Every finding on record at Abington Manor

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).A review of a facility policy entitled Cleaning and Sanitizing Dietary Areas and Equipment last reviewed by the facility on April 29, 2026, indicated that all kitchen areas and equipment shall be maintained in a sanitary manner and be free of build-up of food, grease, or other soil. The facility will provide sanitary foodservices that meet state and federal regulations. The initial tour of the dietary department, conducted and confirmed with the facility's Certified Dietary Manager (CDM) on July 21, 2026, at 10:35 AM, revealed multiple unsanitary conditions that had the potential to contaminate food and food contact surfaces, increasing the risk of food-borne illness. Upon entering the dietary department, the dish room service area contained two brooms and one dust broom stored on the floor rather than in a designated storage holder. The insect attractor light located in the dish room contained a significant accumulation of deceased insects inside the collection compartment. The ice scoop holder attached to the ice machine contained the ice scoop resting in approximately one-quarter inch of standing water. An accumulation of debris was also present alongside the ice machine. The black lids of the four-compartment bulk cereal dispenser felt sticky and had an accumulation of debris. Observations of the second-floor pantry on July 23, 2026, at 9:11 AM, revealed the ice chest contained approximately one-quarter inch of standing water with a black speckled substance and emitted a mildew odor. Debris had accumulated on each shelf of the mobile plastic cart used to hold the ice chest. Observations of the third-floor pantry on July 23, 2026, at 9:25 AM, revealed the top of the ice chest felt sticky and had accumulated debris. Debris had also accumulated on each shelf of the mobile plastic cart used to hold the ice chest. During an interview on July 23, 2026, at 10:40 AM, the Nursing Home Administrator (NHA) reviewed and confirmed the above findings. I actually prefer this version for a CMS-2567. It reads more naturally, avoids repetitive references to surveyors, maintains active voice, and presents the findings in a clear, chronological sequence from the dietary department to the pantry areas and finally the facility's confirmation.28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa Code 211.10 (c) Resident care policies.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses accurately administered medication in accordance with physician orders for three of 25 residents reviewed (Resident 40, Resident 5, and Resident 9). Findings include:A review of the facility policy titled Administering Medications last reviewed by the facility on April 29, 206, revealed that medications are administered as prescribed in a safe, timely manner. Medications are administered in accordance with prescriber orders, and information is verified prior to administering medication including vital signs (measurements of basic body functions such as blood pressure, pulse, temperature, and breathing), are verified prior to administering medications when parameters are ordered. A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included diastolic congestive heart failure (happens when the heart can still squeeze blood out but can't fill properly during each beat). A review of Resident 40's Significant Change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 7, 2026, revealed that Resident 40 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 reflects normal cognition and no difficulty with memory, orientation, or recall). Resident 40 was interviewed on July 22, 2026, at 10:30 AM and stated she was expecting to be discharged from the facility, but was concerned about her blood pressure fluctuating from high to low and vice versa. A review of the physician's order dated June 3, 2026, directed staff to administer Midodrine HCl (medication used to treat low blood pressure) 10 milligrams (mg) orally three times a day for orthostatic hypotension (a sudden drop in blood pressure occurring within 3 minutes of standing or shifting to an upright position which may cause dizziness or fainting). The physician's order specified to hold (not give) the medication if the systolic blood pressure (top number in a blood pressure reading, representing pressure when the heart contracts) was greater than 130 millimeters of mercury (mm/Hg) or greater. A review of the July 2026 MAR (medication administration record) revealed Midodrine was administered four times when the medication should not have been given according to the physician's order of systolic blood pressure 130mm/Hg or greater.The following blood pressure readings were documented at the time the medication was administered:July 2, 2026, at 6:00 AM blood pressure reading of 137/78 mm/HgJuly 5, 2026, at 10:00 PM blood pressure reading of 131/83 mm/HgJuly 15, 2026, at 6:00 AM blood pressure reading of 131/76 mm/HgJuly 22, 2026, at 6:00 AM blood pressure reading of 130/70 mm/Hg Despite the presence of criteria for Midodrine to be held, the medication was administered on the above four occasions during the month of July 2026. The above findings were reviewed with the Nursing Home Administrator on July 22, 2026, at 11:30 AM. The NHA acknowledged the medication was administered and not withheld when the physician-ordered parameters to hold the medication were present. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included sick sinus syndrome (a condition when the heart beats too slowly, too quickly, or erratically). A review of Resident 5's Quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 5 was cognitively intact with a BIMS score of 15. A review of the physician's order dated June 4, 2026, directed staff to administer Midodrine HCl 5 milligrams (mg) daily due to renal dialysis (a process that filters the blood and removes waste, extra water, and certain chemicals when the kidneys no longer work) daily every Monday, Wednesday, and Friday at 8:00 AM. The physician's order specified to hold (not give) the medication if the systolic blood pressure was greater than 130 millimeters of mercury (mm/Hg) or greater. A review of the June 2026 MAR revealed Midodrine was administered 10 times without documentation of a blood pressure reading prior to administration, as required by the physician's order, on the following dates: June 5, 2026 June 8, 2026 June 10, 2026 June 12, 2026 June 17, 2026 June 19, 2026 June 22, 2026 June 24, 2026 June 26, 2026 June 29, 2026 Administration of Midodrine without obtaining the required blood pressure reading prevented nursing staff from determining whether the medication was safe to administer according to the physician's ordered parameters. A review of the clinical record reveal that Resident 9 was admitted to the facility on [DATE], with diagnoses to include cerebral infarction (also known as an ischemic stroke, is the irreversible death of brain tissue caused by a blockage in the blood vessel that disrupts oxygen and blood flow to the brain) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period of time). A review of the clinical record revealed a physician's order initially dated May 5, 2026, for Carvedilol oral tablet 3.125 milligrams, (a beta blocker used to treat heart failure and hypertension) with instructions to give one tablet one time a day for HTN (hypertension), Hold for SBP (systolic blood pressure) less than 100 mm/Hg and a heart rate of less than 60 BPM (beats per minute) . The medication was scheduled to be given at 9:00 AM. A review of Resident 9's May 2026 to July 2026 Medication Administration Record (MAR) revealed that Carvedilol was administered 59 times without documentation of a blood pressure reading or a pulse prior to administration as required by the physician order on the following dates: May 7, 2026, at 9:00 AM May 9, 2026, at 9:00 AM May 10, 2026, at 9:00 AM May 11, 2026, at 9:00 AM May 12, 2026, at 9:00 AM May 13, 2026, at 9:00 AM May 14, 2026, at 9:00 AM May 15, 2026, at 9:00 AM May 16, 2026, at 9:00 AM May 18, 2026, at 9:00 AM May 19, 2026, at 9:00 AM May 20, 2026, at 9:00 AM May 21, 2026, at 9:00 AM May 22, 2026, at 9:00 AM May 24, 2026, at 9:00 AM May 26, 2026, at 9:00 AM May 27, 2026, at 9:00 AM May 28, 2026, at 9:00 AM May 30, 2026, at 9:00 AM May 31, 2026, at 9:00 AM June 3, 2026, at 9:00 AM June 4, 2026, at 9:00 AM June 5, 2026, at 9:00 AM June 6, 2026, at 9:00 AM June 7, 2026, at 9:00 AM June 8, 2026, at 9:00 AM June 9, 2026, at 9:00 AM June 10, 2026, at 9:00 AM June 11, 2026, at 9:00 AM June 12, 2026, at 9:00 AM June 13, 2026, at 9:00 AM June 14, 2026, at 9:00 AM June 15, 2026, at 9:00 AM June 16, 2026, at 9:00 AM June 17, 2026, at 9:00 AM June 18, 2026, at 9:00 AM June 19, 2026, at 9:00 AM June 20, 2026, at 9:00 AM June 21, 2026, at 9:00 AM June 22, 2026, at 9:00 AM June 23, 2026, at 9:00 AM June 24, 2026, at 9:00 AM June 25, 2026, at 9:00 AM June 26, 2026, at 9:00 AM June 27, 2026, at 9:00 AM June 28, 2026, at 9:00 AM June 29, 2026, at 9:00 AM June 30, 2026, at 9:00 AM July 1, 2026, at 9:00:AM July 3, 2026, at 9:00:AM July 8, 2026, at 9:00 AM July 9, 2026, at 9:00 AM July 10, 2026, at 9:00 AM July 13, 2026, at 9:00 AM July 14, 2026, at 9:00 AM July 15, 2026, at 9:00 AM July 16, 2026, at 9:00 AM July 17,2026, at 9:00 AM July 18, 2026, at 9:00 AM July 19,2026, at 9:00 AM Administration of Carvedilol without obtaining the required blood pressure or pulse reading prevented nursing staff from determining whether the medication was safe to administer according to the physician's ordered parameters. The above findings were reviewed with the Director of Nursing (DON) on July 24, 2026, at 11:25 AM. The DON acknowledged the medication was not administered according to the physician order or the facility policy. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 (c)(d) Resident care policies.

Based on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to provide appropriate care and services to residents receiving enteral feedings for one of 25 residents reviewed (Resident 1).Findings include:Review of the facility policy, titled Enteral Tube Feeding via Continuous Pump, reviewed April 29, 2026, provides guidance for enteral feedings (instead of eating or drinking by mouth, food is delivered in liquid form through a small tube placed into the stomach) including verification of a physician's order for the procedure and checking the label (date and time the formula was prepared) with the order prior to administration. A clinical record review revealed Resident 1 was admitted to the facility September 30, 2024, with diagnoses that included esophageal obstruction (blockage in the food pipe that makes it hard or impossible for food and drinks to move from your mouth down into the stomach) and dysphagia, pharyngeal phase (difficulty swallowing). A review of Resident 1's Significant Change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 17, 2026, revealed that Resident 1 had moderate cognitive impairment with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 reflects moderate cognitive issues indicating the individual may have some trouble with memory, orientation, or recall). Review of Resident 1's care plan identified the use of enteral feeding to support Resident 1's nutritional needs. The care plan dated February 9, 2026, and most recently revised June 17, 2026 revealed interventions which included but were not limited to administering the tube feeding formula, hydration, and flushes according to the physician's order. Review of Resident 1's clinical record revealed a physician order dated June 28, 2026, for Glucerna 1.2 Full Strength via pump (delivering a diabetes-approved, calorie-rich nutrition drink through a feeding pump into the stomach) at 40 milliliters (mL)/ hour (hr) for 22 hours. The feeding was to be held for two hours for therapy according to the physician order. Further clinical review revealed a physician's order dated February 16, 2026, for the enteral feed to be initiated at 12:00 PM and end at 10:00 AM daily. Review of Resident 1's July 2026 electronic medication administration record (eMAR, digital checklist that shows what medications a resident is supposed to receive and what time the medication was administered) confirms daily administration of Glucerna 1.2 as ordered. Documentation in the eMAR confirmed that the enteral feeding was started at 12:00 PM and ended at 10:00 AM every day. During an observation on July 21, 2026, at 10:23 AM, the enteral feeding was infusing and labeled July 20, 2026, at 5:00 AM. Review of the eMAR showed the required task to change the feeding bottle and tubing daily lacked documentation confirming completion throughout the entire month of July 2026. On July 22, 2026, at 1:40 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the enteral feeding had been labeled in a manner that did not follow facility policy. On July 23, 2026, at 11:00 AM, the DON confirmed that the enteral feeding in use was labeled July 20, 2026, at 5:00 AM, and acknowledged it was not being administered as ordered. The DON could not provide a rationale for why a feeding labeled July 20, 2026, at 5:00 AM was still infusing more than 24 hours later, and the observed infusion time of 10:23 AM did not correspond with the physician's prescribed feeding schedule. 28 Pa. Code 201.18 Management. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on a review of facility policy, clinical record review, medication administration records, and staff interview, it was determined the facility failed to document that individualized non-pharmacological interventions were attempted prior to the administration of an as needed (PRN) psychotropic medication for one of 25 residents reviewed (Resident 6). Findings include: Federal requirements for the use of psychotropic medications expect that psychotropic medications are used only when necessary to treat a specific, documented condition. Non-pharmacological interventions are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. The resident's medical record should include documentation of this evaluation and the rationale for chosen treatment options. When clinically appropriate, these interventions should be attempted and documented prior to administering PRN psychotropic medication. A review of the facility's policy titled Psychoactive Medication Use reviewed April 29, 2026, indicated that all residents receiving psychoactive medications will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. The policy revealed that individualized non-pharmacological approaches are provided as part of a supportive physical and psychological environment and are directed toward preventing, relieving, or accommodating a resident's distressed behavior. A clinical record review revealed Resident 6 was admitted to the facility on [DATE], with diagnoses that included diastolic congestive heart failure (a condition in which the heart muscle continues to pump normally but does not relax enough to fill properly between heartbeats). A review of Resident 6's Significant Change Minimum Data Set (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 7, 2026, revealed that Resident 6 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 reflects normal cognition and no difficulty with memory, orientation, or recall). A review of physician orders revealed an order dated November 18, 2025, for Alprazolam 0.25 milligrams (an anti-anxiety medication classified as a psychotropic medication) to be administered every eight hours as needed for anxiety. A review of the electronic Medication Administration Record (eMAR, a computerized record that documents medications ordered and administered) revealed staff administered Alprazolam 0.25 milligrams on the following dates and times:November 22, 2025, at 5:39 AMNovember 23, 2025, at 9:00 PMNovember 26, 2025, at 6:12 PMNovember 27, 2025, at 5:27 PMA review of the clinical record failed to identify documentation that staff attempted or that individualized non-pharmacological interventions were ineffective before administering the PRN psychotropic medication on any of the four occasions. Therefore, the facility could not demonstrate that less restrictive interventions were considered before administering the medication. During an interview on July 22, 2026, at 1:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the clinical record did not contain documentation of non-pharmacologic interventions prior to the administration of the psychotropic medication on the four identified occasions.28 Pa. Code 211.2(3) Medical director.28 Pa. Code 211.5(ii)(xi) Clinical records.

Based on review of the Resident Assessment Instrument (RAI) Manual, a review of clinical records, resident observation, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for one of 25 residents sampled (Resident 35).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2024, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A review of the clinical record revealed Resident 35 was admitted to the facility on [DATE], with diagnoses to include dysphagia (difficulty swallowing). A review of the admission MDS (May 23, 2025), Section A 1005 (identification information, including ethnic background and race) indicated 'Resident Unable to Respond'. Upon further review of the clinical record, the resident centered care plan for Resident 35 (initiated May 18, 2025, revised September 2, 2025) described the use of a Spanish communication board and Spanish music among the nursing interventions to care for cognitive loss. Resident 35's daughter is involved in care as indicated by her presence in the building and via phone in multiple instances according to a clinical record review. According to the RAI Manual, if the resident is not able to respond, a family member, significant other, and/ or guardian/legally authorized guardian may be contacted for the requested information. The RAI manual further indicates if the resident cannot respond and no other resources (family, significant other, or legally authorized representatives or medical records) provide the necessary information, code as the resident is unable to respond. The clinical record did not illustrate any attempt to contact the representative for Resident 35 to gather accurate data regarding ethnic background. An interview with the Registered Nurse Assessment Coordinator on September 18, 2025, at 9:26 AM confirmed the coding as described for Resident 35 was not accurate. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, a review of clinical records and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address hearing aid needs for one out of 25 residents sampled (Resident 122). Findings include: A clinical record review revealed Resident 122 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage) and parkinsonism (neurological disorder that causes involuntary shaking, difficulty with balance, and stiffness in the body) Observation on September 18, 2025, at 11:50 AM revealed that Resident 122 had one hearing aid located on the nightstand. An interview conducted on September 18, 2025, at 11:50AM revealed the resident lost one hearing aid approximately 1-2 weeks prior to the interview date. The resident stated staff has not helped him find the lost hearing aid and the facility has not tried to help the resident obtain a replacement hearing aid. Review of Resident 122's inventory sheet revealed the resident came to the facility with 2 hearing aids in his possession. Review of the clinical record revealed a progress note dated September 13, 2025, at 11:55PM documenting on assessment the resident only possessed one hearing aid. The progress note further revealed, the author notified laundry services, dietary services, and the supervisor of the missing hearing aid. Review of Resident 122's inventory sheet confirmed the resident came to the facility with 2 hearing aids in his possession. A review of the facility's grievance logs revealed no grievance filed by staff regarding the lost hearing aid through survey date September 17, 2025. A review of the resident's care plan revealed no documentation regarding the resident's hearing aid. The care plan lacked any information regarding the resident's hearing ability, care of, storage of, or maintenance of the hearing aid. Further review of the clinical record revealed no documented evidence the facility developed a care plan to reflect Resident 122's hearing status including the resident possessing hearing aids upon admission to the facility, and the plan/timeline to maintain the resident's hearing status. During an interview on September 18, 2025, at approximately 11:00 AM, the Director of Nursing revealed the facility is unable to provide any further documentation of the resident's care plan including documentation of the resident's hearing deficit. The facility failed to ensure each resident's comprehensive person-centered care plan includes identified problems and services that are to be provided to assist the residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. 28 Pa Code 211.12 (d)(1)(3) Nursing services.

Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to develop and implement an individualized plan of care to address the toileting needs of one of 25 sampled residents (Resident 12), including restoring the bladder function to the extent possible and preventing recurrence of urinary tract infections.Findings include: A review of facility policy titled 'Urinary Incontinence-Clinical Protocol' reviewed on September 25, 2024, revealed nursing staff will identify, and document circumstances related to incontinence, and based on the category and causes of incontinence, staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. The policy further indicated; the facility will review the progress of individuals with impaired continence until continence is restored or improved as much as possible or it is identified that further improvement is unlikely. Documentation of resident's responses to attempted interventions such as scheduled toileting, prompted voiding, or medications used to treat incontinence will occur in the medical record. A review of Resident 12's clinical record revealed Resident 12 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD- an ongoing lung condition caused by damage to the lungs which results in swelling and irritation). A review of a Resident 12's significant change, comprehensive Minimum Data Set Assessment (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care), dated April 7, 2025, revealed Resident 12 as cognitively impaired with a BIMS score of 6 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information). A score of 6 indicates severe cognitive impairment and suggests the individual may require significant assistance with daily activities. On April 7, 2025, the MDS described Resident 12 as requiring assistance from staff for toileting, toileting hygiene, and transfers and had an indwelling urinary catheter (plastic tube inserted in the bladder to drain urine). A retrospective review of the clinical record from April 4, 2025, to April 6, 2025, illustrated a 'Voiding Trial' to evaluate Resident 12's tendency to retain urine (bladder doesn't completely empty). On April 7, 2025, an indwelling urinary catheter was inserted into the bladder due to findings from the 'Voiding Trial' indicating Resident 12 was retaining urine as evidenced by findings from bladder scans (a noninvasive and portable medical device that measures urine in the blader) and the need to receive straight catheterization (thin tube called a catheter into the bladder which lets the urine flow out). Upon clinical record review, Resident 12 was hospitalized from [DATE] to April 30, 2025, for surgical incision and drainage of a right hip wound. (due to a buildup of fluid, a surgical site must be opened and drained). Upon return from an acute care hospital stay on April 30, 2025, Resident 12 did not have a catheter and experienced bladder and bowel incontinence. The facility provided an electronic report documenting the level of continence status after returning from acute care as follows:May 1, 2025, at 2:16 AM and 7:18 AM: incontinent.May 2, 2025, at 6:26 AM: continent.May 3, 2025, at 5:52 AM, 12:16 PM, and 9:37 PM: incontinent. There was no additional documentation of continence/incontinence status, monitoring for urinary retention, or ongoing evaluation of bladder function. No policies were provided that addressed monitoring continence or urinary retention after catheter removal or following a hospital stay with changes in continence status. A review of the resident's person-centered care plan, initiated and revised on September 5, 2025, indicated Resident 12 experienced bladder incontinence. The stated goal was for the resident to be maintained in a clean and dry dignified state. Interventions included medication administration per physician orders, application of skin barrier creams, reporting signs of urinary tract infection (such as flank pain, burning, fever, hematuria, or change in mental status), reporting changes in urine characteristics, reporting skin integrity changes, and use of absorbent products as needed. However, the care plan did not identify the type of incontinence, nor did it include individualized interventions such as a toileting program, prompted voiding, or scheduled toileting to restore continence or reduce complications. There was no evidence the facility conducted an evaluation of voiding patterns or developed an individualized toileting plan upon the resident's return from acute care on April 30, 2025. An interview with the Director of Nursing on September 19, 2025, at 10:23 AM confirmed the facility could not provide documentation showing Resident 12 was evaluated for continence/incontinence status, type of incontinence, or urine retention after return from the hospital without a catheter, despite the resident's known history of urinary retention. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10(a)(d) Resident care policies.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident was invited to participate in the care planning process for one of 25 residents reviewed (Resident 121).Findings include: A clinical record review revealed Resident 121 was admitted to the facility on [DATE], with diagnosis to include sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage) and myocardial infarction (occurs when blood flow to the heart muscle is blocked, causing damage or death of heart tissue). A review of the quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 12, 2025, revealed that Resident 121 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). During an interview with resident 121 on September 17, 2025, at 12:05 PM, Resident 121 stated she had not been invited to participate in the care planning process for development of her comprehensive person-centered care plan including preferences related to shower times. The interview revealed the resident was showered on September 16, 2025, at 11:00PM, even though the resident's preference is to shower during day shift, specifically early morning. The resident verbalized the concerns with the late shower time to the staff members involved, and the resident stated she was told she would be showered when the staff has time. The resident stated she was cold with her hair wet all night long due to the late shower and had trouble sleeping. A further review of the clinical record revealed no documented evidence that a care plan conference had been conducted for Resident 121 or that the resident had been invited to participate in the development or review of his comprehensive care plan or preferences. During an interview with the Director of Nursing (DON) on September 17, 2025, at 1:45PM, it was determined the resident was scheduled for evening shower times. The clinical record revealed no evidence that the resident had been offered to choose her shower times. The DON confirmed there was no documentation to show that a care plan conference had been held for Resident 121 since admission or that the resident had been invited to participate in the care planning process. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records, facility policy, investigative documentation provided by the facility, and resident and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one of four sampled residents (Resident 3) from neglect by not implementing the individualized care plan intervention for transfers, resulting in actual harm in the form of a mid-humerus fracture. Findings Include: A review of the facility policy titled Identifying Types of Abuse, last reviewed by the facility on September 26, 2024, revealed that abuse of any kind against residents is strictly prohibited. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety results in physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed Resident 3 was originally admitted to the facility on [DATE] , with diagnoses that included chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a significant change in status Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 7, 2025, revealed that Resident 3 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).A review of the individualized care plan revealed Resident 3 had an activity of daily life self-care deficit related to decreased mobility initiated on October 25, 2023. Interventions developed to assist Resident 3 with this deficit included employees utilizing a mechanical lift with the assistance of two staff for transfers initiated on October 25, 2023.A review of the Kardex (a reference tool providing a concise, quick overview of a resident's essential information for nursing staff) dated July 29, 2025, revealed Resident 3 required a mechanical lift and the assistance of two staff members for all transfers.A review of facility provided investigative documentation revealed a written witness statement dated July 29, 2025, provided by Employee 1, Nurse Aide (NA), which indicated Employee 1, NA, was in the shower room getting ready to transfer Resident 3 from the shower chair to her wheelchair. Employee 1, NA, indicated that she put her arms around Resident 3, and when Resident 3 picked her arm up, they heard a cracking sound. Employee 1, NA, indicated she then went to get help. Employee 1, NA, reported Employee 2, Licensed Practical Nurse (LPN), was also present.A written witness statement dated July 29, 2025, provided by Employee 2, Licensed Practical Nurse (LPN), revealed she was asked by Employee 1, NA, to help with a transfer. She indicated Employee 1, NA, wanted her to clean Resident 3 and pull up her brief as Employee 1, NA, assisted her to a standing position. Employee 2, LPN, indicated she heard a pop as Employee 1, NA, lifted Resident 3. Resident 3 was assisted back down and began stating she could not move her arm. Employee 1, NA, left to get assistance. Employee 2, LPN, described specifically that Employee 1, NA, put her arms under Resident 3's arms so that they were chest to chest. As Employee 1, NA, began to stand with Resident 3, they heard the pop.An investigation document provided by the facility dated July 29, 2025, at 10:33 AM revealed Employee 1, NA, attempted to manually lift Resident 3 after completing a shower. Employee 1, NA, heard a crack, lowered Resident 3 back to her chair, and alerted additional staff for further assessment. The certified registered nurse practitioner assessed Resident 3's left arm to have notable swelling and bruising. Resident 3 was guarding her arm and complained of severe pain. The document indicated Employee 1, NA, was suspended pending an investigation.A progress note dated July 29, 2025, at 10:23 AM revealed a call was placed for a stat (immediate) x-ray of Resident 3's left arm.A progress note dated July 29, 2025, at 11:25 AM revealed Resident 3 was transferred to the community hospital by way of ambulance for left arm pain. The resident representative and physician were made aware.A review of x-ray results titled XR Humerus 2 or More Views, dated July 29, 2025, at 12:59 PM revealed three views of the left shoulder and three views of the left humerus (the large arm bone between the shoulder and the elbow). Shoulder views revealed Resident 3 sustained a fracture in the mid-diaphysis humerus (the long, cylindrical shaft or body that forms the middle section of the bone). No dislocation noted. Probable old, healed fracture of the proximal humerus. Views of the left humerus revealed a spiral oblique displaced fracture (a bone broken into at least two pieces by a twisting force, with the break curving around the bone at an angle) mid-diaphysis (long straight shaft of upper arm bone). Other bones were intact, and no dislocation noted. The impression from the x-rays indicated Resident 3 sustained a humerus fracture.A review of community hospital discharge instructions dated August 1, 2025, revealed Resident 3 presented at the community hospital on July 29, 2025, with complaints of left arm pain. Resident 3 was found to have a spiral fracture of the left humerus. Resident 3 was admitted for pain management, orthopedic and vascular consultation, and rehabilitation therapy, and the fracture was treated non-operatively with immobilization and pain control before the resident was discharged back to the facility on August 1, 2025, at 5:37 PM. During a telephone interview on August 20, 2025, at 10:10 AM Employee 1, a nurse aide (NA), confirmed she attempted to lift Resident 3 manually and heard a crack as she lifted the resident from the chair. Employee 1, NA, confirmed that she was aware of Resident 3's need to be transferred by way of mechanical lift with the assistance of two staff, but she explained that she was lifting her enough to slide a lift pad under the resident. Employee 1, NA, explained she no longer works at the facility.During an interview on August 20, 2025, at 10:25 AM, Resident 3 recalled her arm injury but could not describe the incident. She remembered experiencing terrible pain. Resident 3 indicated that her arm remains sore, but the pain has greatly improved.During a telephone interview on August 20, 2025, at approximately 11:00 AM, Employee 2, Licensed Practical Nurse (LPN), explained that Employee 1, NA, asked her to help provide care for Resident 3 in the shower room on July 29, 2025. Employee 2, LPN, explained that she was new to the facility and not familiar with Resident 3 or Resident 3's plan of care. Employee 2, LPN, indicated that she recalled Employee 1, NA, wrapping her arms around Resident 3, beginning to lift the resident, hearing a crack, putting the resident back in the chair, and then going to get assistance. Employee 2, LPN, explained that she no longer works at the facility. During an interview on August 20, 2025, at approximately 12:00 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated the facility's investigation determined that Employee 1 failed to follow Resident 3's plan of care, which required transfers to be performed using a mechanical lift with the assistance of two staff. They confirmed that the failure to follow the plan of care resulted in a serious physical injury in the form of a mid-humerus fracture. The NHA and DON stated that Employee 1 was terminated as a result of the investigation findings. This deficiency was cited as past non-compliance and verified as implemented.The facility's corrective action plan included the following:The facility cannot retroactively correct the deficient practice. Employee 1, Nurse Aide, was terminated.A full house audit was completed on July 29, 2025, on resident transfer status to ensure the care plan and Kardex are up to date and correct.Education was provided to nursing staff regarding the use of the correct sling while operating the mechanical lift, review of the resident Kardex protocol, and the facility's policy for abuse and neglect.Education was initiated on July 29, 2025, and continued on July 30, 2025, and July 31, 2025, with current employees. Nurses not educated by 11:00 PM on July 31, 2025, will not be able to work until education is completed. Education is ongoing with new hires and agency staff.Transfer observations were conducted with staff on each unit. Transfer audits will be completed on every shift daily for one week, with weekly random audits to continue. Results of the audits were reviewed at the AD HOC Quality Assurance Performance Improvement Committee Meeting. The facility's compliance date was July 31, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on facility policy and clinical record review and resident interview, it was determined the facility did not ensure prompt efforts were made to resolve a resident's grievance and/or concerns for two of five residents reviewed. (Resident 1 and 2).Findings include:A review of the facility policy titled, Grievance Process Procedure, indicated concerns may be presented to any staff member and if unable to be resolved at that time a grievance/concern form will be initiated and submitted to be completed. The policy further revealed the facility will investigate the grievance and notify the person filing the grievance of resolution within 5 working days from the date of concern.A review of clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include osteoarthritis (a degenerative joint disease where the protective cartilage cushioning the ends of bones wears down, leading to pain, stiffness, and reduced mobility)A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 7, 2025, revealed that Resident 1 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact).A review of a Resident council Meeting minutes dated May 20, 2025, indicated two of seven residents attending had concerns related to call bell response times (Resident 1 and Resident 2). A review of resident council meeting minutes dated June 17, 2025, revealed that Resident 1 and Resident 2 were still experiencing extended call bell response times. A review of the facility complaint log for May 2025, included a grievance form for the above concern for Resident 1 and Resident 2. There was no evidence that the concern was investigated and resolved in a timely manner.An interview with Resident 1 conducted July 15, 2025, at approximately 10:00AM revealed her concern with call bell response times has not been resolved. The interview further revealed the resident had experienced pressing her call bell and waiting longer than one hour causing her to urinate and defecate on herself. Resident 2 was unavailable for interview. During an interview on July 15, 2025, at approximately 12:00PM with the Nursing Home Administrator confirmed the facility was unable to provide any further documentation that the grievance was resolved in a timely manner according to the facility policy. 28 Pa. Code 201.29(a) Resident rights

Based on observations and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for two out of two nursing units (Floors 1 and 2). Findings include: Observations made on June 3, 2025, during an on-site facility tour revealed a worn, stained, and tattered carpeting with scattered debris throughout four resident hallways on both Floor 1 and Floor 2 nursing units. At 8:48 AM, the 3-Hallway was observed with multiple white stains and scattered white paper pieces approximately the size of a fingernail. Dark discolorations and stains were noted throughout the hallway carpet, ranging in size from one inch to several feet. An observation at 8:56 AM revealed a plastic safety lancet (a medical device used for obtaining capillary blood samples, designed to prioritize safety by incorporating features that minimize the risk of needlestick injuries and accidental contamination) on the floor. The needle was retracted and locked in the protective plastic barrier. An observation at 9:08 AM revealed a white substance buildup on the rug outside of resident room [ROOM NUMBER]. At 10:41 AM, the floor on the door side of resident room [ROOM NUMBER] contained scattered orange chips, several white paper pieces, and a small solid brown object. At 10:42 AM, dark discolorations and stains measuring several inches to several feet were observed throughout the hallway outside resident rooms 301 through room [ROOM NUMBER]. At 10:44 AM, an orange substance was observed encrusted into the carpet between resident rooms [ROOM NUMBERS] During an interview conducted on June 3, 2025, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed the carpeting on both nursing units contained multiple stains, visible debris, and substance build-ups. The NHA stated the facility was aware of the condition and had solicited bids from external contractors for flooring replacement. The NHA acknowledged it is the facility's responsibility to ensure the environment remains clean and homelike for residents. 28 Pa. Code 201.18 (e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of resident clinical records, select facility policy, staff, and staff interview, it was revealed the facility failed to ensure that one of the 17 residents sampled was free of a significant medication error. (Resident 2). Findings include: A review of facility policy titled Administering Medication, last reviewed September 26, 2024, revealed medications are administered in accordance with prescriber orders. The policy indicates the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and a recent left femur fracture (thigh bone). A physician's order for oxycodone 5 mg with directions to give one (1) capsule by mouth every 8 hours as needed for pain management for five days was initiated on May 6, 2025. The medication order was discontinued on May 7, 2025. During an interview on June 3, 2025, at approximately 11:00 AM, the Director of Nursing (DON) revealed the medication dosage was reduced because the resident was responding negatively to the medication. A physician's order for oxycodone 5 mg with directions to give a half (2.5 mg) tablet by mouth every 8 hours as needed for pain management for 14 days was initiated on May 7, 2025. A review of Resident 2's Medication Administration Record (MAR) for May 2025 revealed the resident received oxycodone 5 mg on May 9, 2025, at 8:23 AM. However, facility-provided investigative documentation revealed that the medication administered was not the ordered dose. Employee 1, a licensed practical nurse (LPN), administered the full 5 mg dose rather than the ordered 2.5 mg (half tablet). On May 9, 2025, a physician's order for Narcan (naloxone, an opioid antagonist used to reverse the effects of opioid overdose) 4 mg/0.1 ml nasal spray was initiated for use as needed for opioid reversal. A progress note dated May 9, 2025, at 8:45 AM documented that Resident 2 experienced a sudden change in mental status. The resident appeared diaphoretic (excessively sweating), had a blank stare, and was initially unresponsive. The registered nurse was notified and completed an assessment. Vital signs at that time included blood pressure 107/65 mmHg, oxygen saturation 100% on 2 LPM nasal cannula, temperature 97.9°F, and heart rate 70 bpm. A blood glucose (Accu-check) result was 184. New medical orders were obtained from Employee 2, Certified Registered Nurse Practitioner (CRNP), and the resident began responding within five minutes. The resident asked for ginger ale and was subsequently alert. Although the MAR indicated that Narcan was administered at 10:05 AM, a progress note from the same date reported that the naloxone nasal spray was administered at 8:45 AM in response to the resident's unresponsive episode. Further documentation indicated that a peripheral IV was started in the resident's right lower arm at 9:05 AM, and a CRNP note from that morning stated the unresponsive episode lasted approximately 10 minutes following the administration of oxycodone 5 mg. The CRNP documented that Narcan was administered, and oxycodone was discontinued. A progress note dated May 9, 2025, at 10:45 AM, revealed the resident was alert, the resident's pupils were equal and reactive to light, the resident's hand grasps equal, and the resident's pain response was appropriate. Vital signs included 98/63 (BP), 19 bpm (respirations per minute), 91 (heart rate), 97.7 (temperature), and 98% (oxygen saturation). The resident voiced no complaints of pain. An employee witness statement dated May 9, 2025, submitted by Employee 1, LPN, confirmed that the nurse forgot to split the oxycodone tablet, resulting in administration of the incorrect dose. During an interview on June 3, 2025, at approximately 1:00 PM, the Director of Nursing (DON) confirmed Employee 1, LPN, administered the wrong dose of oxycodone to Resident 2 on May 9, 2025, resulting in the resident having an unresponsive episode and requiring the use of Narcan (naloxone) nasal liquid 4 mg/0.1 ml. The DON stated that a contributing factor in the resident's response was the resident's poor renal clearance (the body's process of removing substances from the blood through the kidneys and excreting them in the urine), as identified by the physician. The DON confirmed it is the facility's responsibility to ensure residents are free of significant medication errors. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services.

Based on a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to ensure that pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one of 17 sampled residents (Resident CR1). Findings include: A review of facility policy titled Administering Medication, last reviewed September 26, 2024, revealed medications are administered in accordance with prescriber orders. A clinical record review revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses that include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and malignant carcinoid tumor (a slow-growing type of cancer that has spread to other parts of the body). Resident CR1's care plan, initiated on May 16, 2025, identified a goal for the resident to report that pain is managed within acceptable limits. The care plan included an intervention to administer pain medications as ordered by the physician. A physician's order for Resident CR1 to be administered oxycodone-acetaminophen 5 mg/325 mg (oxycodone is an opioid pain medication; acetaminophen is a pain medication) with directions to give one tablet by mouth every 12 hours as needed for pain level rated 5-10 (moderate to severe pain) for 14 days was initiated on May 21, 2025. An additional physician's order for Resident CR1 to be administered acetaminophen tablets 325 with directions to give 650 mg by mouth every 6 hours as needed for pain level rated 1-5, mild to moderate, was initiated on May 21, 2025. A review of Resident CR1's Medication Administration Record for May 2025 revealed Resident CR1 received oxycodone-acetaminophen 5 mg-325 mg on four occasions from May 21, 2025 , through May 25, 2025, outside of the parameters prescribed by the physician for the administration of the medication. May 21, 2025, the resident received oxycodone-acetaminophen 5 mg/325 mg for a documented pain level of 0 out of 10. May 22, 2025, the resident received oxycodone-acetaminophen 5 mg/325 mg for a documented pain level of 3 out of 10. May 23, 2025, the resident received oxycodone-acetaminophen 5 mg/325 mg for a documented pain level of 4 out of 10. May 24, 2025, the resident received oxycodone-acetaminophen 5 mg/325 mg for a documented pain level of 3 out of 10. These documented pain scores did not meet the required threshold (pain level 5-10) for administration of the oxycodone-acetaminophen combination, as indicated by the prescriber. During an interview on June 3, 2025, at approximately 1:00 PM, the Director of Nursing (DON) confirmed Resident CR1 received oxycodone-acetaminophen 5 mg/325 mg outside of the parameters set by the physician. The DON confirmed it is the facility's responsibility to ensure that pain management is provided to residents consistent with professional standards of practice. 28 Pa. Code 211.5 (f)(xi) Medical records. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of clinical records and select facility reports, observations and staff and resident interviews it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening and the development of pressure sores for two residents out of 23 residents sampled (Residents 204 and Resident 1). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of the facility policy entitled Prevention of Pressure Injuries, last reviewed September 26, 2024, indicated the facility will review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application, and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and consult current clinical practice guidelines for prevention measures associated with specific devices. Additionally, monitoring of area(s) will include evaluation, report, and documentation of potential changes in the skin, and a review of interventions and strategies for effectiveness on an ongoing basis. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (loss of thinking, remembering, and reasoning skills), aphasia (a language disorder that affects the ability to speak and understand what others say), and contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of the right elbow. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 12, 2024, revealed the resident was severely cognitively impaired and was dependent on staff for all activities of daily living, and was at risk for pressure sore development. A review of Resident 1's care plan initiated October 24, 2021, and last revised on November 1, 2024, revealed the resident was at risk for alteration in skin integrity related to impaired mobility and incontinence. Planned interventions included pressure reducing cushion to chair/wheelchair, sheepskin to protect back in chair and bed, observe for changes in skin condition and report abnormalities, encourage/assist to get out of bed as tolerated, encourage/assist to reposition, encourage/assist to float heels as able when in bed, pressure reduction/relieving mattress on bed, use pillows and/or positioning devices as needed, administer preventative skin treatment per physician orders, and diet and supplement per physician order. Further review of Resident 1's care plan initiated March 5, 2019, and last revised November 1, 2024, revealed the resident was at risk for skin breakdown related to contractures, decreased activity, impaired cognition, impaired sensation, incontinence, limited mobility, shear/friction risks. Planned interventions included off load/float heels while in bed with heels up device, weekly skin assessment by licensed nurse, apply barrier cream after incontinence care, and provide skin preventative skin care (lotions, barrier cream). A review of the facility's investigation report dated September 29, 2024, at 3:38 p.m., revealed the nurse aide, Employee 4 who was providing morning care to Resident 1 identified an open area to the resident's right antecubital (area inside of the elbow). According to the investigation report, the resident's right arm is contracted, and the resident had elbow protectors in place. The area measured 4 cm x 4 cm (no depth identified) and treatment was initiated as ordered by the physician. Employee 4 indicated she noticed the elbow pad was very tight, so she removed it and noticed the open area. A review of Resident 1's clinical record did not identify orders and/or interventions for the application of elbow protectors however, a review of Resident 1's Documentation Survey Report dated September 2024 indicated the resident had Geri-sleeves (protective sleeve to prevent injury) to bilateral arms which were to be removed for care. According to the report, the Geri-sleeves were documented as provided each shift as ordered. The resident was identified to have an elbow protector present that was applied by staff despite no documented physicians order or care plan directive for its use. There was also no skin assessment conducted for the potential risks associated with the use of the elbow protector. The facility failed to implement interventions to prevent the development of a pressure ulcer for a resident with identified contractures. A review of Resident 204's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included end stage kidney disease, anxiety, shortness of breath, and need for palliative care (end of life care). A review of the resident's care plan initiated November 6, 2024, identified a focus area related to skin breakdown with planned interventions which included enhanced barrier precautions related to a wound, observe for changes in skin condition and report abnormalities, encourage and assist as needed to turn and reposition; use assistive devices as needed, encourage/assist to float heels as able when in bed, use lift sheet as tolerate to prevent friction/shear, administer treatment per physician orders, and report evidence of infection such as purulent drainage (thick yellow/green drainage), swelling, localized heat, or increased pain. A review of Resident 204's clinical record revealed documentation dated November 6, 2024, at 12:46 a.m., which revealed the resident was admitted to the facility with a Stage 3(sores that have broken completely through the top two layers of the skin and into the fatty tissue below) pressure ulcer on the right buttock and coccyx that measured 8. 5cm x 5cm x 0. 1cm with slough tissue (dead tissue) in the wound bed, and an intact blister on the right lower back which measured 1. 5cm x 2. 5cm x 0 cm. Review of a Skin and Wound note dated November 7, 2024, at 3:56 p.m., completed by the wound care consultant indicated the pressure area on Resident 204's sacrum (coccyx) was a DTI (deep tissue injury to underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Like a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die) with a scant amount of serosanguineous (drainage which is yellowish with small amount of blood), 50% granulation (new tissue) and 50% epithelial (healing tissue). No measurements were documented. The area on the resident's right lower back was identified as incontinence associated dermatitis which measured 3 cm x 1cm x 0. 2cm, treatment recommendations were made and implemented by the facility. Review of Skin and Wound note dated November 14, 2024, at 11:48 p.m., completed by the wound care consultant indicated the DTI on the sacrum continued to have a scant amount of serosanguineous drainage, 30% epithelial tissue, 30% granulation tissue, and 40% eschar (dead tissue). No measurements were documented. According to the documentation, the sacral wound has worsened greatly since last evaluation and was identified as a potential [NAME] Ulcer (a dark sore that develops rapidly during the final stages of person's life and is often unavoidable). No additional recommendations were identified. Skin assessments were documented on November 7, 2024, and November 14, 2024, however, there were no wound measurements recorded for Resident 204's sacral pressure area to evaluate whether the pressure ulcer was healing, worsening, or remaining unchanged. Facility policy indicates that wounds would be monitored to determine any potential changes. The lack of consistent wound measurements had the potential to prevent accurately evaluating the effectiveness of the treatment plan and adjusting interventions as necessary. Observation of Resident 204 on November 13, 2024, at approximately 11:00 a.m. revealed there was an alternating air mattress on the resident's bed, her heels were elevated, and the resident was without evidence of pain/discomfort. However, Resident 204 declined to allow the surveyor to observe her sacral pressure ulcer. Interview with the Director of Nursing on November 15, 2024, at approximately 2:10 p.m., confirmed there was no evidence the facility thoroughly evaluated Resident 204's sacral pressure ulcer for worsening and/or improvement. The DON further confirmed the facility failed to implement interventions to prevent the development of Resident 1's pressure. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f)(ix) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments accurately reflected the status of two residents out of 20 sampled (Residents 69 and 79). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section O, Special Treatments, Procedures, and Programs O 0110 J1 Dialysis, indicates facilities will code peritoneal or renal dialysis, which occurs at the nursing home or at another facility, and record treatments of hemofiltration, slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAVH), and continuous ambulatory peritoneal dialysis (CAPD) in this item. Intravenous (IV) medication and blood transfusions administered during dialysis are considered part of the dialysis procedure. A clinical record review revealed Resident 69 was admitted to the facility on [DATE]. A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) Section O 0110. Special Treatments, Procedures, and Programs, J1, Dialysis completed for Resident 69, dated October 28, 2024, indicated he received dialysis treatments while a resident at the facility. Further clinical record review revealed no other documented evidence that Resident 69 received dialysis services while a resident at the facility. During an interview on November 13, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed that Resident 69 was not currently receiving dialysis services and has not received dialysis treatments as a resident at the facility. The DON confirmed the facility coded Resident 69's MDS assessment dated [DATE], in error as related to dialysis services. The MDS was coded as the resident receiving dialysis despite no physician order. A clinical record review revealed Resident 79 was admitted to the facility on [DATE]. A review of an admission MDS Section N Medications N0350, Insulin, dated October 10, 2024, indicated Resident 79 received three insulin injections in the last seven days. Further clinical record review revealed no other documented evidence that Resident 79 was administered any insulin injections in the last seven days. The MDS was coded as the resident receiving insulin despite no physician order. During an interview on November 13, 2024, at approximately 9:30 AM, the DON confirmed that Resident 79 did not receive insulin as indicated in Resident 79's MDS assessment dated [DATE]. The DON indicated Resident 79's MDS assessment dated [DATE], was coded in error as it relates to insulin. 28 Pa. Code 211.5(f)(i) Medical records. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on observation, clinical record review, select facility policy, facility investigation reports, and staff interviews, it was determined the facility failed to implement a person-centered fall prevention plan of care for one resident out of 23 sampled (Resident 96). Findings include: A review of facility policy entitled Managing Falls and Fall Risk, last reviewed by the facility on September 26, 2024, revealed it is the facility's policy to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to minimize complications from falling. The policy indicates facility staff will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. A clinical record review revealed Resident 96 was admitted to the facility on [DATE], with diagnoses that include heart failure (a condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe). A care plan focus indicating Resident 96 is at risk for falls due to altered mobility and antidepressant medication use was initiated on October 11, 2024. Interventions implemented to minimize his risk of falls included encouraging transfer and slowly changing positions, assistance with transfers and ambulation as needed, and reinforcing the need to call for assistance. A fall risk form dated October 15, 2024, revealed Resident 96 is at moderate risk for falling with a history of prior falls and overestimating or forgetting his limitations. A review of facility incidents revealed Resident 96 experienced a fall event on the following dates: October 15, 2024 October 20, 2024 October 27, 2024 November 6, 2024 November 8, 2024 A review of Resident 96's fall incident report dated November 8, 2024, revealed Resident 96 fell while being assisted in the bathroom when a nurse aide left him to gather hygiene supplies. A review of a witness statement dated November 8, 2024, revealed Employee 2, Nurse Aide (NA), indicated he took Resident 96 to the bathroom. Employee 2, NA, indicated he left the bathroom while Resident 96 was holding the grab assist bars to get the resident a clean brief. Employee 2, NA, indicated that he heard a thump. The fall incident report dated November 8, 2024, revealed Resident 96 explained he was holding the grab assist bars when he lost his balance and fell to the ground. A skin observation tool dated November 9, 2024, revealed Resident 96 was observed with a skin tear on his right elbow measuring 5.5 cm x 1.5 cm x 0.1 cm and reopened a surgical incision on his face measuring 2.0 cm x 0.1 cm x 0.1 cm. A review of Resident 96's care plan revealed a new intervention was implemented on November 9, 2024, to minimize his risk for falling. The new intervention indicated staff will always stay with the resident while in the bathroom, initiated on November 9, 2024. During an observation on November 12, 2024, at 11:20 AM Employee 1, NA, assisted Resident 96 to the bathroom. Employee 1, NA, left Resident 96 in the bathroom unattended while she gathered supplies for hygiene. Employee 1, NA, returned to the bathroom and assisted the resident without incident. During an interview on November 14, 2024, at approximately 12:00 PM, Employee 1, NA, confirmed Resident 96 had a fall prevention intervention in place to always remain with the resident while in the bathroom. During an interview on November 15, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure staff implement interventions developed on each resident's comprehensive person-centered care plan. The DON confirmed Resident 96's care plan included an intervention for staff to always remain with the resident while in the bathroom. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of select facility policy, and staff interview, it was determined the facility failed to provide quality care as evidenced by the facility failure to ensure physician orders were followed for the administration of medications for two of 23 sampled residents (Residents 64 and 6). Findings include: A review of the facility policy titled Administering Medications last reviewed by the facility September 26, 2024, indicated that medications are administered within one hour of their prescribed time. The individual (licensed nurse) administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next medication. A review of the clinical record reveal that Resident 64 was admitted to the facility on [DATE], with diagnoses to include diabetes mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period), and COPD (chronic obstructive pulmonary disease- an ongoing lung condition caused by damage to the lungs). A current physician's order initially dated September 9, 2023, indicated Accu-checks (a test to check blood glucose levels) BID (twice daily) every morning and at bedtime for diabetes mellitus. A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, the morning Accu-check for 6:00 A.M. for Resident 64 was not completed. A current physician's order initially dated July 27, 2023, indicated that Lantus Solostar Solution Pen injector 100 Units/ML (insulin) Inject 30 units subcutaneously (injection given in the fatty tissue, just under the skin) one time a day for elevated blood glucose related to diabetes mellitus. A review of Resident 64's November 2024 Medical Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed dose of insulin ordered at 06:00 A.M. A current physician's order initially dated December 5, 2022, indicated Spiriva Respimat Aerosol Solution 2.5 MCG/ACT (inhaler), 2 puffs, inhale orally in the A.M. for COPD. A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed dose of the inhaler ordered at 06:00 A.M. A current physician's order initially dated June 11, 2024, indicated Systane Ultra PF Ophthalmic Solution 0.4-0.3% (an eye drop solution) instill 1 drop in both eyes four times a day for dry eyes. A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that on November 7, 2024, Resident 64 did not receive the prescribed eye drops ordered at 06:00 A.M. A current physicians order initially dated July,13, 2023, indicated Pregabalin Capsule (nerve pain medication) 50 mg, give one capsule by mouth two times per day for neuropathy (a term for nerve damage that can occur anywhere in the body). A review of Resident 64's November 2024 Medication Administration Record (MAR) revealed that resident 64 did not receive the prescribed medication ordered at 06:00 A.M. A review of the clinical record revealed that Resident 6 had diagnoses which include diabetes mellitus and cerebral infarction (stroke). A current physician order initially dated October 7, 2023, indicated Basaglar KwikPen 100 Units/ML solution (insulin) inject 20 units subcutaneously once daily for a diagnosis of diabetes mellitus. Review of Resident 6's November 2024 Medication Administration Record (MAR) revealed that on November 12, 2024, the resident did not receive the prescribed dose of insulin which was ordered to be administered at 6:30 AM. An interview with the Director of Nursing (DON) on November 14, 2024, at 1:00 P.M. confirmed the facility failed to follow physician orders and administer physician ordered medications as prescribed for Resident 64 and Resident 6. Specifically, the facility did not administer prescribed medications, including blood glucose monitoring, insulin, inhalers, and other scheduled medications, at the designated times. These failures resulted in residents not receiving necessary treatments as ordered. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policies, and staff interview, it was determined the facility failed to ensure that the resident's drug regimen was free of unnecessary antibiotic medications for one out of 23 residents sampled (Resident 90). Findings included: A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on September 26, 2024, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. The policy indicates if a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic or anti-infective orders. The policy also indicates culture and sensitivity (urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) laboratory results will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. A clinical record review revealed a culture laboratory result report dated October 21, 2024, at 6:32 PM, indicating Resident 90's urine showed growth of Klebsiella oxytoca ESBL (extended-spectrum beta-lactamase) producing organisms of greater than 100,000 colonies/ml and Enterococcus species of greater than 100,000 colonies/ml. The susceptibility report indicated Klebsiella oxytoca ESBL is resistant to ceftriaxone (a class of medicines known as cephalosporin antibiotics). The report did not indicate if Enterococcus species identified in Resident 90's urine were susceptible or resistant to cephalosporin antibiotics. A community provider progress notes dated October 22, 2024, at 10:51 AM indicated Resident 90 was started on Rocephin (Ceftriaxone) for a symptomatic urinary tract infection and can be discharged on an oral antibiotic. A clinical record review revealed Resident 90 was admitted to the facility on [DATE], with diagnoses that included a myocardial infarction (a condition where the blood flow to the heart is reduced or stopped). An admission notes dated October 23, 2024, indicated Resident 90 was transferred and admitted to the facility on [DATE]. The note indicated a review of Resident 90's hospital course, which included a community provider section indicating Resident 90's urine analysis was concerning for a urinary tract infection, and a urine culture was sent, though pending at the time of discharge. Resident 90 was started on ceftriaxone (a cephalosporin class of antibiotics) while a patient and was discharged on Cephalexin/Keflex. She was able to urinate independently, and she was deemed medically ready for discharge on October 22, 2024. The culture laboratory report dated October 21, 2024, did not indicate if the identified organisms were susceptible or resistant to Cephalexin/Keflex (another type of cephalosporin antibiotic). A physician's order for Cephalexin capsule 500 mg with directions to give one capsule by mouth four times a day for infection for five days was initiated on October 23, 2024, at 6:00 AM and discontinued on October 23, 2024. Another physician's order for Cephalexin capsule 500 mg with directions to give one capsule by mouth four times a day for infection for five days was initiated on October 23, 2024, at 12:00 PM and discontinued on October 28, 2024. A medication administration record dated October 2024 revealed Resident 90 received twenty doses of Cephalexin capsule 500 mg between October 23, 2024, and October 28, 2024. There was no documented evidence the resident had experienced any symptoms of a urinary tract infection, such as fever, chills, mental changes/confusion, fatigue, nausea/vomiting, pressure in the lower part of the pelvis, or increased urination, from her admission on October 22, 2024, through the course of her prescribed antibiotic course on October 28, 2024. During an interview on November 15, 2024, at approximately 10:00 AM, Employee 3, Certified Registered Nurse Practitioner (CRNP), confirmed the culture laboratory report did not indicate if the identified organisms were susceptible or resistant to Cephalexin/Keflex (another type of cephalosporin antibiotics). Employee 3, CRNP, was not able to provide documented evidence indicating the necessity for Resident 90 to receive Cephalexin 500 mg. During an interview on November 15, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure the resident's drug regimen was free of unnecessary antibiotic drugs. The DON confirmed that Resident 90's culture laboratory report dated October 21, 2024, did not indicate if the identified organisms were susceptible or resistant to the cephalexin antibiotic medication. The DON was not able to provide documented evidence indicating the necessity for Resident 90 to receive Cephalexin 500 mg. 28 Pa. Code 211.2 (d)(3)(9) Medical director. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(1)(3) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that encounters food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Initial tour of the food and nutrition services department in the presence of the foodservice director on November 12, 2024, at 8:40 AM revealed the following food storage concerns with the potential to increase the potential for food-borne illness: There were 14 four-ounce thawed nutritional beverage shakes on the shelf in the refrigerator which were not dated with a thaw or discard date. The manufacturer label indicated to use within 14 days of thawing. There were two bags of frozen vegetables on the shelf in the freezer which were not dated. Interview with the food service director at the time of the observations confirmed that acceptable practices for food storage were to be followed and all food items were to be properly dated to ensure safety and quality. 28 Pa. Code 201.18 (e)(1) Management

Based on review of clinical records and resident and staff interview, it was determined the facility failed to ensure the clinical record was accurately documented, according to professional standards of practice, reflecting the administration of medication for one resident out of 23 sampled (Resident 204). Findings included: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident 204's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included end stage kidney disease, anxiety, shortness of breath, and need for palliative care. A physician order dated November 6, 2024, was noted for Morphine Sulfate solution 20mg/mL give 0.5 mL by mouth every hour as needed for shortness of breath or pain for 14 days. A review of Resident 204's Medication Administration Record (MAR) dated November 2024 failed to specify the circumstances under which the narcotic medication should be administered for either pain or shortness of breath. An interview the Director of Nursing (DON) on November 15, 2024, at approximately 2:00 PM confirmed the facility failed to specify when narcotic medication may need to be administered to Resident 204. The DON further confirmed that there should have been two separate orders to identify if the resident required the ordered narcotic medication for shortness of breath or pain. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of select facility policy and clinical records, observations and staff, resident and family interviews it was determined that the facility failed to promptly address identified risk factors for skin breakdown and consistently provide planned treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing and prevent worsening of pressure sores for three residents out of six sampled with pressure sores (Resident 54, 35 and 49). Findings include: According to the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians ((ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean would environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. A review of the facility's policy entitled Skin Integrity Management, last revised by the facility on (MONTH) 1, 2019, indicated that the facility will provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of wounds. The facility practice standards include complete comprehensive evaluation on admission, complete risk evaluation, perform skin assessments on admission and weekly, implement pressure ulcer prevention for identified risks factors, determine the need for heel protectors and heel lift devices, and document daily monitoring of ulcer site, with or without dressing. A review of the clinical record revealed that Resident 54 was admitted to the facility on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. blood vessels outside of your heart and brain to narrow, block, or spasm. This can happen in your arteries or veins). A review of an Admission Minimum Data Set Assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 24, 2019, revealed that Resident 54 was at risk for developing pressure sores. The resident required assistance of staff members for all activities of daily living to include bed mobility, transfers, toilet use, hygiene and bathing. Section M (skin section) of the MDS indicated that the resident was at risk for pressure ulcers. The resident had no pressure sores on admission to the facility. A review of the resident's admission Braden scale assessment (a tool developed to assess a patients risk of developing a pressure ulcer) dated (MONTH) 4, 2019, revealed a score of 16, indicating that the resident was at mild risk for developing pressure sores. A review of a Braden scale assessment dated (MONTH) 25, 2019, revealed a score of 14, indicating that the resident was at moderate risk for developing pressure sores. A review of the facility's Event Summary Report dated (MONTH) 27, 2019, at 10 AM, revealed an in-house acquired pressure ulcer on the left heel was found on the resident while staff was applying ace wraps to the resident's legs. The wound was noted as a scabbed necrotic area on the left heel, which measured 3.1 cm x 1.7 cm. The facility noted the root cause of the pressure wound was due to poor mobility. A physician order [REDACTED]. The restorative program called for the resident to ambulate up to 50 feet with a rollator walker and minimum assistance of one staff member with a wheel chair follow and transfer from sit to stand from all surfaces with minimum assistance of one staff member. A review of the facility's documented restorative program for the resident's transfers and ambulation, dated (MONTH) 5, 2019, through (MONTH) 30, 2019, revealed 12 days when restorative transfers were documented as completed. There was no evidence that the facility ambulated the resident for the month of (MONTH) 2019 or through (MONTH) 4, 2019, as planned. A review of the resident's current activities of daily living care plan for decreased ability to perform activities of daily living, to include transfers and ambulation, revealed an intervention to initiate the restorative nursing program for ambulation and transfers. During an interview with the resident and her family on (MONTH) 4, 2019, at 1:46 PM, it was revealed that the resident and her family reported that the resident was never put on a walking program. The resident's family member stated that she received information from the facility on (MONTH) 5, 2019, that the resident was going to be starting on a restorative walking program. The resident's family inquired when the program would begin and the facility's response was soon. Interview with the Director of Nursing conducted on (MONTH) 4, 2019, at 2:30 PM revealed that the facility was unable to explain why the restorative ambulation program was not initiated as planned and ordered by the physician for Resident 54 on (MONTH) 5, 2019. Further review of the Event Summary Report, revealed interventions in place prior to the resident's skin breakdown, were heels floated/suspended if warranted and to elevate heels off pillow while in bed. The facility provided documentation that from (MONTH) 20, 2019, through (MONTH) 27, 2019, the facility was floating the resident's heels with a pillow while the resident was in bed. Further interview with the resident's family on (MONTH) 4, 2019, at 1:50 PM revealed that the resident's family visit daily. According to the resident's family they would often find the resident lying in bed with no pillow under her feet to elevate her heels. The resident's family also stated they were informed on (MONTH) 27, 2019, that heel boots were ordered, but the family did not observe them in use by the resident until (MONTH) 3, 2019. The Event Summary Report also indicated that the corrective action was to utilize heel medix boots (heel protectors which helps relieve pressure on vulnerable heels with an open heel and pillow-like design) and apply [MEDICATION NAME] (a commonly used medicine to treat minor wounds) to the wound daily. The heel boots were an intervention to be added immediately according to the corrective action on the facility Event Summary Report dated (MONTH) 27, 2019. A review of a nursing note dated (MONTH) 27, 2019, revealed an order for [REDACTED]. A review of the (MONTH) 2019, treatment administration record revealed that the resident did not receive the [MEDICATION NAME] treatment as ordered on (MONTH) 27, 2019, until (MONTH) 3, 2019. The bilateral heel boots, which were to be implemented immediately on (MONTH) 27, 2019, were not put into place until (MONTH) 2, 2019, at 9 PM. An observation on (MONTH) 3, 2019, at 12:40 PM, revealed that the resident was seated in a wheelchair in the dining room wearing shoes and socks. An observation on (MONTH) 4, 2019, at 11:50 AM, revealed that the resident was seated in a wheelchair in her room wearing shoes and socks. An observation of the pressure sore on (MONTH) 4, 2019 at 2:03 PM, while the resident was lying in bed, revealed an unstageable black eschar pressure area to the resident's left heel, which was approximately the size of a quarter. At the time of the observation the heel boots were not in place for pressure relief to the resident's heels as planned on (MONTH) 27, 2019. Observations on (MONTH) 5, 2019, at 9:20 AM, of the resident while in bed revealed that no heel boots were in place. Observation of the resident on (MONTH) 5, 2019, at 11:58 AM, revealed that the resident was seated in a wheelchair in her room, wearing shoes and socks. Further review of the resident's clinical record revealed that Resident 54 was seen by the wound specialist on (MONTH) 5, 2019, to evaluate the resident's pressure sore wound. The wound specialist noted that the wound to the resident's left heel was an unstageable DTI (deep tissue injury- purple or maroon localized discoloration of intact skin or blood filled blister due to damage from underlying soft tissue pressure or shearing) with intact skin, measuring 1.5 cm by 1.5. The wound specialist recommended [MEDICATION NAME] daily for 30 days. A review of a nutrition note dated (MONTH) 5, 2019, at 11:05 AM, noted that after speaking with the wound specialist, it was reported that the resident's heel wound had declined within the past week. Observation on (MONTH) 6, 2019, at 11:37 AM revealed that the resident was seated in a wheelchair in her room wearing shoes and socks. Observation of the resident on (MONTH) 6, 2019, at 12:17 PM revealed that the resident remained seated in a wheelchair in her room wearing shoes and socks. A staff member was feeding the resident at that time. The resident's heel boots were observed on top of the resident's bed at the time of this observation. The nursing home administrator and director of nursing confirmed during interview on (MONTH) 6, 2019, at 1:30 PM that the facility had not timely and consistently implemented planned and/or prescribed measures to promote healing of the resident's pressure sore A review of the clinical record revealed that Resident 35 was admitted to the facility on (MONTH) 27, 2006, with [DIAGNOSES REDACTED]. supplying blood and oxygen to the brain and [MEDICAL CONDITION] (paralysis of the legs and lower body). The resident went out to the hospital and was readmitted to the facility on (MONTH) 3, 2019, with a Stage II moisture associated skin damage on the buttocks ({MASD} inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, or wound drainage) and was high risk for developing pressure sores. A review of quarterly Minimum Data Set assessment dated (MONTH) 2, 2019, revealed that the resident was moderately cognitively impaired, required extensive assistance with activities of daily living, always incontinent of bowel and bladder and was at risk for developing pressure areas. A review of the resident's care plan, revised on (MONTH) 30, 2019, revealed that the resident had the potential for skin breakdown due to decreased mobility and urine and stool incontinence. The care plan goal, with a target date of (MONTH) 26, 2020, was the resident will not show signs of skin breakdown x 90 days. Interventions planned were to turn and reposition the resident, every two hours, side to side while in bed, provide peri care (washing the genitals and anal area) every two hours and as needed, skin barrier cream to buttocks every shift and as needed and pressure reducing surfaces to bed and chair. A review of a wound evaluation dated (MONTH) 24, 2019, revealed that the resident had MASD measuring 10 cm (centimeters) x 3 cm x 0.1 cm located on the left posterior (further back in position; of or nearer the rear or hind end of the body) thigh and 1 cm x 1 cm on the right buttock. A review of a wound evaluation dated (MONTH) 31, 2019, revealed that the wound on the left posterior thigh etiology (the cause, set of causes, or manner of causation of a disease or condition) had changed to an unstageable pressure related wound (localized areas of tissue necrosis {the death of most tissue due to injury that typically develop when soft tissue is compressed} due to deeper breakdown and necrosis. The wound now measured 7 cm x 7 cm x 0.1 cm. The evaluation noted that the wound progress had deteriorated. A review of a wound evaluation dated (MONTH) 7, 2019, revealed that the wound on the left posterior thigh classification had changed to a Stage III pressure wound (damage involves the full thickness of the skin and may extend into the subcutaneous tissue {the innermost layer of skin}) and became larger measuring 10 cm x 10 cm x 0.1 cm. The evaluation noted that the resident's wound progress had deteriorated. The wound on the right buttock had increased in size and now measured 4 cm x 4 cm with heavy serous exudate and 50% granulation. The treatment to the Stage III pressure wound of the left posterior upper thigh and MASD on the right buttock was Sliver [MEDICATION NAME] once daily for 30 days. The wound consultant's recommendations were to reposition the resident per facility protocol and off load the wound and apply [MEDICATION NAME] powder An observation of Resident 35 on (MONTH) 3, 2019, at 10:19 AM revealed that the resident was lying in bed on her backside. The wedges to reposition the resident on her side, as care planned, were observed on the floor. A review of facility documentation for Resident 35's turning and repositioning dated (MONTH) 2019, (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed no documented evidence that the task was consistently performed at the scheduled frequency. Documentation revealed five instances that the facility staff failed to turn and reposition the resident in August, 12 instances in September, 12 instances in (MONTH) and 23 instances in (MONTH) 2019. Further review of facility documentation from (MONTH) 2019 to (MONTH) 2019 revealed that staff were documenting the completion of turning and repositioning the resident every two hours for the entire shift prior to this task being completed on a daily basis. A review of facility documentation of treatment administration of Resident 35's application of barrier cream every shift to prevent skin breakdown dated (MONTH) 2019 through (MONTH) 2019, revealed no documented evidence that staff had consistently applied the preventative treatment as planned. During (MONTH) 2019, staff failed to apply the cream on five occassions, on 10 occassions during (MONTH) 2019, on 14 occassions during (MONTH) 2019 and on 21 occassions during (MONTH) 2019. A review of facility documentation for the proper placement of the resident's pressure reducing devices to the bed and chair from (MONTH) 2019 to (MONTH) 2019 revealed that the pressure relieving devices were not consistently checked for placement. During the 6 months reviewed, staff failed to check the placement of the pressure relieving devices 49 times. No documentation was provided by the facility that the intervention of peri care every 2 hours had been implemented as care planned. An observation of Resident 35 on (MONTH) 5, 2019, at 8:46 AM revealed the resident was lying on her backside while in bed. The wedges to reposition her on her sides were again observed on the floor. An interview with the wound care physician on (MONTH) 5, 2019, at approximately 9:20 AM revealed that the physician stated that the resident's wound had progressed from MASD to a Stage III pressure sore due to the wound becoming deeper. The physician stated it has become hard to heal due to the resident always being incontinent. An observation of Resident 35 on (MONTH) 6, 2019, at 8:27 AM revealed that the resident was lying on her backside while in bed and the wedges to reposition her on her sides were on the floor. An observation the resident's wounds on (MONTH) 6, 2019, at approximately 10:00 AM revealed that the resident had two pressure sores in the buttock/back of the thigh area. The first was a large red and purple area to the buttocks with three opens wounds within the large red area. The second area was a large red and purple area with four open wounds within the red area. The facility failed to demonstrate the consistent implementation of planned and recommended interventions to promote healing and prevent worsening of pressure sores for Resident 35. A review of the clinical record revealed that Resident 49 was admitted to the facility (MONTH) 11, 2019, with [DIAGNOSES REDACTED].{insulation} of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of an Admission Minimum Data Set Assessment (MDS) dated (MONTH) 18, 2019, revealed that Resident 49 was at risk for developing pressure sores and required extensive assistance of two staff members for bed mobility, transfers, toilet use, and personal hygiene. Further review of the admission MDS Assessment revealed that Resident 49 was not on a turning and repositioning program and always incontinent of bowel. A review of the resident's care plan created on (MONTH) 11, 2019, revealed that the resident required assistance with mobility and was at risk for skin breakdown related to decreased activity and [DIAGNOSES REDACTED].e. lotions, barrier creams as ordered, apply barrier cream with each cleansing, and to pat (do not rub) skin when drying A review of the facility's Event Summary Report dated (MONTH) 22, 2019, at 12:00 a.m. revealed a new pressure ulcer; in-house acquired that was identified as an unstageable ulcer (localized area of tissue death that typically develops when soft tissue is compressed between a bony prominence and a external surface for a long period of time) located on her sacrum. According to the facility's skin integrity report, the area measured 3.0 centimeters in length, 3.0 centimeters in width and 0.1 centimeters in depth. The facility noted, on the Event Summary Report, that a risk factor identified before the skin breakdown was the resident's [DIAGNOSES REDACTED]. Further review of the Event Summary Report revealed that the resident anticipated beginning oral chemo therapy medication for [MEDICAL CONDITION] and that her [DIAGNOSES REDACTED]. A review of the wound evaluation dated (MONTH) 24, 2019, revealed that the resident had developed an area of boggy necrosis on sacrum. A review of the facility's skin integrity report dated (MONTH) 14, 2019, revealed that the wound on the resident's sacrum was now a Stage IV pressure ulcer (full thickness skin loss with exposed bone, muscle, or tendon) that measured 2.5 cm x 3 cm x .5 cm. A review of the wound evaluation dated (MONTH) 5, 2019, revealed that the wound measured 3.5 cm x 3.5 x 2. 5 cm in depth with undermining (erosion of tissue under the wound edge which results in a pocket beneath the skin at the wound's edge) of 3 centimeters. A wound culture and a bone specimen were obtained. It was noted that the resident had experienced a dramatic decline in the pressure sore and a course of intravenous antibiotics was recommended. Observation of the wound during wound care in the presence of Employee 3, Licensed Practical Nurse (LPN) on (MONTH) 6, 2019, at approximately 10:30 a.m. revealed a Stage IV sacral wound covered with thick brown tissue and the presence of a foul odor. Further review of the resident's clinical record revealed no documented evidence that the facility had promptly implemented sufficient preventative measures to address the resident's risk factors of decreased mobility and bowel incontinence to prevent the development and/or worsening of pressure sores. The facility failed to demonstrate timely and consistent repositioning of the resident, or encouragement of the resident to self-reposition, at the frequency necessary to deter skin breakdown. The resident was identified at risk for skin breakdown upon admission to the facility on (MONTH) 11, 2019. The facility initiated the use of a low air loss mattress to the resident's bed and the placement of side rails on the bed to promote the resident with help in repositioning after the development of the unstageable pressure ulcer on the resident's sacrum on (MONTH) 22, 2019, 11 days after the resident's admission to the facility. An interview with the DON (director of nursing) on (MONTH) 6, 2019 at approximately 2:30 PM confirmed that the facility was unable to demonstrate the timely development of adequate individualized measures to address Resident 49's risk factors for skin breakdown to deter pressure sore development. 28 Pa. Code 211.5 (f)(g)(h) Clinical records Previously cited 12/14/18, 10/29/19 28 Pa. Code 211.12 (a) Nursing services Previously cited 12/14/18, 10/29/19 28 Pa. Code 211.12 (c) Nursing services Previously cited 12/14/18, 10/29/19 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 12/14/18, 10/29/19 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 12/14/18, 10/29/19 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 12/14/18, 10/29/19

Based on a review of clinical records and resident incident/accident reports, interviews with staff and observation, it was determined that the facility failed to maintain the environment free of potential accident hazards resulting in serious injury to one resident out of 23 reviewed (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2016, revealed that the resident required extensive assistance of two persons for bed mobility, transfers and activities of daily living to include bathing, toileting and dressing. A review of a facility investigation into a resident incident/accident dated [DATE], at 2:15 p.m. revealed that while the Speech Therapist was transporting Resident CR1 to the rehabilitation gym in her Broda chair (a tilting and reclining positioning wheeled chair) the resident's left foot got caught on the upward slope of an indentation on the floor created by a 4 inch sewer clean-out cover (floor drain) resulting in the resident's left foot rocking forward and her left leg bending backwards under the Broda chair. The resident called out and the Speech Therapist noticed that the resident was holding her left calf and knee. The Occupational Therapist came out of the rehab gym to assist the speech therapist and she supported the resident's left leg while they both transported the resident back to the nursing unit to be evaluated by the nursing staff. The resident's left knee and calf were noted to be swollen and sore to touch at that time. The physician was notified at that time and a new order was received for an X-ray of the resident's left knee and tibia (larger bone in the lower leg). According to the facility's investigation, leg rests on the Broda chair were not ordered for this resident because the resident self propels in the Broda chair. Ice was applied to the site and Tylenol (pain medication) 650 milligrams (mg) was given for pain. The facility's investigation into the incident identified a contributing factor as the dip in the floor created by the sewer clean-out drain. Review of the Speech Therapist's statement dated [DATE], at 2:10 p.m. revealed that while the therapist was transporting the resident to the treatment gym, the resident placed her feet down on the ground, which the therapist was unaware of, and the resident's left leg bent backwards under the chair. The resident screamed. The therapist stopped pushing. The resident was holding onto her left leg. Review of the X-ray report dated [DATE], revealed that Resident CR1's left tibia and fibula (bones in the lower leg) were fractured. The resident was transported to the emergency roiagnom on [DATE], for further treatment. The resident was admitted to the hospital with [REDACTED]. Review of an orthopedic (a physician specializing in bones) consult dated [DATE], revealed that the resident had previously undergone a revision of the left total knee many years ago. The X-ray report now showed a minimally displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the left proximal (top) of the tibia as well as a minimally displaced fracture of the fibular neck (top of the fibula). The resident was readmitted to the skilled nursing facility on [DATE]. Review of the physician's discharge summary of the resident's stay at the facility dated [DATE], revealed that the resident had expired at the facility and the physician documented that the resident's cause of death was due to iatrogenic (caused by medical personnel or procedures) leg fracture causing multi-symptom failure (the failure of two or more systems in the body for example, the cardiovascular and renal (kidneys) systems. Multiple system failure is also known as multiple organ failure, as when both the heart and kidney give out). Observation of the area at the sewer clean-out drain on [DATE], at 11:00 a.m. and in the presence of the Nursing Home Administrator revealed that the drain in question was located on the first floor hallway near the dining area. There were two drains next to each other and the drain in question, according to the Nursing Home Administrator, had been sunken in about a ,[DATE] of an inch in diameter around the silver metal plate at the time of the incident. There was no evidence that the facility had identified this accident hazard and performed preventative maintenance alterations on this drain prior to this incident. An interview with the Nursing Home Administrator on [DATE], at approximately 11:00 a.m. confirmed that the resident sustained [REDACTED]. Observation of the main dining room on the first floor of the facility on [DATE], at 7:10 a.m. revealed that the steam table was turned on and the covered pans contained hot food held for the breakfast meal service. The surface of the steam table was hot to touch. There was no staff present in the dining area at the time of the observation and the unattended dining room was open and accessible to residents. 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited [DATE]

Based on a review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to demonstrate timely and consistent monitoring of skin integrity and prompt action to eliminate pressure created by the use of a therapeutic device to prevent the development of a pressure sore for one resident out of 23 residents reviewed (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2016, revealed that the resident required extensive assistance of two persons for bed mobility, transfers and activities of daily living to include bathing, toileting and dressing. The resident sustained [REDACTED]. Review of a resident incident/accident report and corresponding facility incident investigation report dated April 21, 2016, at 9:00 a.m. revealed that Resident CR1 developed a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), identified as in-house (facility) acquired on her left heel, which was purple in color and due to pressure on the resident's ankle as the result of the resident's ankle resting on a fixated metal bar inside a leg brace. Review of an employee witness statement dated April 21, 2016 revealed that Employee 6, the Licensed Practical Nurse on the resident's unit, informed Employee 1, the Registered Nurse Unit Manager of Resident CR1's condition. Employee 1 noted that she performed a complete skin check on the resident and noticed that the resident had a purple area on her left heel, which was resting on the metal bar inside the immobilizer. The orthopedic physician (a physician specializing in the bones) was contacted and orders were received to cut the metal bar out of the immobilizer. Review of an employee witness' statement dated April 22, 2016, revealed that Employee 4, a Nurse Aide, noted that she and another Nurse Aide, Employee 7, put the resident to bed and changed her. Employee 4 noted that last night (April 21, 2016) she saw a blue and purple area on the resident's left foot. There was no evidence that Employee 4 had notified the charge nurse of the area on the resident's heel when observed on April 21, 2016. The facility's investigative report also noted that the resident's left leg brace had a fixated metal bar that rested near her heel and a physician's orders [REDACTED]. Review of a, Skin integrity Report dated April 21, 2016, revealed that the resident had developed an in-house pressure ulcer on her left heel. The facility described the site as a deep tissue injury or DTI, which is a unique form of a pressure ulcer. (The National Pressure Ulcer Advisory Panel defines a deep tissue injury as, A pressure related injury to subcutaneous (under the layers of the skin) under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. The [MEDICAL CONDITION] may lead to the subsequent development of a Stage III-VI (break down of dermis, epidermis -specific layers of the skin, fatty tissue, muscle and potentially cartilage and bone) pressure ulcer even with optimal treatment). An interview with Employee 2, a Nurse Aide, on September 1, 2016, at 10:25 a.m. revealed that the brace on the resident's left leg came to her heel and the metal bar rested on the resident's left heel when her foot was bent or placed on a pillow. Interview with Employee 3, a Licensed Practical Nurse, on September 1, 2016, at 10:50 a.m. revealed that the length of the brace ran from the resident's thigh to her ankle. The metal bar extended down to the end of the resident's foot at the resident's heel. The metal bar touched the resident's heel when the resident's foot was flexed. Review of the resident's plan of care for the [MEDICAL CONDITION] and tibia (leg bones) of the left leg dated April 8, 2016, revealed that one of the interventions dated as initiated April 8, 2016, was knee immobilizer to the left leg; remove for skin checks every shift. There was no documented evidence in the resident's clinical record that this immobilizer was removed for skin checks of the resident's left leg to include her foot and heel according to the resident's plan of care. Review of documentation in the resident's Treatment Record for the month of April 2016 revealed that the resident's left foot was checked for color, circulation, sensitivity and movement every shift from April 9, 2016 through April 22, 2016. The treatment record also indicated that the knee immobilizer to the resident's left leg and knee, with an ace wrap (compression bandage), was to remain in place. Interview with the Nursing Home Administrator and Director of Nursing on September 1, 2016, at 10:30 a.m. failed to provide evidence that the staff had consistently and effectively monitored the resident's left heel for the development of a pressure ulcer and had intervened promptly to remove the source of pressure on the resident's foot to prevent skin damage. 42 CFR 483.25(c) Pressure sores Previously cited 8/7/15 28 Pa. Code 211.12(a) Nursing services Previously cited 2/8/16, 11/3/15, 8/7/15 28 Pa. Code 211.12(c) Nursing services Previously cited 12/2/15, 11/3/15, 8/7/15 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 12/2/15, 8/7/15 28 Pa. Code 211.12(d)(3)(5) Nursing services Previously cited 2/8/16, 12/2/15, 11/3/15, 8/7/15