Every finding on record at Allied Services Meade Street Skilled Nursing

Based on a review of clinical records, select facility policies, observation, and staff interviews, it was determined that the facility failed to implement effective procedures to maintain accurate records of controlled medications to ensure timely acquisition and administration of prescribed medications for one resident (Resident 108) and failed to timely obtain and administer prescribed medications for one resident (Resident 115) out of 24 residents sampled. Findings include: A review of the facility policy titled Administration of Medication, Schedule II -V Controlled Drugs last reviewed by the facility on October 23, 2025, revealed the facility will comply with all federal and state laws and regulations, and other requirements related to handling, storage, disposal, and record keeping of Schedule II-V controlled narcotics. (Schedule II-V medications are drugs regulated by federal law due to their medical use and potential for misuse, with Schedule II medications having the highest risk. Narcotics are medications commonly used to treat moderate to severe pain and require strict monitoring due to the risk of dependence).The Licensed Nurse administering the medication immediately enters all the following on the administration recorder, the date and time of administration, amount administered, signature of the nurse administering the dose, and balance of remaining medication to ensure accurate tracking and accountability. A clinical record review revealed that Resident 108 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a condition involving reduced blood flow to the limbs caused by narrowed or blocked blood vessels) and methicillin-resistant Staphylococcus aureus (MRSA) infection (a bacterial infection resistant to many common antibiotics). A review of physician orders revealed that on June 30, 2025, Resident 108 was prescribed Oxycodone HCL oral tablet 5 mg (a schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse and requires strict documentation and accountability), with instructions to administer one tablet every six hours as needed for moderate to severe pain.A review of facility records revealed the facility utilized an Individual Resident's Controlled Substance Record to track the receipt, use, and remaining balance of controlled medications. The facility also utilized a Medication Administration Record (MAR), which serves as the legal record documenting the administration of medications, including the medication given, date and time administered, and the staff member administering the medication. A comparison of Resident 108's Controlled Substance Record and the MAR from August 1, 2025, through January 2026, revealed discrepancies. The Controlled Substance Record reflected six entries indicating Oxycodone 5 mg was removed or utilized, while the MAR lacked corresponding documentation indicating the medication was administered. The discrepancies occurred on the following dates and times:October 22, 2025, at 11:30 AMDecember 16, 2025, at 8:00 PMDecember 18, 2025, at 8:00 AMDecember 22, 2025, at 8:00 PMDecember 23, 2025, at 8:00 PMJanuary 7, 2026, at 8:00 PMThe absence of corresponding MAR documentation indicated the facility failed to maintain accurate and reconciled records for a Schedule II controlled medication, as required by facility policy and professional standards. An interview conducted on January 16, 2026, at 11:45 AM, with the Director of Nursing (DON) included a review of the above findings related to the failure to reconcile Resident 108's controlled substance documentation. A clinical record review revealed that Resident 115 was admitted on [DATE], at 3:00 PM, with diagnoses that included acute on chronic systolic heart failure (a condition in which the heart cannot effectively pump blood over time), history of pulmonary embolism (a blood clot that blocks blood flow in the lungs), atrial fibrillation (AFib) (an irregular heart rhythm that increases the risk of stroke), presence of a pacemaker (a device that helps regulate heart rhythm), and chronic obstructive pulmonary disease (COPD) (a chronic lung condition that restricts airflow and breathing).A review of Resident 115's admission orders dated January 7, 2026, and confirmed by Employee 1, licensed practical nurse (LPN), revealed the following medications were prescribed for administration at 9:00 PM: Acetazolamide 500 mg twice daily, a diuretic used to reduce excess fluid and help control blood pressure. Aldactone (spironolactone) 35 mg twice daily, a diuretic that removes excess fluid while maintaining potassium balance. Eliquis (apixaban) 5 mg twice daily, a blood thinner used to reduce the risk of blood clots and stroke. Furosemide 40 mg twice daily, a diuretic used to treat fluid buildup in heart failure. Losartan 50 mg twice daily, a medication used to lower blood pressure. Metoprolol Succinate ER 25 mg twice daily, a medication used to control heart rate and blood pressure. These medications were prescribed to manage the resident's cardiac and circulatory conditions. The absence of documented administration created the potential for fluid overload, uncontrolled blood pressure, irregular heart rhythm, and increased risk of blood clot formation. A review of Resident 115's electronic Medication Administration Record (eMAR) for January 2026 revealed that the prescribed medications were not administered as ordered. Further review of the clinical record revealed documentation by Employee 1 on January 7, 2026, at 10:35 PM, indicating the medications were waiting on pharmacy delivery. The facility was unable to provide documented evidence that the January 7, 2026, 9:00 PM scheduled medications were administered as prescribed. A review of the facility's automated dispensing system (ADS) at the time of Resident 115's admission revealed that multiple prescribed medications were available within the system, including five (5) Eliquis 2.5 mg tablets, six (6) Furosemide 40 mg tablets, and six (6) metoprolol succinate ER tablets were available. An automated dispensing system is an electronic medication storage and dispensing system intended to provide timely access to medications and prevent delays in care. A review of a facility provided policy entitled Ordering and Receiving Medication: Ordering and Receiving Medications from Pharmacy last reviewed by the facility October 23, 2025, indicated medications and related products are ordered and received from the pharmacy. New medications, except for emergency or stat medications, are ordered as follows: (a) if needed before the next regular delivery, phone the medication order to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery and request delivery within four (4) hours. (b) Timely delivery of new orders is required so that medication administration is not delayed. The emergency/starter kit is used when the resident needs medication prior to pharmacy delivery such as when the medication is urgently needed by the patient or when pharmacy delivery is delayed due to route schedule or a weather event. Use of the starter systems in a non-emergency must be communicated to the Pharmacy prior to administration.During an interview with the Director of Nursing on January 15, 2026, at 10:30 AM, the above findings were reviewed, including the failure to implement facility procedures for obtaining medications for a new admission and accessing medications available through the automated dispensing system. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure documented clinical justification for the use of psychoactive medications for one of five sampled residents for unnecessary medication prescribing practices (Resident 81). Findings included: A review of Resident 81's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Lewy body dementia (a progressive brain disorder associated with problems in thinking, movement, behavior, and mood; visual hallucinations are a common symptom). A review of physician orders revealed that Resident 81 was prescribed multiple psychoactive medications (medications that affect brain activity, mood, or behavior). A physician order dated November 15, 2025, directed Lexapro 10 mg by mouth once daily for depression. This dose was increased to 25 mg by mouth once daily on December 3, 2025. An additional order dated December 3, 2025, directed Desyrel (Trazodone) 50 mg by mouth once daily for depression. Both medications are classified as antidepressants used to treat mood-related conditions. A review of the monthly consultant pharmacist medication regimen review dated December 21, 2025, documented that Resident 81 was receiving two antidepressant medications, Lexapro and Desyrel, for the same condition. The pharmacist noted concern for increased side effects when two or more medications of the same class are used concurrently and recommended documentation of the clinical need for combination therapy, including a risk-versus-benefit assessment. A review of the attending physician/prescriber response dated December 23, 2025, indicated disagreement with the pharmacist's recommendation. The only rationale documented was followed by psych. However, a review of Resident 81's clinical record revealed no documentation that the resident had been evaluated by psychology or psychiatric services since admission on [DATE]. The above findings were reviewed with the Director of Nursing on January 18, 2025, at 12:15 PM. At that time, no additional documentation was provided to demonstrate that Resident 81 had been seen by psychological or psychiatric services or that a documented risk-versus-benefit analysis supported the continued use of multiple antidepressant medications. 28 Pa. Code 211.2 (d) (3) Medical Director. 28 Pa. Code 211.5 (f) (ix)Medical records. 28 Pa. Code 211.9 (k) Pharmacy Services. 28 Pa. Code 211.12 (d)(1)(3) Nursing Services.

Based on a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered therapeutic devices and preventative measures for one of ten residents sampled for quality of care (Resident 4). Findings include: A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include Bullous Pemphigoid (a rare skin condition causing large fluid-filled blisters), congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and chronic kidney disease stage 4 (severe kidney damage with the kidneys functioning between 15-29% of their normal capacity). A review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 4, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates intact cognition). Further review of the clinical record revealed the following active physician orders: A physician's order dated March 17, 2025, directed that Geri-sleeves (a lightly padded protective fabric used to prevent skin tears and bruising on fragile skin) be applied to both upper extremities every shift, as tolerated every shift. A physician's order dated April 25, 2025, directed that ace wraps (elastic bandages used to reduce lower extremity swelling and assist with blood clot prevention) be applied in the morning and removed in the evening. Review of the resident's care plan in effect through the survey end date of May 6, 2025, revealed that while the resident was to be encouraged to wear anti-embolic stockings per physician order, the plan of care failed to address the March 17, 2025, order for Geri-sleeves to the upper extremities. As a result, the care plan did not reflect all current interventions related to skin integrity and prevention of injury. Observation of Resident 4 in his room on May 6, 2025, at 11:00 AM revealed he was sitting in his wheelchair watching television. The resident was not wearing Geri-sleeves on either arm as ordered, and ace wraps were not present on either leg. Interview with Resident 4 at that the time of the observation on May 6, 2025, at 11:00 AM reported staff do not consistently apply the physician ordered ace wraps or Geri-sleeves. He stated, it's a 50/50 chance that someone will put them on. An interview with the Director of Nursing (DON) on May 6, 2025, at 1:30 PM confirmed staff had not consistently followed the physician's orders for application of Geri-sleeves for skin protection or ace wraps for blood clot prevention for Resident 4. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(ix) Medical records

Based on a review of clinical records, controlled medication records, select facility policy, and a staff interview, it was determined the facility failed to implement procedures to ensure the accuracy of controlled medication records for four residents out of 23 residents reviewed. (Residents 23, 61,76 and 350). Findings include: A review of facility policy titled Administration of Medication Schedule II-V Control Drugs, last reviewed by the facility on October 14, 2024, revealed the facility will comply with federal and state laws and regulations in the handling, storage, disposal, and record-keeping of Schedule II-V controlled medication. The policy indicates when a Schedule II-V controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, and remaining balance. The policy indicates that this is to be completed immediately after the medication is administered. A review of facility clinical records revealed the facility utilizes an individual Controlled Medication Utilization Record to track, monitor, and reconcile each controlled medication, such as Oxycodone. Further review of facility clinical records revealed the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. A clinical record review revealed Resident 61 was admitted to the facility on [DATE], with diagnoses to include osteoporosis (a condition in which the body loses more bone than it produces, leading to a decrease in bone density and strength) and peripheral vascular disease (a condition that occurs when the arteries or veins become narrowed or blocked, reducing blood flow to the extremities). A physician's order for Resident 61 to receive tramadol HCI tablet 50 mg (schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) with direction to give 50 mg orally one time a day at 6:00 PM for pain management, was initiated on January 2, 2021. Resident 61's individual controlled medication record documented that a dose of Tramadol HCl 50 mg was removed from the medication supply on January 10, 2025, at 6:00 PM. However, the MAR did not reflect administration of the medication, and a progress note indicated the dose was held due to the resident's lethargy. During an interview on March 6, 2025, at approximately 9:30 AM, the Director of Nursing (DON) confirmed there was no documented evidence the medication was administered or returned, leading to a discrepancy in medication accountability. A clinical record review revealed Resident 350 was admitted to the facility on [DATE], with diagnoses that include atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and left femoral neck fracture (a break in the bone that connects the hip joint to the rest of the thigh bone). A physician's order for Resident 350 to receive Oxycodone HCL 5mg (a schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) was initiated on December 2, 2024, with instructions to administer one tablet every 6 hours as needed for moderate pain. Resident 350's individual controlled medication record indicated that Oxycodone HCl 5 mg was removed and utilized on four separate occasions. January 12, 2025, at 8:00 PM February 2, 2025, at 9:30 AM February 11, 2025, at 7:22 PM February 13, 2025, at 8:00 PM However, the MAR did not contain documentation of administration for those dates. During an interview on March 6, 2025, at approximately 12:30 PM the DON was unable to explain the discrepancies and confirmed the facility failed to implement procedures to accurately reconcile controlled substances. A clinical record review revealed Resident 23 was admitted to the facility on [DATE], with diagnoses that include spinal stenosis (abnormal narrowing of the spinal canal that results in pressure on the spinal cord or nerve roots) and maxillary fracture (a break in the jawbone). A physician's order for Resident 23 to receive Oxycodone HCL 5 mg. (a schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) was initiated on February 19,2025, with instructions to administer one tablet every six hours as needed for moderate to severe pain. Resident 23's individual controlled medication record documented that Oxycodone HCl 5 mg was removed from the supply on February 27, 2025, at 3:00 AM, but there was no corresponding entry in the MAR indicating administration of the medication. During an interview on March 6, 2025, at approximately 9:30 AM, the DON acknowledged the discrepancy and confirmed the facility failed to ensure compliance with controlled substance documentation policies A clinical record review revealed Resident 76 was admitted to the facility on [DATE], with diagnoses that include Intervertebral Disc Degeneration (a breakdown of the disks that separate the bones of the spine) and Diabetes Mellitus II (a metabolic disorder in which the body has high sugar levels for a prolonged period). A physician's order for Resident 76 to receive Hydrocodone Acetaminophen Oral Tablet 5-325 mg. (schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) was initiated on January 13,2025, with instructions to administer one tablet every six hours as needed for moderate pain. Resident 76's individual controlled medication record documented that Hydrocodone Acetaminophen 5-325 mg was removed from the supply on February 9, 2025, at 9:30 PM, and February 20, 2025, at 3:00 PM. However, there was no documented evidence in the MAR indicating the medication was administered. The DON confirmed the discrepancies and acknowledged the facility failed to implement effective procedures to reconcile controlled substance records. The facility failed to follow their own policy to ensure accurate documentation of controlled substances. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1) Pharmacy services 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of one resident out of 23 sampled (Resident 61). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section J Health Conditions Subsection J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment indicates information from all relevant medical records received from facilities where the resident resided during the previous 6 months, any other medical records received are reviewed for evidence of resident falls. A clinical record review revealed Resident 61 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) Section J1900. Number of Fall Since Admission/Entry or Reentry or Prior Assessment, dated December 23, 2024, indicated Resident 61 had one fall with no injury and one fall with injury (except major injury). A clinical record review revealed Resident 61 had experienced three falls since the last MDS assessment. Resident 61 fell on [DATE], December 13, 2024, and December 18, 2024. During an interview on March 6, 2025, at approximately 1:30 PM, the Registered Nurse Assessment Coordinator (RNAC) confirmed the quarterly MDS assessment dated [DATE], failed to include all three falls Resident 61 experienced. During an interview on March 6, 2025, at approximately 1:45 PM, the Director of Nursing confirmed that Resident 61's quarterly MDS assessment dated [DATE], did not accurately include all falls experienced by the resident during the lookback period. 28 Pa. Code 211.5 (f)(iv) Medical records. 28 Pa. Code 211.12(d)(2)(3) Nursing services.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses properly evaluated and provided nursing care according to physician orders for one resident out of 24 residents reviewed (Resident 10) Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records. A review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and occasionally much faster than normal). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 23, 2025, revealed Resident 10 had moderately impaired cognition with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A physician's order dated February 8, 2025, directed staff to obtain Resident 10's blood pressure and heart rate weekly. However, a review of the resident's clinical record, including the task report (an electronic record that summarized planned resident-centered tasks completed by nursing), Medication Administration Record (MAR), and Treatment Administration Record (TAR), revealed no evidence that these vital signs were obtained as ordered. An interview with the Director of Nursing (DON) on March 6, 2025, at approximately 2:45 PM confirmed that the facility failed to ensure that Resident 10 received treatment and care in accordance with professional standards of practice. The DON acknowledged that the physician's orders were not followed, and there was no documentation to support that the required monitoring had been completed. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing Services

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for two residents out of 24 sampled residents (Residents 24 and 90). Findings included: A review of a facility policy entitled Weighing Residents/Reporting Significant Weight Changes that was last reviewed by the facility October 1, 2024, indicated it was the policy of the facility to monitor weights on all residents and to investigate, report, and appropriately intervene when a weight change occurs that may impact the resident's well-being. The nurse and/or dietitian will check weights and verify if there has been a loss or gain of 5% of the total weight in one month or five pounds in one week. Reweights within 48-hours will be scheduled, if necessary. If a weight loss or gain occurs, the nurse will notify the dietitian, physician, and resident or resident representative (RP) and document the notification. The dietitian will reassess energy and hydration needs in a nutrition progress note, as necessary, and may recommend adjustments to the resident's nutrition plan of care (POC). The nurse will review the dietitian's recommendations related to the weight changes, notify the resident or RP of new orders, and document appropriately in the electronic medical record (EMR). A review of Resident 24's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), congestive heart failure (CHF a progressive heart disease that affects pumping action of the heart muscles and causes fatigue and shortness of breath), and pulmonary nodule (are areas of abnormal growth on the lungs and typically caused by infections, autoimmune diseases or cancer). The resident's weight on October 1, 2024, was 164.6 lbs. On October 9, 2024, the resident's weight was documented as 157.3 lbs. upon return from the hospital, indicating a 7.3 lb. (4.4%) weight loss in one week. A review of the clinical record failed to reveal documentation that a reweight was obtained within 48 hours per facility policy. A review of a nutrition progress note completed by the facility's registered dietitian (RD) on October 23, 2024 (14-days post weight loss), at 11:00 AM, indicated the weight loss was likely due to IV (intravenous) Lasix (diuretic medication that removes the build-up of fluid in the body) received during hospitalization . The RD recommended obtaining a reweight, monitoring weekly weights, and adding the resident to nutrition at risk (NAR) status. However, the clinical record lacked documentation that the reweight was completed, that weekly weights were implemented for NAR monitoring, or that the attending physician and resident/RP were notified of the weight change. During an interview with the Director of Nursing (DON) on March 7, 2025, at 10:30 AM, confirmed the facility could not provide documented evidence that a reweight was completed or that weekly weights were completed for NAR status monitoring after Resident 24's weight loss. Additionally, the DON confirmed there was no documented evidence that the resident's attending physician and resident or RP were notified of the weight changes. A review of Resident 90's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included endometrial cancer (also known as uterine cancer, a type of cancer that begins as a growth of cells in the uterus) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). On October 1, 2024, the resident's weight was recorded as 102.4 lbs. By October 7, 2024, the resident's weight had decreased to 96.7 lbs., indicating a significant weight loss of 5.6 lbs. (5.6%) within one week. Resident 90's weight record revealed that on October 1, 2024, the recorded weight was 102.4 lbs., on October 7, 2025, the recorded weight was 96.7 lbs., which showed a weight loss of 5.6 lbs. or 5.6% in one week. Further review of the clinical record revealed that on October 16, 2024, at 3:17 PM, 9-days after the weight loss occurred, the DON obtained orders for Boost (nutritional supplement) three times per day due to weight loss. However, there was no documented evidence that Resident 90's attending physician was timely notified of the significant weight loss of 5.6 lbs. or 5.6% in one week. Further review of the clinical record revealed that the RD did not complete a nutritional evaluation regarding the significant weight loss until November 4, 2024-28 days after the weight change. During an interview on March 7, 2025, at 11:40 AM, the DON confirmed that the facility failed to timely identify Resident 90's weight change, implement timely nutritional interventions, and notify the attending physician of the weight loss. These findings demonstrate that the facility failed to adhere to its own policy regarding timely weight monitoring, reweight verification, physician notification, and nutritional interventions. 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure that pain management is provided to residents consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one resident (Resident 61) out of 23 sampled. Findings include: A review of facility policy titled Pain Management, last reviewed by the facility on October 1, 2024, revealed it is the facility's policy to provide compassion, appropriate assessment, and intervention to control residents' pain by way of interdisciplinary approaches and using non-pharmacological and pharmacological methods. The policy also indicates the licensed nurse is responsible for the accurate assessment of the resident's pain, initiating the appropriate non-pharmacological and pharmacological pain interventions, evaluating the outcome of interventions, and ensuring that all documentation requirements are met. A clinical record review revealed Resident 61 was admitted to the facility on [DATE], with diagnoses that include osteoporosis (a condition in which the body loses more bone than it produces, leading to a decrease in bone density and strength) and peripheral vascular disease (a condition that occurs when the arteries or veins become narrowed or blocked, reducing blood flow to the extremities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 23, 2024, revealed that Resident 61 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Resident 61's care plan, initiated on November 11, 2024, outlined a goal that pain would not interfere with her activities of daily living. Interventions included administering pain medication as prescribed and monitoring its effectiveness. A physician's order effective January 2, 2021, for Resident 61 to receive tramadol HCI tablet 50 mg (an opioid pain medication) with direction to give 50 mg orally one time a day at 6:00 PM for pain management. A clinical record review revealed a real-time medication administration record (the record indicates the actual time the resident received the medication) for Resident 61's tramadol HCI tablet 50 mg. The real-time medication record indicated Resident 61's tramadol HCI tablet 50 mg was administered late on the following dates and times: January 25, 2025, at 8:13 PM (2 hours and 13 minutes after the scheduled administration time) February 11, 2025, at 8:10 PM (2 hours and 10 minutes after the scheduled administration time) February 14, 2025, at 9:36 PM (3 hours and 36 minutes after the scheduled administration time) February 15, 2025, at 10:37 PM (4 hours and 37 minutes after the scheduled administration time) March 1, 2025, at 8:06 PM (2 hours and 6 minutes after the scheduled administration time) March 2, 2025, at 8:00 PM (2 hours after the scheduled administration time) During an interview on March 4, 2025, at 11:06 AM, Resident 61 indicated that her pain medications are sometimes administered late. She explained she takes pain medications at 6:00 PM to prevent her pain from disturbing her sleep. Resident 61 indicated that she usually falls asleep between 8:00 PM and 9:00 PM and when the medication is delayed, she is often awakened by staff administering the medication, which causes frustration. During an interview on March 6, 2025, at approximately 10:30 AM, the Director of Nursing (DON) confirmed Resident 61 was administered tramadol HCI Tablet 50 mg over 2 hours after the scheduled administration time on six separate occasions from January 25, 2025, through March 2, 2025. The DON confirmed it is the facility's responsibility to ensure pain management is provided to residents consistent with professional standards of practice, the residents' comprehensive care plan, and the residents' preferences. 28 Pa. Code 211.5 (f)(xi) Medical records. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of one of 24 residents sampled (Resident 10). Findings include: A review of clinical records revealed Resident 10 was admitted to the facility on [DATE], with diagnoses to include hypertension (blood pressure that is higher than normal) and atrial fibrillation (a condition that causes the heart to beat irregularly and occasionally much faster than normal). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 23, 2025, revealed that Resident 10 had moderately impaired cognition with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of a Consultant Pharmacist Medication Regimen Review dated November 2024 revealed that the consultant pharmacist identified irregularities in Resident 10's medication regimen, specifically noting the resident experienced six times the resident's heart rate was below 60 bpm (beats per minute) within a three-week period. The pharmacist recommended adding hold parameters to the resident's rate control medications to improve safety and prevent potential complications. Further review revealed that the facility's Certified Registered Nurse Practitioner (CRNP) responded to the pharmacy recommendation by noting to hold if HR (heart rate) is less than 60 bpm and notify the provider. However, the CRNP failed to specify which medication(s) this applied to, leaving the order ambiguous. Following questions asked during the survey with the Director of Nursing (DON) on March 6, 2025, at approximately 1:30 PM, it was identified that Resident 10's physician's order for Amiodarone HCL (an antiarrhythmic medication used for heart rate control) was revised to include the pharmacist's recommendations from November 20, 2024. However, a clinical record review revealed a discrepancy: A physician's order, written via telephone order by the DON, instructed staff to administer Amiodarone HCL 200 mg twice daily, with a hold parameter for HR less than 69 bpm, effective March 6, 2025. This did not align with the pharmacy's recommended hold parameter of HR less than 60 bpm, leading to a conflict in medication administration. A review of the Medication Administration Record (MAR) for March 2025 revealed that, on March 6, 2025, at 9:00 PM, the resident's recorded heart rate was 62 bpm, which resulted in the Amiodarone HCL being withheld, contrary to the pharmacist's recommendation. When questioned, the DON confirmed there was a data entry error when inputting the hold parameters and that the correct order should have specified a hold if HR was less than 60 bpm and not 69 bpm. During an interview with the DON on March 7, 2025, at approximately 9:35 AM, the DON confirmed the CRNP failed to accurately respond to the pharmacist's recommendation, leading to delayed and inaccurate medication orders. The DON further confirmed the order was corrected to reflect the appropriate hold parameters following the surveyor's inquiry. The facility failed to ensure that the attending physician/CRNP acted upon pharmacist-identified medication irregularities in a timely and accurate manner. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c)(d)(3) Nursing services.

Based on observation, clinical record review, and staff interviews it was determined the facility repeatedly failed to implement a resident's care plan for pressure relieving measures for one resident out of 25 sampled (Resident 85). Findings include: Review of Resident 85's clinical record revealed that the resident was admitted to the facility March 7, 2024, with diagnoses to include right femur (thigh) fracture and diabetes. Review of Resident 85's current comprehensive care plan initially dated March 8, 2024, indicated that the resident has potential for skin breakdown related to alteration in mobility. Review of the planned interventions failed to indicate that the resident's heels were to be floated over a pillow in bed. Observation on May 2, 2024, at 8:50 AM revealed that the resident was sleeping in bed with his heels directly on the mattress. A second observation on May 2, 2024, at 12:15 PM revealed the resident's heels again were directly on the mattress. Review of the resident's March 2024 through May 2, 2024 Task Report revealed an intervention that staff were to position the resident's heels over a pillow while the resident was in bed. Interview with Employee 5 (nurse aide) on May 2, 2024, at 12:20 PM confirmed that Resident 85's heels were directly on the mattress despite the resident's Task Report and care plan indicating that his heels should be floated over a pillow. Interview with the director of nursing (DON) on May 2, 2024, at 12:45 PM confirmed that Resident 85's heels were to be floated over a pillow while in bed. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care consistent with professional standards of practice by failing to follow physician orders for medication administration for four residents (Residents 69, 85, 90 and 100) out of 25 sampled Findings included: A clinical record review revealed that Resident 100 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs) and hypertension (a condition where the body's blood pressure is higher than normal). The resident had a physician order to receive Metoprolol Tartrate Tablet 50 MG with instructions to give 50 mg by mouth two times a day related to hypertension and to hold the medication if the resident's systolic blood pressure is less than 110 mmHg or her heart rate is less than 60 beats per minute was initiated on July 10, 2023, and discontinued on July 29, 2023. A review of the Medication Administration Record (MAR) from July 1, 2023, through July 29, 2023 revealed that staff administered Metoprolol Tartrate to Resident 100 on four ocassions for blood pressure readings lower than the physician prescribed paramaters (July 15, 2023 at 8:00 AM 104/66 mmHg; July 12, 2023, at 8:00 PM 106/56 mmHg; July 21, 2023, at 8:00 PM 90/54 mmHg and July 28, 2023 at 8:00 AM 100/68 mmHg During an interview on May 2, 2024, at approximately 2:00 PM, the DON confirmed that it is the facility's responsibility to provide care consistent with professional standards of practice, including administering medication within the parameters of a physician's orders. A review of the clinical record revealed that Resident 85 had diagnoses that included hypotension (low blood pressure). The resident had a physician order dated March 16, 2024, for Midodrine (works by causing blood vessels to tighten which increase blood pressure) 5 mg one tablet by mouth daily for a diagnosis of low blood pressure. Hold the medication if systolic blood pressure ([SBP] top number- the maximum pressure the heart exerts while beating) is greater than 130. (Blood pressure is measured in units of millimeters of mercury (mmHg). The readings are always given in pairs, with the upper (systolic) value first, followed by the lower (diastolic - [DBP]) value). The resident also had physician order dated March 8, 2024, for staff to obtain vital signs (which included a blood pressure) daily on the evening shift. Review of Resident 85's March 2024 MAR from March 16, 2024, through March 31, 2024, revealed that nursing staff administered Midodrine 5 mg was administered daily at 8:00 AM without documented evidence that staff obtained the resident's blood pressure prior to administration to assure necessity of administration according to the physician prescribed parameters. Review of Resident 85's April 2024 MAR revealed that on April 1, 2024, staff were unable to administer Midodrine 5 mg as the facility was awaiting delivery of the medication. Review of April 2 through April 30, 2024, revealed that nursing staff administered Midodrine 5 mg was administered daily at 8:00 AM without documented evidence that staff obtained the resident's blood pressure prior to administration to assure necessity of administration according to the physician prescribed parameters. Review of Resident 85's May 1 through 3, 2024 MAR revealed that nursing staff administered Midodrine 5 mg was administered daily at 8:00 AM without documented evidence that staff obtained the resident's blood pressure prior to administration to assure necessity of administration according to the physician prescribed parameters. A review of the clinical record revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses that included epileptic seizures and dependence on supplemental oxygen. heart failure (a condition that develops when the heart doesn't pump enough blood to meet the body's needs) and hypertension (a condition where the body's blood pressure is higher than normal). A physician's order dated January 26, 2024, at 10:20 AM was noted for the resident to receive Midodrine HCL 2.5 milligram (mg) by mouth three times a day for hypotension with parameters to hold the medication if systolic blood pressure (SBP) is greater than 120. The resident's MARs for the months of February 2024, March 2024 and April 2024 revealed that nursing staff administered the Midodrine HCL 2.5 mg for blood pressure readings above the physician prescribed paramaters on the following dates at times: February 5th, 2024 at 3:30 PM, 128/68 February 16th at 12:00 PM, 122/78 February 21st at 12:00 PM, 123/70 March 6th, at 3:30 PM, 141/56 March 29th at 12:00 PM, 122/74 April 17th at 6:00 AM, 122/70 April 17th at 12:00 PM, 122/70 April 18th, 2024 at 12:00 PM, 124/68 A review of the resident's February 2024 revealed that nursing staff held the medication on the following dates despite the resident's systolic blood pressure reading being below 120: February 24th at 12:00 PM, 107/68 February 26th at 12:00 PM, 101/64 A clinical record review revealed that Resident 90 was admitted to the facility on [DATE], with diagnoses that included chronic diastolic (the pressure of the blood against the artery walls while the heart is resting between beats) congested heart failure, chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and hypotension. A physician's order dated November 18, 2023, at 4:52 PM indicated Metoprolol Tartrate 12.5 milligrams (mg) by mouth two times a day related to hypertension with parameters to hold the medication if the resident's systolic blood pressure (SBP) is less than 100, diastolic blood pressure is less than 60, or heart rate is less than 55 beats per minute. A review of the resident's medication administration records and clinical record from November 2023, through April 2024, revealed no evidence that staff obtained the resident's heart rate prior to administration of the Metoprolol Tartrate 12.5 mg. The resident also had a physician order dated November 18, 2023, at 4:52 PM for Midodrine HCL 5 mg by mouth related to hypotension with parameters to hold if the resident's BP is greater than 130/90. A review of MAR for February 2024, March 2024 and April 2024 revealed that staff administered the medication to the resident on the following occassions for blood pressure readings greater than 130/90 February 2nd at 10:00 AM, 131/78 February 3rd at 6:00 PM, 134/84 February 4th at 6:00 PM, 139/61 February 8th at 6:00 PM, 182/80 February 13th at 6:00 PM, 134/85 February 14th at 6:00 PM, 145/74 February 17th at 6:00 PM, 145/74 February 20th at 6:00 PM, 157/78 February 22nd at 2:00 PM, 134/90 February 26th at 6:00 PM, 157/65 February 27th at 6:00 PM, 157/73 February 29th at 2:00 PM, 133/87 March 3rd at 6:00 PM, 156/90 March 5th at 2:00 PM, 136/82 and at 6:00 PM, 136/71 March 7th at 6:00 PM, 158/80 March 9th at 6:00 PM, 176/88 March 16th at 6:00 PM, 151/69 March 17th at 6:00 PM, 145/81 March 20th at 6:00 PM, 135/72 March 23rd at 2:00 PM, 133/84 March 24th at 6:00 PM, 135/88 March 25th at 2:00 PM, 133/88 and at 6:00 PM, 139/85 March 26th at 2:00 PM, 133/72 and at 6:00 PM, 131/69 March 27th at 6:00 PM, 147/79 March 28th at 6:00 PM, 138/63 March 29th at 10:00 AM, 132/90 and at 2:00 PM, 134/86 April 2nd at 6:00 PM, 134/78 April 3rd at 10:00 AM, 134/78 and at 6:00 PM, 131/80 April 4th at 10:00 AM, 133/70 and at 2:00 PM, 134/82 and at 6:00 PM, 156/80 April 5th at 2:00 PM, 136/80 April 6th at 2:00 PM, 133/88 April 8th at 2:00 PM, 133/88 and at 6:00 PM, 133/84 April 10th at 6:00 PM, 133/77 April 11th at 2:00 PM, 132/78 and at 6:00 PM, 180/80 April 12th at 10:00 AM, 143/78 and at 2:00 PM, 138/80 April 13th at 2:00 PM, 131/82 and at 6:00 PM, 149/81 April 15th at 10:00 AM, 147/78 and at 2:00 PM, 142/80 and at 6:00 PM, 178/88 April 16th at 2:00 PM, 138/88 April 17th at 6:00 PM, 139/86 April 18th at 2:00 PM, 134/78 and at 6:00 PM, 132/77 April 21st at 10:00 AM, 132/78 April 22nd at 2:00 PM, 133/72 and at 6:00 PM, 131/80 April 23rd at 2:00 PM, 133/72 and at 6:00 PM, 137/71 April 24th at 10:00 AM, 127/70 April 25th at 2:00 PM, 133/72 and at 6:00 PM, 133/75 April 27th at 2:00 PM, 137/92 April 28th at 2:00 PM, 131/74 and at 6:00 PM, 134/82 April 29th at 2:00 PM, 132/74 and at 6:00 PM, 138/74 April 30th at 6:00 PM, 151/72 During an interview on May 2, 2024, at 9:00 AM with Resident 90 the resident stated that the nurses don't always check her blood pressure or heart rate before giving her medications. During an interview on May 3, 2024, at approximately 12:00 PM the DON confirmed that the expectation was for staff to measure a resident's BP and heart rate prior to administering a medication with specific physician prescribed parameters. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records

Based on observation, a review of clinical records, and staff and resident interviews it was determined that the facility failed to provide and/or efficiently deploy sufficient nursing staff to consistently provide timely and quality of care to residents, including timely provision of assistance to residents requiring the assistance of two nursing staff members for activities of daily living as evidenced by four out of 25 sampled residents (Residents 78, 80, 94 and 161). Findings include: An observation on April 30, 2024 at 6:30 PM revealed that the resident in resident room [ROOM NUMBER]-B was ringing their call bell for assistance for 26 minutes. At 6:56 PM the surveyor informed Employee 7, Licensed Practical Nurse (LPN) and Employee 8, LPN, who were observed seated in the nursing station while the resident's call bell was ringing, that the resident's call bell was ringing and that Resident 26 was requesting a drink of water and for their meal tray to be removed from their bedside so that they could go to sleep. During an interview on April 30, 2024, at approximately 6:45 PM, Employee 4, Nurse Aide, stated that when there are four nurse aides working on the unit, there is enough help to assist the patients with their needs. Employee 4, Nurse Aide, explained that when there are less than four nurse aides, they are not able to promptly address the needs of the residents. Employee 4, Nurse Aide, confirmed the surveyor's observations, that the Licensed Practical Nurses (LPN) do not assist with direct resident care duties that are assigned to the nurse aide. Employee 4, Nurse Aide, explained that LPNs do not assist the nurse aides when the facility is short on staff or when the LPNs are assigned to work as nurse aides to meet staffing ratios. A review of the clinical record revealed that Resident 78 was admitted to the facility on [DATE], and had diagnoses that include hemiplegia (paralysis of one side) and hemiparesis (muscular weakness or partial paralysis restricted to one side) following cerebral infarction ([stroke] a process that results in an area of necrotic [death of most or all cells] tissue in the brain) and osteoarthritis ([OA] long term degenerative joint condition when the tissue and parts of the joint gradually deteriorate). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated March 14, 2024, indicated that the resident was cognitively intact with a BIMS [Brief Interview of Mental Status-a tool to assess cognitive function] score of 15 (a score of 13-15 indicates intact cognition), and requires extensive assistance from staff with activities of daily living (transfers, dressing, toileting). During an interview with Resident 78 on May 1, 2024, at 9:50 AM the resident stated that she has had to wait extended periods of time for nursing staff to answer her call bell and assist her to the toilet. The resident stated that she has waited over 45 minutes and became upset because she cannot transfer independently and requires staff to assist her. A review of the clinical record revealed that Resident 80 was admitted to the facility on [DATE], and had diagnoses that include other abnormalities of gait and mobility, unsteadiness on feet, difficulty walking, and muscle weakness. A quarterly MDS dated [DATE], indicated that the resident was moderately cognitively impaired with a BIMS of 10, and requires extensive assistance from staff with activities of daily living (transfers, dressing, toileting). During an interview with Resident 80 on May 1, 2024, at 9:03 AM the resident stated that she has waited an entire morning for nursing staff to answer her call and most of the afternoon, stating it was approximately 5.5 hours. The resident stated that nursing staff assisted her roommate but continued to ignore her call bell. She said she was calling for assistance to get dressed and get out of bed. A review of the clinical record revealed that Resident 94 was admitted to the facility on [DATE], with diagnoses that included a right femur (thigh bone) fracture. An admission MDS assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 15. Review of the resident's care plan initially dated April 19, 2024, indicated that the resident required the assistance of one staff for transfers and toileting. During interview with Resident 94 on May 1, 2024, at 12:05 PM the resident stated that even though she would like and needs the help of staff, that at times she transfers herself to the toilet because she can't wait 45 minutes for nursing staff to answer her call bell when she needs to go to the bathroom. Resident 94 stated that it often takes longer than 15 minutes for the call bell to be answered which is a long time when you have to use the toilet. Review of the clinical record revealed that Resident 161 was admitted to the facility on [DATE], with diagnoses that included third lumbar vertebra fracture (fracture of the spine). An admission Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 14 and required the assistance of two staff for bed mobility, transfers, and toileting. During interview with Resident 161 on May 3, 2024, at 9:00 AM the resident stated that the other night she had to yell for help because no one was answering her call bell. Resident 61 stated at times that she had to wait a long time for the call bell to be answered. The facility failed to provide and/or efficiently deploy sufficient nursing staff to provide timely care and assistance to residents as assessed including providing care to meet the needs of Residents 78, 80, 94, and 161 in a timely manner to promote the residents' mental and physical well-being. Interview with the Director of Nursing (DON) on May 3, 2024, at approximately 11:30 AM, confirmed that call bells were to answered promptly and that sufficient nursing staff were to be deployed in a manner to ensure residents' needs are timely met. 28 Pa. Code 211.12(c)(d)(1)(3)(4)(5) Nursing services 28 Pa. Code 201.18(e)(1) Management

Based on observation, review of the minutes from Resident Council Meetings, scheduled facility mealtimes, and select facility policy, and resident and staff interviews it was determined that the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including eight residents of 25 sampled (Resident 7, 10, 57, 61, 64, 78, 90 and 104). Findings include: Review of the facility's policy titled Snacks Policy, last reviewed October 2, 2023, indicated that a variety of snacks are available on the units throughout the day. Residents able to consume oral feedings will be offered a nutritious bedtime snack. Review of the facility's scheduled meal times revealed 15 hours between the evening meal and the next day's breakfast meal. Review of Resident Council Meeting minutes dated from February 21, 2024, March 28, 2024, and April 24, 2024, revealed that a meeting topic of snacks was discussed during these meetings. When asked if the residents were being offered a snack after dinner in the evening, most residents responded no, and some that they did not want a snack. During a tour of the facility, observations on April 30, 2024, at 7:24 PM revealed on the fourth floor, Hallway D (resident rooms 428 - 434) snacks were not observed to have been provided to the residents that evening. During an interview with Resident 57 on April 30, 2024, at 7:29 PM the resident stated that the resident does not receive bedtime snacks nor is a snack offered in the evening. During an interview with Resident 104 on April 30, 2024, at 7:33 PM the resident stated that if you want a snack you have to ask the staff, because they do not just automatically bring one or offer one. During an interview with Employee 6, nurse aide, on April 30, 2024, at 7:34 PM Employee 6 stated that if the resident snacks came up from dietary, they would be in the nurse's station. Residents receive snacks from dietary or from the pantry on the floor if requested. Observations at that time revealed no evidence of snacks being delivered to the fourth floor. During an interview with Resident 61 on April 30, 2024, at 9:00 AM the resident stated that the resident has never been offered a bedtime snack. During an interview with Resident 7 on April 30, 2024, at 9:23 AM the resident stated the resident had never been offered a snack in the evening. During an interview with Resident 78 on April 30, 2024, at 9:50 AM the resident stated that they have to ask for a snack before bedtime if they want one. During a group interview with five alert and oriented residents on May 2, 2024, at 10:00 AM, three of the five residents (Residents 64, 10, and 90) in attendance stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. Resident 10 reported that when he has requested a snack, one is provided for him. Interview with the foodservice director (FSD) on May 3, 2024, at 12:30 PM confirmed that there was greater than 14 hours between supper and breakfast the next day. The FSD confirmed that bedtime snacks were to be offered to residents. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on a review of clinical records, facility policy, and the facility's infection assessment tool, and staff interview it was determined that the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use for two residents out of 25 sampled. (Resident 54 and 61) Findings included: Review of a facility policy entitled Antibiotic Stewardship last reviewed October 2, 2023, indicated improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Education - provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use. Cultures are ordered when indicated and microbiology reports are received by the unit, the pharmacy and the infection control office directly from the contracted laboratory. These are monitored for appropriate antibiotic selection. Minimum criteria for initiation of antibiotics is based on the McGeer criteria. Review of a facility policy entitled Surveillance, Infection Control and Prevention last reviewed October 2, 2023, indicated the goal of the facility is to do surveillance of infections to prevent the spread among residents. The infection preventionist or designee will do surveillance of infections among residents by reviewing culture reports and other pertinent lab data, chart review, review of 24-hour report and physician consultation. Documentation is maintained on a line listing of resident's infections. SBAR used to identify infections using McGeer criteria. Review of McGeer Criteria for urinary tract infection ([UTI] an infection of the urinary system), surveillance indicates that UTI without indwelling catheter must fulfill both one and two under criteria which is listed as the following: One: at least one of the following sign or symptoms; acute dysuria (painful urination) or pain, swelling, or tenderness of testes, epididymis, or prostate. Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria (blood in urine), new or marked increased incontinence (involuntary urination), urgency, or frequency. If no fever or leukocytosis, then two or more of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency, or frequency. Two: at least one of the following microbiologic criteria; greater than or equal to 10^5 CFU (colony-forming-unit the estimated number of microbial cells)/milliliter (ml) of no more than two species of organisms in a voided urine sample or 10^2 CFU/ml of any organism(s) in a specimen collected by an in-and-out catheter. Urine specimens for culture should be processed as soon as possible preferably within one to two hours, if the specimen is not processed within 30 minutes of collection they should be refrigerated and used for culture within 24 hours. A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], and had diagnoses that include urinary tract infection ([UTI] an infection of the urinary system), urinary incontinence (involuntary urination) and chronic kidney disease stage three (classified in five stages depending on the amount of permanent damage the kidney has sustained that will include symptoms including frequent urination and changes to the color of the urine). A facility communication tool, SBAR (situation-background-assessment-recommendation) Suspected Infections - V6 documentation dated October 17, 2023, (no time) revealed that resident had a suspected infection of UTI, the date the symptoms were identified were October 16, 2023. The most recent vital signs documented included: blood pressure 118/76 on October 13, 2023, at 1:17 PM, temperature 97.8 degrees on October 15, 2023, at 12:59 AM, pulse 76 on June 23, 2023, at 10:12 AM, respiration 17 on October 23, 2023, at 10:12 AM, oxygen saturation 97 % on room air on August 6, 2023, at 11:56 PM. Comments or related information the resident is incontinent the incontinence is new or worsening, the resident does not have an indwelling catheter. Protocol criteria not met resident does not need an immediate prescription for an antibiotic but may need additional observation. New orders received from the provider for urinalysis ([UA] is an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection), culture and sensitivity ([C & S] identifies the organisms create infections and illnesses. Sensitivity tests to identify the most effective medications to treat the illnesses or infections). A review of a laboratory report for a urinalysis dated October 17, 2023, at 10:33 AM revealed abnormal results, with clarity turbid, small amount of blood, large esterase, 10-19 red blood cells (RBC), WBC (white blood cell) clumps present. A physician's order dated October 17, 2023, at 5:21 PM was noted for Ceftriaxone Sodium Solution reconstituted one gram; inject one gram intramuscularly (IM) one time a day for U/A results (follow-up with end date when C&S results obtained) for administration mix with Lidocaine 1% 2.1 ml. A review of physician's progress note dated October 17, 2023, at 7:25 PM revealed pending UA/C&S report would start resident on Rocephin (Ceftriaxone) one gram IM daily since her mental status change might be to UTI. After cultures come back antibiotic would be changed if necessary. Further review of urine culture results dated October 21, 2023, at 3:44 PM revealed abnormal results of greater than 100,000 colonies/milliliter (ml) Klebsiella pneumoniae (a bacteria that normally lives in your intestines and feces that causes infection in the urinary tract and also has a high tendency to become antibiotic resistant) ESBL (extended-spectrum beta-lactamase - a type of enzyme produced by certain bacteria that makes them resistant to commonly used antibiotics) producing organism. This resident may require isolation (precautions taken to prevent the spread of an infectious agent from an infected or colonized person to susceptible persons). Greater than 10,000 - 100,000 colonies/ml proteus mirabilis (a gram-negative bacteria found in human intestinal tract causes UTI) and 10,000 - 100,000 colonies/ml enterococcus species (a bacteria that causes infections in humans). Ceftriaxone (antibiotic medication) showed to be resistant (the antibiotic medication cannot kill the pathogen and stop their growth). A review of nursing progress notes dated October 22, 2023, at 6:44 PM revealed the physician was called regarding the C&S results and resistance to ceftriaxone and the resident's behaviors and poor intake of food, fluids, and medications. New orders to send the resident to the Emergency Department (ED) for evaluation. A review of nursing progress notes dated October 23, 2023, at 2:36 AM revealed the resident returned from the ED. A physician's order dated October 23, 2023, at 1:10 PM indicated Ertapenem (antibiotic medication) Sodium Injection Solution reconstituted inject 500 mg intramuscularly (IM) one time a day for UTI infection for five days. A review of the Medication Administration Record (MAR) for the month of October 2023, revealed that the resident received five unnecessary doses of Ceftriaxone one gm IM. There was no documented evidence that the facility McGeer Assessment Tool referenced in the facility Antibiotic Stewardship policy for a Urinary Tract Infection was completed and applied to Resident 54 to prevent use of an unnecessary antibiotic use. An interview with the director of nursing on May 3, 2024, at 1:29 PM failed to provide documented evidence that the facility's chosen McGeer Assessment Tool for a Urinary Tract Infection was used to ensure the administration of Ceftriaxone was clinically indicated and the clinical necessity of initiating the antibiotic prior to and based on the urinalysis C&S results. A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], and had diagnoses that include unspecified abnormalities of gait and mobility and muscle weakness. Review of nursing progress note dated February 13, 2024, at 2:35 AM revealed the nurse was called to the resident's room to observe the resident's urine which was cranberry in color. Resident's abdomen was not distended, no pain noted upon palpation (touch). The resident denies pain when urinating. Physician notified new orders for UA and C&S, and representative notified. No vital signs were documented. SBAR Suspected Infections - V6 documentation dated February 15, 2024, (no time) revealed the resident had a suspected infection of UTI, the date the symptoms were identified were February 13, 2024. The most recent vital signs documented included: blood pressure 120/60 on December 28, 2023, at 2:09 PM, temperature 97 degrees on February 12, 2024, at 10:28 AM, pulse 84 on December 28, 2023, at 2:09 PM, respiration 16, on December 28, 2023, at 2:09 PM, oxygen saturation 95 % on room air on February 12, 2024, at 10:28 AM. The resident does not have an indwelling catheter is not incontinent or on dialysis. The resident does not have a fever, but two or more of the symptoms below including urgency (sudden and frequent strong urges to pass urine) and gross hematuria (blood in urine). Protocol criteria met resident may require UA/C&S or an antibiotic. New orders received from the provider that include UA/C&S and antibiotic therapy. A physician's order dated February 14, 2024, at 12:38 PM indicates Ciprofloxacin HCL([Cipro] antibiotic medication) 500 mg by mouth twice daily for UTI. Further review of urine culture results dated February 16, 2024, at 2:15 PM revealed abnormal results of greater than 100,000 colonies/ml enterococcus species. Cipro was not indicated on the susceptibility panel. A nursing progress note dated February 16, 2024, at 8:39 PM revealed UA/C&S results received at this time, call placed to Physician with new orders to discontinue Cipro and start Macrobid 100 mg by mouth twice daily for UTI, resident representative aware. A physician's order dated February 16, 2024, at 8:42 PM indicated Nitrofurantoin Monohyd Macro Capsule (Macrobid - antibiotic medication) 100 mg by mouth twice daily for seven days related to UTI. A review of MAR for the month of February 2024, revealed that the resident received five unnecessary doses of Cipro. There was no documented evidence that the facility McGeer Assessment Tool referenced in the facility Antibiotic stewardship policy for a Urinary Tract Infection was completed and applied to Resident 61 to prevent use of an unnecessary antibiotic use. SBAR Suspected Infections - V6 documentation for Resident 61 dated February 26, 2024, (no time) revealed the resident had a suspected infection of UTI, the date the symptoms were identified were February 27, 2024. The most recent vital signs documented included: blood pressure 107/54 on March 20, 2024, at 9:07 PM, temperature 97.8 degrees on March 26, 2024, at 8:08 AM, pulse 88 on March 12, 2024, at 6:45 PM, respiration 20, on March 12, 2024, at 6:45 PM, oxygen saturation 97 % on room air on March 26, 2024, at 8:08 AM. The resident is not incontinent or on dialysis. The resident does not have a fever but two or more of the symptoms below that include gross hematuria. The documentation only indicates one not two symptoms. Protocol criteria met resident may require UA/C&S or an antibiotic. Interventions included a UA, C&S and notify the provider if symptoms worsen or are unresolved. New orders received from the provider UA/C&S and notify provider if symptoms worsen or are unresolved. A nursing progress note dated February 27, 2024, at 8:11 PM revealed new order to repeat UA, C&S. A review of a laboratory report for a urinalysis dated February 28, 2024, at 9:18 PM revealed the results as abnormal with the color to be noted as yellow and cloudy, a small amount of blood, large amount of esterase, 30-49 RBCs, 50+ white blood cells (WBCs), bacteria and WBC clumps in present. A physician's order dated February 29, 2024, at 6:37 PM indicated Cipro 500 mg by mouth every 12 hours for UTI for 7 days. A nursing progress note dated February 29, 2024, at 7:39 PM revealed UA results sent to physician for review new order via fax for Cipro 500 mg by mouth twice daily for seven days and follow-up with final C&S for new medication if medication is not listed as sensitive. Further review of urine culture results dated March 1, 2024, at 8:07 AM revealed abnormal results of greater than 100,000 colonies/ml enterococcus species. Cipro was not indicated on the susceptibility panel. A physician's order dated March 1, 2024, at 2:50 PM indicated Ampicillin 500 mg by mouth four times daily for UTI for 10 days. A review of the MAR for the month of February 2024 revealed the resident received two unnecessary doses of Cipro. There was no documented evidence that the facility McGeer Assessment Tool referenced in the facility Antibiotic Stewardship policy for a Urinary Tract Infection was completed and applied to Resident 61 to prevent use of an unnecessary antibiotic. An interview with the director of nursing on May 3, 2024, at 1:29 PM failed to provide documented evidence that the facility's chosen McGeer Assessment Tool for a Urinary Tract Infection was used to ensure the administration of Cipro for Resident 61 was clinically indicated prior to receiving the urinalysis C&S results. There was no evidence that the facility consistently followed McGeer Criteria prior to initiating antibiotic therapy for Resident 54 and Resident 61 failing to follow its Antibiotic Stewardship policy to improve antibiotic prescribing, administration, and management practices to reduce inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. Refer F757 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to demonstrate that residents are consistently afforded the right to participate in their treatment plans to include the resident's preferences for diabetes management for one resident out of 25 sampled (Resident 36). Findings included: A review of the clinical record review revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (a condition where the body is unable to produce enough of the hormone insulin to maintain normal blood sugar levels) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). The resident had a current physician's order, initially dated August 28, 2022, for NovoLog Solution 100 unit/ml (Insulin Aspart) with instructions for Resident 36 to receive this insulin per a sliding scale based on the resident's blood glucose level as follows if the resident's blood sugar ranged 151 - 200 = administer 1 unit of Novolog insulin; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 5; 401+ = 6 401 or greater, give 6 units and notify the physician( subcutaneously before meals for diabetes). A review of the resident's Medication Administration Record from October 1, 2023, through December 31, 2023, revealed zero instances of Resident 36 refusing to allow staff to perform blood glucose (blood sugar) monitoring. A review of the Medication Administration Record from February 1, 2024, through April 30, 2024, revealed that on 46 occassions during these months, Resident 36 refused to allow the facility staff to perform a blood glucose (blood sugar) check and to administer NovoLog Solution 100 units/ml, if applicable, on the following dates and times: February 1, 2024 at 11:30 AM February 3 at 11:30 AM February 7 at 8:00 AM March 6 at 7:30 AM March 11 at 11:30 AM March 11 at 4:30 PM March 12 at 7:30 AM March 14 at 7:30 AM March 14 at 11:30 AM March 18 at 11:30 AM March 19 at 4:30 PM March 22 at 11:30 AM March 22 at 4:30 PM March 23 at 7:30 AM March 25 at 4:30 PM March 27 at 11:30 AM March 28 at 11:30 AM March 28 at 4:30 PM March 29 at 4:30 PM April 3 at 11:30 AM April 6 at 11:30 AM April 6 at 4:30 PM April 4 at 7:30 AM April 7 at 11:30 AM April 9 at 11:30 AM April 10 at 7:30 AM April 11 at 11:30 AM April 12 at 11:30 AM April 15 at 7:30 AM April 15 at 11:30 AM April 16 at 7:30 AM April 19 at 7:30 AM April 19 at 4:30 PM April 20 at 11:30 AM April 21 at 7:30 AM April 21 at 11:30 AM April 24 at 7:30 AM April 24 at 11:30 AM April 24 at 4:30 PM April 25 at 7:30 AM April 25 at 11:30 AM April 27 at 7:30 AM April 27 at 11:30 AM April 28 at 7:30 AM April 29 at 7:30 AM April 30, 2024 at 11:30 AM During an interview on May 1, 2024, at 12:28 PM, Resident 36 stated that she takes her medications, but some of them she does not like. Resident 36 explained that she does not like to get the needle in her finger because it hurts (a needle is utilized to draw blood to monitor blood sugar levels prior to the administration of insulin, if applicable). She stated that the needle that the facility uses in the past to obtain her blood sugar reading, didn't hurt, but the new needle causes her pain that lasts for two days. Resident 36 stated that she often refuses to allow staff to check her blood sugar because of the pain the needle causes. She explained that she has told the nursing staff about this, but they still give her the needle that hurts her fingers. During an interview on May 2, 2024, at approximately 2:00 PM, the Director of Nursing (DON) was unable to provide evidence that the facility attempted to discover the reason for the resident's refusal to have staff perform blood sugar monitoring that began during February 2024, that was necessary to administer NovoLog Solution 100 units/ml (Insulin Aspart) when applicable. The DON stated that the facility was able to utilize a different needle for Resident 36's blood sugar monitoring following surveyor inquiry during the survey ending May 3, 2024. 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 201.29 (a) Resident rights

Based on observation, review of select facility policy and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication (saline nasal spray solution) for one of 25 residents reviewed (Resident 26). Findings include: A review of facility policy titled Procedure for Medication Administration, and Self Administration of Medications, last reviewed by the facility October 2, 2023, indicated it is the policy to safely administer medications to the resident as ordered by the physician. Medications are not to be left bedside. A review of the facility policy titled Self Administration of Medications, last reviewed October 2, 2023, indicated it is the policy to promote the right of the resident to self-administer drugs unless the interdisciplinary team (IDT) has determined that this practice would be unsafe. If the resident wishes to self-administer medications, the IDT will review the nursing assessment, resident's cognitive, physical, and visual ability to carry out this responsibility. If it is determined by the IDT that the resident is able to exercise this right, it will be documented on the Annual Status of Resident Self Administration of Medications form, and the charge nurse will establish a plan to instruct the resident regarding his/her medications. This plan will be documented in the residents care plan. The resident may begin self-administration after the instructions and understanding of the instructions has been demonstrated. This will be documented in the nursing notes. Medications must be locked in a cabinet or drawer. Review of Resident 26's clinical record revealed admission on January 18, 2024, with diagnoses to include Chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe) and chronic respiratory failure (condition that occurs when lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body resulting in trouble breathing). The resident was assessed as cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). A physician's order dated January 26, 2024, was noted for Saline Nasal Spray Solution: one spray in each nostril every 2 hours as needed for congestion. The physician order was discontinued on March 28, 2024. During observation and interview with Resident 26 in her room on April 30, 2024, at 7:45 PM, an opened saline nasal spray solution bottle was observed on the resident's bedside table next to her personal items. During the interview, the resident stated that nursing staff left the bottle of saline nasal spray for her to self-administer. She reported that she has been using the saline nasal spray bottle has at the bedside for approximately 2 months. A second observation of Resident 26 on May 1, 2024, at 9:12 AM, revealed the saline nasal spray bottle remained on the resident's bedside table next to personal items. A third observation of the resident on May 2, 2024, at 1:25 PM, in the presence of Employee 1 (licensed practical nurse) confirmed that the saline nasal spray solution bottle was on the resident's bedside table next to personal items. Employee 1 confirmed that Resident 26 does self-administer the saline nasal spray and the physician order for the resident's use was discontinued on March 28, 2024. During an interview on May 2, 2024, at approximately 1:30 PM, with Employee 1, she confirmed that the resident's clinical record contained no physician order for Resident 26 to continue to use, and self-administer the saline nasal spray, no self-administration assessment of the resident's ability to self-administer, and no care plan indicating that the resident does self-administer the product. Employee 1 further confirmed that the physician's order for the resident's use of the saline nasal spray was discontinued on March 28, 2024, but that the saline nasal spray provided by the facility remained at the resident's bedside for the resident's use. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and staff interview, it was determined that the facility failed to provided individualized care for a resident with a diagnosis of PTSD for one out of the 25 residents sampled (Resident 21). Findings include: A clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that included Post-Traumatic Stress Disorder (PTSD- a mental health condition that develops after experiencing a terrifying event, causing symptoms such as flashbacks, nightmares, and severe anxiety). The resident's care noted the resident's diagnosis of PTSD with a history of trauma related to a past car accident, implemented on April 15, 2020, with interventions of enlisting family as needed, offering a change of scenery, reminiscing about past events such as work and family life, offering time to verbalize her feelings and concerns, using social services to follow up as needed or requested, and having a psych consultation in place as needed or requested. A clinical record review revealed an outside provider medication management note dated May 3, 2023, indicating that Resident 21 had a history of anxiety, depression, and PTSD due to an abusive relationship with her husband. The note indicated that the resident received services from an outside counseling service prior to her admission to the facility, she experienced overwhelming feelings and distressful memories during attempts to reduce her medications in the past. A review of an outside provider medication management note dated May 17, 2023, indicated that Resident 21 admitted to feeling more anxiety and worry lately and did not sleep well after experiencing a nightmare. During an interview on May 2, 2024, at approximately 2:00 PM, the Director of Nursing (DON) was unable to explain the discrepancy between Resident 21's medication management notes indicating the resident's PTSD was related to a history of abuse and the resident's care plan indicating PTSD related to a car accident. The DON was unable to provide evidence that Resident 21 was accurately assessed for a risk of re-traumatization or screened for triggers that may cause re-traumatization. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for one out of 25 residents sampled (Resident 61). Findings included: A review of the clinical record revealed that Resident 61 was admitted to the facility on [DATE], and had diagnoses that include unspecified abnormalities of gait and mobility and muscle weakness. Review of nursing progress note dated February 13, 2024, at 2:35 AM revealed that the resident's urine was cranberry in color. Resident's abdomen was not distended, no pain noted upon palpation (touch). The resident denies pain when urinating. Physician notified new orders for UA and C&S, and representative notified. No vital signs were documented. SBAR Suspected Infections - V6 documentation dated February 15, 2024, revealed that new orders were received from the provider that included a UA/C&S and antibiotic therapy. A physician's order dated February 14, 2024, at 12:38 PM was noted for Ciprofloxacin HCL([Cipro] antibiotic medication) 500 mg by mouth twice daily for UTI. The urine culture results dated February 16, 2024, at 2:15 PM revealed abnormal results of greater than 100,000 colonies/ml enterococcus species, but Cipro was not indicated on the susceptibility panel. A nursing progress note dated February 16, 2024, at 8:39 PM revealed UA/C&S results were received at this time, call placed to Physician with new orders to discontinue Cipro and start Macrobid 100 mg by mouth twice daily for UTI, resident representative aware. A physician's order dated February 16, 2024, at 8:42 PM was noted for Nitrofurantoin Monohyd Macro Capsule (Macrobid - antibiotic medication) 100 mg by mouth twice daily for seven days related to UTI. A review of the resident's MAR for the month of February 2024, revealed that the resident received five unnecessary doses of Cipro. SBAR Suspected Infections - V6 documentation dated February 26, 2024, revealed new orders received from the provider UA/C&S and notify provider if symptoms worsen or are unresolved. A nursing progress note dated February 27, 2024, at 8:11 PM revealed a new order to repeat UA, C&S. A review of a laboratory report for a urinalysis dated February 28, 2024, at 9:18 PM revealed the results as abnormal with the color to be noted as yellow and cloudy, a small amount of blood, large amount of esterase, 30-49 RBCs, 50+ white blood cells (WBCs), bacteria and WBC clumps in present. A physician's order dated February 29, 2024, at 6:37 PM was noted for Cipro 500 mg by mouth every 12 hours for UTI for 7 days. The urine culture results dated March 1, 2024, at 8:07 AM revealed abnormal results of greater than 100,000 colonies/ml enterococcus species and Cipro was not indicated on the susceptibility panel. A physician's order dated March 1, 2024, at 2:50 PM was noted for Ampicillin 500 mg by mouth four times daily for UTI for 10 days. A review of the MAR for the month of February 2024 revealed the resident received two unnecessary doses of Cipro. During an interview on May 3, 2024, at 1:29 PM, with the Director of Nursing (DON) confirmed that Residents 61 was not free from unnecessary antibiotic medications. Refer 881 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.5 (f) Medical records

Based on a review of select facility policy and clinical records and staff interviews it was determined that the facility failed to timely notify the physician of abnormal lab results for one resident out of 25 sampled (Resident 54). Findings included: A review of facility policy entitled Change in Resident's Condition: Resident, Physician and Resident Representative Notification last reviewed October 2, 2023, indicated that nursing will assess the resident and make proper documentation as to the resident's condition. Critical and sub-therapeutic lab values along with abnormal diagnostic studies require physician notification and response this can be done via fax or phone message. A review of the clinical record revealed that Resident 54 was admitted to the facility on [DATE], and had diagnoses that include urinary tract infection ([UTI] an infection of the urinary system), urinary incontinence (involuntary urination) and chronic kidney disease stage three (classified in five stages depending on the amount of permanent damage the kidney has sustained that will include symptoms including frequent urination and changes to the color of the urine). A review of nursing progress notes dated October 16, 2023, at 10:35 AM that the Certified Registered Nurse Practitioner (CRNP) was in to see resident and a new order was noted to obtain UA/C&S laboratory work on October 17, 2023. Further review of urine culture results dated October 21, 2023, at 3:44 PM revealed abnormal results of greater than 100,000 colonies/milliliter (ml) Klebsiella pneumoniae (a bacteria that normally lives in your intestines and feces that causes infection in the urinary tract and also has a high tendency to become antibiotic resistant) ESBL (extended-spectrum beta-lactamase - a type of enzyme produced by certain bacteria that makes them resistant to commonly used antibiotics) producing organism. This resident may require isolation (precautions taken to prevent the spread of an infectious agent from an infected or colonized person to susceptible persons). Ceftriaxone, the antibiotic medication the resident was currently receiving, showed to be resistant (the antibiotic medication cannot kill the pathogen and stop their growth. A review of nursing progress notes revealed that nursing staff did not notify the physician of the abnormal results of the C & S until October 22, 2023, at 6:44 PM, and the resistance to prescribed ceftriaxone along with the resident's behaviors and poor intake of food, fluids, and medications. New orders were received at that time to send the resident to the Emergency Department (ED) for evaluation. During an interview with the Director of Nursing (DON) on May 2, 2024, at approximately 1:15 PM the DON stated that the laboratory results are sent to nursing and the physician, and that the timeframe for addressing abnormal lab results should not exceed 24 hours, confirming that the C&S results were not addressed with the physician in a timely manner. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on observation, review of the clinical record, and resident and staff interview, it was determined that the facility failed to provide a nutritional supplement that accommodated a resident's preferences for one resident of 25 residents reviewed (Resident 91). Findings include: A review of the clinical record revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses to include achalasia of cardia (rare disorder making it difficult for food and liquid to pass from the esophagus into the stomach), and dystonia (a movement disorder that causes the muscles to contract involuntarily). Review of a nutrition progress dated March 18, 2024, at 8:56 AM indicated that the house supplement 2.0 at 120 ml BID (twice a day) was ordered for the resident. Documentation indicated that the resident consumed 50% intake of the supplement, with multiple refusals also noted. Review of an administration progress note dated March 21, 2024, at 12:53 PM indicated that, at the request of the resident, the house supplement 2.0 was to be discontinued and a Boost supplement was to be added BID with her breakfast and dinner tray for increased nutritional support. During interview with Resident 91 on May 1, 2024, at 12:45 PM, the resident stated that she had a conversation with a woman from dietary about a month ago regarding substituting the house nutritional supplement for something better tasting. She said she was told that a Boost nutritional supplement would be added to her breakfast and dinner meal trays but that she had not received the Boost supplement or any supplement since then and feels as though she needs additional nutritional support. Observation of the resident in her room during breakfast on May 2, 2024, at 8:30 AM revealed that the resident did not have a Boost nutritional supplement on her breakfast tray. Review of her meal tray ticket revealed no indication that the resident that a Boost supplement was ordered. Interview with Employee 3 (registered dietitian) on May 2, 2024, at 11:35 AM, confirmed that the house supplement 2.0 was discontinued on March 21, 2024, but that the Boost nutritional supplement was not ordered in its place. She confirmed that there was no current order for the Boost, the Boost supplement was not noted on the resident's meal tray ticket, and that Resident 91 did not receive the Boost supplement as discussed and planned. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on review of clinical records, the facility's abuse prohibition policy and procedures, select investigative reports and personnel files and staff and resident interview and observations, it was determined that the facility failed to ensure that one resident out of 12 sampled was free from physical abuse, which resulted in significant bruising due to crush injury, traumatic facial injuries, pain and fear/psychological trauma (Resident 75). Findings include: A review of the facility policy entitled Abuse, Neglect Misappropriation of property dated and revised October 2019, revealed that it is the policy of the facility to protect our residents from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse as used in this policy will refer to the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's abuse prohibition procedures indicated that the facility trains employees and volunteers through orientation and annually on issues related to abuse which includes the facility's abuse prevention policy and procedure. Procedures direct that if abuse is suspected, the following actions may be undertaken to protect the resident from physical and psychosocial harm during and after the investigation. The employee will immediately be removed from resident care areas pending the outcome of the investigation. A review of the clinical record revealed that Resident 75 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Current physicians orders dated December 2019, included [MEDICATION NAME] ([MEDICATION NAME], a blood thinner) 75 mg by mouth, daily and Aspirin 81 mg, take 2 tablets daily. Both these medications increase the resident's risk for bleeding. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated November 15, 2019, revealed that the resident was moderately, cognitively impaired, required staff assistance for most activities of daily living (ADL), including the assistance of two staff members for transfers, bathing and toileting. The resident's BIMS (brief interview for mental status - a tool to assess cognitive function) was a 9 (a score of 8-12 indicates moderate cognitive impairment). The resident's current MDS and care plan in effect on December 14, 2019, did not identify any behavioral symptoms. A review of a facility abuse investigation report dated December 14, 2019, revealed that Resident 75 was involved in an altercation with a nurse aide, employed by a staffing agency, which the facility utilized for nursing employees, during which the resident sustained [REDACTED]. Resident 75's statement at the time of the facility investigation revealed, the nurse aide (Employee 1) twisted the resident's nipples while showering the resident. The facility's investigation revealed that Employee 2 (nurse aide) had witnessed two separate events of physical abuse of Resident 75, both perpetrated by Employee 1, the contracted agency nurse aide, on December 14, 2019. At approximately 2:15 PM Employee 2 responded to the sound of yelling from a central bathroom on the fourth floor of the facility and witnessed Employee 1 twisting the right nipple of Resident 75's breast. Employee 2 intervened and then returned Resident 75 to her room and placed the resident in her recliner. According to Employee 2, approximately 8 minutes later, Employee 2 witnessed Employee 1 enter Resident 75's room. Employee 2 again heard yelling and stated that he witnessed Resident 75 seated in her recliner with Employee 1 standing in front of the resident. Resident 75's nose was bleeding. Employee 2 asked what happened and Resident 75 replied that Employee 1 had hit her in the face, causing her nose to bleed. Employee 1 left the resident's room. She then finished her shift and left the facility at 3 PM. Employee 2 was scheduled to work both the 7 AM to 3 PM and the 3 PM to 11 PM shifts on December 14, 2019. Employee 2 did not report his observations of Employee 1 abusing Resident 75 until 7:30 PM on December 14, 2019, five hours after he had witnessed the incidents. Employee 2 reported his observations to Employee 4 (LPN) at 7:30 PM on December 14, 2019. A review of Employee 2 witness statement signed and dated December 15, 2019, (no time indicated) revealed today (referring to December 14, 2019) at around 2:15 PM, I was giving care to a resident in room [ROOM NUMBER], when I heard {Resident 75} screaming and yelling 'get your hands off of me, and stop touching me.' I left the room to see exactly what was happening because it sounded like she was in trouble. I got to the center by the nurse station and was trying to figure out where the sound was coming from. I then looked to my right to see if I saw anyone, but also heard screaming coming from my right, so I noticed it was coming from the big bathroom in the C hallway, I believe. I walked into the bathroom and saw Resident 75 in her wheelchair say don't you twist my nipple and {Employee 1} was in front of {Resident 75} twisting her right nipple. I said to Employee 1 What are you doing? and she said nothing, {Resident 75} is just crazy. Employee 1 then pulled the resident's shirt down. Resident 75 was swinging and yelling don't touch me. So I said I will take her. Employee 2 and another nursing employee returned Resident 75 to her room, in her recliner chair. I (Employee 2) got on the care tracker system (an electronic charting system located on the hallway walls) to finish my day shift charting before starting my next shift. The care tracker is located just across the hall from {Resident 75's} room. I then saw {Employee 1} walk past me to answer a resident's call bell. About 8 minutes later, I saw {Employee 1} again walked past me and I heard {Resident 75's} door close. Her call light never came on so she didn't call for anyone. A few seconds later, maybe 15-20 seconds, I heard {Resident 75} screaming and yelling help, get her out of here. I {Employee 2} ran into {Resident 75's} room and saw {Employee 1} standing in front of {Resident 75} in her recliner. {Resident 75's} nose was bloody. Resident 75 then said that {Employee 1} struck her in the face. {Employee 1} was trying to clean the blood and said {Resident 75's} nose just started bleeding. {Resident 75} then replied No, you hit me in the face. Employee 1 then said to Employee 2 you are tripping and she walked out of the room. A review of photographs taken of Resident 75's chest injuries on December 15, 2019, (no time indicated) by a representative of the local Area Agency on Aging revealed bilateral breast with purple bruising noted around the areola. There was a large amount of purple bruising noted above the right and left breast area with purple bruising noted under the bilateral breasts, extending to the axilla area. A review of a witness statement from Employee 4 (LPN) dated December 14, 2019 (no time indicated) revealed that Employee 2 reported to me that he had witnessed on day shift an aide grabbing a resident's breast and twisting them in the shower room. We went into the resident's room to see the bruises and the resident had purple bruises all around her nipples of the breasts. Asked the resident what happened and she said the girl with the red hair grabbed her nipples today and twisted them. The resident also stated she was hit in the nose by the nurse aide during the day. The resident's nose was slightly bruised and enlarged at the bridge of the nose. A review of a witness statement from Employee 3 (RN supervisor) dated December 15, 2019, (no time indicated) revealed that on December 14, 2019, I was called up to the fourth floor by Employee 4 (LPN) to come to the floor. I asked Resident 75 what happened and if she could show me the bruising on her breasts. She said I have little nipples, but the girl with the red hair grabbed them and twisted them. She stated that the girl with the red hair also hit her in the nose. Resident 75 stated I tried to hit her back, but I wasn't able to. There was swelling on the bridge of her nose and you could see bruising starting. A review of a witness statement from Employee 5 (RN supervisor) dated December 16, 2019, stated that upon assessment/interview with Resident 75 on December 15, 2019, 7 AM to 3 PM shift at approximately 9:30 AM, a body assessment revealed, bruising to bilateral breasts surrounding the resident's nipples with ecchymosis (black and blue bruise), light blue in color, extending to the axillary area, bilaterally. The resident's nasal bridge appears swollen without redness or ecchymosis noted. Resident's left and right inner canthus (underneath the eyes, top of the nose area) with noted light purple discoloration. Upon interview with resident, she was unable to give an account of the incident from the previous day, stated I don't know when asked how the bruising occurred. The Director of Nursing confirmed during interview on December 19, 2019, at 11 AM that Employee 1 had long red tinted hair, which was confirmed by observation of Employee 1's driver's license conducted during the survey on December 20, 2019. A review of a statement via e-mail sent to the facility dated December 18, 2019, at 2:44 PM Employee 1 stated, that around 12:45 PM I was toileting Resident 75, a very combative patient, but I can handle her. I stood her up by her pants. I started to take the wheelchair from behind her and grab the toileting charge, per usual. So I spin her around and slide her to the toilet. Before I could even get her pants down, she grabbed my hair. At this point I can't see, I'm trying to place her back in her wheelchair. I finally get Resident 75 to let my hair go and place her back in the wheelchair. She was being so combative, I didn't even place her in the bed. Two of my co-workers did. I wasn't around when they did, so she coulda possibly fell , who knows. A review of nursing documentation dated November 2019 and December 2019 revealed no episodes of combative behavior displayed by Resident 75. A review of a current resident care card conducted on December 20, 2019, (Nursing care instruction sheet) revealed that at the time of the incident Resident 75 was a transfer assistance of two staff with a rollator walker. According to Employee 1's statement she transferred the resident without the assistance of another person and the use of a rollator walker as required. On December 14, 2019, at 8 PM the facility's administration, physician and responsible party were contacted and the resident sent to the hospital for evaluation. A review of a hospital history of present illness dated December 14, 2019 at 10:14 PM revealed that the patient presents to the emergence department and reports to being assaulted. Report of abuse with nurse aide twisting her breasts and hitting her in the face. Patient admits that her breasts hurt and her nose was bleeding. She adds that she never got a punch in as she was getting hurt. Pt is on blood thinners and has multiple bruises on her extremities. Wound # 1, location, bilateral breasts, crush injury, wound # 3, location, face, [MEDICATION NAME] trauma and epistaxis of left nares with dried blood in left nostril. The physicians examination included bilateral breasts, areolar, tenderness, ecchymosis and swelling. A review of a social services progress note dated December 17, 2019, revealed Met with {Resident 75}. {Resident 75} was having behaviors towards CNA secondary to incident that occurred over the weekend. CNA looked similar to the alleged perpetrator. Provided much needed conversation and emotional support. The resident's care plan and nursing care instruction sheet was revised December 19, 2019, to include the problem as hitting a female nurse aide that looks like the alleged perpetrator. The intervention initiated at that time was for this resident to have no female African American care givers. (Employee 1 was a female African American with a red tint in her hair) During an interview on December 19, 2019, at approximately 1:30 PM, the Director of Nursing (DON) stated that this intervention was put into place after a female African American nurse aide attempted to render care to Resident 75 on December 17, 2019. The DON stated that Resident 75 started yelling and became very agitated when this nurse aide approached her. The DON stated that there was no nursing documentation of this incident on December 17, in the resident's clinical record, but was noted in the social service entry. During an interview with Resident 75 on December 19, 2019, at approximately 11 AM Resident 75 described to the surveyor the physical abuse she had experienced on December 14, 2019, and confirmed that Employee 1 had struck her in the face and twisted her nipples. Observation of the resident on December 19, 2019, at approximately 11 AM revealed that Resident 75 had fading yellow, green bruised areas across her upper nasal area. She had purple/yellow/green bruising observed around both nipple areas on bilateral breasts extending to the axilla (underarm) area. The right breast was noted with a 17 cm x 4 cm purple/green/yellow bruising extending from 1 o'clock to 7 o'clock (measurement areas based on the face of a clock's hour placement). The areas at the bottom of the right breast were observed to be dark purple, measuring 12 cm, with an area at the extreme bottom of the breast noted with a concentrated dark purple area. The top of the left breast presented a 10 cm x 4 cm purple bruised area. The skin area under the left breast, at the 7 o'clock area, measured 4 cm purple/green/yellow in color with an area of dark purple bruising observed under the breast. There was an area of purple/green/yellow bruising measuring 18.5 cm x 6 cm from the 5 o'clock position extending to the left axilla area. There was purple/green/yellow fading ecchymosis observed to the bridge of her nose measuring 2 cm on each side. The comparison between the photographs taken on December 15, 2019, by the staff representative of the local Area Agency on Aging and the surveyor observation on December 19, 2019, revealed that this resident's bruising continued and spread over the 4 days. Nursing documentation dated December 15, 2019, indicated that Resident 75 had bilateral breast bruising, but there was no continued documentation of the progression of the bruising, despite the resident receiving blood thinning medications. During the observation of the resident on December 19, 2019, at 11 AM and examination by Employee 6, LPN, accompanying the surveyor, the resident stated that her breasts hurt a lot especially when she turns or they are touched. Resident 75 then asked Employee 6 (LPN) if she knew what it felt like when your nipples are twisted. A review of Employee 1's personnel employee file revealed that she was employed by a nurse staff agency. Her first day of employment at the facility was August 21, 2019. There was no documented evidence at the time of the survey ending December 20, 2019, that this employee received training on the facility specific abuse policy prior to the start of her assumption of job duties at the facility. An interview with the nursing home adminsitrator and director of nursing on December 19, 2019, at approximately 2 p.m., confirmed that the staffing agency was contacted immediately following the incident. Employee 1 was arrested by the local police on December 15, 2019, and would no longer work at the facility as the result of the abuse of Resident 75. The NHA and DON also confirmed that Employee 2 had been suspended from employment on December 15, 2019, and his employment would be terminated for failing to timely report the observations of Employee 1 abusing Resident 75. CFR 483.12 (a) Freedom From Abuse Previously cited 5/1/19 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.20(b) Staff Development 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/25/19 28 Pa. Code 201.29(a)(c)(d) Resident Rights Previously cited 10/25/19 28 Pa. Code 211.12 (c)(d)(5) Nursing services. Previously cited 10/25/19

Based on a review of clinical records, observations, staff and resident interviews it was determined that the facility failed to consistently provide prescribed treatment and services, consistent with professional standards of practice, to prevent pressure sore development, promote healing and prevent worsening of pressure sores for one of three residents sampled with pressure sores (Resident 7). Findings include: According to the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians ((ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean would environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. A review of the clinical record revealed that Resident 7 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 30, 2019, revealed that Resident 7 was at risk for developing pressure sores and required assistance of two staff members for all activities of daily living to include bed mobility, transfers, toilet use, hygiene and bathing. Section M (skin section) of the MDS indicated that the resident was at risk for pressure ulcers and four pressure ulcers were present upon admission to the facility. Interventions in place were noted to include pressure reducing devices to bed (standard) and chair. The resident also had an indwelling urinary foley catheter in place. A review of the resident's admission Braden scale assessment (a tool developed to assess a patients risk of developing a pressure ulcer) dated (MONTH) 23, 2019, revealed a score of 15, indicating that the resident was at mild risk for developing pressure sores. A review of the nursing admission assessment dated (MONTH) 23, 2019, revealed five pressure areas were documented upon the resident's admission: - a Stage I pressure area (superficial reddening of the skin or red, blue or purple hues in darkly pigmented skin that when pressed does not turn white) on the resident's left heel measuring 1 cm x 2 cm x 0 cm; - a Stage I to the resident's left dorsal foot measuring 3 cm x 0.5 cm x 0 cm; - a DTI (deep tissue injury-purple or maroon localized discoloration of intact skin or blood filled blister due to damage from underlying soft tissue pressure or shearing) to the resident's right lower extremity shin; - a Stage I on the resident's right dorsal foot measuring 2 cm x 0.5 cm x 0 cm; and - a Stage I on the resident's left lateral ankle measuring 1 cm x 1 cm x 0 cm. Employee 13 (Registered Nurse) stated during interview on (MONTH) 25, 2019, at 10:33 AM, that the resident should have been considered to be at high risk for pressure sore development based on a review of the resident's admission nursing assessment noting the presence of five pressure ulcers. Physician orders [REDACTED].>During an interview with the Resident 7 on (MONTH) 22, 2019, at 10:25 AM the resident was unable to state if staff were repositioning him every hour. A review of the resident's turning and repositioning schedule, revealed that on (MONTH) 23, 2019, (admission) during the 7 AM to 3 PM shift, staff documented turning and repositioning every hour. The documentation did not indicate if the resident was repositioned onto his back, his left side or right side. On (MONTH) 23, 2019, documentation for 3 PM to 11 PM, revealed the resident was repositioned only twice during this shift. On (MONTH) 24, 2019, and (MONTH) 25, 2019, documentation revealed that staff repositioned the resident four times during each (8 hour) shift of nursing duty. On (MONTH) 26, 2019, staff documented that the resident was repositioned twice during the 11 PM to 7 AM shift and four times during the 7 AM to 3 PM and the 3 PM to 11 PM shifts. The facility was unable to provide documented evidence that staff had consistently repositioned the resident every hour as ordered by the physician upon the resident's admission. A review of an Incident/Accident Report dated (MONTH) 27, 2019, at 11:25 AM, revealed that during AM care, a nurse aide found facility acquired open areas on the resident, which were reported to the nurse. According to the report, the open areas consisted of a DTI on the spine of his upper back measuring 8.5 cm x 2 cm; a DTI on the resident's left buttocks measuring 2.5 cm x 2.5 cm and an open area on the penis 5 cm x 1 cm. Interventions planned in response to the development of these skin impairments were to change to an APM 2 (alternating pressure mattress-low air loss and alternating pressure mattress is designed for the prevention and treatment of [REDACTED]. However, the physician's admission orders [REDACTED]. A review of the resident's baseline care plan revealed interventions to address the resident's skin integrity, which included turning/repositioning, a specialty mattress and barrier cream. However, the resident's baseline care plan failed to identify how often staff were to turn and reposition the resident. The facility made a referral to the wound specialst consultant on (MONTH) 27, 2019. Resident 7 was seen by the wound specialist on (MONTH) 1, 2019, to evaluate the resident's pressure sore wounds. The wound specialist noted that the wound to the resident's right upper back was a Stage II pressure area (full-thickness skin loss potentially extending into the subcutaneous tissue layer) measuring 8 cm x 5 cm x 0.1 cm, exudate (fluid that leaks out of blood vessels into a body cavity or nearby tissues as a result of injury or inflammation) was serous (clear watery fluid). The wound specialist recommended for hydrogel (Hydrogel dressings are used to provide hydration to a wound to promote healing phases such as granulation, epidermis repair and the removal of excess dead tissue) three times a day. The wound specialist noted that the wound to the resident's left buttocks was an unstageable (bedsore whose severity cannot be determined with a visual exam. This is usually due to the exudate, or slough, covering the wound) wound due to necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) measuring 3 cm x 2 cm x 0.1 cm, with 80 % slough (Slough is typically a white / yellow color. It can be found in patches or it can cover large areas of the wound. It is made up of dead cells which have accumulated in the exudate) and 20 % granulation tissue (Granulation tissue is reddish connective tissue that forms on the surface of a wound). Recommendations were to treat with Hydrogel daily. The pressure sore to the resident's left heel was noted as a Stage II pressure sore, measuring 3 cm x 5 cm x .1 cm and treated with Hydrogel and foam dressing at the borders. The pressure sore to the right ankle was noted as unstageable DTI measuring 9 cm x 1 cm and treated with skin prep. The pressure sore to the left ankle was noted as unstageable DTI measuring 1 cm x 1 cm and treated with skin prep. The wound specialist noted the wound to the resident's penis was an unstageable wound due to necrosis, measuring 0.8 cm by 1.3 cm by 0.1 cm, exudate was light serous and 100 % thick adherent devitalized necrotic tissue. Further review of the clinical record revealed that this wound was documented as resolved on (MONTH) 29, 2019. The most recent wound specialist note at the time of the survey ending (MONTH) 25, 2019, was dated (MONTH) 21, 2019, indicating that resident's wound to the right upper back was now a Stage III pressure sore (full-thickness skin loss potentially extending into the subcutaneous tissue layer) measuring 1 cm x 0.5 cm x 0.2 cm treated with Santyl (sterile enzymatic [MEDICATION NAME] ointment) dressing. The wound to the resident's left buttock was documented as a Stage III pressure area measuring 1.3 cm x 0.8 cm by 0.2 cm with hypergranulation tissue present within the wound margins to be treated with hydrogel daily for 30 days. An observation of the resident's pressure sores on (MONTH) 24, 2019, at 1:35 PM, with Employee 12 (Licensed Practical Nurse) revealed that the wound bed to the resident's left buttocks was pink in color and measured 2 cm x 0.3 cm x 0.1 cm. A reddened area was observed above the wound, which measured 3 cm by 1 cm. Employee 12 stated at the time that she was not aware of the new reddened area. Observation of the wound to the resident's upper back/spine area revealed purulent (containing pus-thick, yellowish liquid that comes from an infection in the body) with minimal drainage and a small amount of slough. The resident's skin was observed to be red and irritated from the tape that was removed from the wound. Employee 12 stated that she was not aware of the new reddened irritated area that formed underneath the tape. The facility was unable to demonstrate the consistent implementation of prescribed approaches and sufficient preventative measures upon admission, including physician ordered hourly repositioning, to promote healing of existing and prevent the development of new pressure sores. The facility failed to timely identify declines in the resident's skin integrity and failed to promptly implement adequate measures to prevent the development of three new pressure sores and/or worsening of the facility-acquired pressure sores on the resident's buttocks, spine and penis for a resident identified at risk for pressure sore development upon admission to the facility on (MONTH) 23, 2019. During an interview with the Director of Nursing on (MONTH) 25, 2019, at 11:10 AM confirmed the above findings. 28 Pa. Code 211.5 (f)(g)(h) Clinical records Previously cited 9/14/18, 5/1/19 28 Pa. Code 211.12 (a) Nursing services Previously cited 9/14/18, 2/2/19, 3/20/19, 5/1/19 28 Pa. Code 211.12 (c) Nursing services Previously cited 9/14/18, 2/2/19, 3/20/19, 5/1/19 28 Pa. Code 211.12 (d)(1) Nursing services Previously cited 9/14/18, 2/2/19, 3/20/19, 5/1/19 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 9/14/18, 2/2/19, 3/20/19, 5/1/19 28 Pa. Code 211.12 (d)(5) Nursing services Previously cited 9/14/18, 2/2/19, 3/20/19, 5/1/19

Based on review of clinical records and select abuse investigations and staff and family interviews it was revealed that the facility failed to identify one resident's risk (Resident 55) for abusive behavior and devise and implement sufficient measures necessary to protect residents from sexual harassment and abuse for one out of 11 residents reviewed (Resident 71). Findings include: A review of the clinical record revealed that Resident 55 was admitted to the facility on (MONTH) 15, 2019, with a [DIAGNOSES REDACTED]. Subsequent to admission, the resident's wife of [AGE] years, who had been terminally ill, expired. The resident's admission was to be long term. A review of the resident's admission MDS Assessment (minimum data set - a federally mandated assessment process completed at intervals to plan resident care) dated (MONTH) 22, 2019, revealed that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool for assessment of cognition) score of 6 (a score of ,[DATE] equates to severe cognitive impairment). Nursing noted on (MONTH) 16, 2019, at 6 p.m. that the resident was continuing to get up and out of his wheelchair and bed. The resident was displaying increased confusion and was going into different rooms and opening doors. A review of the resident's clinical record revealed the resident's intrusive behaviors continued on (MONTH) 17, 2019, with the resident self-propelling in his wheelchair, banging on doors calling his wife's name. The resident's behaviors continued on that date and at 10 p.m., staff documented that the resident was still awake and wheeling around hallways yelling for wife and brother, will not sit, placed into bed three times. At 1:00 a.m., (MONTH) 18, 2019, staff documented that the resident was seated at the nurses station. The resident was described as continually attempting to stand from the chair and calling for his wife. According to interdisciplinary progress notes dated (MONTH) 18, 2019, at 10 p.m., the resident was described as having increased confusion, running down the halls looking for his brother and wife and jumping up from his wheelchair yelling at the staff. On (MONTH) 23, 2019, the facility's Social Worker documented that the resident was wandering in and out of resident rooms, looking for his wife and yelling at the staff during that assessment period. A review of the resident's clinical record revealed on (MONTH) 30, 2019, the resident was going from room to room looking for his wife. According to review of the resident's clinical record the resident was wandering the hallway on (MONTH) 9, 2019. Resident 69 was interviewed, along with her son on (MONTH) 1, 2019 at 9:06 a.m. A review of the resident's most recent MDS (quarterly) dated (MONTH) 25, 2019, revealed that Resident 69 was moderately cognitively impaired with a BIMS score of 11. Resident 69 stated that was a man on the floor that used to live across the hall (the resident identified Resident 55 by name) who often times came into her room and other resident rooms. Resident 69 stated that he would frequently turn her lights on and off and rummage through her drawers and personal belongings. On one occasion, Resident 69 relayed that she had exited the bathroom to find Resident 55 in her bed, When she asked him to leave Resident 69 stated that Resident 55 became angry and would not leave. She stated she alerted staff, who took him out of her room, but he made a smart remark and was resistive to be escorted out of her room when he left. Resident 69's son confirmed that Resident 55 was known to wander about the facility. He stated that his mother was able to speak for herself and really did not belong on the dementia unit, but the resident liked it there. Resident 69's son stated that Resident 55 did not limit his wandering to Resident 69's room, but went into the rooms of other residents who might not be able to speak for themselves. A review of Resident 55's comprehensive plan of care last revised by the facility on (MONTH) 4, 2019, revealed that the facility had identified the resident's risk for safety related to his [DIAGNOSES REDACTED]. The facility interventions were limited to routine care interventions, including medications and implementing a wander guard (device to alert staff of undetected exit form the unit) and 15 minute checks beginning on (MONTH) 15, 2019. A review of a facility abuse investigation revealed that on (MONTH) 9, 2019, at 3:15 a.m., Resident 55 wandered across the hall into the room of female Resident 71. Employee 1, nurse aide, was at the end of the hallway passing water and saw Resident 55 entering Resident 71's room. Employee 2, the other nurse aide on the unit at the time, was interviewed via telephone on (MONTH) 7, 2019 at 8:05 [NAME]M. Employee 2 stated that she was at the nurses station and witnessed Employee 1, first yelling to Resident 55 to stop and then responding by going to Resident 71's room. Employee 2 stated that she followed Employee 1 and as they entered Resident 71's room, Resident 55 was in bed with Resident 71. According to Employee 1's statement and confirmed through interview with Employee 2, when Resident 55 was told that was not his bed, he put his arms around Resident 71. When the staff requested that he get out of Resident 71's bed, Resident 55 refused to get out of the bed and attempted to hit Employee 1. Employee 1 stated that she responded by attempting to remove the covers and as she did Resident 55 put his arm around Resident 71 again, and grabbed her breast and pressed his groin against Resident 71, who was facing away from the resident in bed. When interviewed on (MONTH) 2, 2019, Employee 2 stated that Resident 55 was holding and rubbing Resident 71's breasts. Employee 2 stated that Resident 71 was wearing a short night gown and her breasts were covered during this encounter. Employee 2 stated that Resident was calling Resident 55[NAME]while rubbing her breasts. According to Employee 2, Resident 71 kept correcting Resident 55, that her name was not Dorothy. The employee stated that neither Employee 1 or 2 were able to redirect Resident 55 away from Resident 71. A review of the written employee statements and confirmed during interview with Employee 2, Employee 2 left the room to look for the nursing supervisor and was unable to find her. Leaving both residents remaining in Resident 71's room, Employee 1 used the telephone outside the resident's room in an attempt to locate the nursing supervisor who was also serving as the nurse on that resident unit. As Employees 1 and 2 were in the hallway they observed Resident 55 sliding his hands down Resident 71's brief. Both employees stated that Resident 55 did remove his hand, when told to do so. Continued interview with Employee 2 revealed that Resident 2 was wearing a short nightgown and the night gown was above the resident's waist and Resident 55's hand was on Resident 71's bare skin as he attempted to place his hand in her brief. Employee 2 stated that Resident 55 did quickly stop when Employee 1 told him to. A review of written statements by Employees 1, 2 and 3 (registered nurse) revealed that Employee 3 arrived on the unit. Resident 55 initially refused, but the three nursing staff members were able to get him to leave Resident 71's room. An interview with Employee 3 on (MONTH) 2, 2019, at 3:30 p.m., via telephone. confirmed that Employee 1 had contacted her on (MONTH) 9, 2019. She confirmed that nurse staffing consisted of Employees 1 and 2 and herself. Employee 3 stated that she was the nurse on duty on that unit, as well as, acting as the nursing supervisor for the facility that evening. A review of Resident 71's clinical record revealed she was admitted to the facility on (MONTH) 21, 2019, with a [DIAGNOSES REDACTED]. The resident required extensive assessment of two staff members for transfer and mobility. The facility failed to adequately supervise Resident 55 and implement effective safety measures to deter intrusive wandering and manage the resident's behavioral symptoms, including searching for his wife, to prevent the sexual abuse of Resident 71. 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 201.29(c)(d) Resident Rights 28 Pa. Code 211.12(a) Nursing Services Previously cited [DATE],[DATE],[DATE] 28 Pa. Code 211.12(c) Nursing Services Previously cited [DATE],[DATE],[DATE] 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited [DATE],[DATE],[DATE] .

Based on a review of clinical records, select reports of resident incidents and resident and staff interviews, it was determined that the facility failed to provide care in a safe manner to prevent a fall with injury for one resident (Resident 98) out of 24 sampled residents. Findings include: A review of Resident 98's clinical record revealed that the resident had diagnoses, which included multiple sclerosis (a disease in which the insulated covers of nerve cells in the brain and spinal cord are damaged. Symptoms include muscular weakness, numbness, loss of bowel and bladder control, and visual disturbances) and morbid obesity. Review of an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated November 3, 2014, revealed that the resident was cognitively intact, understood others and was able to make his needs known. The resident was non-ambulatory and required the assistance of two staff members and the use of a full body lift (an assistive device used to transfer a resident between a bed and chair or other similar resting places, using hydraulic power) for all transfers. At the time of the assessment, the resident weight was noted as 285 pounds and his height was 6'2''. A review of Resident 98's care plan, with an initial date of July 14, 2014 and last reviewed by the facility September 9, 2015, noted that the resident was at risk for safety due to multiple sclerosis, decreased mobility and decreased vision. A review of the Arjo Sling User Guide (the brand name of the full body lift utilized by the facility) with an issue date of March 2005, states that Using the correct sling for each patient is an essential element of safe patient handling. In some cases, medical and physical factors mean that a patient's comfort and safety can only be assured by the provision of a correctly fitted sling. The guide further stated that However, providing the optimum sling for the patient and the purpose is vital in order to ensure safety and comfort. A sling that is the wrong size or a bad fit for its patient creates discomfort and increases the risk of injury. The instructions for utilizing the full body lift included to measure from the coccyx to the top of the head. The color level with the top of the head indicates the required size. If the size falls between two sizes always use the smallest size. Patient width and body proportions should also be considered and a professional judgement made. *This sizing tool is only intended as a guide and is an approximation. Other factors like the patient's physical disabilities, weight distribution and general physique all need to be taken into consideration. A review of the facility's policy entitled Full Body Lift with a review date of January 2015, indicated that at least two nursing staff are needed to transfer a resident when using a full body lift. The procedure instructs that when employing the full body lift to use the control to operate the lift so that the sling holding the resident is just above the bed (or chair). At this time, it is especially important to reassess for placement of straps. If adjustments are needed, repeat the procedure before moving the resident. The assistant is to hold onto the sling and support the resident's legs as you move the lift away from the bed. Slowly use the controls to maneuver the resident. This allows the resident to be lowered into the chair gently by gravity. Continue to guide the resident as he/she is lowered to the chair. Review of a resident incident/accident report dated February 17, 2015, at 6:45 AM revealed that following a shower, Employees 1 and 2 (nurse aides) brought Resident 98 back to the resident's room. Upon returning to the resident's room, the nurse aides activated the resident's call bell and Employee 2 left the room and went into the hall to look for another staff member to assist with the resident's transfer, leaving Employee 1 alone with the resident in the resident's room. While Employee 2 was out of the room the resident slid out of his shower chair and onto the floor. Resident 98 complained of left arm and shoulder pain and was diagnosed with [REDACTED]. (a long bone in the arm or forelimb that runs from the shoulder to the elbow) later that day. Following an assessment the resident was returned to bed with the assistance of three staff members and a full body lift. Subsequent to this incident a physical therapy screen was ordered and Employees 1 & 2 received re-education on safety utilizing full body lift and proper body alignment of residents in a shower chair. Review of the statement written by Employee 1 revealed that prior to taking Resident 98 to the shower they put the sling (to the mechanical lift) on him while he was in bed and connected it to the lift and put him in the shower chair. Employee 1 noted that We adjusted him a few times to get him in the shower chair because the lift would not go all the way up and took him into the shower. (We) washed and dried him and saw he was leaning to the side. So Employee 2 asked another CNA to help boost him with us. We took him to his room and when we removed the sheet he was leaning again. Employee 2 went into the hall to get help and while she was getting help he slid and landed on his hip and shoulder. The employee's statement indicated that after the resident was assessed more nurse aides came in and helped him into bed. Employees 1 & 2 then dressed the resident, got a new battery for the lift, and put him into his chair. Review of the statement written by Employee 2 revealed that prior to taking Resident 98 to the shower, he was in bed. She and Employee 1 placed the sling under him, connected it to the full body lift and put him in the shower chair. The employee noted that We had to adjust him a few times because the lift would not go all the way up. We took him into the shower, washed him, and noticed he was leaning back. They asked another CNA to help boost him up. We took him to his room (and) when we removed the sheet he was leaning again and I went into the hall to get help for a boost. I then heard Employee 1 call out and I saw him (Resident 98) on the floor. The employees then took the resident's vitals (vital signs) and with the assistance of other nurse aides put the resident into bed and got him dressed. Employee 2 stated that she got a new battery for the lift and put him in his chair. Review of the facility's investigation into the incident revealed no evidence that the facility evaluated the full body lift for proper function. Review of facility documentation submitted to the State Survey Agency on February 26, 2015, at 12:00 P.M., revealed that following the resident's fall on February 17, 2015, Resident 98 had complained of left hip and left rib pain on February 25, 2015. X-ray results showed a fractured left hip and was negative for rib fractures. Resident 98 was admitted to the hospital and underwent surgery to repair the hip fracture. The facility's report further indicated that As the resident is a large man, it is determined that he must not have been positioned back far enough on the wheelchair (shower chair), compounded by his lower half still being slightly wet, resulted in resident sliding to floor. The report stated that the resident had relayed that no other event had occurred since he slid from the shower chair (on February 17, 2015). During an interview with Resident 98 October 7, 2015, at 1:00 PM, he stated that on February 17, 2015, following his shower, two nurse aides were transferring him from the shower chair. One went to get help and I was left with one CNA (nurse aide). I slid out of my chair on my left side. During further interview with Resident 98 on October 9, 2015, at approximately 12:55 PM, he stated that prior to his shower on February 17, 2015, Employee 1 and Employee 2 Didn't put the sling far enough beneath me and when it (full body lift) lifted I fell to the floor. Refer F498 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 7/21/15 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services Previously cited 7/21/15, 9/25/14