents R1 and R14. During an interview on 8/7/25, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of seven residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Based on review of facility documents and staff interviews, it was determined that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of seven residents (Resident R1 and R14). Findings include: Review of CMS guidelines, Medicare provider or health plan must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage, (SNF ABN) must be issued to Medicare Fee -for-Service (original Medicare) beneficiaries who are receiving care in a Skilled Nursing Facility (SNF) when: Medicare is expected to deny coverage and when the SNF wants to charge the beneficiary for the non-covered services. Review of the clinical record indicated Resident R1 was discharged from skilled services and discharged from the facility on 7/1/25. Review of the electronic medical record failed to reveal a NOMNC or progress notes that indicated communication of the information contained in a NOMNC to Resident R1's family member, who is responsible for Resident R1's billing statement. Review of Resident R1's paper chart failed to reveal a NOMNC for Resident R1. Review of the clinical record indicated Resident R14 was discharged from skilled services and discharged from the facility on 8/1/25. Review of the electronic medical record failed to reveal a NOMNC or progress notes that indicated communication of the information contained in a NOMNC to Resident R14. During an interview on 8/4/25, at 1:17 p.m. Director of Social Services Employee E8 confirmed that the facility was not able to provide evidence that a NOMNC was issued to the resident or resident representative for Residents R1 and R14. During an interview on 8/7/25, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for two of seven residents. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a): Resident rights.

Review of the facility documents and staff interview, it was determined that the facility failed to permit a resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility for one of six residents (Resident R1).Findings include: Review of the facility policy, Discharge Planning Process dated 10/20/24, indicated the facility must develop and implement an effective discharge planning process. Included in the process description was, Include regular evaluation of patients to identify changes that require modifications of the discharge plan' the discharge plan must be updated to reflect these changes. Review of the American Medical Association Code of Medical Ethics document, Physician Responsibilities for Safe Patient Discharge from Healthcare Facilities indicated, To facilitate a patient's safe discharge from an inpatient unit, physicians should: (a) Determine that the patient is medically stable and ready from discharge from the treating facility. (b) Collaborate with those health care professionals and others who can facilitate a patient discharge to establish that a plan is in place for medically needed care that considers the patient's particular needs and preferences. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 6/4/25, included diagnoses of autism disorder (a neurodevelopmental condition characterized by differences or difficulties in social communication and interaction), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and the presence of a right artificial knee joint. Review of a Certified Registered Nurse Practitioner's note (CRNP) Employee E6 created 6/26/25, at 2:08 p.m. indicated, Concern for start of early infection to R (right) knee incision, begin Keflex (an antibiotic medication) 500 mg BID (twice daily) x5 days, ortho notified. F/U appt (follow-up appointment) 6/27. Review of a certification statement indicated that on 6/27/25, CRNP Employee E6 signed within the recertification section, I certify that post-hospital SNF (skilled nursing facility) care is required on behalf of the above named patient that, as a practical matter, can only be provided in a SNF. The estimated additional period of SNF care was four weeks. Review of the physician's order from Attending Physician Employee E7 dated 6/27/25, at 3:20 p.m. indicated, May discharge to home with home health, skilled PT/OT (physical therapy / occupational therapy) and nursing services. During an interview on 8/4/25, at 12:15 p.m. CRNP Employee E6 confirmed that she signed a recertification of services for Resident R1 on 6/27/25. CRNP Employee E6 stated that she was out of the facility the following week, but when signing the recertification, she had the expectation that she would be following up with Resident R1 upon her return. Review of a progress note dated 7/1/25, at 1:27 p.m. indicated that Resident R1 was discharged from the facility. Review of the Discharge Summary (date illegible) indicated that Resident R1's medical history was TKR (total knee replacement). Under the recapitulation of stay / changes in medical status the entries written by Attending Physician Employee E7 were illegible. On 8/4/25, the Director of Nursing contacted Attending Physician Employee E7, who confirmed that Resident R1 was discharged from the facility based on successfully completing therapy services. During an interview on 8/4/25, at 1:17 p.m. Director of Social Services Employee E8 confirmed that the facility was not able to provide evidence that a Notice of Medicare Non-Coverage (NOMNC) was issued to the resident or resident representative for Resident R1. The Director of Social Services Employee E8 further confirmed that by not providing a NOMNC, the resident representative was not made aware of her right to appeal Resident R1's discharge or provided directions on how to do so. Review of Resident R1's practitioner notes failed to reveal documentation of an evaluation related to Resident R1's facility discharge. During an interview on 8/7/25, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that had Attending Physician Employee E7 reviewed Resident R1's total program of care, including medications and treatments, he would have been aware Resident R1 was recertified for an additional four weeks of SNF care. 28 Pa. Code; 211.12(a)(c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.2(a) Physician Services 28 Pa. Code: 211.5 (f)(g)(h) Clinical records.

Based upon review of facility policy and procedure, clinical record review, and staff interview it was determined the facility failed to ensure the physician was notified of a weight gain for two of 32 residents reviewed (Resident 76 and Resident 147). Findings include: Review of facility policy and procedure titled Weights and Heights, revised 2023, revealed the facility is to notify the physician and dietitian of significant weight changes; document notification of physician and dietitian in the Weight Change Progress Note and the licensed nurse will notify the physician of the dietitian recommendations. Review of Resident 76's physician orders revealed an order stating weigh - daily. Notify MD with weight gain of 1 pound in 1 day or 3 pounds in one week. Review of Resident 76's Weight Summary revealed on January 21, 2025 Resident 76 weighed 226.5 pounds. Further review of Resident 76's Weight Summary revealed on January 22, 2025 Resident 76 weighed 230 pounds indicating a 3.5 pound weight gain in one day. Review of Resident 76's clinical record failed to reveal evidence that Resident 76's physician was notified of Resident 76's weight gain as stated in the physician's order. Interview with the Nursing Home Administrator on February 6, 2025 at 11:27 a.m. confirmed that the physician was not notified of Resident 76's weight gain. Review of Resident 147's clinical record revealed an order for weights to be obtained on Monday, Wednesday and Friday for monitoring. Review of Resident 147's Weight Summary revealed on November 18, 2024 Resident 147 weighed 132 pounds. Further review of Resident 147's Weight Summary revealed on November 20, 2024 Resident 147 weighed 152 pounds indicating a 20 pound weight gain in two days. Review of Resident 147's clinical record failed to reveal documented evidence of notification to the physician of Resident 147's weight gain. Interview with the Director of Nursing on February 6, 2025 at 3:00 p.m. confirmed that Resident 147's physician was not notified of Resident 147's significant weight gain. 28 Pa. Code 211.12(d)(5) Nursing Services 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure a complete and thorough investigation of an incident involving suspected abuse for one of 31 residents reviewed (Resident 78). Findings include: Review of facilities Abuse Prohibition policy, revision date October 24, 2022, states employees are designated as mandated reports and are obligated to immediately report any reasonable suspicion of a crime against a patient. Review of minimum data set (MDS, standardized assessment tool to evaluate residents) dated October 1, 2024, revealed Resident 78 possessed a brief interview for mental status (BIMS) of 14 out of 15 (cognition intact). Clinical record review for Resident 78 revealed nursing documentation dated October 6, 2024, at 8:21 PM that indicated that staff were notified by Resident 78 that she/he was hit multiple times by a staff member during the evening shift (3pm-11pm) on October 6, 2024. Further review of nursing documentation revealed the following [Resident 78] made false accusations of staff hitting her/him during care. But when asked by writer unable to confirm the same. Educated resident on not making false accusations of staff and if she has any concerns or problems about staff to tell the nurse. Will continue to monitor. Review of Resident 78's care plan revealed the resident was not care planed for false accusations. Further review of Resident 78's clinical record failed to find any other documentation of Resident 78 making false accusations. Review of Resident 78's skin assessments for the month of October 2024 reported no new wounds or skin conditions (bruises, lacerations, or rashes). An interview conducted with Resident 78 on February 4, 2025, at 10:07 a.m. reported the incident was nothing and I don't remember saying that. Incident report was requested of the above on February 5, 2025, at 11:12 a.m. during an interview with the Nursing Home Administrator (NHA). Interview conducted with the Director of Nursing (DON) via email on February 6, 2025, at 8:13 a.m. confirmed the facility did not conduct an investigation to the above incident. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 201.18(b)(2)(e)(1) Management

Based on clinical record review and staff interview, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed for two of 31 residents reviewed (Resident 60 and Resident 92). Findings include: The PASRR (Preadmission Screening Resident Review) was created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA) and it has three goals: to identify individuals with mental illness and/or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability. The PASRR Level 1 must be completed on all persons who are considering admission to a Medicaid certified nursing facility. Review of Resident 60's clinical record revealed the resident was readmitted to the facility on August, 2025. Subsequent review of Resident 60's clinical record failed to produce a copy of a completed PASRR. A request for a copy of a completed PASRR was request from the Nursing Home Administrator (NHA) on February 5, 2025, at 11:15 a.m. An interview conducted with the NHA via email on February 6, 2025, at 8:34 a.m. confirmed the facility did not complete a PASRR for the above. 28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.16(a) Social services

Based upon clinical record review, it was determined the facility failed to ensure a baseline care plan was in place for a Foley catheter (rubber tube placed into bladder to drain urine out of the body) upon admission for one of 32 residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed Resident 84 was admitted to the facility with a Foley catheter on January 14, 2025. Review of Resident 84's care plan failed to reveal evidence of a care plan for Resident 84's Foley catheter. Interview with the Nursing Home Administrator on February 6, 2025 at 11:07 a.m. confirmed that there was no baseline care plan completed from admission regarding Resident 84's Foley catheter. 28 Pa. Code 211.12(d)(5) Nursing Services 28 Pa. Code 211.5(f) Clinical Records

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman for four of five residents reviewed (Residents 12, 29, 78, 130). Findings include: Review of Resident 29's progress note of October 20, 2024, revealed resident tested positive for pneumonia and an order was received to send the resident to the hospital. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated October 1, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others. A nursing note for Resident 78, dated October 31, 2024, at 1:27 p.m., indicated that Resident 78 was transferred to [NAME] General Hospital for abnormal other lab value or study. Further review revealed Resident 78 was admitted to the hospital due to critical potassium levels. Review of Resident 130's progress note of October 26, 2024, revealed resident was transferred to the hospital for shortness of breath. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated November 12, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others. A nursing note for resident 12 dated January 3, 2025, at 7:26 p.m. indicated that Resident 12 was transferred to [NAME] State hospital with an admitting diagnosis of acute kidney injury. A request for documented evidence that the state Long-Term Care Ombudsman office was notified of the above hospital transfers was made on February 5. 2025, at 11:15 a.m. with the Nursing Home Administrator (NHA). An interview conducted with the Nursing Home Administrator via email on February 6, 2025, at 9:07 a.m. confirmed the facility has not notified the Office of State Long-Term Care Ombudsman of residents transferred to the hospital since September 2024. Notice Requirements Before Transfer/Discharge Previously cited 3/8/24 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/26/24, 6/11/24, 4/10/24, 3/8/24

Based on facility policy review, clinical records review, and staff interview, it was determined the facility failed to ensure interventions were provided timely for a resident at risk for developing a pressure ulcer and that wound monitoring was done timely for one of three residents reviewed. (Resident CL1). Findings include: A review of the facility's policy titled Skin Integrity and Wound Management, revised on October 15, 2024, revealed, that the plan of care for the patient will reflect assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan as needed. The same policy revealed the identification of the patient's skin integrity status and the need for prevention or treatment intervention through a review of all appropriate assessments and information. Implement pressure injury prevention for identified modifiable risk factors. A review of Resident CL1's admission assessment dated [DATE], revealed that the resident was newly admitted with a diagnosis of Acute Respiratory Failure (a life-threatening condition where the lungs cannot adequately exchange oxygen and carbopn dioxide), presence of Tracheostomy (A procedure to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck), and mouth cancer. A review of Resident CL1's admission skin assessment revealed resident had a redness blanchable (Area of redness disappears on applied pressure- skin is intact) to the sacrum (The triangular bone just below the lumbar vertebrae). A review of Resident CL1's Admission Braden Scale (A scale used for predicting pressure sore risk) completed on December 20, 2024, revealed resident was At Risk for developing a pressure ulcer. A review of Resident CL1's Admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents), dated December 27, 2025, revealed maximal assistance with turning the body from side to side. The same MDS also revealed that the resident was occasionally incontinent of bowel and bladder. A review of the skin assessment dated [DATE], revealed a stage two pressure ulcer (Partial-thickness skin loss with exposed dermis) to Resident CL1's sacrum measuring 0.9 x 0.4 x 0.1 cm. A wound treatment was ordered. A review of Resident CL1's care plan revealed At risk for skin breakdown related to decreased activity, was not developed until December 23, 2024, three days after Resident CL1 was assessed to be at risk for developing a pressure ulcer. Interventions include the following: Pressure redistribution surface to bed and chair; Providing wound treatment as ordered; and Weekly skin check by a licensed nurse. Clinical records review failed to reveal skin check follow-up after Resident CL1 was identified with a stage two to sacrum. An interview conducted with the Director of Nursing on January 23, 2025, revealed Resident CL1's wound rounds were scheduled on Friday (December 27, 2024). The DON was unable to explain as to why it was not done. The DON also confirmed that the plan of care with interventions was not developed and implemented until December 23, 2024, after Resident CL1 was identified with stage two to the sacrum. The facility failed to ensure Resident CL1 was provided with interventions timely to prevent pressure ulcers and timely follow-up to determine wound progress. 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services.

Based on review of the facility's policy, Pennsylvania Department of Health (DOH) 2023-PAHAN-694 review, clinical records review, observations, and staff interviews, it was determined the facility failed to ensure that infection control prevention and management were implemented on two of four units observed ([NAME] and [NAME]) as well as within reception and Rehab department. Findings include: Review of the Pennsylvania Department of Health 2023-PA HAN-694-5-11- UPD (updated) titled Interim Infection Prevention and Control Recommendation for COVID-19 in Healthcare Settings, updated on May 11, 2023, revealed Department of Health (DOH) recommends using the following additional infection control prevention and control practices related to COVID-19 (An infectious respiratory illness caused by the SARS-CoV-2 virus), along with standard practice recommended as a part of routine healthcare delivery to patients. The same PA HAN revealed source control options for HCP (healthcare personnel): A NIOSH-approved particulate respirator with an N-95 filter or higher; A barrier face covering that meets ASTM requirements; or a well-fitting facemask. Source control is recommended in healthcare settings for individuals who have suspected or confirmed SARS-CoV-2 infection or other respiratory infection and who had close contact with someone with SARS-CoV-2 infection, for 10 days after their exposure. HCPs who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use of NIOSH (National Institute for Occupational Safety and Health)-approved N95 respirator, gown, gloves, and eye protector. Review of the facility's policy titled COVID-19, with a review date of July 1, 2024, revealed that in addition to standard precautions, special contact and droplet precautions will be implemented for patients/residents suspected or confirmed to have COVID-19. Special Contact and Droplet Precautions require wearing a N95 respirator upon entry into that patient's room. In addition to the recommended personal protective equipment (PPE), keep the door to the patient's room closed, when safe to do so. The same policy also revealed that any HCP who reports symptoms that meet the criteria will be tested before entry. For transmission-based precautions, the facility will perform contact tracing for both suspected and confirmed cases and document it on the Contact Tracing Log. An outbreak investigation will be organized by the Infection Preventionist or designee when a disease outbreak is suspected. Inteview was conducted upon entrance with the Director of Nursing (DON) on December 26, 2024. The DON reported that there were currently two COVID-19-positive residents in the facility, one in the [NAME] Unit (Resident 1) and the other one in the [NAME] Unit (Resident 2). The DON reported that all staff and visitors must wear a surgical mask while in the building. The DON reported that an N95, a gown, and an eye protector should be worn when entering a room with a COVID-positive resident. Upon entering the facility at 9:15 a.m., Employee E3 was observed sitting in the reception area with no facemask on. Employee E1 grabbed a yellow surgical mask and put it on after the surveyor introduced herself. At 9:27 a.m., Employee E3 was observed at the front desk singing with a face mask on the chin. Observation on the [NAME] Unit conducted on December 26, 2024, revealed the following: at 9:29 a.m., licensed nurse Employee E4 was observed in the hallway giving medications with a surgical facemask on the chin; At 9:29 a.m., licensed employee E5 was observed on Resident 3's room providing treatment wearing a surgical facemask placed on her/his chin, Employee E5 immediately pulled up her/his mask after surveyor introduce self; At 9:35 a.m., licensed nurse Employee E6 was observed on the hallway doing rounds wearing a surgical facemask covering only the mouth at 9:41 a.m. Observation on the Rehab Unit on December 26, 2024, at 9:46 a.m., revealed that licensed Employee E7 was observed wearing a surgical facemask placed on his/her chin while providing treatment to three residents. Observation on the [NAME] Unit conducted on December 26, 2024, revealed the following: At 9:49 a.m., licensed nurse Employee E8 was observed giving medications in the hallway wearing a surgical mask covering only her/his mouth; At 9:51 a.m., licensed nurse Employee E9 was observed providing care to Resident 4 wearing a surgical facemask. Resident 4's room had signage indicating that Resident was on contact and droplet precaution requiring staff to wear an N95 mask, a gown, and an eye shield when entering the room. Employee E9 reported that the precautions were put in place because Resident 4 goes to Dialysis -Hemodialysis (process of purifying the blood of a person whose kidneys are not working normally). Observation conducted on the [NAME] Unit on December 26, 2024, at 1:30 p.m., revealed Employee E6 providing an aerosol treatment to a positive COVID-19 (Resident 1) wearing a surgical facemask. Resident 1's room had signage indicating that the resident was on a contact and droplet precaution, requiring anyone who enters the room to wear an N95 mask, a gown, and an eye protector. Employee E6 reported that she/he initially had all the appropriate PPE worn but had to come back to re-check the resident. Employee E6 confirmed that appropriate PPE should be worn when entering a positive COVID resident. Review of Resident 5 and Resident 6's clinical records revealed Resident 5 and Resident 6, both reside on the Arcadia Unit (secured dementia unit) were sent to the hospital on November 17, 2024, for change in mental condition and respiratory symptoms, both tested positive for COVID in the hospital. All residents and staff that worked in the unit were tested for COVID-19 with 17 resident and six staff (nursing and activities) initially with positive results. The entire unit was placed on droplet and contact precautions with residents placed on isolation. Review of the facility's documentation revealed non licensed staff Employee E10 had a positive COVID test on November 15, 2024. Interview conducted with Employee E10's on December 26, 2024, at 10:00 a.m., revealed, Employee E10 did a self-COVID test after work on November 15, 2024 due to a headache and knee pain, Employee E10 reported that the symptom occurred after work and the test result was positive but did not inform anyone in the facility. Employee E10 reported that she/he did another self-Covid test on November 17, 2024, with a negative result. Employee E10 further reported that she/he came to work on November 18, 2024, served breakfast to the residents on the Arcadia unit, and informed the unit manager of her/his positive/negative test over the weekend. The employee was immediately tested resulted in a positive for COVID reading and was sent home. Interview with the Infection Preventionist, Employee E11, conducted on December 26, 2024, at 10:30 a.m., revealed that after being notified of two positive residents from the hospital, all residents in the unit (Arcadia-Dementia Unit) and staff that worked in the unit were all tested . Positive residents were placed on precautions and isolations and positive staff were sent home and returned following CDC guidelines. However, Employee E11 reported that the facility did not conduct contact tracing to determine possible contact of staff that tested positive as some of the staff members were float nursing staff and activities staff who also traveled to other nursing units. The Infection Preventionist was unable to provide an answer as to why contact tracing was not conducted. The above informatoin was conveyed to the Director of Nursing on December 26, 2024, at 4:00 p.m. The facility failed to ensure infection control and prevention were implemented in the facility. 28 Pa. Code 201.18(a)(b)(1)(2)(3) Management 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records, pharmacy delivery report, and staff interview, it was determined the facility failed to ensure the physician's medication order was followed for one of the three residents reviewed (Resident CL1). Findings include: Review of Resident CL1's physician order dated November 23, 2024, revealed an order for Rytary Oral Capsule Extended Release 23.75-95 MG (Carbidopa-Levodopa) Give 3 capsules by mouth three times a day for Parkinson's (A disorder of the central nervous system that affects movement, often include tremors). Review of the November 2024 Medication Administration Record (MAR) revealed that from November 24, 2024, until November 30, 2024, Resident CL1 was not administered with medication Rytary nine times. Nursing progress notes review dated November 24, 2024, at 9:23 a.m., 11:56 a.m., and 7:00 p.m., November 28, 2024, at 9:17 p.m., November 29, 2024, at 10:22 p.m., November 30, 2024, at 1:12 p.m., all indicated that medication was not administered pending/awaiting delivery from the pharmacy. Review of the pharmacy medication delivery report revealed that medication Rytary (27 capsules) was delivered to the facility on [DATE], and was received by a licensed nurse. Review of Resident CL1's clinical records failed to reveal the physician was notified of the missed medication for Resident CL1's Parkinsons. Interview with the Director of Nursing was conducted on December 26, 2024, at 3:00 p.m. The DON was unable to provide an answer as to why Rytary medication was not administered. The DON confirmed that the physician was not notified of the missed medication. The facility failed to ensure that Cl1's medication order for Parkinson's was followed. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

Based upon clinical record review and interview, it was determined the facility failed to establish a baseline care plan upon admission for a surgical wound for one of one resident reviewed (Resident 1). Findings include: Resident 1's clinical record review revealed Resident 1 was admitted to the facility on [DATE], for short term rehabilitation from surgery. Review of Resident 1's care plan failed to reveal evidence that a baseline care plan was established upon admission for the presence and care of a surgical wound. Interview with Licensed Employee E1 on August 13, 2024, at 10:24 a.m. confirmed Resident 1 did not have a baseline care plan established upon admission for the presence and care of a surgical wound. Interview with the Interim Director of Nursing on August 13, 2024, at 12:30 p.m. confirmed Resident 1 did not have a baseline care plan established upon admission for the presence and care of a surgical wound. 28 Pa. Code 211.11(c)(d) Resident Care Plan

Based upon review of facility policies and procedures, observation and clinical record review, it was determined that the facility failed to ensure that residents were free from significant medication errors which resulted in actual harm with Resident 155 experiencing an unresponsive episode and [MEDICAL CONDITION] requiring hospitalization and [DIAGNOSES REDACTED]. Findings include: Review of facility policy and procedure entitled, Medication Administration: Medication Pass revealed the purpose of the policy is to safely and accurately prepare and administer medication according to physician order [REDACTED]. Read special medication administration instructions. Review of facility policy and procedure entitled [DIAGNOSES REDACTED]: Treatment revealed Factors increasing risk of Hypoglycemic Reaction - too much insulin and/or hypoglycemic agent. Further review of this policy revealed Symptoms of [DIAGNOSES REDACTED] - Severe [DIAGNOSES REDACTED] - loss of consciousness; [MEDICAL CONDITION]. Review of Resident 155's [DIAGNOSES REDACTED]. Review of Resident 155's physician orders [REDACTED]. Review of Resident 155's (MONTH) (YEAR), Medication Administration Record [REDACTED]. Further review of Resident 155's (MONTH) (YEAR), MAR indicated [REDACTED] Review of Resident 155's Nursing Progress Notes dated (MONTH) 18, (YEAR), at 9:42 p.m. revealed 21:15 (9:15 p.m.) resident found unresponsive with top of his body on the bed horizontally (from buttocks and upper torso) and thighs and legs hanging to the floor. Resident was foaming at the mouth and heart rate could not be felt. Resident's head was then turned to the side. Chest compressions started, resident started moaning and radial pulses felt bilaterally. Compressions stopped and BS (blood sugar) checked. 21:20 (9:20 p.m.) BS was 46 and resident was injected with [MEDICATION NAME] (medication used to quickly raise blood sugar levels). Hand and wrist contractures noted at this time. 21:25 (9:25 p.m.) on call DR (doctor) was called with symptoms and resident was referred to the ER (emergency room ). 21:26 (9:26 p.m.) 911 called 21:28 (9:28 p.m.) The nursing note further stated that the hospital emergency room called and spoke to the nursing staff and the resident left the facility via emergency services. Review of Resident 155's Nursing Progress Notes dated (MONTH) 19, (YEAR), revealed Resident was admitted to (hospital) with [DIAGNOSES REDACTED] (low blood sugar levels)/[MEDICAL CONDITION] activity. Review of hospital physician progress notes [REDACTED].[MEDICAL CONDITION] (a disease in which the functioning of the brain is affected by some agent or condition) is likely the lingering sequelae (condition that is a consequence of illness or injury) of [DIAGNOSES REDACTED]. Review of emergency room physician progress notes [REDACTED]. The facility failed to ensure that Resident 155 was free of significant medication errors which resulted in Resident 155 experiencing an unresponsive episode and [MEDICAL CONDITION] requiring hospitalization and [DIAGNOSES REDACTED]. The above-mentioned information was conveyed to the Nursing Home Administrator and the Director of Nursing on (MONTH) 17, (YEAR), at approximately 1:30 p.m. 483.45(f)(2) Residents are free from Significant Medication Errors Previously cited 3/6/17 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 5/7/18, 10/6/17, 9/15/17, 3/6/17, 1/28/17 28 Pa. Code 201.14(c) Responsibility of Licensee Previously cited 5/7/18, 9/15/17 28 Pa. Code 201.18(b)(1) Management Previously cited 5/7/18, 10/6/17, 9/15/17, 3/6/17, 10/11/16 28 Pa. Code 201.18(b)(3) Management Previously cited 10/6/17, 9/15/17, 3/6/17, 10/11/16 28 Pa. Code 201.18(d) Management Previously cited 5/7/18 28 Pa. Code 201.18(e)(1) Management Previously cited 10/6/17, 9/15/17 28 Pa Code 207.2(a) Administrator's Responsibility Previously cited 5/23/18, 9/15/17 28 Pa Code 211.5(f) Clinical records Previously cited 5/23/18, 10/6/17, 9/29/17, 4/19/17, 3/6/17, 12/21/16, 10/11/16 28 Pa Code 211.10(d) Resident care policies Previously cited 10/6/17, 9/29/17, 9/15/17, 4/19/17, 3/6/17, 10/11/16 28 Pa. Code 211.12(c) Previously cited 5/7/18, 10/6/17, 9/29/17, 9/15/17, 4/19/17, 3/6/17, 12/21/16, 10/11/16 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 7/5/18, 5/23/18, 10/6/17, 9/29/17, 9/15/17, 3/6/17, 12/21/16, 10/11/16 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 7/5/18, 9/15/17, 3/6/17, 12/21/16, 10/11/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 7/5/18, 5/23/18, 10/6/17, 9/29/17, 9/15/17, 4/19/17, 3/6/17, 12/21/16, 10/11/16

Based on review of the clinical record, interviews with staff and review of facility policy, it was determined that the facility failed to provide the proper level of assistance during provision of incontinence care to one resident to ensure resident safety which resulted in the resident sustaining a fall from bed resulting in a hematoma to the head and was transferred to the hospital with a [DIAGNOSES REDACTED]. Findings include: Review of facility policy titled, Bed Positioning, reviewed 10/2011, for positioning residents for procedures revealed that turning a resident from back to side, the caregiver should, place one hand behind the shoulder of the resident and the other behind the hip and gently roll the resident toward the caregiver. To position a resident from side to back, place one hand behind the shoulder and the other behind the hip and gently roll the patient away from you until they rest on their back. Review of Resident R1's [DIAGNOSES REDACTED]. Review of the September 2017 physician's orders [REDACTED]. Review of Resident R1's quarterly MDS assessment (Minimum Data Set: MDS, a periodic assessment of resident care needs) dated August 4, 2017, revealed that the resident required the extensive assistance of two persons for bed mobility. The resident's BIMS (Brief Interview For Mental Status- determined cognitive function) was scored at a 4 which indicated severe cognitive function. Review of Resident R1's nursing note dated September 30, 2017, at 1:30 a.m. by the Registered Nurse (RN) Supervisor, Employee E3, revealed that she was called to the resident's room and found the resident on the floor on her left side with her head under a chair. The staff relayed to the nurse that the resident rolled off the bed while care was being provided. The resident stated that her head hurt and a large raised hematoma (collection of blood) was noted above the left temple. Review of the nursing note dated September 30, 2017, which was documented by Employee E3 revealed that the physician/nurse practitioner group was notified of the resident's fall. A physician's orders [REDACTED]. Review of hospital records dated October 2, 2017, revealed that the resident was admitted to the hospital on September 30, 2017 with a [DIAGNOSES REDACTED]. Review of Resident R1's care plan did not address the assistance needed for bed mobility. The resident's kardex (a care plan used by the nursing assistants for directing care) was not available for review since the resident was discharged from the facility. An interview was conducted on October 6, 2017, at approximately 10:40 a.m. with Nursing Assistant, Employee E4, the nursing assistant who provided care to Resident R1. She revealed that she was washing and changing the bed secondary to incontinence. She further stated that she was tucking the sheet under the resident with one hand holding her over and away from her and the other tucking the sheets when the resident suddenly fell off the bed head first. Employee E4 stated during interview that Resident R1 required one person for care which could not be confirmed with the resident's kardex. An interview conducted on October 6, 2017, at approximately 10:30 a.m. with Employee E5, Nursing Assistant, revealed that she was passing ice water and assisting with rounds. When she entered the room and almost reached the bottom of the bed, she observed Nursing Assistant, Employee E4, providing care to Resident R1. She further stated that suddenly the resident was falling out of the bed and she could not get to the resident in time to stop the fall. The facility failed to ensure that Resident R1 was properly positioned and safely turned in bed during incontinence care which resulted in actual harm with Resident R1 sustaining a fall, hematoma to the head and being transferred to hospital with the [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/15/17, 03/06/17, 01/28/17 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 09/15/17, 03/06/17 28 Pa. code 211.5(f) Clinical records Previously cited 09/29/17, 04/19/17, 03/06/17, 12/21/16, 10/11/16 28 Pa Code 211.10(d) Resident care policies Previously cited 09/29/17, 09/15/17, 04/19/17, 03/06/17, 10/11/16 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa Code 211.12(c)(d)(1)(5) Nursing services Previously cited 09/29/17, 09/15/17, 04/19/17, 03/06/17, 12/21/16, 10/11/16

Based on clinical record review and staff interview, it was determined that the facility failed to properly assess and notify the physician of a resident's change in skin condition that resulted in a delay in treatment and subsequent hospitalization with a [DIAGNOSES REDACTED]. Findings include: Review of Resident CL1's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It leads to narrowing and hardening of the arteries. This causes decreased blood flow, which can injure nerves and other tissues), [MEDICAL CONDITION] ([MEDICAL CONDITION] - the heart's inability to pump an adequate supply of blood), and Stage 4 [MEDICAL CONDITION] (advanced kidney damage - As kidney function declines, waste products build up in the blood.) Review of Resident CL1's Admission Screen on August 22, 2017 revealed no documentation of any skin abnormalities on the resident's legs. Review of Resident CL1's physician's orders [REDACTED]. Following the application of the corticosteroid cream, the legs were to be wrapped daily. Review of Resident CL1's nursing notes revealed a nurse's note dated September 6, 2017 at 2:13 p.m stating there was some fluid leaking from (right) ankle. Review of Resident CL1's nurses notes revealed a nurse's note dated September 9, 2017 at 6:12 a.m stating that the resident was showing a large amount of weeping from bilateral extremities. Nurse's note dated September 9, 2017 at 6:33 a.m. noted Both lower legs leaking fluid. Review of Resident CL1's nursing notes dated September 10, 2017 at 12:28 a.m. revealed that the Patient (was) complaining of severe pain in abdomen and legs given Tylenol (due to) [MEDICATION NAME] (narcotic-like pain medication) already given . continues to complain of pain. Review of Resident CL1's nursing notes dated September 10, 2017 at 5:39 a.m. indicated Patient continues to complain of severe pain in bilateral lower legs with a large amount of serous weeping .Patient's lower extremities rewrapped with gauze and patient placed back in bed. Patient sobbed during dressing change. Lower extremities elevated at this time. Will continue to monitor. Review of Resident CL1's nurse's notes revealed a nurse's note dated September 10, 2017 at 10:13 a.m stating that the resident remain(s) in bed with legs elevated, resting at present, but had (complaints of) pain before meds, legs still weeping fluid. On September 10, 2017 at 2:32 p.m. it was noted that the resident's Appetite (was) very poor, refused to eat. Review of Resident CL1's nurse's notes dated September 10, 2017 at 8:05 p.m stated that the resident was Complaining of severe bilateral lower leg pain. He makes 'Yipping' noises whenever either of his legs (are) touched. He does have redness and some open areas on his lower legs, which is somewhat chronic. And chronic weeping that requires dressing changes every shift .(Family member) stated his legs are infected and the pain is more than he has ever had before .also stated (Resident CL1) was having 'unresponsive episodes.' However, whenever I came into the room, (Resident CL1) was alert and responsive and continued to make the 'yipping' sounds when any part of his body was touched. (Family) insisted he be sent to the hospital .Ambulance came at about 19:45 (7:45 p.m.). Review of Resident CL1's clinical record revealed no evidence of that an assessment was completed of any wounds identified on the resident's legs. Further review of Resident CL1's clinical record revealed no documented evidence that the resident's skin was being monitored regularly for temperature, size, color changes, and open wounds from September 6, 2017 when the resident's right ankle was first noted to be weeping fluid. Review of Resident CL1's hospital records revealed that Resident CL1 arrived at 8:16 p.m with a significant increase in pain in his bilateral legs with associated redness and open wounds. His bilateral feet are cold and red and a pulse is not palpable in his right foot. Review of Resident CL1's hospital records revealed the resident was admitted to the hospital on September 10, 2017 with [DIAGNOSES REDACTED].[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body) and septic shock (a life-threatening condition that happens when blood pressure drops to a dangerously low level after an infection.) Interview with Medical Director on September 12, 2017 at approximately 4:30 p.m. revealed that the medical director would have expected the physician to have been notified at the start of Resident CL1's change in condition. Interview with Resident CL1's physician on September 12, 2017 at approximately 5:00 p.m. revealed that the resident's legs weeping was a new change to him and that he would have expected to have been notified when the resident's legs started weeping. An Immediate Jeopardy situation was identified to the the Director of Nursing on September 12, 2017 at 2:45 p.m. for failure to notify the physician at the start of Resident CL1's change in condition from September 6, 2017 to September 9, 2017 and the facility's failure to accurately and timely assess Resident CL1's skin condition which resulted in the resident requiring hospitalization and a [DIAGNOSES REDACTED]. A corrective action plan was requested on September 12, 2017 at 2:45 p.m. to immediately put systems in place to ensure the completion of skin assessments that include color, temperature, drainage, measurements and condition of surrounding skin for all current residents and timely notification to the physician of any alteration in skin integrity and change in the resident's condition. The facility submitted and implemented an acceptable plan of action which included educating all licensed nursing staff on what was considered a change in condition and when the physician should be notified. Skin assessments are to be done on residents weekly, and the assessments are to be documented in the treatment administration record. The Immediate Jeopardy was removed on September 15, 2017 at 10:40 a.m. following the confirmation that the action plan was implemented. 28 Pa 201.14(a) Responsibility of licensee 28 Pa Code 201.14(c) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12 (d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on a review of the Pennsylvania Professional Nursing Practice Act, facility policies, clinical record review, facility documentation and staff interviews, it was determined that the facility failed to meet professional standards in regards to medications administered by the licensed nursing staff that resulted in actual harm to one resident who received the wrong medications, required transfer and admission to an acute hospital with polypharmacy overdose and severe [MEDICAL CONDITION] and required the placement of an endotracheal tube for mechanical ventilation for one of 10 residents reviewed (Resident R9). Findings include: The Professional Code, Title 49, Professional and Vocational Standards, Chapter 21.11(b) states that the registered nurse (RN) is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. Additionally, a licensed practical nurse (LPN) shall follow the written, established policies and procedures of the facility that are consistent with the act. Review of the nurse supervisor job description, with a revised date of January 2016, indicated that the supervisor was to deliver nursing care within the scope of practice, coordinate care delivery, which will ensure that the patient's needs are met in accordance with the professional standards of practice through physician orders, center policies and procedures, and federal, state and local guidelines for currently licensed as a licensed practical nurse or registered nurse. General nursing job function included for the care and responsibilities demonstrating the ability to administer medications timely and according to facility policy. Review of the facility policy, Medication Administration: Medication Pass, dated March 2010, revealed that the nurse when administering medications should identify the patient by calling the name, checking the identification band, and refer to a photo. Review of the facility policy, Medication and Treatment Administration Guidelines, dated December 2014, revealed that medications are administered in accordance with the following rights of medication administration - right patient, right medication, right dose, right route, right time, right documentation, right of patient to refuse, and right clinical indication. Review of Resident R9's clinical record documented that the resident was admitted to facility on February 7, 2017, for a short term stay. Review of Resident R9's nursing progress note, dated March 4, 2017, at 1:42 p.m. documented the following: at 10:15 a.m. LPN (Licensed Practical Nurse, Employee E9)asked me (Licensed Practical Nurse, Employee E4) to assess patient (Resident R9) related to does not feel well. Vital 97.8 (temperature - normal 98.6 degrees Fahrenheit) 64 (heart beats/minute - normal is considered 60 - 100) 18 (respirations/minute - normal is considered 12-20) 72/42 (blood pressure - normal is considered 120/80) flat in bed and sitting 52/26. Oxygen at 3 liters per minute via nasal cannula (a device that delivers oxygen directly into the nose) 88% (percent of oxygen in the blood - normal is above 95), increased oxygen to 4 liters per minute via nasal cannula. Patient awake, alert and oriented x 2 (person, place), skin warm, dry and pale. AR (apical rate- pulsation of the heart) 64 (beats per minute) regular lungs with exp (expiratory), rhonchi (coarse rattling respiratory sounds). Denies pain or discomfort. Notified doctor on call and sent patient to emergency room for evaluation and treatment. Review of Employee E9's statement obtained on March 5, 2017, (no time indicated) revealed that on March 4, 2017, Employee E9 noted in the statement that she (used stock medications for Resident R10 and Employee E4 opened the packets of the routine medications and poured them into the medicine cup. I (Employee E9) swiped my badge to sign off for the medications. Employee E4 picked up the cup of medicine and asked Who are these for? I replied, .(Resident R10). After stating, Oh yes, I know who he is, Employee E4 then walked off with the medications. A direct care nursing staff approached me around 30-40 minutes later and stated, .(Resident R9) said that he doesn't feel right. Resident R9 was short of breath and said, Something isn't right, he said he felt light headed and asked me if I gave him his medications this morning and then asked me why a man came in and gave him medications too. Resident R9 also confirmed that the man that came in had a full medication cup filled to the rim. Employee E9 asked Resident R9 why he took the medications and Resident R9 replied, Because I trusted him. Licensed Practical Nurse Employee E9 further revealed that she requested for Licensed Employee E4 to come to the nursing unit immediately, I think you gave medications to the wrong patient. ) Review of Licensed Employee E4's statement obtained March 5, 2017, (no time indicated) revealed that on March 4, 2017, Employee E4 (I began helping Employee E9 open the medication packs and add them to the cup. Employee E4 went into Resident R9 and R10's room. Resident R9 confirmed out loud for Employee E4 that he was Resident R10. Employee E4 said to Resident R9, Here are your medications. Resident R9 inquired of Licensed Employee E4, Why are there so many?, Employee E4 responded to Resident R9's inquiry, Well, these are your medications. Employee E4 further stated that he sat next to Resident R9 and gave him his medications. At around 10:00 a.m. to 10:30 a.m. Employee E9 called me and said that Resident R9 did not feel right. Employee E9 asked Employee E4 who I gave medications to and Employee E9 told Employee E4 that Employee E4 gave the wrong medications to Resident R9. Licensed Employee E4 went right over to Resident R9 who told Employee E4 he felt dizzy. Employee E4 confirmed that he realized he gave the wrong medications to Resident R9. Employee E4 assessed Resident R9, called the on-call physician who told Employee E4 to call 911 (emergency medical dispatch) and send the resident to the hospital.) Review of the hospital admission information dated March 6, 2017, at 9:20 a.m. documented that Resident R9 arrived at the hospital on March 4, 2017, at 12:08 p.m. and was admitted to the hospital on March 4, 2017, with an acute kidney injury (abrupt deterioration in kidney function); refractory [MEDICAL CONDITION] (abnormally low blood pressure) status [REDACTED]. enough of the carbon [MEDICATION NAME] (CO2) produced by the body) and [MEDICAL CONDITION] (a condition that occurs when the level of sodium in your blood is abnormally low). Resident R9, presented to the emergency department after being provided his daily medications including a calcium channel blocker and was subsequently administered his roommates' medications and developed [MEDICAL CONDITION] with hypoxemia requiring intubation (process of inserting a tube, called an endotracheal tube through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing. The tube is then connected to a ventilator, which pushes air into the lungs to deliver a breath to the patient. This process is done because the patient cannot maintain their airway, cannot breathe on their own without assistance or both). An interview with Licensed Employee E9 on March 5, 2017, at 1:00 p.m. accompanied by the Director of Nursing, revealed that Employee E9 did not request help or decline the assistance that Employee E9 received from Licensed Employee E4 on March 4, 2017, and stated, I didn't say anything to him about helping me it wasn't significant, and further stated, He helps me sometimes, he helped me a couple weeks ago. An interview with Licensed Employee E4 on March 5, 2017, at 2:55 p.m. did confirm that Employee E4 failed to identify Resident R9 by checking the resident's identification bracelet or a picture before administering the medications. An interview with the Director of Nursing on March 5, 2016, at approximately 3:00 p.m. confirmed that the licensed staff who prepare the medications should be the licensed staff administering the medications to the resident. It was also confirmed that the licensed staff were to confirm the resident's name, check the identification band, and check the resident's picture prior to administering the medications, which did not occur. The facility failed to ensure professional standards of practice were being followed by the licensed nursing staff by failing to prepare and administer medications by the same licensed staff person who was responsible to prepare the medications, by confirming the resident's name, and by checking the resident's identification band and the resident's picture prior to the administration of medications for Resident R9. As a result, Resident 9 received their roommate's medication in addition to their own, resulting in [MEDICAL CONDITION] with hypoxemia requiring transportation to an acute care hospital and intubation. Refer to F333. 42 CFR 483.20(b)(3)(i) Services Provided Meet Professional Standards Previously cited 10/11/16 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 09/21/15, 01/28/17 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 09/21/15, 12/08/15, 10/11/16 28 Pa. Code 201.18(e)(1) Management Previously cited 09/21/15 28 Pa. Code 211.9(a)(1)(c) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies Previously cited 10/11/16, 12/21/16 28 Pa. Code 211.12(c) Nursing services Previously cited 10/11/16, 12/21/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously 09/21/15, 12/08/15, 10/11/16, 12/21/16

Based on a review of facility policy, information submitted by the facility, review of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to ensure that one resident remained free of a significant medication error, which resulted in actual harm by administering the incorrect medications to one resident which resulted in the resident being transferred and admitted to the hospital with [REDACTED]. Findings include: Review of facility policy entitled, Medication Administration: Medication Pass, dated March 2010, revealed the purpose was to safely and accurately prepare and administer medication according to the physician's order and the patient's needs. Procedural step 9: Administer medication indicated that the nurse, when administering medication, should identify the resident by calling their name, checking their identification bracelet and referring to their photo; then describing the name of the medication and the reason for ti's use to the resident and answering any questions if needed. Review of the facility policy entitled, Medication and Treatment Administration Guidelines, dated December 2014 revealed that medications were administered in accordance with the following rights of medication administration - right patient, right medication, right dose, right route, right time, right documentation, right of patient to refuse, and right clinical indication. Review of Resident R9's clinical record documented that the resident was admitted to the facility on [DATE], for a short term stay and the resident's admission Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated February 14, 2017, assessed the resident as cognitively intact with a Brief Interview for Mental Status (BIMS - a tool used to assess a resident's cognitive status) score of 15 out of a possible 15. Resident R9's facility listed medical conditions included heart failure (a condition in which the heart can't pump enough blood to meet the body's needs); [MEDICAL CONDITION] stage III (a progressive loss in kidney function over a period of months or years); [MEDICAL CONDITION] ([MEDICAL CONDITION] - a progressive disease that makes it hard to breathe; gets worse over time); [MEDICAL CONDITION] (a condition caused by an abnormally high concentration of potassium in the blood); hypertension (high blood pressure); obesity (a medical condition in which excess body fat has accumulated to the extent that it may have a negative effect on health); [DIAGNOSES REDACTED] (a condition in which an irregular heart rhythm occurs periodically); [MEDICAL CONDITIONS] (a build up of plaque inside your arteries - a leading cause of [MEDICAL CONDITION] and [MEDICAL CONDITION]); and interstitial [MEDICAL CONDITION] disease (a group of lung diseases affecting the interstitial (the tissue and space around the air sacs of the lungs)). Review of documentation submitted by the facility on March 4, 2017, indicated that on March 4, 2017, Resident R9 was given his 9:00 a.m. medications and his roommate's 9:00 a.m. medications. Resident R9 stated he did not feel well at 10:15 a.m. Vital signs were taken and blood pressure was 52/26 (normal is considered 120/80) sitting in bed and then lying it was 72/42. Oxygen at 3 liters per minute calculated oxygen at 88% (percent of oxygen in the blood - normal is considered above 95%) and resident was on continuous oxygen; oxygen was increased to 4 liters per minute. Resident was awake and alert and oriented x 2. Notified doctor and new orders obtained to send to emergency room . Description of follow-up action documented that the resident was admitted to an acute care hospital for an accidental, unintentional overdose. Review of Resident R9's nursing progress note dated March 4, 2017, at 1:42 p.m. documented the following: At 10:15 a.m. LPN (Licensed Practical Nurse, Employee E9) asked me (Licensed Practical Nurse Employee E4) to assess patient (Resident R9) related to does not feel well. Vital 97.8 (temperature - normal 98.6 degrees Farenheit) 64 (heart beats/minute - normal is considered 60 - 100) 18 (respirations/minute - normal is considered 12-20) 72/42 (blood pressure - normal is considered 120/80) flat in bed and sitting 52/26. Oxygen at 3 liters per minute via nasal cannula (a device that delivers oxygen directly into the nose) 88% (percent of oxygen in the blood - normal is above 95), increased oxygen to 4 liters per minute via nasal cannula. Patient awake, alert and oriented x 2 (person, place), skin warm, dry and pale. AR (apical rate- pulsation of the heart) 64 (beats per minute) regular lungs with exp (expiratory), rhonchi (coarse rattling respiratory sounds). Denies pain or discomfort. Notified doctor on call and sent patient to emergency room for evaluation and treatment. Review of Employee E9's statement obtained March 5, 2017, (no time indicated) revealed that on March 4, 2017, Employee E9 poured house stock medications for Resident R10 and Employee E4 opened the packets of the routine medications and poured them into the medicine cup. Employee E9 swiped the badge to sign off for the medications. Employee E4 picked up the cup of medicine and asked Who are these for? I replied, (Resident R10). After stating, Oh yes, I know who he is, Employee E4 then walked off with the medications. A direct care nursing staff approached me around 30-40 minutes later and stated, (Resident R9) said that he doesn't feel right. Resident R9 was short of breath and said, Something isn't right, he said he felt light headed and asked me if I gave him his medications this morning and then asked me why a man came in and gave him medications too. Resident R9 also confirmed that the man that came in had a full medication cup filled to the rim. Employee E9 asked Resident R9 why he took the medications and Resident R9 replied, Because I trusted him. Employee E10 further revealed that she requested for Employee E4 to come to the nursing unit immediately, I think you gave medications to the the wrong patient. Review of Employee E4's statement obtained March 5, 2017, (no time indicated) revealed that on March 4, 2017, I began helping Employee E9 open the medication packs and add them to the cup. Employee E4 went into Resident R9 and R10's room. Resident R9 confirmed out loud for Employee E4 that he was Resident R10. Employee E4 said to Resident R9, Here are your medications. Resident R9 inquired of Employee E4, Why are there so many? Employee E4 responded to Resident R9's inquiry, Well, these are your medications. Employee E4 further stated that he sat next to Resident R9 and gave him his medications. At around 10:00 a.m. to 10:30 a.m. Employee E9 called me and said that Resident R9 did not feel right. Employee E9 asked Employee E4 who I gave medications to and Employee E9 told Employee E4 that Employee E4 gave the wrong medications to Resident R9. Employee E4 went right over to Resident R9 who told Employee E4 he felt dizzy. Employee E4 confirmed that he realized he gave the wrong medications to Resident R9. Employee E4 assessed Resident R9, called the on-call physician who told Employee E4 to call 911 and send the resident to the hospital. An interview with Employee E9, on March 5, 2017, at 1:00 p.m., accompanied by the Director of Nursing, revealed that Employee E9 did not request help or decline the assistance that Employee E9 received from Employee E4 on March 4, 2017, and stated, I didn't say anything to him about helping me it wasn't significant, and further stated, He helps me sometimes, he helped me a couple weeks ago. An interview with Licensed Practical Nurse Employee E11, the second LPN that was working on this unit during the incident on March 5, 2017, at 2:10 p.m. revealed that while Employee E11 was comforting Employee E9 secondary to the medication error; Employee E9 did tell Employee E11 that the supervisor (Employee E4) gave medications to the wrong resident. Employee E11 further revealed that Employee E9 felt responsible for the medication error as Employee E9 was behind in medication administration and could have completed the medication pass without any assistance from the supervisor but when Employee E4 offered to help, Employee E9 accepted the help. An interview with Employee E4 on March 5, 2017, at 2:55 p.m. did confirm that Employee E4 failed to identify Resident R9 by checking the resident's identification bracelet or a picture before administering the medications. Employee E4 further revealed that when the nursing staff are getting behind in their tasks, he will offer to help; and that the result of this was that Resident R9 received another residents' medications in addition to his own. Review of both Resident R9 and Resident R10's March 2017 Medication Administration Records, accompanied by the Director of Nursing on March 6, 2017, at approximately 12:00 p.m. confirmed the following medications were ingested by Resident R9 at approximately 9:00 a.m.: [MEDICATION NAME] HCI 200 milligrams (for treatment of [REDACTED]. 10 milligrams (a steroid; anti-[MEDICAL CONDITION]); [MEDICATION NAME] Handihaler capsule 18 micrograms (a [MEDICATION NAME][MEDICATION NAME].; helps open up the airways in your lungs to make it easier to breathe); Therapeutic tablet (a dietary supplement); Tylenol 1000 milligrams (a medication for pain); Cytotec 100 micrograms (a medication that reduces the risk for stomach ulcers); Eliquis 2.5 milligrams (a medication that blocks the activity of certain clotting substances in the blood to prevent a stroke); [MEDICATION NAME] 600 milligrams (a medication for the treatment of [REDACTED].; Breo Ellipta Aerosol powder breath 100-25 micrograms inhalation (a medication used to treat asthma); Aspirin 81 milligrams; [MEDICATION NAME] 50 milligrams (a medication used to treat high blood pressure); Magnesium Chloride Extended Release 535 64 milligrams (a dietary supplement); [MEDICATION NAME]-[MEDICATION NAME] 1 application inhalation (a medication used to treat asthma) and [MEDICATION NAME] 10 milligrams (a calcium channel blocker which slows the rate at which calcium enters cells; reduces contraction in some types of muscle, causing blood vessels to remain wider and the heart to beat less forcefully and slows down the conduction of electricity in the heart, causing it to beat less rapidly (used alone or together with other medicines to treat chest pain and high blood pressure)). Review of the hospital admission information dated March 6, 2017, at 9:20 a.m. documented that Resident R9 arrived at the hospital on March 4, 2017, at 12:08 p.m. and was admitted to the hospital on March 4, 2017, with an acute kidney injury (an abrupt deterioration in kidney function); refractory [MEDICAL CONDITION] (abnormally low blood pressure) status [REDACTED]. enough of the carbon [MEDICATION NAME] (CO2) produced by the body) and [MEDICAL CONDITION] (a condition that occurs when the level of sodium in your blood is abnormally low). Resident R9 presented to the emergency department after being provided his daily medications including a calcium channel blocker and was subsequently administered his roommate's medications and developed [MEDICAL CONDITION] with hypoxemia requiring intubation (process of inserting a tube, called an endotracheal tube through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing. The tube is then connected to a ventilator, which pushes air into the lungs to deliver a breath to the patient. This process is done because the patient cannot maintain their airway, cannot breathe on their own without assistance or both). An interview with the Director of Nursing and the Nursing Home Administrator on March 6, 2017, at approximately 2:45 p.m. confirmed that Employees E4 and Employee E9 were not to be sharing a medication administration pass and further revealed that Employee E4 did not confirm Resident R9's identity prior to the administration of medications belonging to Resident R10. The facility failed to ensure that Resident R9 was free of a significant medication error, which resulted in harm to the resident; required a transfer and emergent admission to the hospital with [DIAGNOSES REDACTED]. 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 09/21/15, 12/08/15, 10/11/16 28 Pa. Code 201.18(e)(1) Management Previously cited 09/21/15 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies Previously cited 10/11/16, 12/21/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 09/21/15, 12/08/15 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/08/15, 10/11/16, 12/21/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously 09/21/15, 12/08/15, 10/11/16, 12/21/16

Based on observation; review of clinical records; facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that one resident (Resident M4), who had an indwelling catheter, had a clinically valid indication for the use of indwelling catheter resulting in actual harm to the resident; and facility further failed to provide a program to retain or improve bowel and bladder function for 5 of 25 residents reviewed (Residents M4, F8, G7, H4 and O5). Findings include: Review of Resident M4's admitting record indicated resident was admitted from the acute hospital setting to facility, on February 18, 2013, diagnosed upon admission with Benign Prostate Hypertrophy (harmless growth in size of the gland that surrounds the urethra and carries urine from the bladder out of the body) ([MEDICAL CONDITION]) without urinary obstruction. Observation of Resident M4 during initial tour, on September 25, 2013 at 12:50 p.m. and during all days of the survey, confirmed resident with a Foley catheter (thin rubber tube which is placed into bladder to drain urine out of bladder). Surveyor interview with Resident M4, on September 26, 2013 at approximately10:00 a.m., revealed that resident was oriented to the placement of the catheter but did not know why the catheter was initially placed because resident did not recall any difficulty with [MEDICAL CONDITION]. Review of physician admission orders [REDACTED]. Review of hospice coordinated physician's plan of care, for initial authorization period March 14, 2013 through May 12, 2013, did not document for resident to receive a catheter. Review of hospice coordinated physician's plan of care, for authorization period May 13, 2013 through July 11, 2013, and subsequently signed and dated by attending physician, on August 23, 2013, documented for indwelling catheter for incontinence and retention as needed. Resident M4's current hospice coordinated physician's plan of care, for authorization period September 10, 2013 through November 8, 2013, documented for the continued use of the catheter for incontinence and retention as needed. Review of Resident M4's urinary incontinence care plan, initiated March 2, 2013, indicated for the resident to receive an individual toileting planned schedule every two to three hours and as needed. There was no evidence that facility had completed an initial bowel and bladder assessment prior to initiating this urinary incontinence care plan. Review of Resident M4's significant change assessment, dated March 27, 2013, indicated that resident was cognitively intact and was frequently incontinent of urine. Toileting documentation for March and April 2013 indicated that Resident M4 was frequently incontinent; however, detail review of Resident M4 ' s March 2013 documentation for toileting, revealed that resident was being toileted only one time during the day hours for 12 shifts out of a possible 31 shifts; and for the hours of second shift was toileted only one time for 16 shifts, out of a possible 31 shifts. Review of Resident M4's April 2013 documentation for toileting every two to three hours, revealed that resident was toileted only one time for 17 shifts during the evening shift hours, out of a possible 30 shifts. Review of facility documentation, dated May 2, 2013 at 11:30 a.m., indicated that facility notified the physician's office that Resident M4 had not urinated May 1, 2013 since 10:45 p.m. and was bladder scanned May 2, 2013 at 11:30 a.m. for 563 milliliters of urine in bladder. (bladder scan- to measure the amount of unine left in the bladder after passing urine). Facility received a physician order, dated May 2, 2013 at 11:30 a.m., for placement of indwelling catheter. Review of Resident M4's initial indwelling catheter assessment, dated July 11, 2013 and subsequent assessments, dated, July 24, 2013 and September 19, 2013, provided for no identified risk factors for the use of an indwelling catheter. Nurse note, dated August 5, 2013, confirmed that Resident M4 required treatment for [REDACTED]. Physician orders [REDACTED]. Interview with licensed nursing staff, Employee E3, on September 27, 2013 at 11:45 a.m., confirmed that facility could provide no clinical basis for the rationale for the use of an indwelling catheter as evidenced by no diagnostic findings that resident had chronic [MEDICAL CONDITION], with an ongoing inability to void, and no urology consults. Licensed nursing Employee E3 further alleged that the hospice vendor had recommended for the placement of the catheter and declined intermittent catheterization for bladder drainage because it was not considered a comfort procedure and could only increase resident ' s risk for infection. The facility failed to provide an initial comprehensive bladder assessment; failed to identify those factors which predisposed or interfered with resident's ability to empty the bladder and could provide no medical justification for both the initial and continued use of the catheter including no plan for removal of the catheter and restoring bladder function, thus resulting in actual harm to Resident M4 secondary to the development of two urinary tract infections. Review of Resident F8's comprehensive initial assessment dated [DATE] and Medicare 60 day assessment dated [DATE] revealed that Resident F8 was alert and oriented, was always incontinent of bowel and frequently incontinent of bladder and needed assistance of staff for transfer, ambulation and hygiene. Review of the resident's clinical record revealed no evidence that an initial or a 60 day bowel and bladder assessment had been done to determine if a bowel and bladder program could maintain or improve the resident's continent status. Review of Resident G7's comprehensive initial assessment dated [DATE] and quarterly assessment dated [DATE] revealed that Resident G7 was alert and oriented, was frequently incontinent of bowel and bladder and needed assistance of staff for transfer, ambulation and hygiene. Review of the resident's clinical record revealed no evidence that an initial or quarterly bowel and bladder assessment had been done to determine if a bowel and bladder program could maintain or improve the resident's continent status. Review of Resident H4's comprehensive initial assessment dated [DATE] and quarterly assessment dated [DATE] revealed that Resident H4 was alert and oriented, was frequently incontinent of bowel and bladder and needed assistance of staff for transfer, ambulation and hygiene. Review of the resident's clinical record revealed no documented evidence that an initial or quarterly bowel and bladder assessment had been done to determine if a bowel and bladder program could maintain or improve the resident's continent status. Interview with the Director of Nursing on September 30, 2013 at 8:50 a.m. confirmed that the facility does not complete bowel and bladder assessments on their residents. Interview with Employee E8, a licensed nurse on September 30, 2013 at approximately 9:30 a.m. confirmed that the facility does not complete a bowel and bladder assessment on residents to develop an individual bowel and bladder program for residents on the unit. Review of resident O5s annual comprehensive assessment Minimum Data Set (MDS) (assessment of care and needs) dated June 13, 2013 revealed the resident scored 14 out of 15 on the Brief Interview of Mental Status (BIMS) indicating the resident is cognitively intact. Further review of Resident O5's annual assessment revealed the resident was coded as being frequently incontinent of bowel and frequently incontinent of bladder. Review of resident O5s plan of care revealed no care plan for a toileting program or any other program to help improve the resident's bowel and bladder incontinence. Interview with the director of nursing on September 26, 2013 at 2:30 p.m. confirmed there was no bowel and bladder assessment for this resident to determine the cause of incontinency and the appropriateness of a bladder toileting program. 28 Pa. Code: 201.14(a) Responsibility of licensee Previously cited 7/19/`13, 4/26/13 28 Pa. Code: 201.18(a)(b)(1)(3)(e)(1) Management Previously cited 7/19/13, 4/26/13, 2/14/13, 12/24/12, 10/25/12 28 Pa. Code: 211.5(f) Clinical records Previously cited: 4/26/13, 2/14/13, 10/25/12 28 Pa. Code: 211.10(a)(c)(d) Resident care policies Previously cited 7/19/13 28 Pa. Code: 211.10(c) Resident care policies 28 Pa. Code: 211.10(d) Resident care policies Previously cited 4/26/13, 2/14/13, 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Previously cited: 4/26/13, 2/14/13, 10/25/12

Based on clinical record review, facility documentation, facility policy and staff interview it was determined that the facility failed to provide sufficient fluid intake to maintain proper hydration for one of three residents reviewed, resulting in actual harm to resident R1. Findings include: A review of the Resient R1's [DIAGNOSES REDACTED]. A review of the Resident R1's 60 day assessment dated [DATE] revealed the resident required 1 person assistance with hygiene. A review of current physician orders revealed the resident was ordered [MEDICATION NAME] 40 milligrams daily (a diuretic) and Keflex 500 milligrams three times a day (an antibiotic medication). A review of the toileting documentation for resident R1 revealed that the resident had a loose stool on August 7 2012, at 6:04 p.m. Nurses notes dated August 8, 2012 related stool sample for C- Diff obtained (Bacteria that causes diarrhea when competing natural bacteria in the gut have been wiped out by antibiotics.). The lab reported on August 9, 2012 that the stool was positive for [MEDICAL CONDITION] and the physician ordered the antibiotic [MEDICATION NAME] for [MEDICAL CONDITION].. Review of the facility policy for Interventions for Hydration Management related the water out/ water in concept. Residents are offered fluids after toileting and incontinent checks. Staff entering the resident's room while resident awake offer small amout of water. Use beverage plan worksheet to communicate fluid offiering. Review of resident R1 toileting documentation revealed that the resident had 19 loose stools from August 8, 2012 until night shift on August 15, 2012. Nursing documentation dated August 11, 2012 at 3:15 p.m. revealed that the resident was alert with confusion. Nursing notes revealed that the resident continued with confusion on August 12, 2012 at 10:26 a.m.. The change in status report dated August 12, 2012 revealed that the physician was notified of the periods of confusion. Nurses' note dated August 13, 2012 at 5:46 p.m. revealed that the physician's assistant had examined the resident and no new orders were given. A review of the meal intake documentation revealed that on the days of August 2, 2012 to August 8, 2012 the resident ate an average of 72% of the meals with none of them being refused by the resident. From August 10, 2012 to August 15, 2012, documentation revealed that the resident ate an average of 33% of the meals and refused three of the 18 meals offered. Further review of the resident's vital signs for August 15, 2012 at 6:27 p.m. revealed that that resident R1 had a blood pressure of 74/43 (normal 120/80) and a heart rate of 96 (normal is 60-90). A review of residents R1 ' s change in status report dated August 15 2012 at 6:20 p.m. described the resident as lethargic, pale, and confused, and noted that the physician was notified at 6:00 p.m. A review of the physician's orders reveals that there was an order to start an I.V (intravenous fluids) and to start D5NS @125 milliliters per hour for 72 hours for dehydration and for labs to be drawn on August 16, 2012. The results of the labs drawn on August 16, 2012 revealed a BUN (blood, urea, nitrogen) level of 73 milligrams per deciliter (normal range is 10-26) and a creatinine level of 3.26 (normal level between 0.7 and 1.5) which is an indication of dehydration. A progress note dated August 16, 2012 at 10:12 a.m. revealed that the resident was found lethargic and difficult to arouse, Resident R1 was holding arms tight to body and hands clinched. The physician was made aware and an order was given to transfer the resident to an acute care facility for evaluation and treatment. The resident was admitted with a [DIAGNOSES REDACTED]. An interview with licensed Employee E1 on August 23, 2012 at approximately 2:30 p.m. revealed that there was no documentation for fluid consumption of resident R1 other then the meal intake documentation which did not differentiate between food and liquids and the daily hydration charting which is done for every resident in the facility and showed only that the resident received a picture of water once a day and did not document the amount that was consumed. It was confirmed by employee E1 that there was no evidence that the nursing staff had encouraged fluids to resident R1 when the resident experienced continued diarrhea from August 8, 2012 until August 15, 2012 as per policy. There is no evidence that resident R1 after being diagnosed with [REDACTED]. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services.

Based on clinical record review and interview with facility staff, it was determined that the facility failed to accurately assess, timely identify and provide the necessary care and services to provide interventions and timely treatments to promote healing of multiple wounds resulting in actual harm for one of two residents reviewed (Resident K 1) Findings include: Review of Resident K1's admission orders [REDACTED]. admission orders [REDACTED]'s right foot, to elevate the foot, not to bear weight on the right foot and for the resident be seen at the by the orthopedic doctor in one week. Review of the initial nursing admission assessment of of July 20, 2010 indicated that the resident had a cast on the right ankle, pain in the right ankle (tingling), unable to determine if the resident had [MEDICAL CONDITION] or able to palpate the pedal pulse in the right foot and no swelling on the left foot. The nursing assessment indicated that the color in right and left toes were normal. Nurses notes/assessment July 20, 2010 at 6:50 pm indicated that the resident's right leg from knee to toes was were in a cast, toes are normal in color and warm to touch and at the time denied pain. Review of Orthopedic consult documentation revealed that the resident was first seen on August 9, 2010 and ordered that the resident's foot bandage be removed the next day and return to the clinic in two weeks. Review of the clinical record on November 4, 2010 revealed no documented evidence that the bandage on the resident's foot had been removed as ordered or documentation of any abnormal finding on the resident's right foot. Review of Orthopedic follow up consult documentation dated August 24, 2010 indicated that on examination the resident's sock was soaked with drainage. That he had drainage actively dripping from his heel. The medial abrasion was scabbed over and the skin was flaking. Ortho notes related the fracture healing appears to be present and no evidence of any hardware failure. The ortho notes dated August 24, 2010 further indicated that the resident had some [MEDICAL CONDITION] and drainage, ordered wound management, Keflex 500 milligrams three times a day and would be seen the following week for wound check. Review of physician's orders [REDACTED]. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nursing notes dated August 26, 2010 at 12:40 a.m. revealed that the resident refused treatment stating someone was going to show him how to do the treatment, on August 27 at 2:15 p.m., refused therapy due to pain in the right lower extremely and at 11:50 p.m. refused treatment to the lower leg. Nursing notes dated August 29 at 11:00 p.m. also indicated that the resident refused to change the sock on the right foot. Review of the care plan revealed no plan or interventions were put in place to address the resident's refusals or if the resident wanted the wound care done at a different time. Review of nursing notes of August 31, 2010 at 9:15 a.m. indicated that the resident went for Ortho appointment and was sent to the hospital and admitted for [MEDICAL CONDITION] (skin infection caused by bacteria). Nursing readmission assessment of September 10, 2010 at 8:00 p.m. indicated that Resident K1 was readmitted into the facility. Hospital transfer orders dated September 10, 2010 indicated that the resident would be followed up in the wound clinic in 8-10 days, and for wound care be done three times a week for the right ankle wound and wound vac be changed three times a week. Review of the clinical record revealed no documentation that the order for wound care to the right ankle wound was addressed until September 17, 2010 when nurses notes verified with the wound clinic the orders (7 days post readmission). Further, the treatment administration record did not reflect the wound vac dressing change (a suction on the wound to remove drainage) until September 20, 2010 (10 days post readmission). Further, wound documentation dated September 21, 2010 indicated that the resident had surgical ankle wound which measured 8.5 by 2.5 and 1 centimeters deep and 50% slough (dead tissue) and multiple open ulcers on the right foot. In addition, the wound clinic consult dated September 22, 2010 ordered strict decubitus ulcer precautions be observed for resident's right heel. There was no documentation that this was communicated to the attending physician. Review of the resident's care plan failed to reveal that appropriate interventions had been put in place to address the recommendation. physician's orders [REDACTED]. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of physical therapy notes dated September 27, 2010 indicated that the resident had slight discoloration on the left heel and seemed to be in the initial stages of a stage one pressure ulcer and that nursing was notified. Review of Wound Sheet documentation dated October 1, 2010 indicated that the resident now had a left heel necrotic wound measured 2 X 3 centimeters macerated (soft) skin around it, the bottom of resident's right foot also had wound which measured 1.2 X 0.6 centimeters with brownish slough (dead tissue), Right medial ankle wound which measured 1.8 X 1.4 centimeters and other diabetic wounds (number, description, measurements not noted). Review of the resident's care plan failed to reveal adequate interventions in place to specifically address the prevention of wounds. Interview with the Director of Nursing on November 4, 2010 in the morning indicated that the resident went to the hospital for admission and possible amputation in the right leg/foot. Interview with licensed nursing employee E4 on November 8, 2010 in the afternoon revealed that she had measured all the wounds on her documentation of September 21, 2010 and attached it to the record. Interview with the Director of Nursing immediately following failed to find this documentation regarding the wound. The facility failed to ensure that adequate and timely wound care and treatment was provided to prevent infection and promote healing of the right ankle surgical wound resulting in actual harm the resident. F 309 483.25 Quality of Care Previously cited deficiency 10/21/10 28 Pa. Code: 201.18 (b)(1)(e)(1) Management Previously cited deficiency 10/21/10 28 Pa. Code: 201.18 (b)(1)(e)(1) Management Previously cited deficiency 10/21/10, 05/1/710 28 Pa. Code: 211.5(f) Clinical record Previously cited deficiency 10/21/10. 28 Pa. Code: 211.10(c) Resident care policies Previously cited deficiency 09/24/09 28 Pa Code: 211.10(d) Resident care policies Previously cited deficiency 10/21/10, 09/24/09 28 Pa. Code: 211.11(a)(c) Resident care plan Previously cited deficiency 10/21/10, 09/24/09 28 Pa. Code: 211.11(d) Resident care plan Previously cited deficiency 10/21/10. 28 Pa Code: 211.12(c) Nursing services Previously cited deficiency 10/21/10, 09/24/09 28 Pa Code: 211.12(d)(3) Nursing services Previously cited deficiency 10/21/10, 06/04/10 28 Pa Code: 211.12(d)(1)(5) Nursing services Previously cited deficiency 10/21/10, 06/04/10, 02/24/10, 09/24/09

Based on observations, clinical record review and interview with facility staff, it was determined that the facility failed to accurately assess, timely identify and provide the necessary care and services to prevent the development of and/or to promote healing of pressure ulcers for one of two residents reviewed resulting in actual harm. (Resident H7) Findings include: Review of Resident H7's nursing admission evaluation dated July 28, 2010 revealed [DIAGNOSES REDACTED]. A review of the resident's admission Braden Assessment (a tool for determining the risk of developing pressure ulcers) dated July 28, 2010, revealed that the resident was low risk for developing pressure ulcers. A review of the resident's admission assessment dated August 10, 2010, revealed that the resident had limitation/ partial loss on one side of the leg and foot, needed extensive assistance of staff for bed mobility and for transfer. The assessment indicated that the resident did not have any pressure ulcers on admission. The admission summary triggered for a care plan be put in place to prevent pressure ulcer from developing. A review of the admission care plan for Resident H7 revealed no evidence that a care plan was developed to address the pressure ulcer prevention. Review of Physician's fax order sheet dated August 29, 2010 revealed that the resident had developed a blister on the right heel and a Pressure Ulcer on the Left Outer ankle. Review of pressure ulcer documentation dated August 31, 2010 revealed a right heel blister looked like deep tissue injury. The blistered area measured 4 centimeters by 3 centimeters. The pressure ulcer documentation also indicated that the resident's left outer ankle area was red and non blanchable and measured 4 by 4 centimeters. The assessment further indicated that the resident had spasms which maked her slide her heels against the mattress. Review of the pressure ulcer documentation dated September 14, 2010 revealed a right heel open blister measured 3 centimeters by 4 centimeters, a black area in the center and yellow slough in the peri-wound area. The left ankle area measured 2 centimeters by 1 centimeter red area around and tender and painful to touch. Wound consult documentation of September 30, 2010 for Resident H7 revealed Unstageable right posterior heel Pressure Ulcer measured 1.4 centimeters by 1.3 centimeters with slough in it and Unstageable Left Lateral Malleolar wound, with slough in it, measured 2 centimeters by 2.5 centimeters and that the skin around the wound was macerated. physician's orders [REDACTED]. Review of Wound consult documentation dated October 28, 2010 revealed a recommendation for the [MEDICATION NAME] to continue if the resident had no diarrhea or if the wound looked worse. Review of the medical record revealed no documented evidence that the recommendation was communicated to the physician until November 8, 2010 (ten days after the recommendation was made). Review of the bowel record from October 28 to November 7, 2010 revealed no documented evidence that the resident had diarrhea. Observation on November 4, 2010 of Employees E3 during wound treatment to Resident H7 revealed that the resident' s right heel was placed directly in a foam boot with no dressing in place. The ulcer had some yellowish tissue at it's base. The employee failed to change gloves between cleaning of the wound and applying the new dressing, threw dirty gauze that had been used in cleaning of the wound into the box of clean gloves which was later used in the care of the resident. Interview with Employee E3 immediately following revealed that the dressing would have come off when the resident had a shower and that they did not know that the dirty gauze had fallen into the box of clean gloves. Interview on November 8, 2010, at 2 p.m., with licensed nursing employee E2 confirmed that there was no evidence that a care plan had been developed on admission to address the resident's potential for the development of pressure ulcer and could not explain why the wound consult recommendation was not communicated to the physician in a timely manner. The facility failed to develop appropriate interventions for pressure ulcers to prevent the development of pressure ulcers, failed to timely identify the right heel pressure ulcer and failed to consistently implemented proper interventions and services to promote healing of the pressure ulcers, resulting in actual harm to Resident H7. F 314 483.25 (c) Pressure Sores Previously cited deficiency 10/21/10, 2/24/10 28 Pa. Code: 201.18 (b)(1)(e)(1) Management Previously cited deficiency 10/21/10 28 Pa. Code: 201.18 (b)(1)(e)(1) Management Previously cited deficiency 10/21/10, 05/1/710 28 Pa. Code: 211.5(f) Clinical record Previously cited deficiency 10/21/10. 28 Pa. Code: 211.10(c) Resident care policies Previously cited deficiency 09/24/09 28 Pa Code: 211.10(d) Resident care policies Previously cited deficiency 10/21/10, 09/24/09 28 Pa. Code: 211.11(a)(c) Resident care plan Previously cited deficiency 10/21/10, 09/24/09 28 Pa. Code: 211.11(d) Resident care plan Previously cited deficiency 10/21/10.