Every finding on record at Accela Rehab and Care Center at Springfield

Based on clinical record review, review of facility documentation, and staff interview it was determined that the facility failed to maintain complete and accurate medical records for one of three residents reviewed (Resident R3). Findings include: Review of Resident R3's clinical record revealed Resident R3 was admitted to the facility on [DATE], with diagnoses of Unspecified Diastolic Heart Failure (the heart muscle is stiff and cannot relax properly), Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breathe), and Hypertension (high blood pressure). Per clinical record review, Resident R3 was discharged from the facility on July 2, 2026. Review of Resident R3's disenrollment paperwork revealed no information explaining the start and end times of current insurance coverage and new insurance coverage. Further review of the documentation revealed no acknowledgement of what was being signed by Resident R3. Interview with Director of Nursing (DON), Employee E2, on July 20, 2026, at 9:10 a.m., DON, Employee E2, had no knowledge of who was responsible for handling the disenrollment paperwork with the residents at the facility. Interview with Nursing Home Administrator (NHA), Employee E1, on July 20, 2026, at 9:20 a.m., NHA, Employee E1, stated that he/she was responsible for the disenrollment paperwork with the residents at the facility. Follow-up interview on July 20, 2026, at 2:30p.m., NHA, Employee E1, confirmed that the insurance disenrollment agreement for Resident R3 was not complete, and did not contain the resident's current insurance information, the date of disenrollment, the new insurance that was selected, and the date that the new insurance will go into effect. 28 Pa. Code 211.5 (f)(v) Medical records

Based on record review, interviews with residents and staff, and observations on the units, it was determined that the facility did not ensure that portable air conditioning units were properly and safely installed for 13 out of 13 rooms observed (rooms 102, 104, 117, 121, 133, 138, 209, 212, 214, 221, 226, 235, 238). Findings include:Review of the installation manual for portable air conditioning unit Hisense model #AP0836DK1W revealed on page 8, Install The Portable Air Conditioner, subsection, Window Installation revealed that the user should Attach the window exhaust adapter to the outer slider (the piece with the large exhaust hole), and that the unit must be used with the included Duct Window installation kit for effective cooling. In an email sent on June 17, 2026, at 2:20 p.m., employee E1, the Nursing Home Administrator, stated that this model was in use in the facility. He also stated that the other model in use was Black and Decker, model #BPB20KWBL. No manual was provided for this model. Review of records for resident R2, revealed that his most recent BIMS assessment (Brief Interview for Mental Status- an assessment of resident cognition and orientation), was dated April 21, 2026. His score was 15 out of a possible 15, indicating that he was cognitively intact. During an interview with resident R2 on June 17, 2026, at 10:33 a.m., he stated that when the facility installed portable air conditioning units in rooms, they were not properly secured. He stated that as they did not seal the exhaust into the window, the exposed screens let heat in, making units less effective at reducing the temperature in the rooms. Observations conducted in the facility on June 17, 2026, beginning at 11:52 a.m. in the presence of employee E1 revealed rooms 102, 104, 117, 121, 133, 138, 209, 212, 214, 221, 226, 235, and 238 to have portable air conditioning units. All units were observed to be positioned near the windows, with exhaust ducting leading to the partially windows. Ducts were held in place between the windowsill and the windowpane. The ducts were not secured in the window, and the screens were exposed. During observations, employee E1 tripped over a duct, pulling it from the window. He confirmed that the reason it came free was that it was not properly secured.

Based on review of facility policy and interviews with residents and staff, it was determined that the facility did not ensure that an appropriate process was in place for distributing mail to residents within 24 hours of delivery to the facility, including on the weekends for four of eight residents reviewed (Resident R3, R4, R6, and R7). Findings include:Review of facility policy titled Resident Mail Handling Policy, most recently revise in February 2026, revealed that Incoming mail should be distributed to residents within seventy-two (72) hours of receipt by the facility.Interviews were conducted on June 17, 2026, with alert and oriented residents.An interview with resident R3 at 10:45 a.m. revealed that mail is delivered through the administrator at his discretion, but that it isn't delivered on weekends when the administrator was not in the building. She further revealed that she has been waiting on a letter which should include a payment, and that not having it yet has caused her some distress.An interview with resident R4 at 10:57 a.m. revealed that mail delivery is delayed and that I was told it's kept up front so the administrator can go through it before delivery but specified that the mail had not been opened on delivery. An interview with resident R6 at 11:10 a.m. revealed that she was expecting a letter from the social security office for a couple of months, but that it still has not been delivered to her.An interview with resident R7 at 11:19 a.m. revealed that he was also waiting for a letter from the social security office which should be here but had not yet been delivered to him by the facility.In interview with employee E1, the Nursing Home Administrator, at 2:00 p.m. on June 17, 2026, he confirmed that he had implemented a mail delivery system wherein the received mail is given to him so that he can sort it before delivery to the residents. He stated that there is typically a 24-hour turnaround for delivery, but that any mail delivered over the weekend when he is not working would be delivered to the residents the following Monday, which was outside of the required 24-hour window. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(a) Resident rights.

Based on review of clinical records, review of consultation documents, interview with staff and residents, it was determined that the facility failed to ensure that consultation recommendations was reviewed and followed related to medication changes for one of 10 residents reviewed. (Resident R1).Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnosis of Unspecified Intracranial Injury and Unspecified Convulsions. Review of Resident R1's April 2026 physician orders revealed an order for Lamotrigine Oral Tablet 200 MG (Lamotrigine) Give 1 tablet by mouth one time a day for Seizure-order date- 10/17/2025. Further review of Resident R1's physician's order revealed a current order of Lamotrigine Oral Tablet 25 MG Give 1 tablet by mouth one time a day for seizure-order date-10/17/2025. Review of Resident R1's MAR (medication administration record) for April 2026, revealed that Resident R1 received the daily 9AM dose of Lamotrigine Oral Tablet 200 MG. Further review of Resident R1's MAR for April 2026, revealed that Resident R1 received the daily 9AM dose of Lamotrigine Oral Tablet 25 MG Give 1 tablet by mouth. Review of Resident R1's Neurology After Visit Summary from local hospital dated April 8, 2026, revealed the following instructions from the physician: Continue Lamotrigine 200mg. (Stop the extra 25 milligram daily dose that (he/she) is receiving at the facility). Interview with Resident R1 conducted on April 16, 2026, at 10:48AM reveal that Lamotrigine has not been changed. Further Resident R1 revealed that he tried to give the After Visit Summary papers to the unit manager Employee E6, but the Employee E6 did not take it. Interview with first floor Unit Manager Employee E6 conducted on April 29, 2026, at 11:46AM revealed that the resident never gave her the after visit summary papers. Interview with Director of Nursing Employee E2 conducted on April 16 at 9:53 PM confirmed that Resident R1 went to a neurology clinic consultation visit on April 8, 2026. Further, Employee E2 revealed that the facility has problems getting information from the clinic that Resident R1 goes for consultation because the clinic gives the recommendations directly to Resident R1. Further, Employee E2 revealed that Resident R1 did not give permission for clinic to send the after visit summary papers directly to the facility. Further, Employee E1 also revealed that Resident R1 did not give facility access to (his/her) clinic portal where (his/her) clinic visit notes, recommendations and other information are available for review. Further Employee E2 also revealed that Resident R1 does not always provide the facility with the after visit summary upon (his/her) return from (his/her) clinic appointments. Further, Employee E2 revealed that they have to call the clinic every time the resident returns from a consultation visit in order for them to receive the most recent recommendations. Further interview with Employee E2, revealed that the person in charge of appointments attempted to call the local hospital after Resident R1 returned from the clinic appointment on April 8, 2026. Telephone interview with Unit Clerk Employee E7, conducted on April 16, 2026, at 12:58 PM revealed that Employee E7 called the neurology clinic on the April 10, 2026, to follow-up on the neurologist's recommendation because Resident R1 never gave her, the after visit summary for (his/her) clinic visit on April 8, 2026. Further Employee E7 revealed that she did not get a response from the clinic. Further interview with EmployeeE7 confirmed that she did not make a follow-up on the call. Further Employee E7 confirmed that there was no documented evidence that she called the neurology clinic. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical records review, it was determined that the facility failed to ensure that clinical records were accurate for one of three clinical records reviewed. (Resident R1) Findings include:Review of Resident R1's nursing documentation revealed that the resident experienced multiple fall incidents as follows:-1/14/2026 - Resident R1 fell from a chair in the dining room, sustaining minor bleeding to the left hand.-1/25/2026 - Resident R1 stumbled and fell to the knees. The resident suffered no injuries.-1/28/2026 - Resident R1 was hospitalized and diagnosed with a hemoglobin of 6.6 and a subdural hematoma.-2/6/2026 - Resident R1 was readmitted to the facility. Review of Resident R1's assessment completed February 6, 2026, revealed an inaccurate assessment. The nursing assessment noted that the resident was alert and oriented x 3 (people, place and situation), with normal gait and balance, no falls in the prior three months. Review of Resident R1's February 2026 medication review documentation inaccurately indicated the resident had not received psychotropic medications within the prior seven days. Review of Resident R1's February 2026 physician orders revealed that the resident was ordered the following psychotropic medications: Seroquel, Fluphenazine, Divalproex sodium, Benztropine, and Clonazepam. 28 Pa Code 211.12(d)(1) Nursing services

Based on clinical record review, staff interviews, and facility policy review, it was determined that the facility failed to develop and revise a comprehensive, person-centered care plan to related fall risk for 1 of 3 residents reviewed (Resident R1). Findings include: Review of the facility policy titled Care Plans - Comprehensive Person-Centered Care (Revised March 2022) revealed that each resident must have an individualized care plan with measurable goals and timeframes to address physical, psychosocial, and functional needs. The policy states that assessments are ongoing and the interdisciplinary team must review and update the care plan when there is a significant change in condition, after hospitalization, when outcomes are not met, and at least quarterly with the MDS assessment. The policy also requires completion of a Significant Change in Status Assessment when a resident experiences a major decline or improvement affecting multiple areas of health status, requiring interdisciplinary review and revision of the care plan. Events such as falls and hospitalizations require reassessment and care plan updates to address changes in the resident's condition and safety needs. Review of the facility policy titled Fall and Fall Risk Management (Revised March 2024) revealed that staff must assess each resident's fall risk and implement individualized, resident-centered interventions based on identified risk factors and causes to prevent falls and minimize complications. The policy defines a fall as unintentionally coming to rest on the ground, floor, or lower level, including situations where a resident would have fallen without assistance. The policy requires staff, in collaboration with the attending physician, to develop and implement fall prevention interventions, monitor the resident's response, and modify or add interventions if falls continue. If falls recur, staff must reassess the resident, reevaluate potential causes, and implement additional or different interventions while documenting the resident's response and rationale for ongoing risks when falls cannot be prevented. Review of Resident R1's quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident R1 entered the facility on February 28, 2019 and had diagnoses including anemia (low red blood cells causing fatigue and weakness), hypertension(high blood pressure), peripheral vascular disease (reduced blood flow to the extremities), renal failure requiring dialysis (impaired kidney function requiring treatment), anxiety, depression, and schizophrenia (affecting thought processes, perception, and behavior). The MDS indicated the resident required supervision for toileting, showering, dressing, transfers, and walking. The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Review of Resident R1's nursing documentation revealed that the resident experienced multiple fall incidents as follows:-1/14/2026 - Resident R1 fell from a chair in the dining room, sustaining minor bleeding to the left hand.-1/25/2026 - Resident R1 stumbled and fell to the knees. The resident suffered no injuries.-1/28/2026 - Resident R1 was hospitalized and diagnosed with a hemoglobin of 6.6 and a subdural hematoma.-2/6/2026 - Resident R1 was readmitted to the facility.-2/7/2020 - Resident sustained a witnessed fall to the knees during care. Continued review of nursing documentation revealed that the resident was transfer back to the hospital for change of mental status. Interview with nurse aide, Employee E3 on March 10, 2026, at 2:10p.m. revealed that when staff found the resident seated on his bed with an existing eye injury, (he/she) collapsed to his knees while attempting to stand and required staff assistance. The resident resisted help and was physically agitated. Staff reported that although the resident's bed was kept in a low position as a precaution, no additional interventions, supervision measures, or individualized care plan updates were in place to prevent similar incidents. Review of Resident R1's care plan revealed that the resident was care planned for a decline in mobility related to impairments in strength, balance, cognition, and safety awareness, with therapy services initiated in February 2026. Despite documented weakness, decreased safety awareness, and repeated falls, the care plan failed to include specific, individualized interventions to address the resident's progressive functional decline or need for increased supervision. Additionally, Resident R1 was care planned for fall risk with a history of prior falls; however, interventions such as encouraging wheelchair use, therapy referrals, and a pharmacy consult were minimal and were not revised following subsequent falls. There was no evidence that the interdisciplinary team updated the care plan to include enhanced safety measures, increased monitoring, or alternative interventions despite continued fall incidents. Interview with the Director of Nursing (DON), Employee E2 on March 10, 2026, at 2:55 p.m. confirmed that after the resident returned from the hospital on the February 6, 2026, the facility failed to implement formal neurological assessments or update the care plan to address the resident's new needs. Instead, staff relied on routine safety checks and general nursing assessments. The DON noted that discharge instructions from the hospital provided no specific guidance regarding the resident's hematoma, and staff relied solely on standard monitoring for confusion, slurred speech, weakness, or fall risk. 28 Pa Code 211.10 (d)Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observations, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for two of two nursing units observed (First Floor and Second Floor).Findings Include: Review of facility policy, Homelike Environment with a revision date of February 2021 states, Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. On February 2, 2026 a tour was taken of the first-floor nursing unit. Several concerns with the physical environment were observed. room [ROOM NUMBER] had a trash can with gloves that were disposed of in it without a trash can liner. room [ROOM NUMBER] had four brown stained drop-down ceiling tiles, frayed electric wires behind the bed, and a had a trash can with food and cups that were disposed of in it without a trash can liner. room [ROOM NUMBER] had a heavily brown stained privacy curtain for the door bed. room [ROOM NUMBER] had one brown stained drop-down ceiling tile, the entire wall beadboard was peeling on the wall next the door bed, and the wall beadboard was peeling off along the exterior wall on the window bed. Along the edge of window there were four glass tiles sitting. There was a whole under the tv for the window bed. There was a electric outlet not fully covered behind the door bed. room [ROOM NUMBER] had two brown stained drop-down ceiling tiles. room [ROOM NUMBER] had five brown stained drop-down ceiling tiles. 28 Pa Code 201.14(a) Responsibility of licensee Observations on February 3, 2026, in the 2-Main nursing unit revealed the following: Observations at 10:15 a.m. revealed the handrail in the hallway, on the wall outside room [ROOM NUMBER], was broken with exposed sharp plastic edges. Subsequently there were two holes in the wall approximately 1inch by 1 inch in size. Observations at 10:26 a.m. revealed the door of Resident R2's nightstand was broken/hanging off. Further, Resident R2 did not have blinds on his/her window.

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to hand hygiene, on one of the six Medication Administration Reviews, and Enhanced Barrier Precautions on one of the one Wound Treatment Observations. Review of Resident R3's Annual Minimum Data Set (MDS), a federally mandated assessment tool for all residents, dated November 23, 2025, revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (PVD), a condition involving narrowing of the blood vessels that reduces blood flow to the limbs; diabetes mellitus, a chronic condition affecting how the body processes blood glucose; and a Stage IV pressure ulcer of the sacral region, indicating full-thickness tissue loss with extensive tissue destruction over the tailbone area. Observation of wound care being performed on Resident R3 on February 4, 2026, at approximately 4:45 p.m., revealed that Licensed Nurse Employee E8, assisted by Nursing Assistant Employee E9, provided wound care to the resident's sacral region. The wound care included cleansing the wound with appropriate solution, applying dressings to maintain a moist wound environment, and ensuring the area was protected from further injury and potential bacterial contamination. During the procedure, licensed nurse employee E8 and nursing aid Employee E9 were observed wearing gloves; neither staff member wore the required enhanced barrier precaution gown in accordance with facility policy and infection control standards. Interview conducted on February 4, 2026, following the observation, licensed nurse Employee E8, and nursing aid employee E9, both acknowledged that an enhanced barrier precaution gown should have been worn during the wound care procedure. i Review of Facility policy on Medication Administration, and Policy on wound treatment indicated that the staff would follow established infection control procedures such as hand washing, antiseptic technique, masks, gloves, and isolation precautions for administration of medications, and wound treatments as applicable. On February 3, 2026, at 8:29 a.m., during medication administration to Resident R88, Employee E13, a Licensed Nurse; after touching the drawer, medication cart, computer, and medication-blister-pack; without disinfecting her hands; picked medication tablets from the medication-blister-packs; and placed in the medicine- dispensing-cups; with her bare hand. At the time of the finding, E13 confirmed the same. On February 4, 2026, at 11:02 a.m., during wound treatment to Resident R66; Employee E15, and E16, both Licensed Nurses, did not wear Facial Masks, in spite of the care plan insisted to use Enhanced Barrier Precautions while treating R66, as R66 had Tracheostomy and Ventilator. On February 4, 2026, at 11:07 a.m., during wound treatment to Resident R66, the Nurse E15 took a pair of scissors from her pocket; the scissors fell on the floor of R66's room; E15 took the scissors from floor, did not disinfect the scissors; using the unclean scissors, E15 cut gauze roll, and using the same gauze piece, E15 wiped the skin wound of neck of R66. At the time of the finding the same was confirmed with E15. 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, review of clinical records, observation, and staff interview it was determined that the facility failed to provide specialized rehabilitative services based on a resident's comprehensive plan of care for one of 19 residents reviewed (Resident R2). Findings Include: Review of Resident R2's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 20, 2026, revealed the resident was admitted to the facility on [DATE], was rarely/never understood, and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), adult failure to thrive (a state of decline that is multifactorial and manifested by weight loss, decreased appetite, poor nutrition and inactivity) and muscle weakness.Continued review of Resident R2's MDS dated [DATE], revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremities.Review of Resident R2's comprehensive care plan dated January 27, 2026, revealed Resident R2 had positioning deficit related to impairments in range of motion and strength.Observations on February 3, 2026, at 10:32 a.m. revealed Resident R2 had bilateral hand contractures (a shortening and stiffening of muscles that limits joint movement). Resident R2's bilateral hands were observed to lay naturally in a fist. Observations revealed no use of adaptive equipment (include several types of splints and orthotics designed to manage and prevent contractures, improve mobility, and enhance daily functioning) for the contractures.Interview on February 3, 2026, at approximately 10:35 a.m. with Licensed Nurse, Employee E18, confirmed Resident R2 had bilateral hand contractures. Licensed nurse, Employee E18, confirmed the left-hand contracture also appeared worse.Further interview/observations on February 3, 2026, at approximately 10:35 a.m. revealed Licensed nurse, Employee E18, was met with increased resistance when trying to open Resident R2's left fist. Licensed nurse, Employee E18, was unaware of any ordered devices/splints for contractures.Review of Resident R2's clinical record revealed no evidence of care and treatment for the bilateral hand contractures. Review of Resident R2's clinical record revealed a Physical Medicine and Rehabilitation Consult dated September 8, 2025, that assessed the left and right upper extremities as deconditioned. Further review of the assessment revealed the left upper extremity was also described as a increase in tone . left-handed fist, with 3, 4, 5th finger contractureFurther review of Resident R2's Physical Medicine and Rehabilitation Consult dated September 8, 2025, revealed occupational therapy was recommended for functional activities in range of motion, and upper limb strengthening.Interview on February 4, 2026, at approximately 12:36 p.m. with the Director of Rehabilitation, Employee E19, revealed Resident R2 was not seen by Occupational Therapy until January 27, 2026.Further interview on February 4, 2026, at approximately 12:36 p.m. with the Director of Rehabilitation, Employee E19, confirmed there was no assessment or care/treatment for Resident R2's bilateral contractures from the time of his/her admission [DATE]) until January 27, 2026.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for three of six residents during medication administration observation, resulting in significant medication error (Resident R13, R83, R88), and also the facility failed to ensure medications were administered in accordance with physician orders at the prescribed times, resulting in delayed medication administration for multiple residents, placing them at risk for adverse outcomes. Review of the facility policy titled Administering Medications, revised 2019, revealed that the facility is responsible for ensuring medications are administered safely and timely as prescribed. The policy states that staffing schedules must be arranged to allow medication administration without unnecessary interruptions. Medications are to be administered in accordance with prescriber orders, including required administration timeframes. The policy further states that medication administration times are determined by resident need and therapeutic benefit, not staff convenience. Factors to be considered include achieving optimal therapeutic effect, preventing medication or food interactions, and honoring resident preferences consistent with the care plan. The policy requires that medications be administered within one hour of the prescribed time, unless otherwise specified. Observation and record review revealed that on February 2, 2026, the facility experienced a nursing staff call-out, resulting in delayed morning medication administration on the first-floor nursing unit. Review revealed that 18 of 18 residents on the first-floor nursing unit had not received their scheduled morning medications prescribed to be given at 9:00 a.m. by late morning 11:30a.m. Observation of resident R 81 on February 2, 2026, at approximately 11:20 AM, Resident R81 was observed slumped over against his dresser, appeared to be lethargic, uncomfortable with facial grimacing. Interview with Resident R 81at time of the above observation revealed that this resident reported feeling wooziness, dizziness, and blurred vision Interview with Assistant Director of Nursing (ADON)employee E4 at 11:22am on the first-floor unit hallway revealed that she is preparing the morning medication pass for the unit. Employee E4 assessed the resident, including checking blood sugar, and confirmed the resident had not yet received his scheduled morning medications. Employee E4 stated the facility experienced a nurse call-out, resulting in delayed medication administration. The morning medication pass was delayed by several hours beyond scheduled times. Review of resident R81 clinical record physician orders revealed an order for administration at 9:00 AM medications, including Celecoxib 200 mg BID for bilateral hip pain and Metoprolol 50 mg to be administered with food. The resident also reported he had not eaten breakfast. Interview with resident R 90 on February 2, 2026, at 11:45 AM, she reported she had not received morning medications. Review on resident R90's clinical record revealed physician orders Ondansetron for nausea, Eliquis 2.5 mg for DVT, Metoprolol 25 mg BID for hypertension, and Gabapentin 600 mg QID for nerve pain scheduled at 09:00am. The resident reported being in pain while awaiting medications. Interview with R62 revealed that this resident had not received his medications, including Suboxone. review of resident R 62 clinical record physician orders revealed an order for Suboxone to be administered at 09:00 am and every 12 hours and Keppra 750 mg (2 tablets) for seizure management and expressed increasing anxiety while waiting. Observation of first floor nursing unit On February 3, 2026, at 12:05 pm revealed licensed nurse employee E7 preparing medications at the cart confirmed that the morning medications were being administered late, and that the remainder of the unit had not yet received their medications. Staff confirmed a nurse had walked off the shift, preventing timely administration. a similar staffing issue occurred when a nurse walked off the shift, again leaving residents on the first-floor unit without timely morning medications. Review of 13 of 18 residents revealed that they were still awaiting morning medications late into the morning. On February 2, 2026, at 9:53 a.m., observed that Employee E12, a Licensed Nurse, decanted Colace (Docusate) 100MG, two capsules; and Aspirin Chewable 81MG, one tablet for Resident R13. E12 crushed the Aspirin Chewable 81MG tablet in a plastic pouch. E12 opened the Colace (Docusate) capsules and poured the medication into a dispenser- cup. E12 poured the crushed Aspirin Chewable 81MG tablet into the same dispenser cup which had the Colace medication. E12 mixed all the medications with one and half teaspoon of apple sauce and administered half of the mixture to R13 by mouth; and quickly discarded the remaining medications in the dispenser-cup, by throwing it away into the trash can, in R13's room, before being prevented from discarding the half quantity of the medications for R 13. On February 2, 2026, at 9:59 a.m., observed that Employee E12, the Licensed Nurse, decanted Aspirin Chewable tablet 81MG, one tablet; Sertraline HCl tablet 25 MG, three tablets; and Losartan Potassium tablet 100 MG, one tablet. E12 crushed all the medications in a plastic pouch and poured the medications into a plastic dispenser cup and mixed all with one and a half teaspoon of Apple sauce.E12 administered, half of the mixture to R83 by mouth; and initiated to throw away the remaining medications into the trash can in R83's room, but immediately being prevented from discarding the remaining medications, and enquired why did E12 want to discard half the quantity of medications without administering it to R 83; then only E12 did administer the remaining medications to R83. On February 2, 2026, at 10:07 a.m., reviewed the physician order for R13. It revealed an order dated August 30, 2018, to administer Aspirin Chewable tablet 81MG, one tablet. Review of physician order indicated an order dated August 7, 2024, to administer Colace (Docusate) 100MG, two capsules, do not crush or open Colace (Docusate) capsules, switch to tablets if crushing is needed. Reviewed literature, and it indicated as follows: Opening the Docusate Sodium capsule is not recommended due to the potential for throat irritation and the medication's unpleasant taste. Additionally, altering the capsule's form could affect the medication's absorption and efficacy. If the physician has ordered not to open the Colace Capsule, the nurse should follow this instruction to ensure patient safety and medication effectiveness. If the nurse intends to crush the Docusate use tablet form, they should consult with a healthcare provider for guidance on safe usage and potential alternatives. Administering only half the quantity of Docusate sodium to a patient can lead to insufficient stool softening, resulting in harder stools that may cause straining or fecal impaction. The medication's primary function is to soften stool, making it easier to pass, and if not enough is administered, it may not achieve the desired effect, potentially causing discomfort and complications. Therefore, it is crucial for nurses to ensure that the correct dosage is administered to prevent these consequences. Administering only half the quantity of Aspirin 81 can lead to reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy. At the time the finding the same was confirmed with E12. On February 2, 2026, at 10:11 a.m., reviewed the physician order for R83. It revealed an order dated March 18, 2025 to administer by mouth Aspirin Chewable tablet 81MG, one tablet, related to Cerebral Infraction; an order dated March 4, 2025, to administer by mouth, Sertraline HCl tablet 25 MG, three tablets, for Major Depressive Disorder; and an order dated May 8, 2023, to administer by mouth, Losartan Potassium tablet 100 MG, one tablet, related to Hypertension. Reviewed literature, and it indicated as follows: Administering only half the quantity of Aspirin 81 can lead to increased risk of bleeding and reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy. Administering only half the quantity of Sertraline HCl can lead to inadequate treatment of symptoms, such as depression or anxiety. It can also cause increased risk of side effects, including gastrointestinal issues, sleep disturbances, and mood changes. It is crucial for healthcare providers to ensure that patients receive the appropriate dosage of their medications to avoid these consequences. Administering only half the prescribed dosage of losartan can lead to ineffective antihypertensive treatment, which may result in high blood pressure and increase the risk of stroke. The reason for this consequence is that losartan is a first-line treatment for hypertension, and its effectiveness is directly related to the dosage. Administering a lower dose than prescribed can compromise the medication's ability to lower blood pressure effectively, potentially leading to serious health risks. At the time the finding the same was confirmed with E12. On February 3, 2026, at 8:20 a.m., reviewed the physician order for R88. The physician order dated January 21, 2026, indicated an order to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject 15 unit subcutaneously with meals related to Type 2 Diabetes Mellitus Without Complications; administer within 15 minutes of meals. The physician order dated August 30, 2025, indicated to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously with meals for Insulin-Dependent Diabetes Mellitus (IDDM), administer within 15 minutes of meals. On February 3, 2026, at 8:27 a.m., observed that E13, a Licensed Nurse checked the Blood Sugar (BS) level of R88, and the BS was 218. E13 stated that R88 would get 15 units of Insulin Aspart Injection Solution, and additionally per the sliding scale order, four units of Insulin Aspart Injection Solution 100 UNIT/ML totaling 19 units of Insulin Aspart Injection Solution. On February 3, 2026, at 8:29 a.m., observed that E13 drew Insulin Aspart Injection Solution 100 UNIT/ML. E13 was going to inject the drawn Insulin Aspart Injection Solution to R88, but prevented before injecting it, requested E13 to recheck how many units of Insulin Aspart Injection Solution were drawn in the syringe. E13 rechecked the syringe and found that only 16 units of Insulin Aspart Injection Solution was drawn in the syringe instead of the ordered 19 units of Insulin Aspart Injection Solution. Then, E13 redrew additional 3 units of Insulin Aspart Injection Solution to make the total drawn unit of Insulin Aspart Injection Solution as 19 units. On February 3, 2026, at 8:31 a.m., reviewed literature and it indicated that underdosing Insulin Aspart (administering 16 units instead of the ordered 19 units) primarily results in hyperglycemia (high blood sugar), because the patient is receiving less fast-acting medication than needed to manage their glucose levels, particularly around mealtimes. And it may cause increased thirst, frequent urination, headache, blurry vision, fatigue, and drowsiness etc. At the time of the finding the same was confirmed with E13. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for three of six residents observed during medication administration (Resident R13, R83, R88).On February 2, 2026, at 9:53 a.m., observed that Employee E12, a Licensed Nurse, decanted Colace (Docusate) 100MG, two capsules; and Aspirin Chewable 81MG, one tablet for Resident R13. E12 crushed the Aspirin Chewable 81MG tablet in a plastic pouch. E12 opened the Colace (Docusate) capsules and poured the medication into a dispenser- cup. E12 poured the crushed Aspirin Chewable 81MG tablet into the same dispenser cup which had the Colace medication. E12 mixed all the medications with one and half teaspoon of apple sauce and administered half of the mixture to R13 by mouth; and quickly discarded the remaining medications in the dispenser-cup, by throwing it away into the trash can, in R13's room, before being prevented from discarding the half quantity of the medications for R 13.On February 2, 2026, at 9:59 a.m., observed that Employee E12, the Licensed Nurse, decanted Aspirin Chewable tablet 81MG, one tablet; Sertraline HCl tablet 25 MG, three tablets; and Losartan Potassium tablet 100 MG, one tablet. E12 crushed all the medications in a plastic pouch and poured the medications into a plastic dispenser cup and mixed all with one and a half teaspoon of Apple sauce.E12 administered, half of the mixture to R83 by mouth; and initiated to throw away the remaining medications into the trash can in R83's room, but immediately being prevented from discarding the remaining medications, and enquired why did E12 want to discard half the quantity of medications without administering it to R 83; then only E12 did administer the remaining medications to R83.On February 2, 2026, at 10:07 a.m., reviewed the physician order for R13. It revealed an order dated August 30, 2018, to administer Aspirin Chewable tablet 81MG, one tablet. Review of physician order indicated an order dated August 7, 2024, to administer Colace (Docusate) 100MG, two capsules, do not crush or open Colace (Docusate) capsules, switch to tablets if crushing is needed.Reviewed literature, and it indicated as follows:Opening the Docusate Sodium capsule is not recommended due to the potential for throat irritation and the medication's unpleasant taste. Additionally, altering the capsule's form could affect the medication's absorption and efficacy. If the physician has ordered not to open the Colace Capsule, the nurse should follow this instruction to ensure patient safety and medication effectiveness. If the nurse intends to crush the Docusate use tablet form, they should consult with a healthcare provider for guidance on safe usage and potential alternatives.Administering only half the quantity of Docusate sodium to a patient can lead to insufficient stool softening, resulting in harder stools that may cause straining or fecal impaction. The medication's primary function is to soften stool, making it easier to pass, and if not enough is administered, it may not achieve the desired effect, potentially causing discomfort and complications. Therefore, it is crucial for nurses to ensure that the correct dosage is administered to prevent these consequences.Administering only half the quantity of Aspirin 81 can lead to reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy.At the time the finding the same was confirmed with E12.On February 2, 2026, at 10:11 a.m., reviewed the physician order for R83. It revealed an order dated March 18, 2025 to administer by mouth Aspirin Chewable tablet 81MG, one tablet, related to Cerebral Infraction; an order dated March 4, 2025, to administer by mouth, Sertraline HCl tablet 25 MG, three tablets, for Major Depressive Disorder; and an order dated May 8, 2023, to administer by mouth, Losartan Potassium tablet 100 MG, one tablet, related to Hypertension.Reviewed literature, and it indicated as follows:Administering only half the quantity of Aspirin 81 can lead to increased risk of bleeding and reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy.Administering only half the quantity of Sertraline HCl can lead to inadequate treatment of symptoms, such as depression or anxiety. It can also cause increased risk of side effects, including gastrointestinal issues, sleep disturbances, and mood changes. It is crucial for healthcare providers to ensure that patients receive the appropriate dosage of their medications to avoid these consequences. Administering only half the prescribed dosage of losartan can lead to ineffective antihypertensive treatment, which may result in high blood pressure and increase the risk of stroke. The reason for this consequence is that losartan is a first-line treatment for hypertension, and its effectiveness is directly related to the dosage. Administering a lower dose than prescribed can compromise the medication's ability to lower blood pressure effectively, potentially leading to serious health risks.At the time the finding the same was confirmed with E12.On February 3, 2026, at 8:20 a.m., reviewed the physician order for R88.The physician order dated January 21, 2026, indicated an order to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject 15 unit subcutaneously with meals related to Type 2 Diabetes Mellitus Without Complications; administer within 15 minutes of meals. The physician order dated August 30, 2025, indicated to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously with meals for Insulin-Dependent Diabetes Mellitus (IDDM), administer within 15 minutes of meals.On February 3, 2026, at 8:27 a.m., observed that E13, a Licensed Nurse checked the Blood Sugar (BS) level of R88, and the BS was 218. E13 stated that R88 would get 15 units of Insulin Aspart Injection Solution, and additionally per the sliding scale order, four units of Insulin Aspart Injection Solution 100 UNIT/ML totaling 19 units of Insulin Aspart Injection Solution. On February 3, 2026, at 8:29 a.m., observed that E13 drew Insulin Aspart Injection Solution 100 UNIT/ML. E13 was going to inject the drawn Insulin Aspart Injection Solution to R88, but prevented before injecting it, requested E13 to recheck how many units of Insulin Aspart Injection Solution were drawn in the syringe. E13 rechecked the syringe and found that only 16 units of Insulin Aspart Injection Solution was drawn in the syringe instead of the ordered 19 units of Insulin Aspart Injection Solution. Then, E13 redrew additional 3 units of Insulin Aspart Injection Solution to make the total drawn unit of Insulin Aspart Injection Solution as 19 units.On February 3, 2026, at 8:31 a.m., reviewed literature and it indicated that underdosing Insulin Aspart (administering 16 units instead of the ordered 19 units) primarily results in hyperglycemia (high blood sugar), because the patient is receiving less fast-acting medication than needed to manage their glucose levels, particularly around mealtimes. And it may cause increased thirst, frequent urination, headache, blurry vision, fatigue, and drowsiness etc.At the time of the finding the same was confirmed with E13.The facility incurred a medication error rate of 21.43%.Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on review of Narcotic Shift Count Records, Medication Administration Record, and staff interview, it was determined that the facility failed to implement procedures to promote accurate narcotic medication records on one of three medication carts reviewed. On February 5, 2026, at 10:07 a.m., a review of the Narcotic and Controlled Substances Shift to Shift Count Sheets for the First-Floor Main Medication Cart, and the Medication Administration Record of R43, revealed that even though the medication named Lorazepam 0.5 mg oral tablet was dispensed to R43 on February 1, 2026, at 9 a.m., the same information was not documented in the Narcotic book.Interviewed the charge nurse, an LPN, E14, at the time of the finding, and E14 confirmed the findings.28 Pa Code 211.9(a)(1)(k) Pharmacy services.28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, and interviews with staff and residents revealed the facility failed to ensure sufficient nursing staff were available to administer medications in a timely manner, resulting in widespread delayed medication administration, resident complaints, and observed symptoms potentially related to missed or delayed medications for 18 pf 18 resident reviewed. Observation of resident R 81 on February 2, 2026, at approximately 11:20 AM, Resident R81 was observed slumped over against his dresser, appeared to be lethargic, uncomfortable with facial grimacing.Interview with Resident R 81at time of the above observation revealed that this resident reported feeling wooziness, dizziness, and blurred vision:Interview with Assistant Director of Nursing (ADON)employee E4 at 11:22am on the first-floor unit hallway revealed that she is preparing the morning medication pass for the unit. Employee E4 assessed the resident, including checking blood sugar, and confirmed the resident had not yet received his scheduled morning medications. Employee E4 stated the facility experienced a nurse call-out, resulting in delayed medication administration. The morning medication pass was delayed by several hours beyond scheduled times. Review of resident R81 clinical record physician orders revealed an order for administration at 9:00 AM medications, including Celecoxib 200 mg BID for bilateral hip pain and Metoprolol 50 mg to be administered with food. The resident also reported he had not eaten breakfast.Interview with resident R 90 on February 2, 2026, at 11:45 AM, she reported she had not received morning medications. Review on resident R90's clinical record revealed physician orders Ondansetron for nausea, Eliquis 2.5 mg for DVT, Metoprolol 25 mg BID for hypertension, and Gabapentin 600 mg QID for nerve pain scheduled at 09:00am. The resident reported being in pain while awaiting medications.Interview with R62 revealed that this resident had not received his medications, including Suboxone.review of resident R 62 clinical record physician orders revealed an order for Suboxone to be administered at 09:00 am and every 12 hours and Keppra 750 mg (2 tablets) for seizure management and expressed increasing anxiety while waiting.Observation of first floor nursing unit On February 3, 2026, at 12:05 pm revealed licensed nurse employee E7 preparing medications at the cart confirmed that the morning medications were being administered late, and that the remainder of the unit had not yet received their medications. 28 Pa. Code 201.18 (a)(1)(3) management28 Pa. Code 201.120 (a)(6) Staff Development 28b Pa. Code 211.12 (c)(d)(3)(5) Nursing Services

Based on review of facility policy, resident's clinical record, observation and interview with staff, it was determined that the facility failed to ensure the safety of the resident's environment related to medication found on the floor bedside for one of nineteen residents reviewed. (Resident R5)Findings Include: Review of facility policy titled Administrating Medications revised April 2019 states, Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Review of Resident R2's admission Minimum Data Set (MDS- a federal mandated assessment tool for all residents) dated, revealed Resident R5 was admitted into the facility on December 21, 2024 with the diagnosis of Chronic Heart Failure ( a long-term, progressive condition where the heart cannot pump blood efficiently to meet the body's needs), Morbid Obesity (s a chronic, severe disease defined by a Body Mass Index (BMI) , Schizoaffective Disorder (a chronic mental health condition blending schizophrenia symptoms like hallucinations or delusions), Anemia (condition marked by a lack of healthy red blood cells or hemoglobin), and Depression (a serious, common mood disorder causing persistent sadness, loss of interest, and functional impairment). Observation of Resident R5 on February 2, 2026 at 10:49 a.m Revealed a off white colored pill on the floor at the head on the bed for Resident R5. Resident R5 was asked if she administered her own medication and she stated, no I do not. The Assistant Director of Nursing Employee E4 was asked to assist with obtaining the pill from the floor and trying to identify was it was. Employee E4 came to the room at 10:54 a.m. and was able to obtain one off white pill. An interview with Employee E4 revealed they could not identify what the pill was. 28 Pa Code 211 .10 (c) Resident care policies 28 Pa Code 211.12 ( d)(1)(3)(5) Nursing services

Based on record review, interviews, and observation, the facility failed to follow physician orders, failed to monitor and assess residents following changes in condition, failed to ensure consistent wound care, and failed to ensure consistent medication administration for a resident on hospice. (R8, R10, R71)Findings Include: Review of Resident R10's clinical record revealed the resident was admitted to the facility on [DATE]. The resident currently had the following diagnosis: Adult Failure to Thrive (a syndrome, most common in the elderly, characterized by a rapid decline in physical, cognitive, and functional health), Fracture of the Rib (a crack or break in a rib bone), Heart Disease (disease which affects the heart), and Hypertension (a chronic condition defined by consistently high force (130/80 mmHg or higher) of blood against artery walls). Review of Psychological progress note dated January 12, 2026 states, Diagnosis- Generalized anxiety Disorder and Adjustment disorder with mixed anxiety and depressed mood. Further review of the note revealed, Provided emotional validation and active listening as the patient expressed concerns about hospice scheduling and personal care routines. Processed feelings of frustration related to insufficient communication and care from aids, along with challenges she faced in maintaining autonomy in her daily activities. Observation of Resident R10's room revealed at 11:00 a.m. the call bell was turned out and answered by a nurse aide at 11:02 a.m. the nurse aid came out and said that Resident R10 needed to be changed but her aide was not around. At 11:34 a.m. the surveyor went into Resident R10's room to interview them and an interview was held with Resident R10 which revealed the resident was ordered medication for anxiety, but she was not currently getting it. The resident stated, I was getting it for three days, and it was really helping and then one day it just never came, and it has not since then. The resident stated, I am not feeling myself at all, I am sitting here waiting to be changed. Review of Resident 10's clinical record revealed the resident is currently on hospice. Review of Resident R10's physician orders revealed an order from January 13, 2026 for Lorazepam 2mg/ml, give 0.125 ml by mouth in the morning for Anxiety. Review of Resident R10's nursing progress notes reveal several dates that the medication was held and not given due to not having the proper syringe size to administer the medication. The dates that were missing were 1/13, 1/14, 1/16, 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/23, 1/24, 1/25, 1/26, 1/27, 1/31, and 2/2. Review of Resident R8's Minimum Data Set (MDS- a federal mandated assessment) dated November 14, 2025, revealed the resident R8 was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, cerebrovascular accident(stroke), and respiratory failure. The resident was dependent on enteral feeding (tube feeding), required total assistance with all activities of daily living, and received medications including an anticoagulant. Review of Resident R8's the clinical record revealed a nursing progress note dated February 1, 2026, documenting that the resident did not tolerate PEG tube feeding due to emesis(vomiting). the on-call physician was notified. New orders were received to obtain an abdominal X-ray, CBC, and CMP, and to hold tube feeding until February 2, 2026, pending physician evaluation. Review of the Medication Administration Record (MAR) revealed a scheduled order for enteral feeding every shift from 4:00 PM to 10:00 AM, totaling 1350 mL. Also, a one-time order to hold tube feeding for 24 hours for evaluation of emesis, beginning February 1, 2026, at 7:30 AM. Further review of the resident medication administration record revealed that on February 1, 2026, tube feeding was documented as being held during the morning shift per physician order but was restarted during the evening shift, with documentation indicating 680 mL administered. There was no order for restarting the feeding. Interview conducted on February 5, 2026, at 1:30 PM, a licensed nurse employee E11 confirmed she initiated tube feeding per supervisor instruction. Review of the clinical record revealed a nursing note dated February 2, 2026, documenting that the resident vomited multiple times overnight. Review of nursing notes dated February 3, 2026, revealed that results of the abdominal X-ray performed on February 1, 2026, were received and showed no obstruction. An interview conducted on February 5, 2026, at 12:15 PM, with the Assistant Director of Nursing Employee E4 confirmed she received the X-ray and laboratory results and reported them to the on-call physician by telephone on February 3, 2026. Further review of the clinical record revealed a nursing note dated February 3, 2026, documenting that the resident was observed with coffee-ground emesis. Tube feeding was stopped, the supervisor was notified, EMS was contacted, the resident was transferred to the hospital, and the family was notified. Further review of Residents R8's the clinical record revealed no documented nursing assessments, physician assessments, or medical evaluations from the onset of symptoms on February 1, 2026, until the resident was transferred to the hospital on February 3, 2026. There was no documentation of vital signs, abdominal assessments, or ongoing monitoring during this period. interview with the Director of Nursing employee E2 conducted on February 4, 2026, confirmed that no physician or physician assistant assessments were completed from February 1 through February 3, 2026. Documentation of a telephone interview conducted on February 4, 2026, between the Director of Nursing and the resident's attending physician revealed the attending physician was not notified of the resident's change in condition beginning February 1, 2026 through February 3,2026 and did not evaluate the resident prior to hospital transfer. Review of resident 71's quarterly Minimum Data Set (MDS)dated December 26, 2025, revealed that resident R71 entered the facility on September 18, 2025, with diagnosis including diabetes. Resident R71 is moderately dependent for ADLs (activities of daily living) and has been assessed of a risk of pressure ulcer. Review of information dated January 12, 2026, submitted by the facility revealed the resident R 71s daughter alleged that the resident's right lower extremity wound care was not completed as ordered and that the resident did not receive consistent assistance with activities of daily living (ADLs). Review of the resident R71's physician wound care orders revealed an order to cleanse the right lateral shin wound with normal saline solution (NSS), apply calcium alginate, and cover with bordered gauze, to be completed every evening shift. Review of the facility's investigation revealed that during an interview conducted on January 14, 2026, a licensed nurse admitted she documented completion of wound care for the resident's right lower extremity on January 13, 2026, during the 3:00 PM–11:00 PM shift but did not perform the wound care. Personnel documentation of licensed nurse employee E10 revealed the licensed nurse received discipline action of a verbal warning on January 14, 2026, for documenting completion of a treatment that was not performed. The warning was acknowledged and signed by both the employee and the Director of Nursing. Further review of the facility's investigation concluded the allegation of neglect was unsubstantiated, stating the resident missed one day of wound care due to nurse error, and that no negative outcome was identified. During an interview conducted on February 2, 2026, at 10:40 AM, the resident stated that her wound care had been missed on multiple occasions and was not performed consistently. The resident stated she reported the issue to nursing staff and administration, and the issue continued. The resident further stated wound care was typically completed during the evening shift. 28 Pa Code 201.18 (b)(1) Management 28 Pa. Code 201.20 9(a)(5)(6) Staff Development 28 Pa. Code 211.12(c)(1)(5) Nursing Services

Based on review of facility policy, review of clinical records, observations, and staff interview it was determined that the facility failed to maintain personal care needs for dependent residents for one of 28 residents reviewed (Resident R2). Findings Include:Review of facility policy Activities of Daily Living (ADL), Supporting revised March 2018, revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene.Review of Resident R2's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 20, 2026, revealed the resident was rarely/never understood and had diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), adult failure to thrive (a state of decline that is multifactorial and manifested by weight loss, decreased appetite, poor nutrition and inactivity) and muscle weakness.Continued review of Resident R2's MDS dated [DATE], revealed the resident had impairment in functional limitation in range of motion in the upper and lower extremities and was dependent on staff for personal hygiene.Review of Resident R2's comprehensive care plan dated September 5, 2025, revealed the resident was dependent on staff for meeting physical needs related to cognitive deficits.Observations on February 3, 2026, at 10:32 a.m. revealed Resident R2 had bilateral hand contractures (a shortening and stiffening of muscles that limits joint movement). Fingernails (on both hands) were observed to be long and folding in toward the palms.Interview on February 3, 2026, at approximately 10:35 a.m. with Licensed Nurse, Employee E18, confirmed Resident R2 had long fingernails on bilateral hands that required trimming.28 Pa. Code 211.10 (d) Resident care policies.

Based on observation, clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to adhere to acceptable standards of nursing practice related to medication administration for three of six residents observed during medication administration (Residents R13, R83, R88). The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11(b), General Functions of the Registered Nurse (RN), and 21.14(a), Administration of Drugs, indicated that the RN is fully responsible for all actions as a licensed nurse and is accountable to patients for the quality of care delivered, and administers medication ordered for the patient in the dosage and manner prescribed. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145(a)(b), Functions of the Licensed Practical Nurse (LPN), indicated that the LPN functions as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency, and administers medication ordered for the patient.On February 2, 2026, at 9:53 a.m., observed that Employee E12, a Licensed Nurse, decanted Colace (Docusate) 100MG, two capsules; and Aspirin Chewable 81MG, one tablet for Resident R13. E12 crushed the Aspirin Chewable 81MG tablet in a plastic pouch. E12 opened the Colace (Docusate) capsules and poured the medication into a dispenser- cup. E12 poured the crushed Aspirin Chewable 81MG tablet into the same dispenser cup which had the Colace medication. E12 mixed all the medications with one and half teaspoon of apple sauce and administered half of the mixture to R13 by mouth; and quickly discarded the remaining medications in the dispenser-cup, by throwing it away into the trash can, in R13's room, before being prevented from discarding the half quantity of the medications for R 13.On February 2, 2026, at 9:59 a.m., observed that Employee E12, the Licensed Nurse, decanted Aspirin Chewable tablet 81MG, one tablet; Sertraline HCl tablet 25 MG, three tablets; and Losartan Potassium tablet 100 MG, one tablet. E12 crushed all the medications in a plastic pouch and poured the medications into a plastic dispenser cup and mixed all with one and a half teaspoon of Apple sauce.E12 administered, half of the mixture to R83 by mouth; and initiated to throw away the remaining medications into the trash can in R83's room, but immediately being prevented from discarding the remaining medications, and enquired why did E12 want to discard half the quantity of medications without administering it to R 83; then only E12 did administer the remaining medications to R83.On February 2, 2026, at 10:07 a.m., reviewed the physician order for R13. It revealed an order dated August 30, 2018, to administer Aspirin Chewable tablet 81MG, one tablet. Review of physician order indicated an order dated August 7, 2024, to administer Colace (Docusate) 100MG, two capsules, do not crush or open Colace (Docusate) capsules, switch to tablets if crushing is needed.Reviewed literature, and it indicated as follows:Opening the Docusate Sodium capsule is not recommended due to the potential for throat irritation and the medication's unpleasant taste. Additionally, altering the capsule's form could affect the medication's absorption and efficacy. If the physician has ordered not to open the Colace Capsule, the nurse should follow this instruction to ensure patient safety and medication effectiveness. If the nurse intends to crush the Docusate use tablet form, they should consult with a healthcare provider for guidance on safe usage and potential alternatives.Administering only half the quantity of Docusate sodium to a patient can lead to insufficient stool softening, resulting in harder stools that may cause straining or fecal impaction. The medication's primary function is to soften stool, making it easier to pass, and if not enough is administered, it may not achieve the desired effect, potentially causing discomfort and complications. Therefore, it is crucial for nurses to ensure that the correct dosage is administered to prevent these consequences.Administering only half the quantity of Aspirin 81 can lead to reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy.At the time the finding the same was confirmed with E12.On February 2, 2026, at 10:11 a.m., reviewed the physician order for R83. It revealed an order dated March 18, 2025 to administer by mouth Aspirin Chewable tablet 81MG, one tablet, related to Cerebral Infraction; an order dated March 4, 2025, to administer by mouth, Sertraline HCl tablet 25 MG, three tablets, for Major Depressive Disorder; and an order dated May 8, 2023, to administer by mouth, Losartan Potassium tablet 100 MG, one tablet, related to Hypertension.Reviewed literature, and it indicated as follows:Administering only half the quantity of Aspirin 81 can lead to increased risk of bleeding and reduced effectiveness in preventing heart attacks and strokes. Aspirin works by reducing blood clot formation, and a lower dose may not provide the same protective benefits. Therefore, it is crucial to ensure that the correct dosage is administered to avoid adverse effects and maintain the medication's therapeutic efficacy.Administering only half the quantity of Sertraline HCl can lead to inadequate treatment of symptoms, such as depression or anxiety. It can also cause increased risk of side effects, including gastrointestinal issues, sleep disturbances, and mood changes. It is crucial for healthcare providers to ensure that patients receive the appropriate dosage of their medications to avoid these consequences.Administering only half the prescribed dosage of losartan can lead to ineffective antihypertensive treatment, which may result in high blood pressure and increase the risk of stroke. The reason for this consequence is that losartan is a first-line treatment for hypertension, and its effectiveness is directly related to the dosage. Administering a lower dose than prescribed can compromise the medication's ability to lower blood pressure effectively, potentially leading to serious health risks.At the time the finding the same was confirmed with E12.On February 3, 2026, at 8:20 a.m., reviewed the physician order for R88.The physician order dated January 21, 2026, indicated an order to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject 15 unit subcutaneously with meals related to Type 2 Diabetes Mellitus Without Complications; administer within 15 minutes of meals. The physician order dated August 30, 2025, indicated to administer Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart), Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously with meals for Insulin-Dependent Diabetes Mellitus (IDDM), administer within 15 minutes of meals.On February 3, 2026, at 8:27 a.m., observed that E13, a Licensed Nurse checked the Blood Sugar (BS) level of R88, and the BS was 218. E13 stated that R88 would get 15 units of Insulin Aspart Injection Solution, and additionally per the sliding scale order, four units of Insulin Aspart Injection Solution 100 UNIT/ML totaling 19 units of Insulin Aspart Injection Solution. On February 3, 2026, at 8:29 a.m., observed that E13 drew Insulin Aspart Injection Solution 100 UNIT/ML. E13 was going to inject the drawn Insulin Aspart Injection Solution to R88, but prevented before injecting it, requested E13 to recheck how many units of Insulin Aspart Injection Solution were drawn in the syringe. E13 rechecked the syringe and found that only 16 units of Insulin Aspart Injection Solution was drawn in the syringe instead of the ordered 19 units of Insulin Aspart Injection Solution. Then, E13 redrew additional 3 units of Insulin Aspart Injection Solution to make the total drawn unit of Insulin Aspart Injection Solution as 19 units.On February 3, 2026, at 8:31 a.m., reviewed literature and it indicated that underdosing Insulin Aspart (administering 16 units instead of the ordered 19 units) primarily results in hyperglycemia (high blood sugar), because the patient is receiving less fast-acting medication than needed to manage their glucose levels, particularly around mealtimes. And it may cause increased thirst, frequent urination, headache, blurry vision, fatigue, and drowsiness etc.At the time of the finding the same was confirmed with E13.The facility failed to adhere to acceptable standards of nursing practice related to medication administration.28 Pa. Code: 201.18(b)(1) Management.28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of facility initiated emergency transfers and discharges for six of six months reviewed. (August, September, October, November, December, January) Review of Resident R93's discharge Minimum Data Set (MDS – federally mandated resident assessment and care screening) dated January 9, 2026, revealed the resident had an unplanned discharge to the hospital on January 9, 2026. Findings Include: Administration was asked to show proof that the State Long-Term Ombudsman was notified of the facility initiated emergency transfers and discharges for the past four months. A list of dischargers was given for the months requested, but there was no proof of notification to the State Long-Term Care Ombudsman. Interview conducted on February 5, 2026, at 1:55 p.m. with The Social Worker, Employee E3, confirmed that there was no proof of notification of facility-initiated discharges for the last four months requested, October 2025, November 2025, December 2025, and January 2026 . Employee E3 asked when the last time was the discharge lists had been sent and Employee E3 stated February of 2025. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident Rights

Based on observation and staff interviews, the facility failed to ensure that moist, ready-to-eat food items were protected from contamination during transportation to residents. Findings Include:On August 14, 2025, at approximately 12:00 p.m. during observation of the lunch meal delivery to the first-floor unit, the surveyor observed a dietary staff member transporting meal tray in a mobile tray cart with doors. Upon inspection of the trays, it was observed that each tray included a serving of canned fruit, pears and tangerines, placed in a small bowl without a cover or lid. In an interview conducted on August 14, 2025, at 12:15 p.m., with the Food Service Manager, Employee E3, confirmed that there are no coverings available for all nursing units. The facility served uncovered canned fruit in open bowls, placing residents at risk for foodborne illness due to potential cross-contamination. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility documentation, observations, and resident and staff interviews, it was determined that the facility failed to provide food and drink that was palatable and served at the proper temperature. Findings include:Review of facility policy titled, Food Temperatures, undated, revealed that Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to unit storage areas to maintain temperatures at or below 41 Fahrenheit (F) for cold foods and at or above 135 F for hot foods. Interview with Resident R2 on August 14, 2025, at 12:00 p.m. revealed that food is not good. Interview with Resident R4 on August 14, 2025, at 11:00 a.m. revealed food temperatures are often cold. Observations during a test tray conducted with the Food Service Director, Employee E3, on August 14, 2025, at 12:28 a.m. revealed that milk registered at 59.9 degrees Fahrenheit (F); tangerines registered 70.8 degrees F; and apple juice registered 58.6 degrees F. Follow-up interview with the Food Service Director, at 12:33 p.m. confirmed that the tested food items were too warm to be palatable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(f) Dietary services

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to thoroughly investigate sexual abuse for three residents of three residents reviewed for sexual abuse (Residents R5, R36 and R71). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36. Findings include: Review of facility policy, Abuse Investigation and Reporting, last reviewed October 2022, revealed that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Continued review revealed that The individual conducting the investigation will, as a minimum: Review the completed documentation forms .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident (as medically appropriate) .Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . Interview the resident's roommate, family members, and visitors .Interview other residents to whom the accused employee provides care or services; and .Review all events leading up to the alleged incident. Reviews of facility reported incident submitted to the State Survey Agency dated February 22, 2024, revealed [Resident R36] engaged in consensual sex with another resident. [Resident R36] is awake alert and oriented. She is of sound mind and does have a mental health history. She and another alert and oriented x's 3 resident in the facility had engaged in a sexual encounter. [Resident R36] was educated on safe sex as was the other resident involved. MD and family notified Review of psychiatric notes for Resident R36 dated February 17, 2024, at 9:30 a.m. revealed During the visit, the patient appeared confused and faced difficulty engaging in conversation. Although they exhibited no acute distress, a noteworthy observation was the patients' pacing in and out of building while talking to themselves. This behavior raises concerns about the patient's cognitive functioning. The note further indicated that the resident was unable to respond to questions due to level of cognitive impairment and noted that Resident R36 was uncooperative, apathetic, difficult to engage, restless, psychomotor retardation noted, incoherent speech, dysphoric mood and affect, incongruent mood, visual and auditory hallucinations. Resident R36 was cognitively impaired and did not have the capacity to consent to a sexual relationship with Resident R119. An interview with Resident R36 was conducted on May 9, 2024, at 1:22 p.m. When asked if she had any difficulties with any male residents at the facility, Resident R36 replied that they were not nice, that one asked her to have sex with him and that I said no, I did not want to go to jail. Resident R36 was asked what happened and replied He forced me to suck his d*#*. He pushed my head. I didn't say I wanted to do it. I didn't want to for sexual favors. I never was a cheap slut. I did it by accident because I was afraid he would kill me. I asked to borrow money for cigarettes and soda. He gave me a dollar a piece for the cigarettes. Resident R36 further stated that she wanted to go home, that she did not want to be in the facility and that I don't even know where I am. Interview on May 9, 2024, at 9:06 a.m. Resident R48 stated that Resident R119 manipulated Resident R36 to perform oral sex. Resident R48 stated that he was Resident R119's roommate at the time of the incident and described that on February 22, 2024, Resident R36 entered the room, approached Resident R119 and asked him for five dollars to buy cigarettes. Resident R48 stated that Resident R119 replied, Give me a blow job. Resident R48 stated that he heard sucking sounds. After a few minutes, Resident R48 stated that he heard Resident R36 state, I need five dollars to which Resident R119 replied, You're not done yet I didn't cum. Resident R48 stated that he again heard sucking sounds, then Resident R36 asked again for five dollars. The facility failed to obtain a written statement from the perpatrator, Resident R119; who was alert and oriented. Clinical record documentation indicated that Resident R119 denied the allegation of sexual assault to Resident R36 saying that there was no sexual contact with this resident; when the local Police Department arrived at the facility for pending arrest of Resident R119. Review of facility documentation that was submitted to the State Survey Agency, dated February 22, 2024, revealed that Residents R36 and R119 were engaged in sexual relations. The facility's investigation into the incident included an incident report and two statements: an interview with Resident R36 and a statement from Resident R48, who was Resident R119's roommate at the time. There were no other resident interviews conducted at the time of this incident Interview on May 8, 2024, at 3:34 p.m. the Nursing Home Administrator revealed that the facility was not able to provide any additional documents at that time related to the facility's investigation. In addition, the Nursing Home Administrator was not able to provide any documentation that Resident R36 was assessed for her capacity to consent to sexual relations. Interview on May 8, 2024, at 3:52 p.m. Employee E7, Supervisor, confirmed that the facility had not obtained a statement from the alleged perpetrator, Resident R119. Interview on May 9, 2024, at 9:06 a.m. Resident R48 stated that stated that several weeks later he heard from another resident that Resident R119 was found on the second floor nursing unit with his fingers in the vagina of a patient that was lethargic but that he did not know the name of this resident. Interview on May 9, 2024, at 10:12 a.m. Resident R67 stated that he was aware of an incident that occurred between Resident R119 and Resident R5. Resident R67 stated that he was walking past the second floor unit dining room when he observed Resident R119 sitting right next to Resident R5 who was in a geri chair. Resident R67 stated that Resident R119 was touching on her. Resident R67 stated that he did not witness Resident R119 put his hands in Resident R5's vagina, but stated that he heard about it later that day and that Resident R119 even told him that he did it. Resident R67 stated that Resident R119 told him, She had the look in her eyes that she wanted it and that there were no other residents or staff in the room at the time that the incident occurred. Review of Resident R5's care plan, dated initiated April 9, 2024, revealed, Documented Safety Concerns inappropriate resident to resident interaction. Review of nursing notes for Resident R5 revealed a note, dated April 9, 2024, at 11:00 a.m. which stated, Resident to resident inappropriate interaction witnessed in 2nd floor lounge. Review of facility documents related to the above note for Resident R5 revealed that the incident was witnessed by Employee E11, Central Supply. A written statement by Employee E11, Central Supply, dated April 9, 2024, revealed, As I was walking down 2P hallway, I was standing by the elevator wait for the elevator and saw [Resident R119] sitting next to [Resident R5]. I witnessed [Resident R119] put his hands down her pants. I immediately went in the room to separate them. [Resident R119] immediately withdraw his hand sniffed his fingers and exited on the elevator. I immediately told the Unit Manger, [Employee E10]. I went over and told the DON [Director of Nursing] and AA [Administration] about the situation. Interview on May 9, 2024, at 11:44 a.m. Employee E11, Central Supply, stated that he witnessed the incident between Residents R119 and R5. Employee E11, Central Supply, stated that he was delivering supplies to the second floor nursing unit, and while waiting for the elevator he saw Resident R119 sitting next to Resident R5 in the dining room with his left hand digging into her pants. Employee E11, Central Supply, stated to Resident R119, What are you doing? Employee E11, Central Supply, stated that Resident R119 then removed his hand, smelled and then tasted his hand. Employee E11, Central Supply, stated that he immediately reported the incident to the unit manager and administrative staff. Employee E11, Central Supply, stated that Resident R119 went down the elevator, was interviewed by the police and sat in the lobby waiting to be discharged . Review of facility documentation related to the incident between Residents R119 and R5 on April 9, 2024, revealed that there were no additional witness statements or evidence of interviews with any other residents or staff available for review at the time of the survey. There was no evidence that the incident was reported to the State Agency Ombudsman and Adult Protective Services as required. Interview on May 9, 2024, at 4:35 p.m. the Nursing Home Administrator confirmed that there was no documentation available was unable to explain why the incident of sexual abuse involving Resident R5 was not reported to the State Agency as required. Futher interview the Nursing Home Administrator confirmed that the investigations into the incidents involving Residents R36 and R5 were not thoroughly investiged and lacked interviews from other residents and staff. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that potential sexual abuse was thoroughly investigated. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on May 9, 2024, at 4:37 p.m. The facility initiated a plan of correction to address the failure of ensuring that sexual abuse was thoroughly investigated. Facility plan of correction included the following: 1. R5 and R36 incidents will be completed thoroughly and appropriately reported to the state survey agency by May 9, 2024. 2. NHA and DON/designee will receive education on allegations of abuse and thorough investigations per regulation by May 10, 2024, by RVP/designee. 3. All facility Staff will be tracked for education on recognizing, reporting, and investigating allegations of abuse or neglect before working on units by DON/designee by May 10, 2024. 4. Agency staff will work on units once educated on policy for investigating allegations of abuse and reporting by May 10, 2024. 5. 100% compliance of training will be achieved for Accela staff by May 14, 2024.and all remaining staff will be trained prior to working on the units of the center by DON/Designee. 6. An audit of the abuse reportables for the last 30 days will be conducted for thoroughness of investigation by RVP/NHA/DON. A weekly audit of abuse reportables will be conducted weekly for one month and monthly for three months and quarterly thereafter and reassessed by QAPI. Review of facility documentation revealed that the corrective action plan was immediately initiated. The incidents for Residents R5 was reported to the state survey agency. Audits were initiated to ensure that all applicable incidents were reported accurately to the State Survey Agency. Facility in-services for staff were promptly initiated and included abuse and neglect and reporting and investigation requirements. Topics of education included how to investigate allegations and possible incidents of abuse, who is responsible for the investigations, and how to appropriately report allegations and investigations to the state survey agency. Interviews were conducted on May 9, 2024, between 1:00 p.m. and 4:00 p.m. with staff from various departments. All staff reported that they received the in-service training. It was confirmed during the interviews that they were knowledgeable on reporting and investigating resident abuse as well as their role in the abuse investigation process. The Immediate Jeopardy was lifted on May 9, 2024, at 6:17 p.m. Review of the May 2024 physician orders for Resident R71 included the following diagnosis: obesity, lymphedema; diabetes and spinal stenosis (a condition in which the spaces in the spine narrow, compressing the spinal cord). Resident R71 also utilized a wheelchair for mobility. Review of the resident's quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated August 20, 2023, indicated that the resident was assessed as being awake, alert and oriented. Review of reportable incident dated October 15, 2023 indicated that during the 3:00 p.m.-11:00 p.m. shift, Employee E39 (nurse aide) reported that the nurse aide (Employee E41) for Resident R71 from the previous shift (7:00 a.m. through 3:00 p.m.) informed Employee E39 while in Resident R71's room, that she (Employee E41) was going to wash Resident R71. Employee E39 informed Employee E41 that the resident is on paired care, so both employees provided care to the resident. Review of a statement obtained by Employee E39 dated October 16, 2023 reported that after care was provided, Employee E39 left the room, and came back approximately an hour later and observed Employee E41 touching Resident R71 by his open brief in an intimate fashion. Employee E39 also reported that during this observation, Resident R71 was masturbating. Continued review of Employee E39's statement indicated that Employee E39 stepped out of the resident's room, and notified the nursing supervisor of what he observed. Review of a statement provided by the nursing supervisor (Employee E40) who Employee E39 notified about his observation indicated that Employee E40 entered the resident's room after being notified, and noticed that the resident's privacy curtain was pulled halfway around the resident's bed. Continued review of Employee E40's statement indicated that Employee E40 witnessed Employee E41 pulling her hands away and the resident's lower half was exposed. Employee E40 reported in her statement that Resident R71 told her that he was fine when she asked him how he was upon her entering the resident's room. Continued review of the statement from Employee E40 indicated that she asked Employee E41 what she was doing in the resident's room, and Employee E41 reported that she was washing the resident. Employee E41 also reported that she was not friends with Resident R71 when Employee E40 asked her if she was. Continued review of Employee E40's statement indicated that Employee E41 confirmed that her shift ended at 3:00 p.m. when asked by Employee E40. Employee E40 then requested that she leave the building and informed Employee E41 that she was not working for the facility at the time of her presence, and that she cannot provide any care to residents after clocking out. Review of the investigation also indicated that Resident R71 refused to comment on the relationship that he had with Employee E41. The investigation also indicated that the resident denied being abused by Employee E41when he was asked during his interview. Review of the investigation indicated the facility unsubstantiated the investigation. After review of the statements and resident's denial of abuse, allegation is NOT SUBSTANTIATED. Continued review of the investigation did not show evidence that the facility conducted a complete and through investigation. Although the facility unsubstantiated the incident, there was no evidence of any additional interviews with any other residents who may have received care from Employee E41, including interviews with Resident R71's roommate(s). In addition, continued review of the investigation indicated that there was no evidence that the facility conducted any additional interviews with any other staff members who may have worked with Employee E41 on any of the shifts and may have witnessed something or heard something that may have provided additional information for the investigation. In addition, Employee E41 reported to the nursing supervisor that she was washing the resident when Employee E40 asked her what she was doing. There was no information in the investigation as to why Employee E41 would be washing the resident a 2nd by herself when Employee E41 washed the resident with Employee E39 just an hour prior to the alleged incident that Employee E39 observed, and reported to the nursing supervisor. During an interview with one of the facility's Assistant Director of Nursing (Employee E13) on May 13, 2024 at 3:05 p.m. it was discussed that the investigation was not a complete and thorough investigation to ensure that abuse was ruled out due to, but not limited to, the limited interviews conducted by the employees with employees and residents. Refere to F600 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29 (c) Resident rights 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff and residents, it was determined that the facility failed to ensure that residents were free from sexual abuse for two of 23 residents reviewed (Residents R5 and R36). This failure resulted in an Immediate Jeopardy situation for Residents R5 and R36 who were sexually abused by Resident R119. Findings include: Review of facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, undated, revealed that, each resident will be free from 'Abuse'. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion .Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the center. No abuse or harm of any type will be tolerated. Continued review revealed that Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Further review revealed that, Every resident is unique and may be subject to 'abuse' based on a variety of circumstances, including center physical plant, environment, the resident's health, behavior, or cognitive level .Before admission, prospective residents will be screened to help determine suitable placement within the center .Center population demographics, physical plant vulnerabilities, resident behaviors and specialty programming will be assessed to identify potential vulnerabilities affecting residents. Review of professional literature, Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists published in 2008 by the American Bar Association and the American Psychological Association, revealed, Long-term care facilities . have a legal obligation to protect its residents from unreasonable harm. Sexual consent is a complicated construct, with knowledge, capacity and voluntariness, intertwined. Continued review revealed, Knowledge . requires that an individual be able to demonstrate a basic knowledge of the sexual activities in question, potential risks and how to prevent them, the responsibilities of pregnancy and parenthood, illegal sexual activities, how to determine whether sexual activities are not desired by the partner, and appropriate times and places for sexual activities . Capacity . includes the ability to understand the options related to the sexual behavior, appreciate the consequences of various courses of action, and express a choice that is based on rational or logical consideration of relevant knowledge, including the personal benefits and risk of the sexual activity, and is consistent with the individual's values and preferences .Voluntariness . requires that an individual have the ability to make a decision regarding sexual activity that does not result from coercion, unfair persuasion or inducements. Review of Resident R36's comprehensive Minimun Data Set (MDS-an assessment of care needs) dated February 10, 2024, revealed that the resident had the diagnosis of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior. Schizophrenia is a serious mental disorder that effects how people interpret reality). The assessment also indicated that Resident R36 was prescribed and was ordered antipsychotic and antidepressant medications. Continued review of the MDS assessment revealed that Resident R36 often expressed the behavior of social isolation. Review of Resident R36's clinical record revealed that the resident was evaluated and assessed by the psychiatrist on February 17, 2024. The psychiatrist's assessment indicated that Resident R36 had a diagnosis of cystic fibrosis (genetic disorder of the lungs and digestive system, causing an accumulation of mucus), dyskinesia (uncontrolled movements of the face, arms or legs), paranoid (feeling of extreme nervousness and worry because they believe other people are trying to harm them) schizophrenia (mental desease characterized by los of reality and delusions). The psychiatrist said that Resident R36 was having active hallucinations and difficulty adjusting to the routine of the facility. The psychiatrist also noted that Resident R36 exhibited confusion and had difficulty engaging in conversation. The psychiatrist documented that Resident R36 was pacing in and out of the nursing unit, while talking to herself. The psychiatrist indicated that this behavior raised concerns about the resident's cognitive functioning abilities. The psychiatrist was not able to ask Resident R36 questions about her bodily systems, due her decreased level of cognition and medical status. The psychiatrist assessed Resident R36 as being oriented to person only. The psychiatrist advised the staff to give Resident R36 supportive care, reorient and redirect the resident daily. Review of the facility information submitted to the State Survey Agency dated February 22, 2024, indicated that female, Resident R36 was engaged in sexual contact with an alert and oriented male resident, Resident R119 at 9:00 p.m., on February 22, 2024. Review of nursing progress dated February 22, 2024, indicated that the nursing staff were monitoring Resident R36 for sexually inappropriate behavior. Nursing progress notes dated February 23, 2024, indicated that Resident R36 was interviewed by staff and the Police Department. Resident R36 reported that she received $5.00 dollars from Resident R119 for performing sexual activities. Resident R36 said that she performed oral sex for cigarette money. Review of Resident R36's clinical record revealed no documented evidence to indicate that the physician or psychiatrist were contacted related to Resident R36's inappropriate sexual behavior with Resident R119 on February 22, 2024. There was no documentation to indicate that the physician or psychiatrist evaluated Resident R36 and her capacity for consent to engage in a sexual relations with Resident R119. The nursing staff failed to notify the physician or psychiatrist for the case of sexual assault that had transpired on February 22, 2024, for Resident R36 that was convinced by a known sexual offender to perform sexual acts with him for money. The facility failed to protect Resident R36, who was cognitively impaired, required supportive nursing care, reorientation and redirection on a daily basis, from sexual abuse. Clinical record review revealed a psychiatrist progress not dated March 25, 2024, that indicated Resident R36 was oriented to person only. The resident exhibited signs and symptoms of delirium (a mental disturbance marked by confusion, incoherent speech and hallucinations). The psychiatrist indicated that Resident R36 requires redirection and reorientation routinely. The psychiatrist stated that Resident R36 was not able to respond to questions about bodily review of systems because of the resident's cognitive impairment and medical condition. Clinical record review on April 29, 2024, revealed a psychiatrist progress note dated April 29, 2024, that indicated Resident R36 had diagnoses of schizophrenia, paranoid personality disorder, agitation and depression. The psychiatrist assessed Resident R36 with cognitive loss, poor safety awareness, auditory and visual psychotic features. The psychiatrist indicated that Resident R36 did not always accept staff redirection. and the resident was verbally aggressive and physically aggressive toward staff and residents. The psychiatrist's assessment of Resident R36 revealed that this resident's thought process was illogical. The assessment also indicated that this resident's mood was angry. Observations of Resident R36 at 10:30 a.m., on May 7, 2024 revealed that this resident was living on a secured dementia nursing care unit within the facility. Interview at 10:00 a.m., on May 9, 2024, with a licensed nurse, Employee E8, who was famliar with Resident R36 reported that Resident R36 was not alert and cognitively intact. The nurse said that Resident R36 was not reliable for reporting accurate information due to her confusion and lack of safety awareness. The nurse said that resident R36 presented as agitiated, when approached. Employee E8 reported that Resident R36 will often refuse medications and tells her to go to hell. Interview with nursing assistant, Employee E12 at 1:45 p.m., on May 9, 2024 indicated that Resident R36 needed redirection from staff to maintain a safe environment and relationship with other residents and staff. The nursing assistant said that this resident was placed on the dementia care unit for close supervision. If the resident was not on the secure unit, the resident would attempt leaving the building to go home, that Resident R36 talks frequently about wanting to go home or leaving the facility. Employee E12 stated that it was not uncommon for Resident R36 to be seen pacing about the secure nursing unit and wandering into other resident rooms. That Resident R36 required reorientation and redirection on a daily basis due to her mental confusion. The nursing assistant, Employee E12 explained that Resident R36 can not focus enough to process information or be aware of her surroundings. Further Employee E12 indicated that she had escorted the resident on a shopping trip outside the facility on May 9, 2024. The nursing assistant said that Resident R36 was not responsible to handle money or purchase needed accessories without the direction of a nursing staff member. The nursing assistant reported that she was holding money for the resident to use. The resident was repeatedly asking for a puffer or a vaping device to smoke nicotene. While Employee E12 was out shopping with Resident R36 she purchased a vaping (smoking) device for her and she also purchased some new clothing. Interview with Resident R36 at 1:30 p.m., on May 9, 2024 revealed that the male residents are not nice at the facility. Resident R36 said that she did go into a male resident's room to get $5.00 dollars for cigarettes and soda. Resident R36 indicated that the male resident asked her to have sex with him. Resident R36 reported that she was forced to perform sexual acts. Resident R36 reported that the male resident pushed her head toward his penis. Resident R36 reported that the male resident told her, if she did not perform the sexual act, that he would kill her. Review of psychiatric notes for Resident R36 revealed a note, dated February 17, 2024, at 9:30 a.m. which indicated, During the visit, the patient appeared confused and faced difficulty engaging in conversation. Although they exhibited no acute distress, a noteworthy observation was the patients' pacing in and out of building while talking to themselves. This behavior raises concerns about the patient's cognitive functioning. The note further indicated that the resident was unable to respond to questions due to level of cognitive impairment and noted that Resident R36 was uncooperative, apathetic, difficult to engage, restless, psychomotor retardation noted, incoherent speech, dysphoric mood and affect, incongruent mood, visual and auditory hallucinations. Interview on May 9, 2024, at 9:39 a.m. with licensed nurse, Employee E8, revealed that Resident R36 was currently out of the building on a shopping trip with staff. Employee E8, licensed nurse, stated that Resident R36 did not engage in conversations with her, that the resident was not a reliable historian and that the resident told her this morning that she was going out to see her mother. An interview with Resident R36 was conducted on May 9, 2024, at 1:22 p.m. when asked if she had any difficulties with any male residents at the facility, Resident R36 replied that they were not nice, that one asked her to have sex with him and that I said no, I did not want to go to jail. Resident R36 was asked what happened and replied He forced me to suck his d*#*. He pushed my head. I didn't say I wanted to do it. I didn't want to for sexual favors. I never was a cheap slut. I did it by accident because I was afraid he would kill me. I asked to borrow money for cigarettes and soda. I didn't know what he had [meaning money]. He gave me a dollar a piece for the cigarettes. Resident R36 further stated that she wanted to go home, that she did not want to be in the facility and that I don't even know where I am. Interview on May 9, 2024, at 1:52 p.m. nurse aide, Employee E12, stated that she knew Resident R36 well and that she frequently took care of her. Employee E12, stated that Resident R36 frequently paces and walks up and down the hallways, talking to herself and her hallucinations. Employee E12 stated that Resident R36 was difficult to redirect and that she was not focused enough to be able to process what's going on around her to make decisions. Interview on May 9, 2024, at 9:06 a.m. with Resident R48 stated that Resident R119 manipulated Resident R36 to perform oral sex. Resident R48 stated that he was Resident R119's roommate at the time of the incident and described that on February 22, 2024, Resident R36 entered the room, approached Resident R119 and asked him for five dollars to buy cigarettes. Resident R48 stated that Resident R119 replied, Give me a blow job. Resident R48 stated that he heard sucking sounds. After a few minutes, Resident R48 stated that he heard Resident R36 state, I need five dollars to which Resident R119 replied, You're not done yet I didn't cum. Resident R48 stated that he again heard sucking sounds, then Resident R36 asked again for five dollars. Continued interview, Resident R48 stated that several weeks later he heard from another resident that Resident R119 was found on the second floor nursing unit with his fingers in the vagina of a patient that was lethargic but that he did not know the name of this resident. Interview on May 9, 2024, at 10:54 a.m. licensed nurse, Employee E10, stated that Resident R36 did not talk, but was able to communicate her needs. Employee E10, stated that Resident R5 was oriented to self only and usually goes to activities in a geri chair. Employee E10 stated that she was not ware of any resident-to-resident interactions involving Resident R5. Interview on May 9, 2024, at 10:12 a.m. Resident R67 stated that he was aware of an incident that occurred between Resident R119 and Resident R5. Resident R67 stated that he was walking past the second floor unit dining room when he observed Resident R119 sitting right next to Resident R5 who was in a geri chair. Resident R67 stated that Resident R119 was touching on her. Resident R67 stated that he did not witness Resident R119 put his hands in Resident R5's vagina, but stated that he heard about it later that day and that Resident R119 even told him that he did it. Resident R67 stated that Resident R119 told him, She had the look in her eyes that she wanted it and that there were no other residents or staff in the room at the time that the incident occurred. Interview on May 9, 2024, at 10:26 a.m. with Resident R5 was observed resting in a geri chair in the lounge area on the secured/locked part of the second floor nursing unit. Resident R5 was asked if she had any problems with any other residents at the facility. Resident R5 nodded her head yes. Resident R5 was then asked if she wanted to go back to her room to talk, and again Resident R5 responded by nodding her head yes. Upon further interview in her room, Resident R5 stated that she was unable to remember any incidents or events involving other residents. Review of Resident R5's Annual Minimun Data Set (MDS- assessment of resdient's care needs), dated March 7, 2024, revealed that the resident was admitted to the facility on [DATE], with the diagnoses of dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), cerebrovascular accident (damage to the brain from interruption of its blood supply), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis) and depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Continued review revealed a BIMS (Brief Interview for Mental Status) score of nine, indicating that the resident was moderately cognitively impaired. Review of Resident R5's care plan, dated initiated December 2, 2014, revealed that the resident was dependent for ADL (Activities of Daily Living) care in bathing, grooming, dressing, eating, bed mobility, transfer and toileting due to cognitive loss/dementia. Continued review of Resident R5's care plan revealed that she has impaired cognitive function related to dementia and anoxic brain damage. Continued review of Resident R5's care plan revealed that she has a communication problem unclear speech. Further review of Resident R5's care plan, dated initiated April 9, 2024, revealed, Documented Safety Concerns inappropriate resident to resident interaction. Review of nursing notes for Resident R5 revealed a note, dated April 9, 2024, at 11:00 a.m. which stated, Resident to resident inappropriate interaction witnessed in 2nd floor lounge. Review of facility documents related to the above note for Resident R5 revealed that the incident was witnessed by Employee E11, Central Supply. A written statement by Employee E11, Central Supply, dated April 9, 2024, revealed, As I was walking down 2P hallway, I was standing by the elevator wait for the elevator and saw [Resident R119] sitting next to [Resident R5]. I witnessed [Resident R119] put his hands down her pants. I immediately went in the room to separate them. [Resident R119] immediately withdraw his hand sniffed his fingers and exited on the elevator. I immediately told the Unit Manger, [Employee E10]. I went over and told the DON [Director of Nursing] and AA [Administration] about the situation. Interview on May 9, 2024, at 11:44 a.m. Employee E11, Central Supply, stated that he witnessed the incident between Residents R119 and R5. Employee E11, Central Supply, stated that he was delivering supplies to the second floor nursing unit, and while waiting for the elevator he saw Resident R119 sitting next to Resident R5 in the dining room with his left hand digging into her pants. Employee E11, Central Supply, stated to Resident R119, What are you doing? Employee E11, Central Supply, stated that Resident R119 then removed his hand, smelled and then tasted his hand. Employee E11, Central Supply, stated that he immediately reported the incident to the unit manager and administrative staff. Employee E11, Central Supply, stated that Resident R119 went down the elevator, was interviewed by the police and sat in the lobby waiting to be discharged . Review of Resident R119's Quarterly MDS assessment, dated March 1, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including respiratory failure (not enough oxygen passes from your lungs to your blood), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things) and generalized muscle weakness. Continued review revealed a BIMS (Brief Interview for Mental Status) score of fifteen (15), indicating that the resident was cognitively intact. Review of psychiatric notes for Resident R119 revealed a note, dated February 17, 2024, which indicated that the resident had a history of depression and did not express any new mental health concerns. The resident was oriented to person, place, time, date of birth, had good attention, intact abstract thinking and fair insight/judgement. Review of Megan's Law Public Report data (federal law that requires information about registered sex offenders to be available to the public) on May 9, 2024, revealed that Resident R119 was a Tier 1 offender. Continued review revealed that Resident R119 was convicted of the sexual offense of indecent assault on September 1, 2020. Review of Resident R 119's care plan, dated revised February 23, 2024, revealed that the resident has expressed wanting to have sexual relations with interventions including Education relating to safe consensual sex and practicing safe sex when needed. Offer talk therapy to work through feelings of sexual frustrations and be educated on legalities around propositioning individuals for sex is illegal. Review of nursing notes for Resident R119 revealed a note, dated February 23, 2024, at 12:01 a.m. which stated, Roommate reported [Resident R119] for paying another patient for sexual activities. Pt [patient] denied when interviewed by police. Continued review of nursing notes for Resident R119 revealed a note, dated February 23, 2024, at 7:20 a.m. which stated, No sexually inappropriate behaviors noted this shift. Further review of progress notes revealed that there was no documentation available for review at the time of the survey to indicate if Resident R119 received any additional monitoring or supervision after the incident with Resident R36 to ensure her safety as well as the safety of other residents to protect them from further potential abuse. Continued review of nursing notes for Resident R119 revealed a note, dated April 9, 2024, at 6:22 p.m. which stated, Pt [patient] discharged to shelter with remaining medications and personal belongings. Further review of progress notes revealed that there was no documentation available for review at the time of the survey to indicate if Resident R119 received increased supervision after the incident with Resident R5 to ensure her safety as well as the safety of other residents to protect them from further potential abuse. Interview on May 9, 2024, at 4:35 p.m. the Nursing Home Administrator confirmed that there was no documentation available in Resident R119's clinical record related to supervision after the incidents with Residents R36 and R5 to protect them from further abuse. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that residents were free from sexual abuse. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on May 9, 2024, at 4:37 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from sexual abuse. Facility plan of correction included the following: 1. Resident R119 has been discharged from the facility. 2. Residents R36 and R5 will be assessed and evaluated by SS/psych/designee for potential negative effects of abuse, and support services by 5/10/2024 3. All interviewable residents in the facility will be assessed and evaluated for potential negative effects of abuse and support services through a screening tool of questions by SS/Designee by 5/10/2024 4. All non-verbal or non-interviewable residents in the facility will have a skin assessment to ensure that the potential for negative effects of abuse are absent and completed by UM/Designee by 5/10/2024 5. All facility Staff will be tracked for education on recognizing, reporting, and preventing abuse before working on units by DON/Designee by 5/10/24 6. Agency staff will work on the units once educated on recognizing, reporting, and preventing abuse units by DON/designee by 5/10/2024 7. 100% compliance of training will be achieved for Accela staff by 5/14/2024 and all remaining staff will be trained prior to working on the units of the center by DON/Designee 8. A random audit of 5 interviewable residents will be conducted to ensure that a screening tool of questions are completed by SS/Designee weekly to assess and evaluate residents' potential for negative effects of abuse weekly for one month and monthly for three months and quarterly thereafter and reassessed by QAPI 9. A random audit of 5 nonverbal or non interviewable residents in the facility will have a skin assessment completed by UM/Designee weekly to assess and evaluate residents' potential for negative effects of abuse weekly for one month and monthly for three months and quarterly thereafter and reassessed by QAPI Review of facility documentation revealed that the corrective action plan was immediately initiated. Residents R5 and R36 were evaluated by the physician, and psychology consultations were scheduled. Audits were initiated to screen residents for abuse. Residents were interviewed by facility staff, and skin assessments were completed. Residents expressed no concerns and no further occurrences of abuse. Facility in-services for staff were promptly initiated and included abuse and neglect and reporting requirements. Topics of education included how to assess residents verbally and non-verbally for signs of abuse, what to do if abuse is witnessed or suspected, and who to report allegations of abuse to. Interviews were conducted on May 9, 2024, between 1:00 p.m. and 4:00 p.m. with staff from various departments. All staff reported that they received the in-service training. It was confirmed during the interviews that they were able to identify types of abuse, recognize signs of resident abuse including verbal and non-verbal cues, that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process. Interviews conducted on May 9, 2024, between 11:00 a.m. and 1:45 p.m. with residents from all nursing units reported that they had no concerns related to sexual abuse or other forms of abuse. Residents denied any concerns of abuse and reported that they felt safe at the facility. The Immediate Jeopardy was lifted on May 9, 2024, at 6:17 p.m. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29 (c) Resident rights 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy, review of clinical record, review of facility documentation, interview with staff and resident, it was determined that the facility failed to ensure that an indwelling catheter was not used without a valid medical justification for catheterization. This failure resulted in actual harm to Resident R1 who experienced gross hematuria from the penis, required transfer to the hospital into the intensive care unit and intravenous antibiotics for one of three residents reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Continued review of the resident's clinical record revealed that Resident R1 was most recently hospitalized on [DATE], and was readmitted to the facility on [DATE]. Resident R1 diagnoses included multiple sclerosis (degenerative disease of the nervous system that can result in muscle weakness and trouble with coordination), bipolar disorder (a mental disorder that is characterized by periods of depression and periods of elevated mood), paraplegia (impairment of movement and sensation of the lower extremities) and benign prostatic hyperplasia (BPH-enlargement of the prostate gland) without lower urinary tract symptoms (frequent urination during the day and night, a weak urine stream, leaking or dribbling or urine). Review of Resident R1's Annual MDS (Minimum Data Set-a federally required resident assessment completed at a specific interval) dated August 11, 2023, revealed a BIMS (Brief Interview for Mental Status) Summary Score of 15, suggesting that Resident R1 was cognitively intact. Review of Section title Bowel and Bladder revealed that the resident was frequently incontinent of bladder. Review of Resident R1's care plan revealed a care plan for Urinary Incontinence revised August 7, 2023. review revealed a care plan for urinary incontinence which indicated the resident R1 was incontinent of urine and was unable to cognitively or physically participate in a retraining program due to diagnosis. The care plan's goals were as follow: Resident will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. Interventions were as follow: assist with perineal care as needed, encourage resident to consume all fluids during meals. Offer/encourage fluids of choice, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, use absorbent products as needed. Review of Resident R1's nurse aide tasks for Urinary Continence from October 15, 2023, to October 20, 2023, revealed that Resident R1 was consistently coded as incontinent. Further, the section for did not void was consistently left blank from October 10, 2023, to October 20, 2023, indicating that Resident R1 voided and was incontinent from October 10, 2023 to October 20, 2023. Interview with nurse aide, Employee E4 conducted on November 13, 2023, at 11:05 a.m revealed that when a resident had incontinent episode the nurse aide would know because they must check their assigned residents and they would have to change the resident's incontinent brief if wet. Further, if resident had no urine output during their shift, they would have to inform the charge nurse and an entry will be made in the resident's clinical record under the Urinary continence section that resident did not void. Further review of Resident R1's clinical record revealed no documented evidence that Resident R1 was evaluated for urinary retention and there was no documented evidence that Resident R1 had urinary retention on or before October 20, 2023. Review of Resident R1's October 2023 physician's orders revealed no physician order to catheterize Resident R1. Further review of Resident R1's October 2023, physician orders revealed an order dated October 20, 2023, to remove foley one time only. Review of Resident R1's Treatment Administration record for October 2023 revealed an entry to remove foley one with start date of October 20, 2023. The treatment administration record was initial by nursing staff on October 20, 2023, indicating that the catheter was removed. Review of Resident R1's entire clinical record revealed no documented evidence regarding the attending practitioner's valid clinical indication to support the use of an indwelling catheter. Review of Resident R1's clinical record revealed that there was no documentation from Licensed nurse, Employee E5 that she inserted the catheter on Resident R1 on October 20, 2023, there was no documented evidence that resident was assessed before and after the catheter insertion and there was no record of the amount of urine output from foley catheter, description of the urine or outcome of the catheter insertion. Review of nursing note dated October 20, 2023, at 6:00 p.m. revealed that Resident R1 was transfer to the local hospital at 5:00 p.m. for bleeding on his penis, and the resident's family and physician were notified. Review of Resident R1's discharged record confirmed that the resident was hospitalized from October 21-27, 2023. The resident was admitted to the Intensive Care Unit for gross hematuria, urosepsis and hypotension. The resident received 5 days of intravenous antibiotic. Continued review revealed. On arrival to the ED (Emergency Department) patient had active hemorrhage from this urethra, bright red blood .Patient presented to the ED without a foley catheter .Patient endorsed fatigue. Interview with Licensed nurse, Employee E5 conducted on November 13, 2023, at 9:14 a.m. revealed that she worked 7 a.m.-7 p.m. on October 20, 2023. Further Employee E5 revealed that she received the report from the outgoing nurse but was unable to recall who the nurse who told her that Resident R1 was retaining urine and that Resident R1 needed to be catheterized. Employee E5 stated that it was what the doctor wanted. Employee E5 confirmed that she got the information to catheterize the resident from the verbal report and not from a physician's order. Follow-up call with Employee E5 at 10:26 a.m. confirmed that she did not receive a verbal order from the physician, and she did not speak with the physician before and after the insertion for the catheter. Interview with Resident R1 conducted on November 13, 2023, at 12:32 p.m. revealed that he remembered the day he was sent to the hospital due to bleeding from his penis after he was catheterized but wasn't sure of the date of the incident. Resident R1 stated it happened a few weeks ago. Further interview with Resident R1 revealed that on the day that he was sent to the hospital, he was voiding and that the nurse aide had to change his diaper because he was wet. Further resident revealed that he did not have any discomfort on his belly on the day that he was catheterized. Further resident revealed that he asked the nurse why he had to be catheterized but the nurse never told him why. Further review of Resident R1's clinical record revealed that there was no documented evidence that Resident R1 was involved and informed of care and treatment including the potential use and indications for the need for a catheter and how long the catheter use is anticipated. Further, there was no documented evidence of information and education on Resident R1 on the identification of risks and benefits for the use of a catheter. Interview with Licensed nurse, Employee E6 conducted on November 13, 2023, at 1:06 p.m. confirmed that she was assigned to Resident R1 on October 20, 2023, during the 7-3 shift (day shift). Employee E6, revealed that during the day shift (7 a.m. to 3 p.m.) of October 20, 2023, Resident R1 did not have any complaints of distension, did not complaint that he couldn't urinate and did not have any complaints. Further, Employee E6 revealed that she did not notice any distress or changes in Resident R1's condition during the day shift of October 20, 2023, and that there was no report from the nurse aides that Resident R1 did not void during the 7 a.m. to 3 p.m. shift of October 20, 2023. Further interview with Employee E6 revealed that she did not call the physician never received any telephone order from physician or nurse practitioner to catheterize Resident R1. Interview with licensed nurse, Employee E7 conducted on November 13, 2023, at 3:10 pm confirmed that she worked October 20, 2023, during the 3-11 shift (evening shift). Employee E7 revealed that during report at 3:30 p.m. it was reported to her that Resident R1, had a catheter in place and that there was blood on Resident R1's brief. Employee E7 further revealed that she went to check on Resident R1 and found that there was a lot of blood on his diaper. Employee E7 then called Nurse Supervisor, Employee E8 to witness the bleeding. Employee E8 told her that the Resident R1 had to be sent to the hospital. Interview with Nurse Supervisor, Employee E8 conducted on November 13, 2023, at 1:25 p.m. revealed that she was not aware what was going on with Resident R1 until she was alerted by the nurse. Further Employee E8 revealed that she was the one who called 911 (Emergency Medical Services). Interview with Nurse Practitioner. Employee E10 conducted on November 13, 2023, at 1:21 p.m. revealed that she did not recall getting a call from the nursing home during the daytime of October 20, 2023, and that she did not recall ordering catheterization for Resident R1 at all. Employee E10 only recalled getting a call in the early evening of October 20, 2023, regarding Resident R1 having hematuria. The facility failed to ensure that an indwelling catheter was not used without a valid medical justification for catheterization. This failure resulted in actual harm to Resident R1 who experienced gross hematuria from the penis, required transfer to the hospital into the intensive care unit and intravenous antibiotics. 28 Pa. Code 211.3(a) Verbal and telephone orders 28 Pa. Code 211.3(d)(2) Verbal and telephone orders 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, review of clinical record, review of facility documents, interview with staff and resident, it was determined that the facility failed to ensure that a resident received treatment and care according to professional standards of practice, related to insertion of catheter without a physician's order for one of three residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1, who experienced gross hematuria from the penis, required transfer to the hospital and admission into the intensive care unit. Findings include: Review of facility policy entitled Foley Catheter Insertion, Male Resident with revised date of October 2010, section Purpose, revealed that the purpose of this procedure is to provide guidance for the asceptic insertion of a urinary catheter. Section Preperation, #1 Verify that there is a physician's order for this procedure.#2 Review the resident's care plan to assess for any special needs for this resident. Section Documentation revealed that The following should be recorded in the resident's medical record: #1. The date and time the procedure was performed. #2. The name and title of the individual(s) who performed the procedure. #3. All assessment data (e.g. character, color, clarity etc.) obtained during the procedure.#4. The size of the foley catheter inserted and the amount of the fluid used to inflate the baloon. #5. How the resident tolerated the procedure, #7. The signature and title of the person taking the data. Section Reporting revealed that, #2. Notify the physician of any abnormalities (i.e. bleeding, obstruction, etc.) #3. Report other information in accordance with facility policy and professional standards of practice. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Continued review of the clinical record revealed that Resident R1 was most recently hospitalized on [DATE], and was readmitted to the facility on [DATE]. Resident R1 diagnoses noted in the clinical record included multiple sclerosis (degenerative disease of the nervous system that can result in muscle weakness and trouble with coordination), bipolar disorder (a mental disorder that is characterized by periods of depression and periods of elevated mood), paraplegia (impairment of movement and sensation of the lower extremities) and benign prostatic hyperplasia (BPH-enlargement of the prostate gland) without Lower Urinary Tract Symptoms (Frequent urination during the day and night, a weak urine stream, leaking or dribbling or urine). Review of Resident R1's Annual MDS (Minimum Data Set-a federally required resident assessment completed at a specific interval) dated August 11, 2023, revealed a BIMS (Brief Interview for Mental Status) Summary Score of 15, suggesting that Resident R1 was cognitively intact. Review of Section titled Bowel and Bladder revealed that the resident was frequently incontinent of bladder. Review of Resident R1's care plan revealed a care plan for Urinary Incontinence revised August 7, 2023, review revealed a care plan for urinary incontinence which indicated the Resident R1 was incontinent of urine and was unable to cognitively or physically participate in a retraining program due to diagnosis. The care plan's goals were as follows: Resident will have incontinence care needs met by staff to maintain dignity and comfort and to prevent incontinence related complications. Interventions were as follows: assist with perineal care as needed, encourage resident to consume all fluids during meals. Offer/encourage fluids of choice, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, use absorbent products as needed. Review of Resident R1's October 2023 physician's orders revealed no physician order to catheterize Resident R1. Continued review of Resident R1's physician orders revealed an order dated October 20, 2023 to please remove foley one time only. Review of Resident R1's Treatment Administration record for October 2023 revealed an entry to remove foley one with start date of October 20, 2023. The treatment administration record was initialed by nursing staff on October 20, 2023, indicating that the catheter was removed. Review of a nursing note dated October 20, 2023, at 6:00 p.m. revealed that Resident R1 was transferred at 5:00 p.m. to the local hospital for bleeding on his penis, and the family and physician were notified. Review of Resident R1's discharged record revealed that the resident was admitted to the Intensive Care Unit for gross hematuria, urosepsis and hypotension. The resident received 5 days of intravenous antibiotic. Interview with Licensed nurse, Employee E5 conducted on November 13, 2023, at 9:14 a.m. revealed that she worked 7 a.m.-7 p.m. on October 20, 2023. Further, Employee E5 confirmed that she inserted a Foley Catheter French 16 in Resident R1 on October 20, 2023, at the end of morning shift (7 a.m.-3 p.m. shift). Employee E5 revealed that she received the report from nurse (whom she could not remember who the nurse was) that Resident R1 was retaining urine and that Resident R1 needed to be catheterized. Licensed nurse, Employee E5 also confirmed that she got the information verbally to catheterize the resident and not from a physician's order. Employee E5 also confirmed that she did not speak with the physician after the foley was inserted and that she left the facility at approximately 8:30 p.m. Follow-up call with Licensed nurse, Employee E5 at 10:26 a.m. who worked on November 13, 2023, confirmed that she did not receive a verbal order from the physician, and she did not speak with the physician before and after the insertion for the catheter. Further she confirmed that she received the information to catheterize the resident from the outgoing nurse, but she was not able to recall who the nurse was. Interview with Resident R1 conducted on November 13, 2023, at 12:32 p.m. revealed that he remembered the day he was sent to the hospital due to bleeding from his penis after he was catheterized but wasn't sure of the date of the incident. Resident R1 stated it happened a few weeks ago. Further interview with Resident R1 revealed that on the day that he was sent to the hospital, he was voiding and that the nurse aide had to change his incontinence brief because he was wet. Further resident revealed that he did not have any discomfort on his belly on the day that he was catheterized. Further resident revealed that he asked the nurse why he had to be catheterized but the nurse never told him why. Interview with Licensed nurse, Employee E6 conducted on November 13, 2023, at 1:06 p.m. confirmed that she was assigned to Resident R1 on October 20, 2023, during the 7-3 shift (day shift). Further Employee E6, revealed that during the day shift (7 a.m. to 3 p.m.) of October 20, 2023, Resident R1 did not have any complaints of distension, did not complain that he couldn't urinate and did not have any complaints. Further, Employee E6 revealed that she did not notice any distress or changes in Resident R1's condition during the day shift of October 20, 2023, and that there was no report from the nurse aides that Resident R1 did not void during the 7 a.m. to 3p.m. shift of October 20, 2023. Licensed nurse, Employee E6 revealed that she did not call the physician and never received any telephone order from physician or nurse practitioner to catheterize Resident R1. Interview with Licensed nurse, Employee E7, conducted on November 13, 2023, at 3:10 p.m. confirmed that she worked October 20, 2023, during the 3-11 shift (evening shift). Further interview with Licensed nurse, Employee E7 revealed that during report at 3:30 p.m., it was reported to her that Resident R1, had a catheter in place and that there was blood on Resident R1's brief. Employee E7 further revealed that she went to check on Resident R1 and found that there was a lot of blood on his brief. Employee E7 then called Nurse Supervisor, Employee E8 who witnessed the bleeding. Employee E8 told her that Resident R1 had to be sent to the hospital. Interview with Nurse Supervisor, Employee E8 conducted on November 13, 2023, 1:25 p.m. revealed that she was not aware what was going on with Resident R1 until she was alerted by nurse. Further Employee E8 revealed that she was the one who called 911 (Emergency Medical Services). Interview with Physician's office personnel, Employee E9 conducted on November 13, 2023, at 1:17 p.m. revealed that Employee E9 was responsible for receiving call from the nursing homes and forwarding the calls to the designated providers (Physicians or Nurse Practitioners). Further interview with Employee E9 revealed that she did not receive any calls from the facility on October 19, 2023, and October 20, 2023. Interview with Nurse Practitioner, Employee E10 conducted on November 13, 2023, at 1:21 p.m. revealed that she did not recall getting a call from the nursing home during the daytime of October 20, 2023, and that she did not recall ordering catheterization for Resident R1 at all. Further interview with Nurse Practitioner, Employee E10 revealed that she only recalled getting a call on October 20, 2023, regarding Resident R1 having hematuria and ordered for the resident to be transfer to the hospital. The facility failed to ensure that there was a written physician order with the type of catheter and size to be used prior to the insertion of the catheter which resulted in actual harm to Resident R1. This failure resulted in Resident R1 experiencing gross hematuria from the penis, requiring transfer to the hospital and admission into the intensive care unit. Refer to F690 28 Pa. Code 211.3(a) Verbal and telephone orders 28 Pa. Code 211.3(d)(2) Verbal and telephone orders 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to timely assess a resident's weight change, assess potential contributing factors to decreased oral intake, implement applicable interventions and address resident's nutritional status for four of seven residents reviewed for nutrition maintenance (Resident R9, R4, R62, and R84). This failure resulted in actual harm to Resident R9 who sustained a 35 pounds weight loss in one month, was transferred to the hospital and admitted with elevated sodium levels related to poor oral intake and dehydration. Findings include: Review of facility policy Nutritional Assessment revealed the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutrition assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The multidisciplinary team shall identify the following situations that place the resident at risk for impaired nutrition including: chewing or swallowing abnormalities, cognitive or functional decline, increased needs for calories and/or protein. Review of facility policy Weight Assessment and Intervention revealed residents will be weighed on admission, and weekly for four weeks thereafter. If no weight concerns are noted, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian. The Dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Care planning for weight loss should include individualized care plans to address the identified causes of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. The threshold for significant unplanned and undesirable weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R9's admission Minimum Data Set (MDS- assessment of resident care needs) dated April 1, 2022, revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R9's care plan initiated March 31, 2022 revealed that the resident was to maintain adequate nutritional status as evidenced by maintaining weight at baseline, no signs and symptoms of malnutrition and consuming over 51%-100% of most meals and supplements daily; to monitor/record/report to the physician as needed signs and symptoms of malnutrition such as emaciation, muscle wasting, signs of weight loss: 3 pounds in 1 week, over 5 pounds in 1 month, over 7.5% in 3 months, and over 10% in 6 months. Review of Resident R9's nutrition admission assessments dated March 31, 2022, and April 21, 2022, by Registered Dietitian, Employee E17, revealed Resident R9 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutrition interventions included liquid protein supplement three times/day. Monitoring included weekly weights for 4 weeks, monitoring intakes, labs, skin, and tolerance to supplement with goal for weight maintenance. Review of Resident R9's weight history revealed Resident 9's weight was 260 pounds April 2, 2022, and on April 9, 2022. There were no weekly weights obtained as recommended by the dietitian. Continued review of Resident R9's clinical record revealed a nutrition admission assessment dated [DATE], by Employee E18, no documented title, revealed Resident R9 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutrition interventions included protein liquid three times/day and Ensure supplements were added two times/day due to Resident R9 disliking most of the meals. Monitoring included weekly weights for four weeks, and monitoring intakes, labs, skin, and tolerance to supplements. Further review of Resident R9's weight history revealed Resident 9's weight was 224.6 pounds May 19, 2022, a 35 pound and 15% severe weight loss in one month. Continued review of weight history revealed that the next documented weight was 224.6 pounds on June 7, 2022. There were no weekly weights obtained as it was recommended by the dietitian on May 11, 2022. Continued review of Resident R9's weight history revealed no documented evidence monthly weights were completed in July or August 2022. Review of Resident R9's entire clinical record revealed no documented evidence the Registered Dietitian or the resident's physician was made aware of significant weight loss. Continued review of clinical record revealed no documented evidence the resident's severe weight loss was addressed by the Physician or Registered Dietitian. Review of Resident R9's speech therapy evaluation and plan of treatment revealed the resident received speech therapy services from June 17, 2022, through July 16, 2022. Review of speech therapy notes dated June 17, 2022, revealed Resident R9's diet texture was downgraded from chopped to ground related to resident pocketing foods in mouth. Review of Speech Therapy Discharge Summary dated July 23, 2022, revealed PO (food by mouth) trials were limited due to Resident R9's frequent refusals. Further Review of Resident R9's clinical record revealed the resident's diet was upgraded on August 24, 2022, from ground to mechanical soft textures. Interview on September 7, 2022, at 11:45 a.m. with Licensed Nurse, Employee E11, revealed she was not typically assigned to Resident R9 but reported colleagues would report that Resident R9 usually never ate his meals. Interview on September 7, 2022, at 11: 45 a.m. with Resident R9 confirmed he was not really eating due to consistency of the food. Interview on September 7, 2022, at 12:10 p.m. with Licensed Nurse, Employee E19, never really saw him [Resident R9] eat, he only consumed ensures [supplements]. Interview on September 7, 2022, at 12:45 p.m. with Speech Therapist, Employee E20, revealed Resident R9 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee E20 reported Resident R9 had poor intakes of meals and did not like the downgraded ground consistency of the food. Continued interview with Employee E20 revealed she did not coordinate with the dietitian because there was no dietitian available at the facility. Review of Resident R9's clinical record revealed no documented evidence the Registered Dietitian coordinated with the interdisciplinary team, assessed severe weight loss, assessed potential contributing factors to decreased oral intake, and implemented applicable interventions to support/improve nutrition and hydration status. Review of Nursing documentation dated August 3, 2022, revealed Resident R9's foley was noted to be draining an amber color urine (urine color can be reflective of hydration status - amber color urine can be consistent with symptoms of dehydration). Further review of clinical record revealed documentation dated August 9, 2022, that Resident R9's foley was noted to be draining milky/cloudy color and a urinary analysis was ordered. Review of Resident R9's clinical record revealed nursing documentation dated August 12, 2022, that Resident R9 refused medications, both meals and appeared lethargic. Resident R9 was subsequently transferred to the hospital on August 12, 2022, for change in mental status and admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R9's hospital records revealed a history and physical assessment dated [DATE]. Review of assessment revealed swallow safety was a concern as there was pocketed food in the resident's mouth that needed to be manually removed upon arrival to the emergency room . It was further noted that Resident R9 had elevated sodium levels consistent with poor P.O. intake and dehydration as also evidenced by elevated blood urea nitrogen (BUN) creatinine levels (laboratory values to assess hydration status). Continued review of Resident R9's hospital records revealed a consult by infectious disease dated August 13, 2022, who indicated Resident R9 had muscle wasting in all four extremities and was chronically ill-appearing. Interview on September 7, 2022, at 2:00 p.m. with Employee E5, Registered Dietitian Eligible, revealed she started around July 18, 2022. Employee E5 reported she knew very little about him [Resident R9] and was not made aware the resident was not eating well. Employee E5 revealed during interview that Registered Dietitian, Employee E6, was the Registered Dietician who was the prior dietitian. Email communication on September 7, 2022, at 2:45 p.m. with Registered Dietitian, Employee E6, revealed she never assessed Resident R9. Interview on September 9, 2022, at 8:30 a.m. with Regional Dining Director, Employee E21, revealed lack of monitoring and follow-up to Resident R9's nutritional status was related to shortage of dietitian coverage in the building. Interview on September 9, 2022, at 11:00 a.m. with the Director of Nursing confirmed there was no documented evidence that the physician was made aware of Resident R9's weight and appetite changes but reports to have spoken with the physician via phone. The Director of Nursing reported the physician indicated that Resident R9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview with the Director of Nursing confirmed there was no coordination or follow-up by the Registered Dietitian to assess, monitor, and implement interventions related to Resident R9's weight and poor PO intakes. The facility failed to timely assess a resident's weight change, assess potential contributing factors to decreased oral intake, and implement applicable nutritional interventions with resulted in actual harm to Resident R9 who experienced a severe weight loss, required admission to the hospital and was diagnosed with a urinary tract infection, elevated sodium levels and dehydration. Review of Resident R4's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R4's care plan revised April 5, 2022, revealed the resident had a nutritional problem related to overweight/obesity and limited adherence to nutritional guidelines related to heart failure, fluid overload, and morbid obesity. Continued review of the residen't care plan revealed the resident used diuretics (medication to help the body get rid of excess water) and risk for weight changes. Review of Resident R4's clinical record revealed a nutrition admission assessment dated [DATE]. Review of nutrition assessment revealed the Registered Dietitian, Employee E17, recommended a fluid restriction due to resident's risk for fluid overload. Review of Resident R4's weight history revealed resident was weighed on June 7, 2022, at 256 pounds and weighed again on July 26, 2022, at 307.6 pounds. Documented weights indicated Resident R4 had a severe weight gain of 16% and 51 pounds over one month. Review of Resident R4's entire clinical record revealed no documented evidence the physician or dietitian were made aware of the resident's significant weight gain. Review of Resident R4's clinical record revealed the significant weight gain was not addressed until September 1, 2022, by the Registered Dietitian Eligible, Employee E5. Continued review of Resident R4's clinical record revealed no documented evidence the resident was being routinely monitored and assessed by the Registered Dietitian on quarterly basis between January 25, 2022, and September 1, 2022. Review of Resident R62's clinical record revealed the resident was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R62's care plan revealed the resident had a nutritional problem related to swallowing difficulty, inadequate intakes, and need for enteral (delivery of nutrition via tube) feedings. Review of Resident R62's weight history revealed the resident was weighed on June 16, 2022, at 127.4 pounds and weighed again on July 21, 2022, at 151.2 pounds. This would reflect a severe weight gain of 15% and 23 pounds in one month. Further review of Resident R62's weight history revealed the resident was weighed again on July 24, 2022, at 180 pounds. This would reflect a severe weight gain of 16% and 28 pounds in 3 days. Review of Resident R62's clinical record revealed a reweigh was not taken until August 5, 2022, which confirmed a weight of 180 pounds. Review of Resident R62's clinical record revealed no documented evidence the physician or the Registered Dietitian were made aware of the resident's severe weight gain. Continued review of Resident R62's clinical record revealed the Registered Dietitian did not address the weight gain from July 21 and July 24, 2022, until August 12, 2022. Review of Resident R84's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with [CONDITION(S)] and a [CONDITION(S)] to assist with breathing and a gastrostomy for nutrition. Resident R84's physician ordered weekly weights for four weeks starting on August 25, 2022. Further review of Resident R84's clinical record revealed weights were not documented as ordered on August 25, September 1, and September 7, 2022. 28 Pa. Code 211.6 (d) Dietary Services 28 Pa. Code 211.(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing serives 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review, facility policy and procedure review, hospital documentation review, and staff interview, it was determined that the facility failed to assess for an increased risk for pressure ulcer development for residents who were recently readmitted from the hospital, and failed to develop interventions for the prevention of pressure ulcers, causing harm to the residents and the development of Stage III pressure ulcers, for two of four residents reviewed. (Resident R1 and CL1). Findings include: Review of the facility policy and procedure titled, Pressure Injury Risk Assessment, last revised March 2020, revealed the purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed and which will take time to modify. The risk assessment should be completed as soon as possible after admission, but no later than eight hours after admission is completed. Use only a facility-approved risk assessment tool to obtain risk assessment data. Supplement the risk assessment tool with assessment of additional risk factors. Once the assessment is conducted and risk factors are identified and characterized, the resident-centered care plan can be created to address the modifiable risk for pressure injuries. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the residents overall clinical condition, and the residents stated wishes and goals. Review of Resident R1's clinical record diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents R1's progress notes revealed a nursing entry on June 19, 2020, stating the resident was readmitted to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has excoriation (loss of the top layer of skin epidermis, caused by prolonged moisture and friction) 3x2x0.1cm (centimeters) to sacrum (lower back) area with foam dressing, no drainage. Review of Resident R1's Transfer Form from the Hospital, dated June 19, 2020, revealed the resident had a Braden Risk Score (tool used to determine the residents risk of developing a pressure ulcer) of 15, which places the resident at risk of a pressure ulcer. The resident also had an area of non-blanchable [CONDITION(S)] (superficial reddening of the skin that when pressed does not turn white classified as a stage I pressure ulcer) to the sacrum (lower back). There were no wound care orders for the transfer documentation from the hospital. Review of Resident R1's physician orders from after the readmission on June 19, 2020, revealed the original orders of Barrier Cream after incontinence (the loss of bladder control) care, turn and position, and chair pressure relieving mattress all dated February 7, 2019, were to continue after the readmission. There were no new orders for care or prevention of pressure ulcers. Review of Resident R1's assessments revealed the facility had not completed a Braden scale prior to the readmission of June 19, 2020. Review of Resident R1's Significant Change Minimum Data Set (periodic assessment of resident needs), dated June 26, 2020, revealed the resident was at risk for pressure ulcer development and had no current pressure ulcers. Further review of the MDS revealed there were no interventions coded as in place for treatment or prevention of pressure ulcers. Further review of the MDS revealed the resident required extensive assistance of two staff members for changing positions in bed, transfers, dressing and toileting. Review of Resident R1's most recently completed MDS, prior to his readmission of June 19, 2020, revealed there was a significant change MDS dated [DATE]. This MDS codes the resident as needing the help of only one staff member for changing positions in bed and dressing and only limited assistance of one staff member for toileting. This indicates a change in the resident mobility after the readmission, increasing the resident's risk for pressure ulcer development. Review of Resident R1's progress notes revealed a nursing entry on June 29, 2020, at 11:50 p.m. stating CNA (certified nursing assistant) notified charge nurse that the resident has an open area noted to his sacral region. Scant amount of serosanguinous (contains or relates to both blood cells and the liquid part of blood) /yellow drainage noted to area. No odor noted, maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) noted peri-wound (surrounding the wound), slough (mass of dead tissue separated from surrounding living tissue) present at wound base. Review of the entire clinical record revealed there was no further description of the wound or measurement of the size of the wound. Review of a Wound Care Specialist visit report, dated July 2, 2020, revealed the Resident R1 had a stage III (subcutaneous fat is visible but bone, tendon or muscle are not exposed). Initial wound encounter measurement is 1.9cm length x 1.3cm width x 0.2cm depth, necrotic (dead) muscle is exposed. There is a moderate amount of serosanguineous drainage (yellow colored fluid) noted which has no odor. Wound has 20% epithelialization (healing) 40% slough (mass of dead tissue separated from surrounding living tissue), 40% pale grey, pink granulation (lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound). Interview with the Director of Nursing (DON), on October 28, 2020, at 11:30 a.m. revealed the facility had not completed a pressure ulcer risk assessments until June 19, 2020, and was unable to provide the assessment used to identify the resident as a risk for pressure ulcers as coded on the significant change MDS of June 26, 2020. The DON also confirmed there was no care plan developed for the prevention of pressure ulcers until June 29, 2020 and there were no new interventions developed after Resident R1 was readmitted to the facility on [DATE], despite having a decrease in ADL (activities of daily living) as coded on his Significant change MDS of June 26, 2020. Resident R1 was readmitted to the facility on [DATE], and the facility failed to complete an assessment to determine if the risk for the development of pressure ulcers had increased after a hospitalization and failed to develop interventions to prevent a pressure ulcer. Resident R1 was discovered to have a pressure ulcer on June 29, 2020, (ten days after admission), that was not fully assessed and documented until July 2, 2020, when it was classified as a stage III pressure ulcer. Review of Resident CL1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident CL1's progress notes revealed a nursing entry dated December 23, 2019, at 11:53 p.m. stating the resident was readmitted from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident CL1's progress notes revealed a nursing entry on January 10, 2020, at 7:36 a.m., stating Resident found with open area to sacrum by aide while performing care. Review of Resident CL1's assessments revealed the resident had a Braden Scale completed on January 10, 2020, identifying the resident as at risk for pressure ulcers. There was no Braden Scale completed after the resident was readmitted from the hospital on December 23, 2019. Review of Resident CL1's Significant Change MDS assessment dated [DATE], revealed Resident CL1 is at risk for pressure ulcers and there were no interventions in place at this time to prevent or treat pressure ulcers. Further review of the MDS revealed the resident required extensive assistance of two staff members for changing positions in bed, transfers and an extensive assist of one person for dressing and toileting. Review of Resident CL1's physician orders revealed there were no new interventions to prevent pressure ulcers, only to continue the current treatments of Barrier Cream after incontinence care, and to monitor skin observation, both orders dated May 31, 2018. Review of Resident CL1's care plan revealed there was no care plan developed for the resident being at risk for the development of pressure ulcers, or interventions in place to prevent pressure ulcers. Review of a Wound Care Specialist visit report, dated January 16, 2020, revealed that Resident CL1 had an acute stage III (subcutaneous fat is visible but bone, tendon or muscle are not exposed) pressure injury pressure ulcer. Initial wound encounter measurement is 1cm length x 0.5cm width x 0.1cm depth. There is a scant amount of serosanguinous drainage. Wound bed is 20% epithelialization, 10% slough, 70% granulation. Interview with the Director of Nursing on October 28, 2020, at 11:30 a.m., revealed Resident CL1 had not been assessed for pressure ulcer risk upon return from the hospital on December 23, 2020, and no new interventions had been put into place until a pressure ulcer was discovered on January 10, 2020. The facility failed to assess to determine if Resident R1 and CL1 had an increase in pressure ulcer risk after a hospitalization and failed to develop interventions until a pressure ulcer developed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services