Every finding on record at Amoroso Healthcare and Rehabilitation Woodridge

Based on employee file review, facility labor report, and staff interviews, it was determined that the facility failed to ensure an individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, has completed a competency evaluation program approved by the state, for one of four employee files reviewed (Employee 1). Findings include: Review of Employee 1's (Nurse Aide in Training) Nurse Aide Training Competency and Evaluation Program Certificate, revealed a Course Completion Date of October 21, 2025. Employee 1 had until February 21, 2026, to work independently and pass the exam to be a Nurse Aide. During an interview with the Director of Nursing on July 13, 2026, at 1:17 PM, she revealed there was a nurse aide in training that had worked here past her 120 days because she did not pass her test and didn't tell anyone. She further revealed when they found out this was the case, she was terminated. During an interview with Employee 2 (Human Resources Director) on July 13, 2026, at 2:21 PM, she revealed she was working two different roles at the time Employee 1 should have taken her test and passed, so she wasn't checking the nurse aide registry once a month like she usually does. Employee 2 stated when she got around to doing it for all nurse aides in June of 2026, she realized she could not find Employee 1's name on the registry. She then reached out to Employee 1 about her certification, but she never replied back to her and she was terminated on June 15, 2026. Review of document titled Employee Labor Report with a date range of February 21, 2026, through June 15, 2026, revealed Employee 1 had worked 418 hours after the point that she should have completed a competency evaluation program approved by the state. During an interview with the Nursing Home Administrator on July 13, 2026, at 2:26 PM, she revealed she was aware of the concern and they have plans to fix the process for verification. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for one of six residents reviewed (Resident 1).Findings include: Review of facility policy, titled Weighing and Measuring the Resident, last revised May 2026, read, in part, The purposes of this procedure are to determine the resident's weight and height. If practical, weigh at the same time of day each time. If possible, use the same scale for weighing the resident each time. If possible, weigh the resident with approximately the same amount of clothing on the resident each time. Report significant weight loss or gain to the nurse supervisor. Report other information in accordance with facility policy and professional standards of practice. Review of Resident 1's clinical record revealed diagnoses that included deficiency of other specified B group vitamins, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things), and hypomagnesemia (low blood magnesium level). Review of Resident 1's physician orders revealed an order for monthly weights with a start date of February 23, 2025. Review of Resident 1's clinical record revealed a weight measure obtained on January 1, 2026, of 169.8. This measure was obtained at 10:58 AM, using a seated scale. The weight measure was noted to be stricken from the record on February 20, 2026. This weight triggered for a significant weight gain of 23.8 lbs (pounds)(16.3%) from her weight measure of 145.2 lbs on December 1, 2025, utilizing a mechanical lift scale. Review of Resident 1's clinical record revealed a weight measure obtained on January 7, 2026, of 169.0 lbs. This measure was obtained at 6:00 AM using a mechanical lift scale. The weight measure was noted to be stricken from the record on February 20, 2026. This weight triggered for a significant weight gain of 24.6 lbs (16.9%) from her weight measure of 145.2 lbs on December 1, 2025. Review of Resident 1's clinical record revealed a physician note on January 21, 2026, containing the weight measure obtained on January 7, 2026, and detailed the Resident had no edema (fluid retention). The note did not discuss her significant weight change in January 2026. Review of Resident 1's clinical record revealed a dietitian note with an effective date of January 31, 2026, and a created date of February 10, 2026, that stated, evaluating the significant weight change. The dietitian note revealed this weight gain was undesirable, and recommended labs if the weight gain is confirmed with another consistent weight. Review of Resident 1's clinical record revealed a weight was obtained on February 16, 2026, of 136.2 lbs at 10:47 AM, utilizing a sitting scale. This weight was a significant loss from the January 7, 2026 weight (19.4), and a 9 lb (6.1%) loss from her December 2025 weight. Review of Resident 1's clinical record revealed a weight was obtained on February 19, 2026, of 136.4 lbs at 9:29 PM, utilizing a mechanical lift scale. This weight was a significant loss from the January 7, 2026, weight (19.2%), and a 9 lb (6.1%) loss from her December 2025 weight. Further review of Resident 1's clinical record revealed a dietitian note with an effective date of February 20, 2026, and a created date of February 24, 2026, that read, in part, Updated weights indicate that January weights on 1/1 and 1/7 are likely inaccurate and were struck out. Resident does not appear to gain/lose 20-20 lbs over the past month and is likely a scale error. Will continue to monitor weight trend and adjust interventions as needed. During an interview with the Director of Nursing on July 13, 2026, at 1:10 PM, she revealed she would have expected a reweigh in January 2026 in response to the significant changes to confirm if they are accurate. The surveyor revealed the concern with striking out weights from the record without confirmation of accuracy with a reweigh, the lack of a timely weight assessment in response to the significant changes, and the use of different scales and different times of day for weight monitoring. She revealed the facility tries to get monthly weights by the 7th of each month, and she agrees that staff should be utilizing the same scales and shifts for weight monitoring to ensure accuracy. 28 Pa Code 201.18(b)(1) Management28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of six residents reviewed (Resident 2). Findings Include: Review of facility policy, titled Activities of Daily Living (ADL), Supporting, last revised April 2025, read, in part, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). The resident's responses to interventions are monitored, evaluated, and revised as appropriate. Review of Resident 2's clinical record revealed diagnoses that included hypertension (persistent high blood pressure), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and facial weakness following cerebral infarction (stroke caused when a blot clot blocks an artery in the brain). Review of Resident 2's care plan revealed interventions for: Assist resident with ADLs as needed, . mouth care every morning and at bedtime, and Provide mouth care as per ADL personal hygiene. Review of facility grievance log revealed a grievance filed on behalf of Resident 2 on June 4, 2026, that read, in part, Reported that [Resident 2's] teeth are not being brushed, with a response order placed for brush teeth twice a day and document refusals. Review of Resident 2's nurse aide tasks revealed a task for Brush resident's teeth and provide oral hygiene. Review of the aforementioned task revealed there was no documentation to indicate Resident 2 had his teeth brushed on June 26, 27, and 29, 2026, and July 3, 2026; no documentation to indicate Resident 2 had his teeth brushed twice on June 14, 18, 19, 22, 23, 28, and 30, 2026, and July 1, 2, 7, 10, and 11, 2026; and it was documented no to indicate he didn't get his teeth brushed on June 30, 2026, and July 6 and 9, 2026. No refusals were documented. During an interview with the Director of Nursing (DON) on July 13, 2026, at 12:59 PM, she revealed sometimes Resident 2 refuses care and they have care planned the same. Review of Resident 2's care plan revealed refusals noted for doctor visits, adaptive equipment, and medications; no refusals related to oral care/hygiene care were noted. During a follow up interview with the DON on July 13, 2026, at 2:15 PM, she revealed she could not find any documentation that the Resident refused oral care on the aforementioned dates, and she would expect oral care to be provided or documented if it was refused. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on observations, facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement (Resident 1). Resident 1 exited the building through an unlocked door and was found in the facility's parking lot. This failure placed eight additional residents in an Immediate Jeopardy situation who were identified as an elopement risk (Residents 2, 3, 4, 5, 6, 7, 8 and 9). Findings Include: Review of facility policy, titled Wandering and Elopements, revised March 2019, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included aphasia (a language disorder caused by brain damage, typically from a stroke or head injury, that impairs a person's ability to communicate), Bipolar Disorder (a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression), and hemiplegia (paralysis) and hemiparesis (weakness) affecting the right dominant side. Review of Resident 1's facility assessment form, titled Elopement/Wander Risk Evaluation, dated February 18, 2026, revealed the Resident scored a 13, indicating she was a high wander risk. Review of Resident 1's facility assessment form, titled Elopement/Wander Risk Evaluation, dated February 19, 2026, revealed the Resident scored a 14, indicating she was a high wander risk. Review of Resident 1's care plan revealed a care plan initiated on February 19, 2026, stating that Resident 1 was an elopement risk/wanderer. Intervention, dated February 19, 2026, is that all staff should be aware of the Resident's tendency to wander, including receptionist. Observation of the elopement book at the receptionist desk on May 11, 2026, at approximately 1:30 PM, revealed Resident 1 was not listed in the book as being an elopement risk. Review of Resident 1's nursing progress note, dated February 19, 2026, revealed Staff observed resident ambulating independently in the hallways aimlessly. Resident put on elopement watch. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 11, 2026, at 11:49 AM, they were asked what an elopement watch entails. The DON stated that it means staff should be monitoring and making sure that the resident is not exit-seeking. She further stated that she does not believe that the elopement watch is documented anywhere in the clinical record. Review of Resident 1's nursing progress note dated April 30, 2026, revealed that Resident 1 was observed all dressed up with shoes, going to another resident's room. The nurse went to check on the Resident and Resident 1 stated she was finding her way to go home. The note further stated that Resident 1 was redirected back to her room. Review of Resident 1's skilled nursing note, dated May 2, 2026, revealed the Resident was alert with no behaviors noted and Elopement issues was listed under Other Information. The note provided no additional details regarding the elopement issues. Review of Resident 1's nursing progress note on May 3, 2026, revealed Resident was found by LPN [licensed practical nurse], walking in the parking lot of the facility, with a pack of cigarettes in her hand at approximately 2:50 PM. Resident stated she was trying to get to her car and she needs her keys, she said she want[s] to get a lighter for her cigarette [and] that she got the cigarette from the shop. Resident was redirected back to the facility. The note further stated that an assessment was performed and vital signs obtained. New order was received for hourly elopement checks. Provider and Resident's Responsible Party were notified. Review of Resident 1's incident report dated May 3, 2026, at 2:55 PM, revealed that Resident 1 was found by the LPN walking along the side of the building from the back door to the dumpsters, which was approximately 45 feet. Review of Employee 1's (Nurse Aide) witness statement, dated May 3, 2026, revealed Employee 1 did not know Resident 1 was outside. Employee 1 last saw Resident 1 at approximately 1:00 PM and Resident 1 was in her room. Review of Employee 2's (LPN) witness statement, dated May 3, 2026, revealed that Resident 1 was last observed in her room at 2:10 PM. Review of an additional statement from Employee 2, dated May 4, 2026, revealed Employee 2 was working a double shift and took a break in between shifts. Employee 2 stated she left to get a drink and when she left, she did not notice any issues and did not see Resident 1 in the hall or near any doors. Employee 2 stated she was parked in the side lot and did not see Resident 1 or anyone else outside when she left. Further review of Employee 2's statement revealed she was gone for approximately 10 minutes and upon her arrival back is when she noticed Resident 2 near the dumpsters, with a bag and a pack of cigarettes. Employee 2 then brought Resident 1 back into the facility and alerted the supervisor and nurse aides of what happened. Review of Employee 3's (Nurse Aide) witness statement, dated May 4, 2026, revealed that on May 3, 2026, at approximately 2:20 PM, Employee 3 took a lunch break and was sitting in her car on her phone. Employee 3 stated she looked straight ahead and noticed a female walking in the back parking lot where the dumpster is. Employee 3 stated she thought it was a visitor, so she continued playing on her phone. The statement further stated that Employee 3 looked up again and noticed a worker approach the female and the nurse walked the female back into the building. Review of facility reported incident, dated May 3, 2026, revealed that it was determined Resident 1 had exited through a side door that is used to take trash outside. It further stated that the door is locked with a code, but it was noted that the locking mechanism was not fully engaged. Further review of the facility reported incident revealed that staff immediately performed a head count on all residents in the facility. All exit doors were monitored every 15 minutes throughout the rest of the day and into the night and morning. Review of the door check documentation that the facility provided, revealed the door checks were started on May 3, 2026, at 5:45 PM, and only completed hourly until 10:45 PM. At 10:45 PM, the door checks were then completed every 15 minutes, through May 4, 2026, at 6:30 AM. The facility reported incident also stated that staff education on door locks, monitoring surroundings, checking doors to ensure they are closed as well as monitoring residents during change of shift to ensure residents safety prior to leaving was initiated immediately. It further states that maintenance checked the door and it was properly engaging. Review of Resident 1's nursing progress notes revealed a note on May 3, 2026, at 7:13 PM, stating that during nursing rounds, the Resident was sitting in the common area, fully dressed with sneakers on. She had a bag full of clothing, a hand bag and sunglasses. Resident 1 informed the nurse I am waiting for my ride. They are coming to get me. LPN and Nurse Aide were made aware to continue visually monitoring the Resident hourly while she is in the common area. RN (Registered Nurse) Supervisor will continue to monitor all exit doors to the facility hourly. The RN confirmed that all exit doors were locked at 6:45 PM. Review of a late entry progress note, dated May 6, 2026, revealed that on May 3, 2026, the speech therapist noted the Resident with increased confusion in the morning. She was observed in the hallway on that day with her front wheeled walker and multiple shirts on hangers draped over the walker. Resident had her purse over her shoulder and said she was going to the VA to get the baby. The speech therapist was able to redirect the Resident to her room. Review of an additional speech therapy progress note, dated May 6, 2026, at 1:03 PM, revealed that Resident 1 had confusion at lunch time. She had two garbage bags packed with her clothing and had another bag. Resident wanted to put the items in her car and stated that her husband will be picking her up. Resident was then found ambulating down the hallway pushing her wheelchair with her coat and one garbage bag. Resident was redirected. Review of nursing progress note on May 6, 2026, at 1:49 PM, revealed that the Resident was fully clothed with her shoes and jacket on. She had bags of clothes packed and her purse. The note stated that Resident 1 was actively exit seeking confused stating she is going home to take care of her dogs. She is stating her kids are going to pick her up and they are already outside waiting for her. When redirected she does not understand and keeps saying she is leaving and she knows how to get out. Review of a nursing progress note on May 6, 2026, at 2:27 PM, revealed that the nurse aide reported that Resident 1 was in the back hall attempting to get out of the door. She was redirected back to her room. Review of a nursing progress note on May 6, 2026, at 2:28 PM, revealed that the provider recommended to send Resident 1 to the hospital for evaluation and to seek safe placement following multiple attempts to elope. Resident 1 had been actively seeking exit from the facility. On May 6, 2026, Resident 1 was transferred to the hospital. Despite reported interventions from the facility reported incident regarding the door's locking mechanism, observation during an onsite survey on May 11, 2026, at 11:49 AM, revealed the door that Resident 1 eloped from on May 3, 2026, was not locked. The surveyor was able to push open the door without entering the door code. When the door was closed, the locking mechanism did not engage and the door remained unlocked. Further observation revealed there were seven concrete steps outside of the door that need to be descended in order to reach the parking lot. During an interview with the NHA and DON on May 11, 2026, at 11:50 AM, the DON confirmed which door the Resident eloped from. She confirmed that Resident 1 exited the side door and was found by the dumpsters. She stated that staff take the trash out that door but signs have been put on the door stating that they can no longer take trash out that way. She stated there is a code on the door to go out and to come back in. The DON further stated that, as far as she is aware, the door does not alarm if it is left open and not locked. On May 11, 2026, at 12:02 PM, surveyors and the DON approached the side door that Resident 1 eloped from. The surveyor was again able to push on the door and open the door without putting the code in. When the door slammed shut, the lock did not engage and the door was able to be pushed open again. The door needed to be physically pulled closed in order to latch and lock. At that time, the DON confirmed that the door was not locked and was able to be opened without the code. Clinical record review for Residents 2, 3, and 4 revealed they all scored a high risk on their most recent Elopement/Wander Risk Evaluation. On May 11, 2026, at approximately 1:30 PM, the receptionist provided the surveyor with the elopement book. Residents 5, 6, 7, 8 and 9 were all listed in the book as being a risk for elopement. Residents 1, 2, 3, and 4 were not in the elopement book, even though they all scored high on their most recent elopement/wandering assessments. During an interview with the DON on May 11, 2026, at 2:41 PM, she stated that staff place resident information in the elopement book at the receptionist desk when they feel that a resident is at risk for elopement based on circumstances. She stated that if a resident was exit-seeking or wandering near exits and was not cognitively intact, that resident would be added to the book. She also stated that they do not just go by a resident's elopement assessment because score of the assessment may not be an accurate reflection of the resident's status. She said that on occasion a resident may trigger as an elopement risk based on orientation, mood, medications, or diagnoses, but the resident may be unable to independently ambulate or propel their chair which would eliminate the risk. The facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of Resident 1. In addition, the facility failed to ensure the locking mechanism on the door was fully functioning. This placed all residents with a high risk for elopement score, and those listed in the elopement book, in an Immediate Jeopardy situation. The NHA was provided the immediate jeopardy template on May 11, 2026, at 3:17 PM, and an immediate action plan was requested. On May 11, 2026, at 5:59 PM, the facility's immediate action plan was accepted, which included:Head count completed and all residents accounted for.Door vendor contacted to evaluate door. Awaiting response for a date/time a tech will report onsite.Staff will observe the door 24 hours/day until the door vendor evaluates and reports consistent functioning. A staff member will be sitting in a chair at the door to ensure the door is secure.All exterior doors checked by maintenance and determined to be properly secured. All staff currently on shift will receive education on door safety. Staff not working will receive the education prior to their next shift or at the beginning of their next shift. Nursing staff currently on shift will receive education on elopement prevention. Staff not working will receive the education prior to their next shift or at the beginning of their next shift. All current residents' most recent Elopement evaluation scores will be reviewed to identify anyone at moderate or high risk for elopement. Removal plan and event will be reviewed by QAA Committee. Compliance date: May 12, 2026 Observations, interviews, review of education, review of audits, and clinical record reviews conducted on May 12, 2026, between 9:50 AM and 1:20 PM, revealed the facility had completed all immediate actions as stated in their plan. The door repair vendor was noted to be at the facility at 9:45 AM. Interviews were conducted with one Registered Nurse, two Licensed Practical Nurses, two Nurse Aides, one laundry aide, one dietary aide, one housekeeping supervisor, one Physical Therapy Assistant, and one transportation aide/acting receptionist; all who were able to verbalize education they had received regarding elopement risk and door closures. All stated that they completed the training either on May 11, 2026, or prior to their shift starting today, May 12, 2026. During a staff interview with the NHA on May 12, 2026, at 9:50 AM, she stated that she and the DON had decided to expand elopement education to all staff instead of just nursing staff. She further stated that the facility had completed a Quality Assurance Performance Improvement Meeting this morning and reviewed Resident 1's elopement and the facility's immediate action plan. On May 12, 2026, at 1:24 PM, the Immediate Jeopardy was lifted. During a final staff interview with the NHA on May 12, 2026, at 1:27 PM, she confirmed that the door failed to secure properly and that she would have expected staff to make sure the door was fully closed/locked when using the door. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide routine drugs to its residents and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of the four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled' Policy Services Overview, revised April 2019, reads, in part, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy continued, Pharmacy services are available to residents 24 hours a day, seven days a week. Also, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner. Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and muscle weakness, with an admission date to the facility on February 25, 2026. Review of Resident 2's Medication Administration Record (MAR), dated February 1 through 28, 2026, revealed the following medication order: Amlodipine Besylate give 5 mg by mouth one time a day related to essential hypertension (primary). Review of the MAR revealed that on February 26, 2026, the medication was not administered by the nursing staff as ordered by Resident 2's physician. Additional review of Resident 2's MAR revealed the following medication order: Valsartan-Hydrochlorothiazide oral tablet 320-25 MG, Give 1 tablet by mouth one time a day related to essential hypertension (primary). Review of the MAR revealed that on February 26, 2026, the medication was not administered by the nursing staff as ordered by Resident 2's physician. Review of Resident 2's progress notes, dated February 26, 2026, regarding those medications not administered, read Awaiting delivery. RN [Registered Nurse] Supervisor, RP [Resident Representative], and provider aware. An interview with the Director of Nursing on March 11, 2026, at 11:28 AM, revealed an acknowledgment that those medications ordered for Resident 2 were not available from the contracted pharmacy. The interview also revealed that the facility has contracted pharmacy services with another provider to prevent medication shortages for its residents. 28 Pa. Code 211.12 (d) (5) Nursing services

Based on a review of clinical records and a staff interview, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice and the comprehensive plan of care for one of four residents reviewed (Resident 2).Findings Include: Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed a recent hospitalization resulting in surgery to the spine. According to documentation, Resident 2's wound/incision required staples, and the care to the site should be open to air. Review of a document titled Employee Progress Discipline Notification, dated February 26, 2026, revealed that the Nurse Aide (Employee 3) assigned to provide care to Resident 2 was suspended for three days for double briefing Resident 2 with the knowledge that the surgical site needed to be open to air. An interview with the Director of Nursing on March 11, 2026, at 12:23 PM, confirmed Employee 3 was suspended and ultimately terminated from her position at the facility related to the care provided to Resident 2, and confirmed Resident 2 should not have been provided with briefs covering the surgical site. 28 Pa. Code 201.18 (b) (1) Management28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on policy review, document review, and staff interview, it was determined that the facility failed to ensure that the services provided met professional standards of quality for two of four resident records reviewed (Residents 1 and 4).Findings Include: Review of the facility's policy, titled Administering Medications, revised April 2019, read, Medications are administered in a safe and timely manner, as prescribed. The policy continued, The individual administering medications verifies the resident's identity before giving the resident his/her medications. Review of Resident 1's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive, incurable, but treatable inflammatory lung disease causing obstructed airflow) and hypotension (abnormally low blood pressure). Review of Resident 4's clinical record revealed diagnoses that included respiratory failure (a critical condition where the lungs cannot adequately oxygenate the blood or remove carbon dioxide) and atrial fibrillation (a common heart condition characterized by an irregular, often rapid heart rate). Review of the facility's incident report dated March 1, 2026, read, as follows: [Resident 1] told this nurse that on evening shift Sunday, the LPN [licensed practical nurse/Employee 4] brought in medications for both her and her roommate [Resident 4], put them down on the bedside tables, and left. The report continued, [Resident 1's] roommate [Resident 4] noticed a pink and white pill in there she did not take, she said 'these are not mine' [Resident 1] stated 'I take a pink and white pill' they called the nurse [Employee 4] in who realized she gave them the wrong medications. An interview with the Director of Nursing on March 11, 2026, at 11:22 AM, revealed she was made aware of the medication error on the next day and confirmed Residents 1 and 4 did not take each other's medications. The interview also revealed that Employee 4 was an agency-contracted nurse and will not be returning to the facility for employment. 28 Pa. Code 201.18 (b) (1) Management28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to treat each resident with respect and dignity and care for each resident in a manner that enhances his or her quality of life for one of four residents reviewed (Resident 2).Findings Include: Review of the facility's policy, titled Dignity, dated 2001, read, Residents are treated with dignity and respect at all times. Also, Resident goals, choices, preferences, values, and beliefs, are respected and honored.This begins at initial admission and continues throughout the resident's stay. Review of Resident 2's physician orders revealed diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves) and hypertension (elevated blood pressure). Review of Resident 2's clinical record revealed an admission date to the facility on February 25, 2026. Review of a documented statement, dictated to the Director of Nursing, dated February 26, 2026, revealed that upon admission to the facility, Resident 2 was provided with a bedpan for use with toileting with assistance by staff and Resident 2's daughter. Review of the facility's Grievance/Concern form, completed by Resident 2's daughter, read the Nurse Aide (Employee 3), Encouraged Resident 2 to 'pee' in her brief and they will change her. The Grievance/Concern continued that Employee 3 put a pamper on her [Resident 2]. Review of a document titled Employee Progress Discipline Notification, dated February 26, 2026, revealed that Employee 3 was assigned to provide care to Resident 2, including toileting, and was subsequently suspended for three days for double briefing Resident 2 instead of offering the bedpan or assistance with ambulating to the restroom. An interview with the Director of Nursing on March 11, 2026, at 12:23 PM, confirmed Employee 3 was suspended and ultimately terminated from her position at the facility related to the care provided to Resident 2. 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three pantry areas.Findings include: Review of facility policy, titled Policy: Storage Areas last reviewed May 21, 2025, read, in part, All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. All freezer units are always kept clean and in good working condition. Review of facility policy, titled Food from Outside Sources last reviewed May 21, 2025, read, in part, Visitors/family member will label food and beverages with the resident's name, room number, and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility.Observation of the dry storage area on September 29, 2025, at 9:27 AM, revealed one bag of spiral pasta open without an open date, and one bag of elbow pasta open without an open date. Interview with Employee 2 (Cook) on September 29, 2025, at 9:28 AM, revealed bags of pasta should be labeled with an open date once opened. Observation of the reach-in freezer 1 in the main kitchen on September 29, 2025, at 9:31 AM, revealed two bags of steak fries with one open and both not dated; one package of hot dogs not dated with a heavy presence of ice crystals; and one package of sausages not dated with a heavy presence of ice crystals. Observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:33 AM, revealed one bag of sausage patties open and not dated. Further observation of the reach-in freezer 2 in the main kitchen on September 29, 2025, at 9:34 AM, revealed the bottom of the freezer was heavily soiled with food debris. Interview with Employee 2 on September 29, 2025, at 9:35 AM, revealed she was not aware of a formal cleaning schedule for kitchen equipment, but it is the expectation that kitchen equipment is kept clean at all times. Observation in the Unit 2 Pantry Refrigerator on September 29, 2025, at 9:39 AM, revealed two bags of food from outside sources not labeled with resident names or dates. Observation in the Unit 2 Pantry Freezer on September 29, 2025, at 9:40 AM, revealed one ice cream container spilled over without a lid; two frozen beverages from outside sources without resident names or dates; and one frozen meal from an outside source with an expiration date of August 25, 2025. Observation of the April 2025 Unit 2 Refrigerator/Freezer Temperature Log revealed the refrigerator temperature failed to be recorded on April 5. Observation in the Unit 1 Pantry Refrigerator on September 29, 2025, at 9:43 AM, revealed cream of wheat in a Styrofoam cup without a date; a bag of food labeled with a resident's name, dated August 4 that appeared rotten; and a container of wilted salad, labeled with a resident's name, not dated, with a four odor. Observation of the September 2025 Unit 1 Refrigerator/Freezer Temperature Log on September 29, 2025, at 9:44 AM, revealed temperatures failed to be recorded on September 13, 21-23; and temperatures were already filled for September 30. Observation of the August 2025 Unit 1 Refrigerator/Freezer Temperature Log revealed temperatures failed to be recorded on August 5 for the refrigerator and August 19 for both the refrigerator and the freezer. Observation in the Unit 3 Pantry Refrigerator on September 29, 2025, at 9:47 AM, revealed four containers of applesauce not dated; one can of kidney beans from an outside source open and not properly sealed; and one container of food from an outside source not labeled with a resident's name or date. Interview with the Nursing Home Administrator on October 1, 2025, at 10:40 AM, revealed his expectation that expired items are discarded, foods items are labeled and dated per facility policies, and food storage equipment is utilized in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.6(f) Dietary services

Based on policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to provide interventions to prevent accidents for two out of 19 residents reviewed (Residents 4 and 83).Findings include: Review of the facility policy, titled Falls - Clinical Protocol, with a last revised date of March 2018, and a last reviewed date of May 21, 2025, revealed, The staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's clinical record progress notes revealed that she had a fall from her bed on September 20, 2025. Review of Resident 4's clinical record progress note dated September 20, 2025, at 9:55 AM, that revealed that the facility had contacted Resident 4's hospice provider about providing Resident 4 with a different bed that could be positioned lower to the floor since the one that they had already provided could be positioned in this manner. In addition, a progress note dated September 20, 2025, at 10:29 AM, indicated that the facility had contacted Resident 4's Representative to update her on the incident. The note further indicated that Resident 4's Representative requested that Resident 4 be provided with a second body pillow and that fall mats be placed on the floor for safety. Review of Resident 4's care plan revealed a care plan focus for potential for falls with interventions that included, but were not limited to, body pillow to left and right side when in bed, dated September 20, 2025; keep bed in lowest position, dated July 26, 2024; and fall mats to bilateral sides of bed requested by [representative], dated September 20, 2025. Observation of Resident 4 on September 29, 2025, at 1:30 PM, revealed that she was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. Subsequent observations on September 30, 2025, at 10:00 AM and 12:25 PM; and on October 1, 2025, at 8:55 AM, all revealed the same findings: the Resident was in bed with bilateral body pillows placed, her bed was approximately two feet off the floor, and no fall mats were present. During a staff interview on October 1, 2025, at 11:07 AM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), observations and care plan findings were shared by the surveyor. The NHA indicated that the fall mats were not placed because the interdisciplinary team had reviewed the request by Resident 4's Representative and decided against them and, therefore, the fall mats should not have been care planned. When observation of the bed height of approximately two feet in the lowest position was discussed, the DON indicated that they were awaiting a different bed from hospice and that hospice had provided her current bed. During a staff interview with Employee 5 (Nurse Aide) on October 1, 2025, at 11:45 AM, she demonstrated that the bed was as low as it could go. She indicated that she had told administrative staff about it several times. Observation of Resident 4 on October 1, 2025, at 12:35 PM, revealed that the bilateral fall mats had been placed on both sides of her bed. Observation of Resident 4 on October 21, 2025, at 9:00 AM, revealed she was in bed with bilateral body pillows in place, her bed was approximately two feet off the floor, and the bilateral fall mats were present at both sides of her bed. During a final staff interview with the NHA and DON on October 21, 2025, at 11:17, the NHA again indicated that, although the interdisciplinary team had decided against the fall mats, staff went ahead and implemented them since they were care planned. The NHA confirmed that since they were care-planned, they should have been in place since September 20, 2025. He also confirmed that Resident 4's lowest bed height was still approximately two feet from the floor and that the falls mats could help prevent injuries should Resident 4 fall from bed again. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed a fall risk care plan with an intervention for Resident 83 to have a fall mat to the right side of the bed, initiated on February 7, 2025, and revised on February 8, 2025; and an intervention to keep bed in lowest position, initiated on February 14, 2024. Review of a fall incident report on Resident 83 that occurred on July 3, 2025, revealed the Resident had an unwitnessed fall in their room and was found lying on the right side of the bed, without injury. Further review of the incident report revealed Resident 83's bed was not in a low position at the time of the fall and their fall mat was not present. Observation of Resident 83 on September 30, 2025, at 1:55 PM, revealed the Resident was lying in bed with no fall mat present on the floor and their bed was not in the lowest position. Interview conducted with the NHA on October 21, 2025, at 11:05 AM, revealed they would have expected Resident 83's interventions to have been in place. 28 Pa. Code 201.18(b)(1)(2) Management28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident condition for six of 19 residents reviewed (Residents 2, 4, 5, 7, 15, and 32).Findings include: Review of Resident 2's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 4 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), hypertension (persistent high blood pressure), and schizophrenia (a chronic mental health condition characterized by disruptions in thought, perception, and behavior). Review of Resident 2's Annual MDS (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 18, 2025, revealed under Section M- Skin Conditions, Resident 2 was marked no to indicate he was not at risk of a pressure ulcer. During an interview with the Director of Nursing (DON) on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed orders for a consistent carbohydrate diet with a pureed texture and thin liquids, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's Quarterly MDS with the assessment reference date of March 26, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Modified Quarterly MDS with the assessment reference date of June 26, 2025, revealed in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. Review of Resident 4's Quarterly MDS with the assessment reference date of September 24, 2025, revealed in Section K. Swallowing/Nutritional Status that Resident 4's was not coded as receiving a therapeutic diet; and in Section O. Special Treatments, Procedures, and Programs that Resident 4 was not coded as receiving hospice care. During a staff interview with the Nursing Home Administrator (NHA) and DON on October 1, 2025, at 11:29 AM, the DON confirmed that Resident 4's aforementioned assessments were coded inaccurately and that modifications would be completed. Review of Resident 5's clinical record revealed diagnoses which included atrial fibrillation (irregular heartbeat) and chronic respiratory failure (respiratory disease that results in decreased ability of the lungs to either oxygenate the blood or remove carbon dioxide from the blood). Review of Resident 5's physician orders revealed an order for olanzapine (atypical antipsychotic medication used to treat mental health conditions) 5 milligrams twice a day, which was active since January 29, 2025. Review of Resident 5's Quarterly MDS with an assessment reference date of May 4, 2025, revealed Section N - Medications was coded to reflect Resident 5 was not receiving an antipsychotic medication; however, review of Resident 5's medication administration record revealed that at the time of the Quarterly MDS, Resident 5 had been receiving the antipsychotic medication. During a staff interview on October 21, 2025, at approximately 1:10 PM, the DON confirmed that Resident 5's Quarterly MDS with assessment reference date of May 4, 2025, should have been coded to reflect Resident 5's use of an antipsychotic medication. Review of Resident 7's clinical record revealed diagnoses that included gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), feeding difficulties, and abnormal posture. Review of Resident 7's Quarterly MDS with ARD of August 4, 2025, revealed under Section K- Swallowing/Nutritional Status was marked yes to indicate he had received intravenous (IV) fluids during the look back period for the assessment. Review of Resident 7's clinical record failed to reveal notation that they received IV fluids during the lookback. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 15's clinical record revealed diagnoses that included acute and chronic respiratory failure with hypoxia (conditions where the lungs cannot adequately exchange gases leading to low oxygen levels and potentially high carbon dioxide levels) and encounter for palliative care (specialized medical care aimed at enhancing the quality of life for patients with serious illnesses). Review of Resident 15's clinical record revealed she was admitted to hospice care (medical care for people who are expected to live six months or less, and focus on comfort and quality of life) on July 13, 2024, with an admitting diagnosis of chronic respiratory failure and hypoxia. Review of Resident 15's Quarterly MDS with ARD of July 19, 2025, revealed under Section I- Active Diagnoses, subsection I6300. Respiratory failure, it was marked no to indicate she did not have that active diagnosis. During an interview with the DON on October 21, 2025, at 1:09 PM, she revealed the aforementioned MDS was coded incorrectly, and she would expect the MDS to be coded accurately. Review of Resident 32's clinical record revealed diagnoses that included type II diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin) and chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body). Review of Residents 32's Annual MDS with an ARD of April 7, 2025, and Quarterly MDS's with assessment reference dates of July 28, 2025, and September 23, 2025, revealed that Resident 32 was coded in Section N. Medications that he had received one insulin injection in all the aforementioned assessment periods. Review of Resident 32's clinical record physician orders and Medication Administration Records for April 2025, July 2025, and September 2025, failed to reveal that Resident 32 was ordered or received any insulin injections during the assessment periods. During a staff interview with the NHA and DON on October 1, 2025, at 11:20 AM, the DON indicated that Resident 32 had received Ozempic injections during the assessment periods and that it was coded inaccurately as insulin on Resident 32's aforementioned assessments. She further indicated that assessment modifications would be completed. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status for two of 19 residents reviewed (Residents 4 and 85). Findings include: Review of facility policy, titled Weighing and Measuring a Resident last reviewed May 21, 2025, read, in part, The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident. Review the resident's care plan to assess for any special needs of the resident. Review of Resident 4's clinical record revealed diagnoses that included chronic kidney disease stage 4 severe (longstanding disease of the kidneys leading to renal failure), vascular dementia (brain damage caused by multiple strokes which causes memory loss in older adults), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction). Review of Resident 4's physician orders revealed the following orders: Glucerna with Carb Steady 1.5 calories 300 milliliters via feeding tube every six hours, dated September 8, 2025; a consistent carbohydrate diet with a pureed texture and thin liquids; may have pleasure foods per hospice, dated December 10, 2024; and hospice services, dated January 7, 2025. Review of Resident 4's physician order history revealed that she had an order for monthly weights until September 11, 2025. Review of Resident 4's weight documentation revealed that no weight was documented in January 2025, February 2025, April 2025, May 2025, or July 2025. Further review of Resident 4's documented weights revealed that on March 11, 2025, she weighed 225 pounds; June 1, 2025, she weighed 201 pounds; August 5, 2025, she weighed 200 pounds; and September 1, 2025, she weighed 192.4 pounds. Review of Resident 4's clinical record revealed that she had no nutritional assessments completed by the facility dietician between December 11, 2024, and September 8, 2025. Review of Resident 4's clinical record failed to reveal any documentation that Resident 4's physician, hospice provider or family were notified of her 24 pound weight loss in June 2025. Review of Resident 4's hospice nurse's visit note dated June 4, 2025, revealed that she was tolerating tube feedings and refusing to be fed orally. Pt is spitting food out. The note failed to include any documentation about the 24-pound weight loss. Review or Resident 4's hospice nurse's visit note dated June 13, 2025, revealed that she was tolerating tube feedings, but failed to include any documentation of the 24-pound weight loss. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated June 18, 2025, revealed that the hospice physician documented Resident 4 was receiving Glucerna 1.5 calories 250 milliliters every six hours via her feeding tube with 120 milliliter water flushes before after feedings; that she was allowed comfort feedings with pureed diet and nectar thick liquids as tolerated. The note failed to include any notation of Resident 4's 24-pound weight loss but did include that Resident 4 no longer responds to her daughter or takes anything by mouth from her. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated July 16, 2025, the hospice physician again documented the use of tube feeding for Resident 4 but failed to include any documentation of her weight loss. Review of Resident 4's Resident's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated August 13, 2025, the physician again documented the use of a tube feeding for Resident 4 and indicated that she no longer takes anything by mouth but failed to include any documentation of her weight loss. Review of Resident 4's progress notes revealed a note by the dietician dated September 8, 2025, at 5:57 PM, that indicated she was evaluating Resident 4 for a new onset of a pressure injury and that she was triggering for desirable significant weight loss of 32-33lb (-14.5%) over six months. The note further indicated that she had recommended changes to Resident 4's tube feeding amount, water flushes, and added vitamins to promote wound healing. During a staff interview with the Director of Nursing (DON) on October 1, 2025, at 1:30 PM, she indicated that the facility dietician does not complete nutritional assessments on residents receiving hospice services. She said that this would be deferred to hospice since she was under their services. She further indicated that the facility does not typically weigh people on hospice. During a final interview with the Nursing Home Administrator (NHA) and DON on October 21, 2025, at 1:14 PM, the DON indicated that Resident 4 was a unique case given she is under hospice services, but receiving tube feedings and remaining a full code. She confirmed that staff should have been weighing her monthly since that was the physician's order. The DON further confirmed that Resident 4's physician, hospice provider, and Representative should have been notified of the weight loss in June 2025 when it was noted to have occurred to have possibly prevented further weight loss. She confirmed that there was no documentation to support that Resident 4's provider, hospice provider, or the dietician had been made aware of Resident 4's weight loss or made in changes in her treatment regimen until September 8, 2025. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. During an interview with Resident 85 on September 29, 2025, at 10:59 AM, he revealed he has been losing weight at the facility because he sometimes receives food he can't eat and doesn't get food per his preference. Review of Resident 85's care plan revealed a focus area that read, in part, The resident has [a] potential nutritional problem related to food allergies/sensitivities with an intervention for Obtain weight as ordered. Notify Medical Doctor, Registered Dietitian of any significant changes for further review, with a start date of September 11, 2025. Review of Resident 85's physician orders revealed an order for Weigh daily times 3 then weekly times 4 then monthly, every day shift every Sunday for 4 weeks, with a start date of September 9, 2025. Review of Resident 85's clinical record revealed he had a weight measure obtained on September 14, 2025, and not again until September 28, 2025. Review of Resident 85's weight change from September 14 to 28, 2025, revealed he had experienced a 5.1% significant weight loss from 138.8 pounds to 131.6 pounds. Review of Resident 85's clinical record revealed the facility obtained another weight measure on October 1, 2025, that was back up to 139.2 pounds. During an interview with the DON on October 1, 2025, at 10:34 AM, she revealed the facility weight policy indicated weight is usually measured upon admission and monthly during the resident's stay, but since current professional standards of practice recommend residents should be weighed weekly for the first 4 weeks after admission it should be updated. She further revealed since the Resident had a physician order for weekly weights at that time, it should have been followed. The DON also stated that staff had obtained a reweigh measure in response to the weight measure on September 28, 2025, due to it likely being a discrepancy, but she would expect reweigh weight measures to be completed within 24 hours. 28 Pa Code 201.18(b)(1) Management28 Pa. Code 211.10(c)Resident care policies28 Pa Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 9).Findings include: Review of facility policy, titled Psychotropic Medication Use, with a last review date of May 21, 2025, revealed, in part, Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. 2. Circumstances that warrant an evaluation of the resident's underlying medical condition and medications include: a. admission or readmission; c. an irregularity identified during the drug regimen review. Behavioral and Other Non-Pharmacological Interventions: 1. Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permit the lowest possible dose if indicated, and support gradual dose reduction. Informed consent: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendation; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representatives right to accept or decline treatment. Dose, Duration, and Duplicate Therapy: 3. Duplicate therapy (use of two or more medications of the same pharmacological class or category .) is generally not indicated unless there is a documented clinical rationale for the use of multiple medications from the same class or with similar effects. 5. Medications prescribed by a specialist or began in another care setting, such as the hospital, must be clinically indicated and documented in the resident's medical record. Review of facility policy, titled Medication Regimen Reviews, with a last review date of May 21, 2025, revealed, in part, Timeframe for Reporting: 3. The consultant pharmacist provides the director of nursing and medical director with a written, signed, dated copy of all medication regimen reports. 4. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. Physician Response: 1. Upon receiving the MRR [Medication Regimen Review] report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them. 2. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator. Review of Resident 9's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 9's current physician orders revealed orders for duloxetine (a medication used to treat depression) 60 milligrams one capsule daily, dated June 19, 2025; mirtazapine (a medication used to treat depression)15 milligrams one tablet at bedtime, dated June 19, 2025; sertraline (a medication used to treat depression) 150 milligrams daily, dated June 19, 2025; quetiapine (a medication used to treat psychotic disorders) 100 milligrams administer one and a half tablets at bedtime, dated June 19, 2025; quetiapine 25 milligrams administer one tablet one time daily, dated September 5, 2025; and consult psychiatry to evaluate and treat as needed, dated August 21, 2025. Review of Resident 9's clinical record failed to reveal any documentation that education was provided to Resident 9 or her Representative regarding the risk versus benefit of the ordered antipsychotic and antidepressant medications or that consent was obtained to administer the medications. Review of Resident 9's clinical record failed to reveal any documentation of Resident 9's identified target behaviors, any behavior monitoring for the use of the antipsychotic medication, or any side effect monitoring of the antipsychotic medication. Review of Resident 9's care plan failed to reveal any identified target behaviors. Review of Resident 9's clinical record revealed that the facility consultant pharmacist issued a recommendation to Resident 9's physician on July 15, 2025, which indicated, in part, Black box warning .Residents with dementia-related psychosis treated with atypical antipsychotics are at an increased risk of death .increased incidence of cerebrovascular adverse events (including fatalities) has been reported in elderly patients with dementia-related psychosis .Please evaluate current therapy and indicate below the appropriate option for this resident. The form failed to reveal any physician documentation or review signature. Review of Resident 9's clinical record revealed an initial psychiatry consult note dated September 4, 2025, which indicated that Resident 9 had no supporting diagnosis for the quetiapine and that a gradual dose reduction would be initiated. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on October 1, 2025, at 11:15 AM, the DON indicated that Resident 9 was admitted to the facility on all the psychotropic medications. She said that the practitioner at the facility was not comfortable adjusting any of Resident 9's medications because of her long-term use of the medications. The DON indicated that the practitioner wanted psychiatric services to evaluate Resident 9 regarding the July 2025 recommendation and to assume management of Resident 9's psychotropic medications. The DON said that she could not answer as to why the practitioner did not consult psychiatric services until August 21, 2025, instead of in July 2025 when the pharmacist had made the recommendation to review the antipsychotic medication. Review of Resident 9's progress notes revealed that she was seen by her practitioner at the facility on July 18, 22, and 28, 2025; and August 14, 2025, and, although documentation included the medications Resident 9 was taking and her mood status at the time of the visit, the documentation failed to include any documentation regarding consulting psychiatry services to manage her psychotropic medications. Further review of Resident 9's progress notes revealed a note by her practitioner dated August 19, 2025, which indicated that a psych consult has been placed for recommendations. During a staff interview with the NHA and the DON on October 1, 2025, at 1:25 PM, the DON indicated that Resident 9 was admitted to the facility on all her psychotropic medications so the facility would not have obtained any consents. During a final staff interview with the NHA and the DON on October 21, 2025, at 11:22 AM, both confirmed that Resident 9's target behaviors should have been identified, and care planned and that behavior monitoring and side effect monitoring should have been in place. The DON confirmed that this should have been done at time of Resident 9's admission to the facility in June 2025. The DON confirmed that the pharmacy recommendation from July 15, 2025, was not addressed until September 4, 2025, when the psychiatry finally saw the Resident and began reducing the antipsychotic medication dose because Resident 9 was noted to have no supporting diagnosis for its use. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.2(d)(3) Medical director28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that all residents had access to a call bell for assistance from staff for one of 19 residents observed (Resident 74).Findings include: Review of the facility policy titled, Answering the Call Light with last revised date of September 2022, and a last reviewed date of May 21, 2025, revealed 4. Be sure that the call light is plugged in and functioning at all times. Review of Resident 74's clinical record revealed diagnosis including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing). Review of Resident 74's comprehensive care plan reveals an ADL (Activities of daily living) care plan with an intervention for the Resident's call bell to be within reach, initiated on July 9, 2018. Observation conducted on September 30, 2025, at 12:30 PM, revealed Resident 74 was lying in bed with no call bell attached to their room or accessible to the Resident. Further observations conducted at 1:06 PM and 1:36 PM revealed Resident 74 still did not have a call bell attached or accessible to them in their room. Interview conducted with Employee 4 on September 30, 2025, at 1:51 PM, revealed that they were not sure why Resident 74 did not have a call bell, and further inspecting revealed the cord broke off. Employee 4 revealed that no one put a ticket for maintenance to look at it in their system and then left the room and returned at 1:54 PM with a new cord and plugged it in to ensure it worked. During an interview with the Nursing Home Administrator on October 1, 2025, at 11:05 AM, he revealed that he would have expected Resident 74 to have had a call bell attached to his room and accessible for the Resident to use and was unable to determine how long it was not functioning. 28 Pa. Code 201.14 (a) Responsibility of licensee28 Pa. Code 201.18 (b)(1) Management

Based on facility policy review, observation, manufacturer product information, and staff interviews, it was determined that the facility failed to discard expired medications in a timely manner in one of three medication carts reviewed (Unit 2 Cart 4).Findings include: Review of facility policy, titled Medication Labeling and Storage, with a last review date of May 21, 2025, revealed, in part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy, titled Administering Medications, with a last review date of May 21, 2025 revealed, in part, The expiration/beyond use date on the label must be checked prior to administering. During a medication pass observation on Unit 2 on October 1, 2025, at 9:05 AM, Employee 1 was administering medications from Cart 4. Employee 1 retrieved a house stock bottle of famotidine 10 mg (milligrams) (an over-the-counter medication used to reduce stomach acid) in preparation to administer to Resident 50. Surveyor review of the bottle noted that an open date of March 4, 2025, was written on the bottle and that the manufacturer expiration date was January 2025. Employee 1 was observed confirming the medication name and dose on the bottle to Resident 50's orders, but Employee 1 failed to confirm the expiration date of the medication. During an immediate interview with Employee 1 on October 1, 2025, at 9:08 AM, she confirmed that the bottle was opened three months after the manufacturer expiration date. She also confirmed that there were no other bottles of famotidine in the cart and that staff would have been administering from this bottle. The bottle was approximately one-third full. During a staff interview with the Nursing Home Administrator and Director of Nursing on October 21, 2025, at 11:30 AM, both confirmed that the medication should not have been opened and utilized past the manufacturer expiration date. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.10(b)(d) Resident care policies28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 19 residents reviewed (Residents 18 and 83).Findings include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting with a last revised date of April 2025, and a last reviewed date of May 21, 2025, revealed 5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care including appropriate support and assistance with: mobility (transfer and ambulation). Review of Resident 18's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hypertension (high blood pressure). Review of Resident 18's comprehensive care plan revealed an ADL care plan with an intervention that Resident 18 requires total lift and 2-staff participation with transfers, with an initiation date of March 6, 2023, and a revision date of June 30, 2025. Another intervention included in Resident 18's ADL care plan includes that they prefer to be out of bed in their chair after they are changed, initiated on March 22, 2023, and revised on July 26, 2024. Further review of Resident 18's care plan revealed a focus area that there is a potential risk of adjustment due to resident age is younger than general population, with an initiation date of March 7, 2023, and a revision date of April 20, 2023; and an intervention that Resident 18 would like to arise at 7:00 AM and be put back to bed at approximately 9:30 PM - 10:00 PM. Interview conducted with Resident 18 on September 29, 2025, at 10:00 AM, the Resident revealed that the Resident was waiting to get up out of bed. Interview conducted with Employee 4 on September 29, 2025, at 10:02 AM, revealed that Resident 18 is hard to understand and that the Resident was waiting to get up. Observations of Resident 18 on September 29, 2025, at 10:20 AM, 11:14 AM, and 11:40 AM, revealed Resident 18 was still lying in bed waiting to get up. Observation at 11:47 AM revealed two staff members went into Resident 18's room with a lift to get them up out of bed. During an interview with the Nursing Home Administrator (NHA) on October 21, 2024, at 11:05 AM, he revealed he would have expected Resident 18's care plan to have been followed. Review of Resident 83's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 83's comprehensive care plan revealed an ADL care plan with an intervention that the Resident required total lift and 2-staff participation with transfers, initiated on February 14, 2024, and revised on July 26, 2024. Further review of Resident 83's care plan revealed a care plan for dialysis and an intervention that after Resident 83 returns from dialysis, to offer them rest period in bed (Resident request to be laid down after she gets back from dialysis), initiated on August 15, 2025. Observation conducted on September 30, 2025, at 1:04 PM, revealed Resident 83's call light was on. Interview conducted with Resident 83 on September 30, 2025, at 1:17 PM, revealed that she wanted to get put back in bed and has been back from dialysis since 11:00 AM, and does not feel well. Observation conducted on September 30, 2025, at 1:22 PM, revealed a staff member going into Resident 83's room and turning the call bell off and exiting the room. Interview conducted with Resident 83 on September 30, 2025, at 1:24 PM, revealed that the staff member told Resident 83 they will get someone to assist putting Resident 83 into bed. Observation on September 30, 2025, at 1:52 PM, revealed two staff members going into Resident 83's room with a lift to assist them into bed. During an interview with the NHA on October 1, 2025, at 10:52 AM, they revealed that they would expect Resident 18's plan of care to have been followed, and for Resident 83 to have been put back into bed upon returning from dialysis. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy reviews, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with required included information upon transfer/discharge; failed to provide residents with a copy of the facility's bed hold policy for three of four residents reviewed for hospitalization (Residents 8, 12, and 85).Findings include: Review of facility policy, titled Bed-Holds and Returns last reviewed May 21, 2025, read, in part, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of facility policy, titled Transfer or Discharge, last reviewed May 21, 2025, revealed that subsection titled Transfer or Discharge Documentation in the Medical Record, stated, 1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: .b. That an appropriate notice was provided to the resident and/or legal representative . Review of Resident 8's clinical record revealed diagnoses that included congestive heart failure (disease process that results in the decreased ability of the heart to pump blood through the body effectively) and chronic kidney disease (disease of the kidneys that affects kidney function). Review of Resident 8's clinical record revealed that on June 22, 2025, Resident 8 was sent to the hospital for an acute medical change in condition. Resident was admitted to the hospital and returned to the facility on June 26, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided a notice of transfer or bed hold policy. Resident 8 was also transferred to the hospital for an acute medical change in condition on July 12, 2025. Resident 8 returned to the facility on July 16, 2025. Review of available documentation revealed no evidence that Resident 8 nor Resident 8's Representative Party were provided with a notice of transfer or bed hold policy. Review of Resident 12's clinical record revealed diagnoses that included vascular dementia (changes in the blood vessels of the brain that results in decreased ability to perform activities of daily living and decreased contact with reality) and atrial fibrillation (irregular heartbeat). Review of Resident 12's clinical record revealed that on August 23, 2025, Resident 12 was sent to the hospital after an acute medical change. Review of the available documentation revealed no evidence that Resident 12 nor Resident 12's Representative Party were provided a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed diagnoses that included infection following a procedure, dysphagia (difficulty swallowing), and repeated falls. Review of Resident 85's clinical record revealed he was transferred to the hospital for an acute medical change in condition on August 15, 2025. Resident 85 returned to the facility on August 21, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. Review of Resident 85's clinical record revealed he was also transferred to the hospital for an acute medical change in condition on August 31, 2025. Resident 85 returned to the facility on September 6, 2025. Review of available documentation failed to reveal evidence that Resident 85 was provided with a notice of transfer or bed hold policy. During an email correspondence with the Nursing Home Administrator (NHA) on September 30, 2025, at 2:15 PM, the surveyor revealed the concern with the facility not being able to provide the bed hold and transfer notices for Resident 85's aforementioned hospital transfers. The NHA revealed he agreed with the concern about the notices as he does not have proof that they were sent. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide sufficient and timely social services related to the admission and discharge planning process for one of two residents reviewed (Resident 1).Findings include:Review of facility policy, titled Social Assessment, with a last review date of May 21,2025, revealed, in part, A social assessment shall be completed within fourteen (14) days of the resident's admission to the facility. A social assessment will be done to help identify the resident's personal and social situation, needs, and problems. Social services staff will obtain information during the initial interview of the family and upon the resident's admission. The purpose of obtaining this data is to identify information to help staff develop a personalized plan of care that will utilize the individual ' s existing strengths, try to compensate for physical and functional deficits, optimize function and quality of life, and meet the individual ' s needs and preferences.Review of facility policy, titled Social Services, with a last review date of May 21,2025, revealed, in part, The director of social services is a qualified social worker and is responsible for maintaining records related to social services and meeting or assisting with the medically-related social service needs of residents. The social worker/social services staff are responsible for assisting with informing and educating residents, families and representatives about health care options, making referrals and obtaining needed services from outside entities, helping residents with transitions of care services (for example, community placement options, home care services, transfer arrangements, etc.), and identifying and seeking ways to support resident needs through the assessment and care planning process.Review of facility policy, titled Discharge Summary and Plan, with a last review date of May 21, 2025, revealed, in part, Discharge Planning: 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. 2. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. 3. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident ' s discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. 7. A member of the IDT {interdisciplinary team} reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 8. The final discharge plan of care shows what arrangements have been made for the resident regarding: a. where the resident will live after leaving the facility; b. follow-up care the resident will receive from other providers, and that provider's contact information; c. needed medical and non-medical services (including medical equipment); d. community care and support services, if needed; and e. when and how to contact the continuing care provider. In section titled Discharge to the Community: 3. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record.Review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia with behavioral disturbance (cognitive decline accompanied by significant changes in behavior), repeated falls, and generalized muscle weakness. Further review of Resident 1's clinical record revealed that she was discharged home on October 2, 2025.Review of Resident 1's Social Services Evaluation-admission dated September 12, 2025, revealed it was blank. Further review of Resident 1's clinical record failed to reveal any documented social service assessments. Review of Resident 1's care plan revealed a care plan focus for: chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia; impaired visual function; communication problem related to hearing deficit; activities of daily living self-care performance deficit; limited physical mobility; at risk for falls; and Resident wishes to discharge back to the community, all with an initiated date of September 20, 2025. Review of Resident 1's progress notes revealed a physician's history and physical note dated September 14, 2025, at 5:45 PM, that indicated in the Assessment and Plan section that Resident 1 had a fall prior to admission that resulted in facial injuries; that physical therapy would work on balance and transfers; and that she needed 24-hour support secondary to her diagnosis of dementia. Review of Resident 1's progress notes revealed a note dated September 16, 2025, at 2:37 PM, by the Nursing Home Administrator (NHA) that indicated he had met with Resident 1 and that her friend participated by phone. The note further indicated that Resident 1 was doing well with supervision for transfers, was walking 150 feet with her walker and supervision, and needed a lot of cueing. The note also revealed that there was discussion about Resident 1's care needs at home upon discharge and that the plan was to pay privately for home care assistance until she would be eligible to apply for a waiver program.Review of Resident 1's progress notes revealed a physician's progress note dated September 19, 2025, at 12:05 PM, that indicated Resident 1 was still very confused.Review of Resident 1's progress notes revealed a physician's progress note dated September 22, 2025, at 6:54 PM, that indicated Resident 1 was still very confused. The note further indicated that the provider reviewed Resident 1's medications and treatment plan with her POA who was at Resident 1's bedside. The note indicated that Resident 1's plan was to receive short-term rehabilitation services and then be discharged . In addition, the note still indicated that she needed 24-hour support secondary to her diagnosis of dementia. This progress note was the last physician progress note prior to Resident 1's discharge from the facility.Review of Resident 1's progress notes revealed a note dated September 23, 2025, at 2:19 PM, by the NHA that indicated he had made a call to Resident 1's friend and that Resident 1's only barrier is her confusion which they will set up private duty aides. The note also indicated that a discharge was planned for October 2, 2025, unless Resident 1's insurance decided otherwise and that home health would be set up. Review of Resident 1's physician orders revealed an order, dated October 2, 2025, for home health upon discharge for physical therapy and occupational therapy.Review of Resident 1's progress notes between September 23, 2025, and October 2, 2025, failed to reveal any documentation of home health referral(s), if private duty care had been arranged, or if any assistance had been provided with transitions of care services for her discharge back to the community.Review of Resident 1's facility Discharge Summary revealed in the Social Services section that Resident 35 was documented as being occasionally confused; needing occasional cueing; was being discharged home alone and not with a relative or friend; that a referral for home health was made on September 29, 2025, with an order summary sent to the accepting agency; and that she needed to follow up with her primary care physician in 7-10 days after discharge. Documentation failed to include the name or contact information for the home health agency or for her primary care physician.Review of Resident 1's progress note dated October 2, 2025, at 2:38 PM, revealed that she was discharged to home. The note further indicated that Resident 1 was provided her medications, medication summary, and discharge paperwork which was explained to Resident 1 and her family. The note failed to indicate Resident 1's living arrangement post discharge or any information about services that had been organized for her transition back to the community.During an interview with the NHA and the Director of Nursing (DON) on October 21, 2025, at 1:25 AM, the NHA indicated that at the time of Resident 1's discharge, that he and the facility admission Coordinator were covering social service activities as the facility was in the process of hiring a new Social Worker. He said that he had just spoken to the Admissions Coordinator and she indicated that she had forgotten to document the home health referral information for Resident 1. He further indicated that he was aware that Resident 1's Representative (which he identified as a friend of Resident 1) had wanted Resident 1 to apply for a waiver program to receive care assistance at home, but that Resident 1 did not qualify financially. He said that he provided Resident 1's Representative with a list of private duty care providers that she could contact for care assistance at home. He confirmed that he was not aware if this was set up by Resident 1's Representative or not at time of Resident 1's discharge from the facility. He further confirmed that there was no documentation of a review of Resident 1's discharge plan or the assessment of the discharge plan to determine if Resident 1 would have all necessary measures in place that she required to be safe. He also confirmed that no social services assessment was completed during Resident 1's stay at the facility between September 11, 2025, and October 2, 2025, which would have helped with her discharge planning. He revealed that a new social worker had been hired on October 7, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18 (b)(1)(3) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide and document sufficient preparation to residents to ensure a safe and orderly discharge from the facility; and failed to provide a discharge summary that included a post-discharge plan of care, including post-discharge services, for one of two discharged residents reviewed (Resident 1).Findings include:Review of facility policy, titled Discharge Summary and Plan, with a last review date of May 21, 2025, revealed, in part, 2. The discharge summary provides necessary information for continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge. 3. By the time the resident leaves the facility, the discharge summary is furnished to the provider who is assuming responsibility for care of the resident after discharge. 4. The discharge summary may be provided in printed or electronic format. If in electronic format, the receiving provider will acknowledge there is a way to receive and access the discharge summary electronically. 5. The medical record contains a copy of the discharge summary with the identity of the recipient of the summary. In addition, in the section titled Discharge Summary: 1. A discharge summary includes: a. a recapitulation of the resident's stay at the facility (a concise summary of the resident's stay and course of treatment in the facility); b. a final summary of the resident's status at the time of the discharge available for release to authorized individuals and agencies, with the consent of the resident or representative.In section titled Discharge Planning: 1. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. 2. The purpose of the discharge plan is to ensure a safe transition from the facility to the post-discharge setting. 3. The discharge plan is developed by the care planning/ interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the resident's discharge goals and needs that must be addressed before the resident can be safely discharged (e.g., caregiver support and education, rehabilitation, etc.). 4. The discharge plan is based on the resident assessment, the goals for care, the desire for discharge and the resident's capacity for discharge. 5. Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. 7. A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. 8. The final discharge plan of care shows what arrangements have been made for the resident regarding: a. where the resident will live after leaving the facility; b. follow-up care the resident will receive from other providers, and that provider's contact information; c. needed medical and non-medical services (including medical equipment); d. community care and support services, if needed; and e. when and how to contact the continuing care provider.In section titled Discharge to the Community: 3. The facility makes referrals to local agencies, the local ombudsman, and support services that can assist in accommodating the resident's post-discharge preferences, as appropriate. Referrals made for this purpose, and the response to these referrals, are documented in the medical record.Review of Resident 1's clinical record revealed that she was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia with behavioral disturbance (cognitive decline accompanied by significant changes in behavior), repeated falls, and generalized muscle weakness.Further review of Resident 1's clinical record revealed that she was discharged home on October 2, 2025.Review of Resident 1's physician orders revealed an order, dated October 2, 2025, for Home Health upon discharge for physical therapy and occupational therapy. Review of Resident 1's care plan revealed a care plan focus for: chronic/ progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making and thought process related to dementia; impaired visual function; communication problem related to hearing deficit; activities of daily living self care performance deficit; limited physical mobility; at risk for falls; and Resident wishes to discharge back to the community, all with an initiated date of September 20, 2025. Review of Resident 1's progress notes revealed a physician's history and physical note dated September 14, 2025, at 5:45 PM, that indicated in the Assessment and Plan section that Resident 1 had a fall prior to admission that resulted in facial injuries; that physical therapy would work on balance and transfers; and that she needed 24-hour support secondary to her diagnosis of dementia. Review of Resident 1's progress notes revealed a note dated September 16, 2025, at 2:37 PM, by the Nursing Home Administrator (NHA) that indicated he had met with Resident 1 and that her friend participated by phone. The note further indicated that Resident 1 was doing well with supervision for transfers, was walking 150 feet with her walker and supervision, and needed a lot of cueing. The note also revealed that there was discussion about Resident 1's care needs at home upon discharge and that the plan was to pay privately for home care assistance until she would be eligible to apply for a waiver program.Review of Resident 1's progress notes revealed a physician's progress note dated September 19, 2025, at 12:05 PM, that indicated Resident 1 was still very confused.Review of Resident 1's progress notes revealed a physician's progress note dated September 22, 2025, at 6:54 PM, that indicated Resident 1 was still very confused. The note further indicated that the provider reviewed Resident 1's medications and treatment plan with her POA who was at Resident 1's bedside. The note indicated that Resident 1's plan was to receive short-term rehabilitation services and then be discharged . In addition, the note still indicated that she needed 24-hour support secondary to her diagnosis of dementia. This progress note was the last physician progress note prior to Resident 1's discharge from the facility.Review of Resident 1's progress notes revealed a note dated September 23, 2025, at 2:19 PM, by the NHA that indicated he had made a call to Resident 1's friend and that Resident 1's only barrier is her confusion which they will set up private duty aides. The note also indicated that a discharge was planned for October 2, 2025, unless Resident 1's insurance decided otherwise and that home health would be set up. Review of Resident 1's progress notes revealed a note dated September 29, 2025, at 11:14 AM, which indicated that Resident 1's insurance would not cover her stay at the facility after October 2, 2025. Review of Resident 1's progress notes revealed a note dated September 30, 2025, at 11:22 AM, which indicated that Resident 1 was receiving physical therapy when she became unresponsive. The note further indicated that when she was put back to bed, Resident 1 immediately became alert, that her vital signs were at baseline, had no signs of distress noted or reported, and that her provider was made aware. The note failed to indicate that Resident 1's Representative was made aware of the unresponsive episode.Review of Resident 1's progress note dated October 2, 2025, at 2:38 PM, revealed that she was discharged to home. The note further indicated that Resident 1 was provided her medications, medication summary, and discharge paperwork, which was explained to Resident 1 and her family. The note failed to indicate Resident 1's living arrangement post discharge. Review of Resident 1's clinical record revealed no evidence that her discharge destination was identified or assessed to ensure it would meet Resident 1's health and safety needs, that a member of the interdisciplinary team had reviewed the final discharge plan with the Resident and Representative or family at least 24 hours before her discharge, that home health services or private duty services were set up prior to Resident 1's discharge from the facility, or that her Discharge Summary was provided to her care providers for continuity of care purposes. Review of Resident 1's facility Discharge summary dated [DATE], at 2:40 PM, but with actual discharge date of Resident left blank, indicated that the reason for Resident 35's admission to the facility was falls. The instructions indicated that the form and the Order Summary Report must be printed and given to the Resident/Responsible Party upon discharge, and that it must be documented in the progress notes that these items were given to the resident. Further review of Resident 1's facility Discharge Summary revealed in the Social Services section that Resident 35 was documented as being occasionally confused; needing occasional cueing; was being discharged home alone and not with a relative or friend; that a referral for home health was made on September 29, 2025, with an order summary sent to the accepting agency; and that she needed to follow up with her primary care physician in 7-10 days after discharge. There was no documentation noted that included the name or contact information for the home health agency or for her primary care physician.Further review of Resident 1's facility Discharge Summary revealed in the Nursing section that Resident 1 ambulated with a walker, needed assistance with activities of daily living, and that the discharge instructions were provided to Resident 1 as family member/representative was not marked. This section failed to include any documentation about Resident 1 having an unresponsive episode or that this could be a possible care concern at home.Further review of Resident 1's facility Discharge Summary revealed in the Dietary Services section was incomplete except for documentation of Resident 1's admission height and weight.Further review of Resident 1's facility Discharge Summary revealed in the Rehabilitation Services section that she was able to ambulate 250 feet with a rolling walker and stand-by assistance; able to negotiate 8 steps with bilateral handrails and stand-by assistance; that she needed stand-by assist with transfers, dressing, and toileting needs with cueing for completion of tasks; and that she needed minimal assistance with light meal prep.During an interview with the NHA and the Director of Nursing (DON) on October 21, 2025, at 1:25 AM, the NHA indicated that at the time of Resident 1's discharge, that he and the facility admission Coordinator were covering Social Service activities as the facility was in the process of hiring a new Social Worker. He said that he had just spoken to the Admissions Coordinator and she indicated that she had forgotten to document the home health referral information for Resident 1. He further indicated that he was aware that Resident 1's Representative (which he identified as a friend of Resident 1) had wanted Resident 1 to apply for a waiver program to receive care assistance at home, but that Resident 1 did not qualify financially. He said that he provided Resident 1's Representative with a list of private duty care providers that she could contact for care assistance at home. He confirmed that he was not aware if this was set up by Resident 1's Representative or not at time of Resident 1's discharge from the facility. He further confirmed that there was no documentation of a review of Resident 1's discharge plan or the assessment of it to determine if Resident 1 would have all necessary measures in place that she required to be safe. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed (Resident 5). Findings include: Review of Resident 5's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition where the kidneys are damaged and can't filter blood as they should) and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). Review of Resident 5's hospital referral paperwork revealed an assessment/plan on December 17, 2024, for: will need outpatient, in-lab PSG (polysomnography) with BiPAP (a noninvasive ventilator that helps people breathe by delivering pressurized air through a mask) titration. Review of Resident 5's hospital referral paperwork revealed an assessment data on December 17, 2024, for the following: Pulmonary following the patient continue BiPAP at night, continue BiPAP at night and as needed during the day. Review of Resident 5's clinical record revealed the Resident was admitted to the facility on [DATE], at approximately 5:00 PM from the hospital. Review of Resident 5's clinical record revealed a nurse's progress note on December 18, 2024, at 5:34 PM, that read: Alerted by charge nurse that Resident 5 came from the hospital with discharge paperwork and order for a Bi-PAP at bedtime. No spare Bi-PAP in house, contact made to facility's oxygen supply company, requesting Bi-PAP via phone and email. Unable to deliver bi-PAP until Thursday, December 19, 2024. Verbalized to charge nurse to contact physician for further orders. Review of Resident 5's clinical record revealed a nurse's progress note on December 19, 2024, at 12:02 AM, that the Resident requested to be sent back to the hospital if the facility could not get a Bi-PAP for the night. Resident 5 was sent back to the hospital. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on December 20, 2024, at 10:37 AM, revealed they did receive a referral that mentioned Resident 5 needing a bi-PAP, although the hospital the Resident came from uses Careport for communication of their referrals and do not have any verbal communication with facilities. The DON revealed that herself, the NHA, and Director of Social Services are responsible for reviewing and approving referrals that come in. 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of the facility's policy, observation, clinical records review, and staff interviews, it was determined that the facility failed to ensure a pressure ulcer was assessed, and treated in a timely manner, which resulted in actual harm from the deterioration of the pressure ulcer, hospitalization , [CONDITION(S)], bacteremia and a [CONDITION(S)] for one resident (Resident 2); and failed to ensure that physician orders were followed to promote healing of pressure ulcers for one of two residents reviewed with pressure ulcers (Resident 3). Findings include: Review of facility policy titled Wound Care states that the purpose is to provide guidelines for the care of wounds to promote healing. Staff are to verify that there is a physician's order for the procedure. After the wound care staff are expected to document the following information: type of wound care given, any change in the resident's condition and all assessment data (i.e., wound bed color size drainage ect.) obtained when inspecting the wound. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's admission assessment revealed no pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) present on admission. On September 28, 2020, Licensed Practical Nurse (LPN) 2 documented skin breakdown on Resident 2's buttocks and that she notified Registered Nurse (RN) 1. LPN 2 wrote a progress note of her assessment findings which stated, Large DTI (deep tissue injury) left buttock measuring 4[cm]x 6[cm]. Multiple open areas in the right buttock. Right upper buttock open area measuring 0.5[cm] x 0.6[cm], distal right buttock open area measuring 1[cm] x 1.5[cm]. Left buttock open area measuring 1[cm] x 1[cm]. Gluteal slit (between buttocks) open area measuring 0.7[cm] x 0.5 [cm]. Review of Resident 2's nursing progress notes revealed that there was no progress note from the RN. Further review of the clinical record for Resident 2 revealed that RN 1 initiated three wound evaluation flowsheets on September 28, 2020 and they were signed off on October 5, 2020. One wound evaluation was for the right buttock. The measurements were 6 cm x 6 cm and the stage of the pressure ulcer was marked N/A. Under additional description RN 1 noted that there were two areas upper 0.5 x 0.6 and distal 1 x 1.5. The wound evaluation for the left buttock by RN 1 noted a 4 cm x 6 cm deep tissue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). The third wound assessment was for the coccyx (base of the spine, also called the tailbone) 0.7 cm x 0.5cm and the stage of the wound was not assessed. There were no further RN assessments for Resident 2's pressure ulcers. A new order was initiated on September 28, 2020, for a dressing change to the pressure ulcer. The order was to cleanse sacrum (triangular bone at the base of the spine) with normal saline solution and pat dry; apply skin prep to periwound; place [MEDICATION(S)] (wound dressing with water resistant outer layer) every day shift every three days. Review of the Treatment Administration Record (TAR) for October 2020, revealed that on October 2, the dressing change was not documented as changed. On September 29, 2020, a care plan was initiated for Resident 2's pressure ulcer with interventions that included incontinence care every 2 hours and as needed with use of moisture barrier after each episode of incontinence, assist with turning and positioning, administer treatments as ordered and observe for effectiveness and pressure reduction gel cushion to wheelchair. On October 5, 2020. LPN 1 (wound nurse) assessed Resident 2's wounds during her weekly wound rounds. The pressure ulcers increased in size significantly and also had depth to them. LPN 1 did a wound assessment noting an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and eschar (brown or black in the wound bed) pressure ulcer on the coccyx measuring 13.0 cm x 11.0 cm and 0.5 cm deep. Additional description notes the right buttock at 11.0 cm x 5.5 cm with a necrotic (occurs when there is not enough blood flowing to the tissue, ultimately resulting in death of body tissue) area 5.5 cm x 2.0 cm. Left buttock 1.5 cm x 1.5 cm x 0.5 cm deep. Intergluteal cleft (are between buttocks) 4.0 cm x 0.5cm x 0.5 cm deep. She described the area as swollen and a moderate amount of serosanguineous drainage with 25 % necrotic tissue. Due to the deterioration of the wounds the treatment order was changed. LPN 1 also wrote a progress note on October 5, 2020, that stated that the nurse practitioner was in room to assess wound with LPN 1. New verbal orders received for indwelling catheter (tube inserted into the bladder to drain urine) for wound healing and to be discontinued when the wound resolved. Review of the clinical record revealed no evidence that the foley catheter was placed. The resident started on hospice services on October 13, 2020. Review of hospice notes revealed a hospice nursing note on October 13, 2020, that stated that upon assessment, Resident 2 had a sacral wound noted with strong foul smell. Further review of Resident 2's clinical record revealed no note of change in status of wound from facility staff. On October 14, 2020, LPN 1 assessed Resident 2 on weekly wound rounds. The pressure ulcer continued to deteriorate. The wound was now described as other instead of coccyx. The pressure ulcer remained unstageable. The measurement was 13.0 cm x 13.0 cm x 2.5 cm deep. Additional description notes tunneling (a wound that's progressed to form passageways underneath the surface of the skin) of 2.8 cm on the left buttock. The pressure ulcer was found to have copious amounts of drainage with foul odor. The wound was not 100% necrotic. The treatment was changed due to deterioration of pressure ulcer. Review of the clinical record revealed that a verbal order was put into the system on October 14, 2020, for a foley catheter for wound healing. Review of the record revealed that the foley catheter was not placed until October 14, 2020, despite the order on October 5, 2020. During LPN 1's assessment she also noted on October 14, 2020, an additional pressure ulcer on the residents left outer ankle. The assessment noted a stage two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) 1.5 cm x 1.5 cm x 0.2 cm deep. Further review of the clinical record revealed no further assessment for the pressure ulcer on the ankle. On October 15, 2020, LPN 1 entered a telephone order from the physician for a wound culture of the drainage from the pressure ulcer. On October 16, 2020, the wound clinic received a referral for Resident 2 to be seen in their clinic. An appointment was made for Resident 2 to be seen on October 20, 2020. The pressure ulcers were assessed by a RN on the day they were discovered on Resident 2's buttocks. After that, there was no RN assessment. There was no RN assessment of the ankle pressure ulcer. Review of practitioner notes revealed no wound assessments. The notes acknowledge the pressure ulcer and stated that Resident 2 will continue to be seen by wound team (LPN 2). Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses, Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice. The wound care policy states that staff should document in the resident's clinical record when performing wound care all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Review of Resident 2's clinical record revealed no assessments from the nurses that were performing the dressing changes. During an interview with LPN 1 (wound nurse) on October 27, 2020, at 12:58 PM she confirmed that nursing staff should be charting characteristics of the wound with dressing changes and reporting any changes to the wound nurse or supervisor. She also confirmed from October 5 to October 14, the deterioration of the pressure ulcer should have been noted by nursing staff. During an interview the Director of Nursing on October 30, 2002, at 4:40 PM he acknowledged that the treatment nurses did not document characteristics of the pressure ulcers. There is no facility documentation for turning and positioning or incontinence care every two hours per plan of care. The facility was unable to provide any additional information. The pressure ulcer presented with signs and symptoms of infection on October 14, 2020. A wound culture was obtained on October 15, 2020, no antibiotics were started. When Resident 2 left the faciity on [DATE], the facility did not obtain the result of the wound culture. During an interview with the Director of Nursing on October 30, 2020, at 4:45 PM he stated that the facility did not get the results of the wound culture as of October 20, 2020 and confirmed that no antibiotics were started. During an interview with the consulting wound clinic facility's wound nurse (RN) 2 on October 28, 2020, at 1:00 PM she stated that she personally assessed Resident 2's wound and from her experience and professional opinion, Resident 2's pressure ulcer was a result from laying or sitting for extended periods of time. She stated that the cushion on his wheelchair the day of the appointment was hard and did not appear to be pressure reducing. She reported that the wound had a foul odor and they could not treat the resident in the clinic as outpatient and sent the resident to the emergency room for treatment. Review of the wound assessment on October 20, 2020, from the wound clinic assessed the pressure ulcer on the left buttock wound as 11 cm x 6.5 cm and 3.7 cm deep with tunneling of 6 cm and another are that tunneled 6.7 cm. Large brown yellow drainage with large amount of necrotic eschar. Around the wound revealed [CONDITION(S)] (swelling), ecchymosis (bruising) and [CONDITION(S)] (redness). Another pressure ulcer was noted on the right buttock was 3 cm x 2.5 cm x 0.1 cm deep. Medium amount of red and yellow drainage and the wound bed was red and eschar. The third pressure ulcer assessed was on the left ankle. That pressure ulcer measured at 0.7 cm x 0.4 cm x 0.2 cm deep with large amount of red and yellow drainage. They transported the resident to the ER for admission for surgical debridement (procedure for removing all infected and dead tissue) and IV (intra venous) antibiotic therapy to treat the infection. Review of hospital records revealed that Resident 2 was admitted to the hospital on October 20, 2020. Labs revealed that Resident 2's white blood cells (help the body fight infection) were elevated 11.1 (normal 3.5-9.5). The resident was started on two kinds of IV antibiotics. Blood cultures and would cultures were obtained. On October 21, 2020, Resident 2 was found to have bacteremia (bacterial infection that has spread to the blood stream) due to gram negative bacteria in the wound. Infection control department was consulted. The resident was also taken to the operating room for debridement of the pressure ulcers on the sacrum. Further review of hospital records revealed that on October 22, 2020, a sacral bone biopsy revealed [CONDITION(S)] (infection of the bone). On October 25, 2020, Resident 2 was assessed, and family agreed to insert a [CONDITION(S)] for diversion from the sacral wound. The resident was scheduled for the operating room on October 27, 2020, for placement of the [CONDITION(S)] and another debridement of the sacral wound. On October 27 the [CONDITION(S)] was placed, and wound was debrided without complication. On October 28, 2020, a wound vac (a device used to remove fluid secretions and promote wound healing) was placed on Resident 2's sacral wound. Resident 2's final blood cultures and tissue culture from the wound revealed one type of bacteria in the blood and four different types of bacteria present in the wound. Infectious disease recommended 3-4 weeks of IV antibiotics to treat infection. During interviews with the Director of Nursing on October 30, 2020, at 4:20 PM, he stated that he thought there was no delay in treatment and no deficient practice by the facility. Review of Resident 3's physician order on October 27, 2020, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then pack with black foam and clear occlusive dressing and attach the wound vac (a device used to remove fluid secretions and promote wound healing). On October 27, 2020, at 9:57 AM, Licensed Practical Nurse (LPN) 1 performed a dressing change to Resident 3's pressure ulcer. LPN 1 completed the dressing change without applying the silver mesh into the wound. During an interview with LPN 1 on October 27, 2020, at 12:50 PM, she stated that despite the current physician order, the silver mesh was discontinued last week. She stated that the order needed to be changed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(c)(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to reduce falls or injury after multiple falls occurred for one of six residents reviewed, resulting in a fall with injury when the resident was found on the floor, bleeding from her forehead and knee and was subsequently sent to the hospital (Resident 1). Findings include: Review of the facility Falls Management System revealed that, it is the policy of the facility to provide each resident with appropriate evaluation and interventions to prevent falls and to minimize complications if a fall occurs. Additionally, all resident falls in the facility are analyzed and trended through the Performance Review process to maintain a safe environment. When a resident sustains a fall, an evaluation will include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be initiated at the time of the fall and reviewed by Nursing Management following the next morning stand-up meeting and also at the next Falls Management Meeting. Interventions secondary to the investigation will be documented in the Care Plan, as indicated. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Further review of Resident 1's clinical record revealed an admitted (MONTH) 27, 2019. Review of the admission note revealed that the resident was admitted alert to self with some confusion, that she was Spanish speaking and doesn't speak any English. The resident had a dry intact dressing on her left hip following surgical repair of a fracture following a fall. Review of Resident 1's care plan initiated dated (MONTH) 28, 2019, intervention in place were resident is totally dependent on staff for ambulation. The resident requires assists with transfers. Review of the facility's fall reports between (MONTH) 31, 2019 and (MONTH) 9, 2019, revealed that the resident had 13 falls. Review of the resident's care plan failed to reveal the implementation of any interventions for seven of the 13 falls, including a fall on (MONTH) 9, 2019, which resulted in Resident 1 being sent to the hospital at the request of the family. Review of a facility fall report dated (MONTH) 31, 2019, revealed that Resident 1 had a fall on this date. The report indicated that the nurse was behind the nurse's station, heard a loud smack, then observed the resident on the floor in front of her wheelchair. The resident was assessed by the Assistant Director of Nursing (ADON) and placed back in her wheelchair. No injuries were observed at the time of the fall. Review of the resident's care plan revealed that it was updated to include the wearing of non-skid socks when in the wheelchair on (MONTH) 1, 2019. Review of a facility fall report dated (MONTH) 5, 2019, revealed that Resident 1 had a fall on this date. The nursing description indicates that the resident was observed in the dining room on the floor laying on her back. The resident was incontinent. The resident was transferred to a chair. The resident was assessed, and no injuries were observed at the time of the incident. The resident's care plan was updated on (MONTH) 5, 2019, to include that the staff were to offer to take the resident to the restroom when she appeared anxious or agitated. Review of a facility fall report dated (MONTH) 7, 2019, revealed that Resident 1 had a fall on this date. The description of the fall revealed that the resident fell on to the floor after getting up out of the wheelchair in the dining room. The resident was assessed, no injuries were apparent, and the resident denied pain. The resident was assisted back into the wheelchair and given a blanket. Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of facility fall report dated (MONTH) 18, 2019, revealed that Resident 1 was found crawling on the floor in her room, on her hands and knees on this date. Incontinence care was provided. An assessment was conducted, and no injuries were observed at the time of the incident. Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of a facility fall report dated (MONTH) 29, 2019, revealed that on this date Resident 1 was attempting to get up out of bed into the wheelchair and that the chair slid from beneath the resident, and the resident fell . The resident assessment revealed Resident 1 sustained an abrasion to the right iliac crest (hip). Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of a facility fall report and nursing progress notes revealed that Resident 1 was found on the floor in the dining room on (MONTH) 2, 2019. It was reported to the nurse that the resident slid out of her wheelchair. The resident was assessed, and no injuries were observed at the time of the incident. The resident's care plan was updated effective (MONTH) 2, 2019, to include anti-roll back brakes to the wheelchair and dycem (an anti-slip material) to the wheelchair, under and on top of the cushion. An additional care area, actual fall, was added to the care plan effective (MONTH) 2, 2019, directing staff to keep the bed in the lowest position, continue interventions on the at-risk plan, observe for/document/report to MD (pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation) and to consult PT for strength and mobility. Review of a facility fall report dated (MONTH) 4, 2019, revealed that Resident 1 was observed on this date on the floor in her room in a sitting position without grip socks. The resident was assessed, and no injuries were observed. The resident was transferred to bed and grip socks were applied. The fall report indicated that there was a new intervention to apply grip socks, however the care plan indicated that the intervention of non-slip socks when in the wheelchair was initiated on (MONTH) 1, 2019. Review of a facility fall report dated (MONTH) 7, 2019, revealed that Resident 1 was found lying on her back on the floor in the dining room. The report indicated that the resident was very impulsive and confused, and was brought to the dining room to be fed. The resident got up from her wheelchair and fell in the dining room. No injuries were observed at the time of the incident. The fall report indicated that the immediate action taken was one on one monitoring when awake; however, that is not indicated in the resident's care plan. During an interview with the Director of Nursing on (MONTH) 3, 2020, at 11:51 AM he revealed that the nurse who wrote the report is not from this country and that she was referring a nursing measure that is taken to not leave the resident alone immediately following a fall, and this was not referring to an ongoing one to one monitoring of the resident. Review of a facility fall report dated (MONTH) 16, 2019, revealed that on this date Resident 1 was found on the floor in the dining room approximately five feet from her wheelchair. The resident was displaying non-verbal signs of pain (facial grimacing and holding her head). An assessment was conducted and there were no injuries observed at the time of the incident. An additional care area, terminal restlessness, was added to the care plan effective (MONTH) 16, 2019, directing staff to encourage the resident to remain seated and to provide medications as prescribed for anxiety and restlessness. Review of Hospice (medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) progress note dated (MONTH) 17, 2019, revealed that a Broda chair (tilt-in-space positioning and mobility wheelchair) was delivered on (MONTH) 16, 2019. Additionally, review of a durable medical equipment company invoice revealed a Broda chair was delivered to the facility on (MONTH) 16, 2019. Review of a facility fall report dated (MONTH) 22, 2019, revealed Resident 1 was found lying on the floor next to the bed on this date. The resident was assisted back to bed. An assessment was conducted which revealed old hematomas on her face healing and in various stages. No new injuries were noted. Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of documentation from the wound clinic, dated (MONTH) 25, (MONTH) 2 and (MONTH) 9, 2019, indicate the resident had a pressure injury to left heel secondary to deep tissue injury (a pressure related injury with intact skin). The treatment plan indicated that the interventions in place are bilateral HL boots. Review of a facility fall report dated (MONTH) 28, 2019, revealed that on this date Resident 1 was found lying on the floor parallel to the bed. The resident was incontinent and non-slip socks were on. The assessment revealed no new injuries but noted an old hematoma that was present and healing. The resident was washed and dried and placed in the wheelchair. Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of Hospice progress note dated (MONTH) 30, 2019, revealed an order was placed for fall mats for both sides of Resident 1's bed. During an interview with the Director of Nursing on (MONTH) 3, 2020, at 11:51 AM he confirmed that he personally put the fall mats into place immediately following the order. Review of a facility fall report dated (MONTH) 5, 2019, revealed the resident was found on the floor in the dining room on this date. The assessment revealed no new injuries but noted old hematomas on face healing in different stages. The resident expressed pain and was given [MEDICATION NAME]. Review of the resident's clinical record and care plan failed to reveal that any additional care plan interventions were put into place to prevent future falls or injury from falls. Review of a facility fall report dated (MONTH) 9, 2019, revealed that on this date the nurse sitting at the nurse's station heard someone hit the floor, went to the resident's room and found her lying face down on the floor with boots on. The fall report indicates the RN Supervisor was called and an assessment was done by the RN, the resident was noted to be bleeding from her right knee and her right forehead. No other injuries were noted except for the old facial hematoma. Review of Resident 1's clinical record revealed that the resident was later sent to the hospital on this date to be evaluated per her family's request and was subsequently discharged from the facility. During an interview with RN (Registered Nurse) 2 on (MONTH) 10, 2019, at 3:10 PM she revealed that Resident 1 would attempt to climb out of her Broda chair. When this occurred, nursing staff would attempt to assist her back into her chair and place her at the nursing station. RN 2 revealed that Resident 1 would become upset and rigid at times when attempting to assist her back into her chair. At these times, nursing staff would stand beside her or walk with her until she could be seated safely. RN 2 revealed they attempted to keep Resident 1 in sight. During an interview with NA (Nurse Aide) 1 on (MONTH) 10, 2019, at 4:30 PM she revealed that Resident 1 would attempt to get up a lot. She revealed that nursing staff would attempt to redirect her, or keep her hands busy by giving her food, cards, or laundry to fold. NA 1 revealed that this would only work for a few minutes before Resident 1 would attempt to get up again and everyone was mad dashing all of the time. NA 1 revealed that nursing staff attempted to keep Resident 1 in common areas and would only put her to bed in her room when they knew she was good and sleepy. NA 1 revealed Resident 1 would often sit in the dining room or within sight of nursing staff. Review of physical exam documentation from the hospital, dated (MONTH) 9, 2019, revealed that multiple bruises were noted throughout the forehead, bilateral (both) maxillary bones (upper jaw bones), nose, bilateral mandibles (lower jaw bones). The resident had raccoon eyes (bruises around both eyes that often indicates skull or [MEDICAL CONDITION]) but no Battle signs (a bruise that indicates a fracture to the bottom of the skull) were noted. The resident had sluggish, 2 mm pupils which were minimally responsive to light. The hospital documentation also indicated that the resident had bruises in multiple stages of healing on the face, neck and left tibia (lower leg bone). During an interview with the Director of Nursing on (MONTH) 3, 2020, at 11:51 AM he revealed that many of the above falls occurred before his tenure at the facility, which began on (MONTH) 23, 2019, but that they should have been reviewed and the care plan should have been updated with new interventions as applicable. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 10/24/19, 6/28/19, 7/13/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 7/18/19, 6/28/19, 12/27/18, 7/13/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/28/19, 2/5/19, 7/13/18. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.5(f) Clinical records. Previously cited 6/28/19, 4/1/19, 12/19/18, 7/13/18. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 6/28/19, 1/24/19. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 6/28/19. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/20/19, 10/24/19, 6/28/19, 5/3/19, 4/1/19, 12/19/18, 12/27/18, 7/13/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 11/20/19, 10/24/19, 6/28/19, 5/3/19, 12/19/18, 12/27/18, 7/13/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/20/19, 10/24/19, 7/18/19, 6/28/19, 5/3/19, 4/1/19, 12/19/18, 12/27/18, 7/13/18.

Based on facility's records and policy review, staff interview and resident record review, it was determined that the facility failed to be administered in an effective manner regarding the implementation of policies and procedures for abuse. This failure resulted in sexual harassment and sexual abuse by an agency staff person (Employee 1) to two out of 56 residents reviewed (Resident 1, 2). Findings include: Review of the facility's Abuse Reporting and Investigation policy last revised (MONTH) 28, (YEAR), reveals comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatments of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Training-Mandated staff/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Training is provided at time of hire, annually, and as needed. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's 14-day MDS (Minimum Data Set an assessment of the functional status of the resident) dated (MONTH) 26, (YEAR), revealed Resident 1's BIMS (brief interview for mental status) was 11, which indicates cognitive moderately impaired. Review of a facility event report dated (MONTH) 14, (YEAR), for an incident that occurred on (MONTH) 13, (YEAR), at 5:00 p.m. revealed that Resident 1 complained that Employee 1 has touched him inappropriately, by rubbing his leg above the amputation site, and touching his genitalia on multiple occasions while giving personal care in the therapy gym. Resident 1 also revealed Employee 1 has made inappropriate sexual comments, such as Boy you have a big dick. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 7, (YEAR), at 3:52 p.m. signed by Employee 1 revealed, Gentle massage was given on his right stump and was rub with lotion d/t (do to) skin dryness. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 13, (YEAR), at 3.55 p.m. signed by Employee 2 revealed, Patient expressed concerns over working with PT (Physical Therapist/Employee 1). Informed RPM (Rehab Program Manager) and statement was written. Review of Resident 2's clinical record revealed [DIAGNOSES REDACTED].)) Review of Resident 2's Annual MDS dated (MONTH) 24, (YEAR), revealed Resident 2's BIMS was 12, which indicates cognitive status is intact. Review of a facility event report dated (MONTH) 9, (YEAR), for an incident that occurred on (MONTH) 9, (YEAR), at 5:00 p.m. revealed that Resident 2 complained that Employee 1 has touched him inappropriately, he became too familiar with my junk, he juggled them, stretched it, and asked me if it got bigger. Resident 2 went on to say this has occurred multiple times over a period of about four weeks. During an interview on (MONTH) 21, (YEAR), starting at approximately 2:15 p.m., Resident 2 stated that he didn't report the incidents because I thought at first it was just part of changing me, but when it happened all the time, I knew what was up. Review of a physician report dated (MONTH) 9, (YEAR), revealed Resident 2, is seen today to follow up on his condition. I was told around 1440 (2:40 p.m.) by Licensed Practical Nurse 1 that the pt (patient) was self propelling in the hallway when he told her that PT (Physical Therapist) Employee 1 has been molesting him. Review of Employee 1's personnel file revealed the employee was hired on (MONTH) 11, (YEAR), and there was no evidence that Employee 1 was provided with Abuse Training as per the facility's policy. During an interview with the Nursing Home Administrator dated on (MONTH) 9, (YEAR), at 11:10 a.m. it was disclosed the expectation that the alleged perpetrator should have been given abuse training prior to starting in accordance with Gardens at Blue Ridge abuse policy. She also expected that the facility owner and contract agency should have notified her when a contract employee is starting work at the facility. She expects all residents at the facility to be free from any form of sexual abuse including, verbal inappropriate comments about resident genitals or physically touching residents' genitals without residents' consent. The facility failed to ensure Employee 1 was trained on abuse, in accordance with their facility policy, which resulted in sexual harassment and sexual abuse to two out of 54 residents reviewed (Resident 1, 2). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/4/17, 8/3/17, 6/27/17, 5/26/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/27/17, 6/27/17, 5/26/17, 1/26/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/26/17, 1/26/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/27/17. 28 Pa. Code 201.19 Personnel policies and procedures. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/27/17, 8/3/17, 1/26/17, 11/8/16, 7/15/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/27/17, 8/3/17, 5/26/17, 2/8/17, 1/26/17, 11/8/16, 7/15/16.

Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to ensure that abuse training was completed upon hire for one of 67 employee files reviewed (Employee 1). Findings include: Review of the facility's Abuse Reporting and Investigation policy last revised (MONTH) 28, (YEAR), reveals comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatments of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Training-Mandated staff/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Training is provided at time of hire, annually, and as needed. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's 14-day MDS (Minimum Data Set an assessment of the functional status of the resident) dated (MONTH) 26, (YEAR), revealed Resident 1's BIMS (brief interview for mental status) was 11, which indicates moderate cognitive impairment. Review of a facility event report dated (MONTH) 14, (YEAR), for an incident that occurred on (MONTH) 13, (YEAR), at 5:00 p.m. revealed that Resident 1 complained that Employee 1 has touched him inappropriately, by rubbing his leg above the amputation site, and touching his genitalia on multiple occasions while giving personal care in the therapy gym. Resident 1 also revealed Employee 1 has made inappropriate sexual comments, such as Boy you have a big dick. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 7, (YEAR), at 3:52 p.m. signed by Employee 1 revealed, Gentle massage was given on his right stump and was rub with lotion d/t (do to) skin dryness. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 13, (YEAR), at 3.55 p.m. signed by Employee 2 revealed, Patient expressed concerns over working with PT (Physical Therapist/Employee 1). Informed RPM (Rehab Program Manager) and statement was written. Educated patient this writer spoke with orthotic's provider yesterday and they reported patient needs to be self massaging residual (remaining) limb to de-sensitize to improve tolerance to wear prosthetic (artificial limb). Educated patient on correct massage technique and to perform residual limb desensitization massage several times per day. Review of Resident 2's Annual MDS dated (MONTH) 24, (YEAR), revealed Resident 2's BIMS was 12, which indicates moderate cognitive impairment. Review of a facility event report dated (MONTH) 9, (YEAR), for an incident that occurred on (MONTH) 9, (YEAR), at 5:00 p.m. revealed that Resident 2 complained that Employee 1 has touched him inappropriately, he became too familiar with my junk, he juggled them, stretched it, and asked me if it got bigger. Resident 2 went on to say this has occurred multiple times over a period of about four weeks. During an interview on (MONTH) 21, (YEAR), starting at approximately 2:15 p.m., Resident 2 stated that he didn't report the incidents because I thought at first it was just part of changing me, but when it happened all the time, I knew what was up. Review of a physician report dated (MONTH) 9, (YEAR), revealed Resident 2, is seen today to follow up on his condition. I was told around 1440 (2:40 p.m.) by Licensed Practical Nurse 1 that the pt (patient) was self propelling in the hallway when he told her that PT (Physical Therapist) Employee 1 has been molesting him. Review of Employee 1's personnel file revealed the employee was hired on (MONTH) 11, (YEAR), and there was no evidence that Employee 1 was provided with Abuse Training as per the facility policy. Employee 1 has provided therapy services to 54 different residents. 11 of those residents had a BIMS of less than eight indicating severe cognitive impairment. During an interview with the Nursing Home Administrator dated on (MONTH) 9, (YEAR), at 11:10 a.m. it was disclosed the expectation that the alleged perpetrator should have been given abuse training prior to starting, in accordance with Gardens at Blue Ridge abuse policy. She also expected that the (facility owner) and (contract agency) should have notified her when a contract employee is starting work at the facility. She expects all residents at the facility to be free from any form of sexual abuse including verbal inappropriate comments about resident genitals or physically touching residents' genitals without residents' consent. The facility failed to ensure Employee 1 was trained on abuse, in accordance with their facility policy, which resulted in sexual harassment and sexual abuse to two residents (Resident 1, 2). 42 CFR 483.12(b)(1)-(3) Develop/Implement/Abuse/Neglect Policies. Previously cited 6/27/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/4/17, 8/3/17, 6/27/17, 5/26/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/27/17, 6/27/17, 5/26/17, 1/26/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/26/17, 1/26/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/27/17. 28 Pa. Code 201.19 Personnel policies and procedures. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 8/3/17, 1/26/17, 11/8/16, 7/15/16. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/27/17, 8/3/17, 1/26/17, 11/8/16, 7/15/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/27/17, 8/3/17, 5/26/17, 2/8/17, 1/26/17, 11/8/16, 7/15/16.

Based on observation, review of clinical records, facility documentation, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure residents were free from staff abuse, which resulted in sexual harassment and sexual abuse to two out of 56 residents reviewed (Resident 1, 2). Findings include: Review of the facility's Abuse Reporting and Investigation policy last revised (MONTH) 28, (YEAR), revealed comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatments of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Training-Mandated staff/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. Training is provided at time of hire, annually and as needed. Review of Resident 1's 14-day MDS (Minimum Data Set an assessment of the functional status of the resident) dated (MONTH) 26, (YEAR), revealed Resident 1's BIMS (brief interview for mental status) was 11, which indicates moderate cognitive impairment. Review of a facility event report dated (MONTH) 14, (YEAR), for an incident that occurred on (MONTH) 13, (YEAR), at 5:00 p.m. revealed that Resident 1 complained that Employee 1 has touched him inappropriately, by rubbing his leg above the amputation site, and touching his genitalia on multiple occasions while giving personal care in the therapy gym. Resident 1 also revealed Employee 1 has made inappropriate sexual comments, such as Boy you have a big dick. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 7, (YEAR), at 3:52 p.m. signed by Employee 1 revealed, Gentle massage was given on his right stump and was rub with lotion d/t (do to) skin dryness. Review of a Physical Therapy Treatment Encounter Notes dated (MONTH) 13, (YEAR), at 3.55 p.m. signed by Employee 2 revealed, Patient expressed concerns over working with PT (Physical Therapist/Employee 1). Informed RPM (Rehab Program Manager) and statement was written. Educated patient this writer spoke with the Orthotic provider yesterday and they reported patient needs to be self massaging residual (remaining) limb to de-sensitize to improve tolerance to wear prosthetic (artificial limb). Educated patient on correct massage technique and to perform residual limb desensitization massage several times per day. Review of Resident 2's annual MDS dated (MONTH) 24, (YEAR), revealed Resident 2's BIMS was 12, which indicates cognitive status is moderately impaired. Review of a facility event report dated (MONTH) 9, (YEAR), for an incident that occurred on (MONTH) 9, (YEAR), at 5:00 p.m. revealed that Resident 2 complained that Employee 1 has touched him inappropriately, he became too familiar with my junk, he juggled them, stretched it, and asked me if it got bigger. Resident 2 went on to say this has occurred multiple times over a period of about four weeks. During an interview on (MONTH) 21, (YEAR), starting at approximately 2:15 p.m., Resident 2 stated that he didn't report the incidents because I thought at first it was just part of changing me, but when it happened all the time, I knew what was up. Review of a physician report dated (MONTH) 9, (YEAR), revealed Resident 2 is seen today to follow up on his condition. I was told around 1440 (2:40 p.m.) by Licensed Practical Nurse 1 that the pt (patient) was self propelling in the hallway when he told her that PT (Physical Therapist) Employee 1 has been molesting him. Review of Employee 1's personnel file revealed the employee was hired on (MONTH) 11, (YEAR), and there was no evidence that Employee 1 was provided with Abuse Training as per the facility's policy. Employee 1 has provided therapy services to 54 different residents. 11 of those residents had a BIMS of less than eight indicating severe cognitive impairment. The BIMS score indicates the following about a resident's cognitive status: 13-15 is cognitively intact; 8-12 is moderately impaired; 0-7 is severe impairment. Resident 1's BIMS was coded as an 11, out of a possible 15, on a 14-day MDS assessment dated (MONTH) 26, (YEAR). Resident 2's BIMS was coded as a 12, out of a possible 15, on an Annual MDS assessment dated (MONTH) 24, (YEAR). Resident 3's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 31, (YEAR). Resident 4's BIMS was coded as a 09, out of a possible 15, on an Unscheduled MDS assessment dated (MONTH) 26, (YEAR). Resident 5's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 6's BIMS was coded as a 00, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 12, (YEAR). Resident 7's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 8's BIMS was coded as a 03, out of a possible 15, on an Annual MDS assessment dated (MONTH) 12, (YEAR). Resident 9's BIMS was coded as a 05, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 10's BIMS was coded as a 10, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 11's BIMS was coded as a 10, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 29, (YEAR). Resident 12's BIMS was coded as a 00, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 5, (YEAR). Resident 13's BIMS was coded as a 12, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 12, (YEAR). Resident 14's BIMS was coded as a 15, out of a possible 15, on an Annual MDS assessment dated (MONTH) 29, (YEAR). Resident 15's BIMS was coded as a 13, out of a possible 15, on an Admission MDS assessment dated (MONTH) 07, (YEAR). Resident 16's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 03, (YEAR). Resident 17's BIMS was coded as a 03, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 01, (YEAR). Resident 18's BIMS was coded as, unable to complete the interview on the standard assessment, the staff coded the resident as a modified independence on an Annual MDS assessment dated (MONTH) 26, (YEAR). Resident 19's BIMS was coded as a 15, out of a possible 15, on an Admission MDS assessment dated (MONTH) 01, (YEAR). Resident 20's BIMS was coded as a 08, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 22, (YEAR). Resident 21's BIMS was coded as a 15, out of a possible 15, on an Admission MDS assessment dated (MONTH) 26, (YEAR). Resident 22's BIMS was coded as a 00, out of a possible 15, on an Admission MDS assessment dated (MONTH) 31, (YEAR). Resident 23's BIMS was coded as a 07, out of a possible 15, on an Admission MDS assessment dated (MONTH) 08, (YEAR). Resident 24's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 25's BIMS was coded as a 13, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 26's BIMS was coded as a 03, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 29, (YEAR). Resident 27's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 28's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 05, (YEAR). Resident 29's BIMS was coded as a 10, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 12, (YEAR). Resident 30's BIMS was coded as a 03, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 05, (YEAR). Resident 31's BIMS was coded as a 13, out of a possible 15, on an Admission MDS assessment dated (MONTH) 04, (YEAR). Resident 32's BIMS was coded as a 02, out of a possible 15, on an Admission MDS assessment dated (MONTH) 05, (YEAR). Resident 33's BIMS was coded as, unable to complete the interview on the standard assessment, the staff coded the resident as a modified independence on an Annual MDS assessment dated (MONTH) 26, (YEAR). Resident 34's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 35's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 03, (YEAR). Resident 36's BIMS was coded as a 14, out of a possible 15, on an Admission MDS assessment dated (MONTH) 18, (YEAR). Resident 37's BIMS was coded as a 08, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 12, (YEAR). Resident 38's BIMS was coded as a 15, out of a possible 15, on an Annual MDS assessment dated (MONTH) 08, (YEAR). Resident 39's BIMS was coded as a 15, out of a possible 15, on an Annual MDS assessment dated (MONTH) 14, (YEAR). Resident 40's BIMS was coded as a 03, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 08, (YEAR). Resident 41's BIMS was coded as a 06, out of a possible 15, on an Admission MDS assessment dated (MONTH) 08, (YEAR). Resident 42's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 43's BIMS was coded as a 13, out of a possible 15, on an Admission MDS assessment dated (MONTH) 02, (YEAR). Resident 44's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 31, (YEAR). Resident 45's BIMS was coded as, unable to complete the interview on the standard assessment, the staff coded the resident as a modified independence on an Annual MDS assessment dated (MONTH) 26, (YEAR). Resident 46's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 47's BIMS was coded as a 15, out of a possible 15, on an Admission MDS assessment dated (MONTH) 26, (YEAR). Resident 48's BIMS was coded as a 03, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 49's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 27, (YEAR). Resident 50's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 01, (YEAR). Resident 51's BIMS was coded as a 15, out of a possible 15, on an Annual MDS assessment dated (MONTH) 26, (YEAR). Resident 52's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 08, (YEAR). Resident 53's BIMS was coded as a 14, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 54's BIMS was coded as a 15, out of a possible 15, on a Quarterly MDS assessment dated (MONTH) 26, (YEAR). Resident 55's BIMS was coded as a 7, out of a possible 15, on a Significant Change MDS assessment dated (MONTH) 1, (YEAR). Resident 56's BIMS was coded as a 08, out of a possible 15, on a Significant Change MDS assessment dated (MONTH) 08, (YEAR). During an interview with the Nursing Home Administrator on (MONTH) 1, (YEAR), at 8:00 a.m. it was revealed she had a conversation on (MONTH) 28, (YEAR), with the police detective doing the incident investigation. The detective informed the Nursing Home Administrator, that Employee 1 gave a confession stating, he touched residents inappropriately and made inappropriate comments. The detective also disclosed that charges were going to be filed against Employee 1 for Simple Assault. On (MONTH) 27, (YEAR), charges were filed for indecent assault without the consent of others. During an interview on (MONTH) 9, (YEAR), at 11:10 a.m. the Nursing Home Administrator disclosed the expectation that Employee 1 should have been given abuse training prior to starting, in accordance with Gardens at Blue Ridge abuse policy. She also expected that the facility owner and the contract agency should have notified her when a contract employee is starting work at the facility. She expects all residents at the facility to be free from any form of sexual abuse including, verbal inappropriate comments about resident genitals or physically touching residents' genitals without residents' consent. The facility failed to ensure residents were free from staff abuse, which resulted in sexual harassment and sexual abuse to two out of 54 residents reviewed (Resident 1, 2). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 12/4/17, 8/3/17, 6/27/17, 5/26/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 12/27/17, 6/27/17, 5/26/17, 1/26/17. 28 Pa. Code 201.18(b)(3) Management. Previously cited 5/26/17, 1/26/17. 28 Pa. Code 201.18(e)(1) Management. Previously cited 6/27/17. 28 Pa. Code 201.19 Personnel policies and procedures. 28 Pa. Code 201.20(b) Staff development. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 12/27/17, 8/3/17, 1/26/17, 11/8/16, 7/15/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 12/27/17, 8/3/17, 5/26/17, 2/8/17, 1/26/17, 11/8/16, 7/15/16.

Based on review of clinical records, facility documentation, facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that the residents were protected from neglect by failing to train nurse aides on how to apply a splint to six of 6 residents reviewed (Residents 1, 2, 3, 4, 5 and 6). The facility failed to train the nurse aides in applying splints resulting in actual harm to one resident (Resident 1) who acquired 12 deep tissue injuries. This situation was identified as an Immediate Jeopardy to the residents' health and safety. Findings include: Review of Resident 1's clinical record on January 24, 2017, at approximately 9:00 a.m. revealed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's clinical record revealed that on January 6, 2017, at approximately 2:10 p.m. Resident 1 was found by Licensed Practical Nurse (LPN) 1 to have a splint applied to the left arm and hand. LPN 1 observed that Resident 1's left hand was swollen. When LPN 1 removed the splint, LPN 1 observed multiple deep tissue injuries (DTI - injury to the soft tissue caused by compression being applied over a bony area for an extended period of time, or too much compression applied to tissue, which cause tissue death) to the left hand and one DTI to the left forearm described as a blister (fluid filled sac created by separation of layers of the skin caused by trauma to the skin layers). On January 6, 2017, at approximately 2:10 p.m., LPN 1 reported the findings to the Assistant Director of Nursing (ADON). An assessment at that time, performed by the ADON, found that the resident had a DTI, characterized as a blister, of the left forearm that measured 0.5 centimeters (cm) by 1.3 cm, two DTI's of the fifth finger (one that measured at 0.8 cm by 1.0 cm and one that measured at 0.5 cm by 0.3 cm), two DTI's of the fourth finger (one that measured at 0.3 cm by 0.2 cm and one that measured at 0.2 cm by 0.5 cm), two DTI's of the third finger (one that measured 0.3 cm by 0.5 cm and one that measured 0.2 cm by 1.0 cm), two DTI's of the second finger (one that measured 1.2 cm by 0.9 cm and one that measured at 0.5 cm by 1.2 cm), and three DTI's of the first finger (thumb) (one that measured 0.3 cm by 1.5 cm, one that measured 0.8 cm by 1.5 cm, and one that measured 2.3 cm by 1.0 cm). According to the facility investigation report, Resident 1 was unaware of the injuries due to not having the sensation (feeling) in the left arm. Review of Resident 1's physician's orders [REDACTED]. During an interview on January 24, 2017, at approximately 10:35 a.m. the Director of Nursing (DON) revealed that there was no splinting program (program implemented by therapy for splint usage) for Resident 1 for the nursing staff to apply a splint to Resident 1. During the interview the DON revealed that Resident 1 had never had a splinting program in place since Resident 1's admission on December 22, 2015. Review of a physician's visit progress note completed by Physician Assistant 1 (PA 1) dated October 27, 2016, revealed that PA 1 assessed Resident 1 to have a left hand contracture (stiffening of tendons, muscles, and or ligaments, resulting in deformity) and PA 1 had documented a recommendation for a physical therapy/occupational therapy consultation for treatment and a left hand splint. Review of the occupational therapy plan of care, completed and signed on November 27, 2016, by Occupational Therapist 1 (OT 1) revealed that Resident 1 presented with a decline in functional range of motion of the left fingers and wrist due to the left sided paralysis. The identified occupational therapy goal was to increase tolerance of a left resting splint to achieve proper positioning. Review of the occupational therapy notes revealed that between October 27, 2016, and November 10, 2016, OT 1 attempted to provide splinting to Resident 1's left arm. During an interview on January 24, 2017, at approximately 12:40 p.m. OT 1 revealed that a splint was never fitted for Resident 1 due to the resident's refusal. OT 1 revealed that after three refusals the splinting program was discontinued. Review of the occupational therapy progress notes and the occupational therapy discharge summary revealed that on November 11, 2016, Resident 1's splinting program was discontinued. Review of PA 1's progress note dated December 14, 2016, revealed that PA 1 documented that Resident 1 was requesting a splint for the left arm. PA 1 documented, (Physical therapy/Occupational therapy) needs to get his splint. Will talk to them about this. During an interview with PA 1 on January 24, 2017, at approximately 11:55 a.m., it was revealed that PA 1 attempted to speak with therapy personnel regarding a splint for Resident 1 after his visit with Resident 1 on December 14, 2016, but was unable to because the therapy staff were involved with the care of other residents. Review of PA 1's progress note dated December 19, 2016, revealed that Resident 1, received a left hand/wrist splint from therapy and he thanked me for that. Further review of the PA 1 written progress note stated, Nursing home chart reviewed including recent orders, lab results and interdisciplinary notes. Review of PA 1's written statement, dated January 24, 2017, revealed that PA 1 stated, On 12/19/16, I went to see (Resident 1) again and he had a splint on his left wrist/hand. During an interview on January 24, 2017, PA 1 revealed that PA 1 did not review the chart to ensure that there was an order for [REDACTED]. Review of a signed written statement, dated January 9, 2017, Nurse Aide 1 (NA 1) stated that the splint, was in place on my shift (2:45 p.m. to 10:45 p.m.) on Wednesday (January 4, 2017) and (2:45 p.m. to 10:45 p.m.) on Thursday, (January 5, 2017). I removed it to do care and placed it back on, those two occations (occasions) his hand was intact. During an interview on January 24, 2017, at approximately 12:53 p.m., the DON, the ADON and OT 1 revealed that they did not know where the splint was at that time. The State Surveyor went with the ADON and OT 1 to Resident 1's room and were granted permission, verbally, by Resident 1 for the ADON and OT 1 to search the room and Resident 1's belongings. At approximately 12:55 p.m., the ADON located the splint that had been applied to Resident 1, in Resident 1's bedside dresser. During an interview on January 25, 2017, at approximately 12:30 p.m. the DON revealed that NA 1 had not been trained to apply a splint to Resident 1. During the interview on January 25, 2017, 11:50 a.m. OT 1 revealed that there was no documentation that NA 1 was trained to apply a splint to Resident 1. During an interview on January 26, 2017, the Nursing Home Administrator (NHA) revealed that it was the facility's expectation that the residents of the facility are free from neglect. The NHA revealed that it was the facility's expectation that the staff provide care and services in accordance with the residents' physician's orders [REDACTED]. The NHA revealed it was the facility's expectation that the physicians/physician assistants review the residents' program of care during visits and documented that a review had been conducted. The NHA then revealed that it was the facility's expectation that the staff are educated on the proper placement and application of splints prior to utilization. The neglect by the facility to train the nurse aides in applying splints resulted in actual harm to one resident (Resident 1) who acquired 12 deep tissue injuries to the left arm and left hand requiring physician treatments. Review of Resident 2's clinical record on January 25, 2017, at approximately 8:00 a.m. revealed [DIAGNOSES REDACTED]. Review of Resident 2's clinical record revealed a document titled, 'Safe Transitions' Goals/Functional Maintenance plan, dated March 22, 2016, which revealed that Resident 2 was to wear a metal upright ankle brace (also known as a molded ankle-foot orthotic (MAFO)) on the right leg when out of bed. Review of the document revealed an area at the bottom titled, Facility Staff Inservice Attendance Signatures. Review of the document failed to reveal any staff signatures. Review of Resident 3's clinical record on January 24, 2017, at approximately 2:20 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 3's clinical record revealed a Safe Transitions Goals/Functional Maintenance Plan dated June 27, 2012. Review of the document revealed that Resident 3 was to wear a splint on the right hand that was to be applied during the morning, and removed during the evening. Review of the document revealed that four facility staff were educated regarding the splint. During an interview on January 25, 2017, the Director of Nursing revealed that of the four staff signatures present on the document, two were no longer employed at the facility. Review of Resident 4's clinical record on January 25, 2017, at approximately 8:20 a.m. revealed [DIAGNOSES REDACTED]. Review of Resident 4's OT progress and discharge summary dated June 27, 2012, revealed that Resident 4 was provided with a splint program that was still in effect as of January 25, 2017. As of January 25, 2016, at 12:00 p.m., the facility was unable to provide documentation that education had been provided to the facility staff regarding use of the splint. Review of Resident 5's clinical record on January 25, 2017, at approximately 8:30 a.m. revealed [DIAGNOSES REDACTED]. Review of Resident 5's clinical record revealed a Safe Transitions Goals/Functional Maintenance Plan dated November 20, 2007. Review of the document revealed that Resident 5 was to wear a splint on the right hand to be applied at bedtime and removed in the morning. Review of the clinical record revealed a Safe Transitions Goal/Functional Maintenance Plan dated March 22, 2016. Review of the document revealed that Resident 5 was to wear an ankle-foot orthotic splint to the right leg and foot at all times when out of bed and in a wheelchair. Review of the documents revealed no signatures of staff who were trained to apply either of the splints. Review of Resident 6's clinical record on January 25, 2017, at approximately 8:45 a.m. revealed [DIAGNOSES REDACTED]. Review of Resident 6's clinical record revealed that Resident 6 was to wear splints on both hands, and both legs and feet. During an interview on January 25, 2017, at approximately 11:30 a.m. NA 2 revealed that NA 2 had applied and removed the splints to Resident 6's hands and legs/feet. NA 2 revealed that she had performed the splinting application and removal multiple times on Resident 6 during the previous 3 months. NA 2 revealed she had not been educated by PT/OT staff, or any licensed nurse on the application and removal of the splints. NA 2 revealed that NA 3 instructed her on how to place the splints on and off. During an interview on January 25, 2017, at approximately 11:00 a.m. the DON revealed it is a nurse aide responsibility to apply and remove a residents' splint(s) on a daily basis, once OT/PT has discharged a resident from OT/PT care with a splint. During an interview with NA 3 on January 25, 2017, at approximately 11:32 a.m. NA 3 revealed that she had been applying and removing Resident 6's hand and leg/feet splints for almost two years. NA 3 stated she was not provided education by any facility staff as to how to apply the splints on the hands and/or legs/feet of Resident 6. On January 25, 2017, at approximately 12:16 p.m. NA 2 was observed applying a splint to Resident 6's right hand, and a splint to Resident 6's right leg/foot. On January 25, 2017, at approximately 12:16 p.m. NA 3 was observed applying a splint to Resident 6's left hand and left leg/foot. During a staff interview on January 25, 2017, OT 1 revealed that there was no education provided by PT/OT staff to NA 2 and NA 3 regarding the correct placement of Resident 6's splints. During the interview OT 1 stated that NA 3 has a history of applying splints to Resident 6 and OT 1 felt that provided evidence of competency. OT 1 revealed OT/PT staff have never assessed NA 2, and NA 3's application of splints to Resident 6 for proper placement or appropriate knowledge of splinting for Resident 6. OT 1 revealed it was OT 1's opinion that nurse aides were able to train other nurse aides regarding the application of splints to the residents, as was the case with NA 3 to NA 2. During an interview on January 25, 2017, at approximately 1:20 p.m. the DON stated that the staff were not trained on splint utilization after the initial OT/PT training. During the interview the DON revealed that there was no education for applying splints that could be provided for the nurse aides who were responsible for applying splints to the residents. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 25, 2017 at 2:04 p.m. related to the staff applying splints to Residents 1, 2, 3, 4, 5, and 6 without training resulting in harm to one resident as evidenced by the development of 12 deep tissue injuries that were discovered on January 6, 2017. An immediate corrective action plan was requested from the NHA and the DON on how education was going to be provided to the staff responsible for the application of splints to the residents of the facility. An acceptable corrective action plan was received from the facility on January 25, 2017, at 5:30 p.m., that included staff education on identifying residents who are to utilize splints, assessment of residents currently utilizing splints for proper application and injury, training of the staff for proper placement of the splints on residents and proper notification of skin impairments, monitoring by the staff of splint appropriateness, documentation of training of current staff, policy development and implementation of splint education and splint use for current staff and new or as-needed staff members. The NHA was notified that the Immediate Jeopardy was removed on January 26, 2017, at 12:00 p.m., after the implementation of the corrective action plan was verified. 42 CFR 483.12(a)(1) Prohibit Mistreatment/neglect/misappropriation. Previously cited 11/8/16. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 7/16/15. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 11/8/16, 7/15/16, 1/21/16, 7/16/15. 28 Pa. Code 211.12(d)(1) Nursing services. .Previously cited 11/8/16, 7/15/16, 1/21/16, 7/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/8/16, 7/15/16, 1/21/16, 10/4/15, 7/16/15.

Based on clinical record reviews and interviews with the staff, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being with regard to the application of a splint without a physician's orders [REDACTED]. Findings include: Review of Resident 1's clinical record on January 24, 2017, at approximately 9:00 a.m. revealed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's clinical record revealed that on January 6, 2017, at approximately 2:10 p.m. Resident 1 was found by Licensed Practical Nurse (LPN) 1 to have a splint applied to the left arm and hand. LPN 1 observed that Resident 1's left hand was swollen. When LPN 1 removed the splint, LPN 1 observed multiple deep tissue injuries (DTI - injury to the soft tissue caused by compression being applied over a bony are for an extended period of time, or too much compression applied to tissue, which cause tissue death) to the left hand and one DTI to the left forearm described as a blister (fluid filled sac created by separation of layers of the skin caused by trauma to the skin layers). On January 6, 2017, at approximately 2:10 p.m., LPN 1 reported the findings to the Assistant Director of Nursing (ADON). An assessment at that time, performed by the ADON, found that the resident had a DTI, characterized as a blister, of the left forearm that measured 0.5 centimeters (cm) by 1.3 cm, two DTI's of the fifth finger (one that measured at 0.8 cm by 1.0 cm and one that measured at 0.5 cm by 0.3 cm), two DTI's of the fourth finger (one that measured at 0.3 cm by 0.2 cm and one that measured at 0.2 cm by 0.5 cm), two DTI's of the third finger (one that measured 0.3 cm by 0.5 cm and one that measured 0.2 cm by 1.0 cm), two DTI's of the second finger (one that measured 1.2 cm by 0.9 cm and one that measured at 0.5 cm by 1.2 cm), and three DTI's of the first finger (thumb) (one that measured 0.3 cm by 1.5 cm, one that measured 0.8 cm by 1.5 cm, and one that measured 2.3 cm by 1.0 cm). According to the facility investigation report, Resident 1 was unaware of the injuries due to not having the sensation (feeling) in the left arm. Review of Resident 1's physician's orders [REDACTED]. During an interview on January 24, 2017, at approximately 10:35 a.m. the Director of Nursing (DON) revealed that there was no splinting program (program implemented by therapy for splint usage) for Resident 1 for the nursing staff to apply a splint to Resident 1. During the interview the DON revealed that Resident 1 had never had a splinting program in place since Resident 1's admission on December 22, 2015. Review of a physician's visit progress note completed by Physician Assistant 1 (PA 1) dated October 27, 2016, revealed that PA 1 assessed Resident 1 to have a left hand contracture (stiffening of tendons, muscles, and or ligaments, resulting in deformity) and PA 1 had documented a recommendation for a physical therapy/occupational therapy consultation for treatment and a left hand splint. Review of PA 1's written statement, dated January 24, 2017, revealed that PA 1 stated, On 12/19/16, I went to see (Resident 1) again and he had a splint on his left wrist/hand. During an interview on January 24, 2017, PA 1 revealed that PA 1 did not review the chart to ensure that there was an order for [REDACTED]. Review of a signed written statement, dated January 9, 2017, Nurse Aide 1 (NA 1) stated that the splint was in place on my shift (2:45 p.m. to 10:45 p.m.) on Wednesday (January 4, 2017) and (2:45 p.m. to 10:45 p.m.) on Thursday, (January 5, 2017). I removed it to do care and placed it back on, those two occations (occasions) his hand was intact. During an interview on January 26, 2017, the Nursing Home Administrator (NHA) revealed that it was the facility's expectation that the residents of the facility receive care and services by staff in accordance with the residents' physician's orders [REDACTED]. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being with regard to the application of a splint without a physician's orders [REDACTED]. 42 CFR 483.24, 483.25(k)(1) Provide Care/services For Highest Well Being. Previously cited 10/4/15. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 7/16/15. 28 Pa. Code 211.12(d)(1) Nursing services. .Previously cited 11/8/16, 7/15/16, 1/21/16, 7/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/8/16, 7/15/16, 1/21/16, 10/4/15, 7/16/15.

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to provide care designed to prevent pressure sore development resulting in harm regarding the acquiring of 12 deep tissue injuries for one of 6 residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record on January 24, 2017, at approximately 9:00 a.m. revealed that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a witness statement written by NA 1, dated January 9, 2017, revealed that Nurse Aide 1 (NA 1) applied a splint to Resident 1's left hand and forearm on January 5, 2017 sometime between the start of NA 1's shift, at 2:45 p.m., and the end of NA 1's shift at 10:45 p.m. and that Resident 1's skin was, intact. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's most recent care plan revealed that Resident 1 was not care planned for a splint to be applied to the left arm. During an interview on January 24, 2017, at approximately 12:40 p.m. OT 1 revealed that NA 1 applied the splint to Resident 1 with no training regarding the proper placement or the tightness of the splint straps. Review of Resident 1's clinical record revealed that the splint found on the resident, on January 6, 2017, was never assessed for proper placement or fitting and was never assessed by physical therapy/occupational therapy for therapeutic effectiveness. On January 6, 2017, at approximately 2:10 p.m. (approximately one day later after NA 1 applied the splint) Resident 1 was found by Licensed Practical Nurse (LPN) 1 to have a splint applied to the left arm and hand. LPN 1 observed that Resident 1's left hand had localized [MEDICAL CONDITION] in the fingers and hand (swelling of an extremity as a result of constricted blood flow from an extremity back to the heart). When LPN 1 removed the splint, LPN 1 observed multiple deep tissue injuries (DTI - injury to the soft tissue caused by compression being applied over a bony area for an extended period of time, or too much compression applied to tissue, which cause tissue death) to the left hand and one DTI to the left forearm described as a blister (fluid filled sac created by separation of layers of the skin caused by trauma to the skin layers). LPN 1 identified 12 DTI's on Resident 1's left hand and forearm. Observation of the splint found for Resident 1 revealed that the DTI locations were consistent with strap application on the hand and forearm. During an interview on January 24, 2017, at approximately 10:35 a.m. the Director of Nursing (DON) revealed that there was no splinting program (program implemented by therapy for splint usage) for Resident 1 for the nursing staff to apply a splint to Resident 1. During the interview the DON revealed that Resident 1 had never had a splinting program in place since Resident 1's admission on December 22, 2015. During an interview on January 25, 2017, at approximately 12:30 p.m. the DON revealed that NA 1 had not been trained to apply a splint to Resident 1. During the interview on January 25, 2017, at approximately 12:30 p.m. OT 1 revealed that there was no documentation that NA 1 was trained to apply a splint to Resident 1. The facility failed to provide care designed to prevent pressure sore development resulting in harm regarding the acquiring of 12 deep tissue injuries from a splint applied to the left arm and hand for one of 6 residents reviewed (Resident 1). 42 CFR 483.25(b)(1) Treatment/Services To Prevent/heal Pressure Sores. Previously cited 1/21/16. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(b)(3) Management. Previously cited 7/16/15. 28 Pa. Code 211.12(d)(1) Nursing services. .Previously cited 11/8/16, 7/15/16, 1/21/16, 7/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/8/16, 7/15/16, 1/21/16, 10/4/15, 7/16/15.

Based on observations, facility policy reviews, clinical record reviews, staff interviews and resident interviews, it was determined that the facility failed to provide an environment that remained free of accident hazards related to falls and failed to provide supervision related to fall prevention for 4 of 19 residents reviewed (Residents 3, 5, 13 and 15) and 1 of 3 nursing units observed (Unit 100). The facility also failed to ensure the environment remained free of accident hazards related to smoking for 4 of 9 residents observed (Residents 7, 10, 14 and 23), hot water temperatures and inadequate stairway railing, thereby placing the health and safety of the residents in Immediate Jeopardy. Findings include: Observations on July 14, 2014, at 3:45 p.m., revealed hot and cold water dispensers present in the 100 hall dining room and outside of the activity area. These dispensers were accessible to all of the residents in the hallway and dispensed hot water at the touch of a button to any person touching the red button. The only cups available in the area were cups designated by the manufacturer as, "cold cups". The hot water was dispensed at 159.6 degrees Fahrenheit from the dispenser in the 100 hall dining room and 153.5 degrees Fahrenheit from the dispenser outside of the activity area. On July 14, 2014, at 4:00 p.m., the Nursing Home Administrator and the Directors of Nursing were notified that Immediate Jeopardy had been identified related to the hot water dispensers. The Nursing Home Administrator and the Directors of Nursing were then asked to provide a corrective action plan. Review of the facility's smoking guidelines, last revised in 2013, revealed a Smoking Safety Assessment was used to identify risk factors indicating the residents' ability to smoke safely and to develop a plan of care that promoted safety for the residents who smoked. The policy also stated that the facility is responsible for the development and implementation of a facility-specific resident smoking policy and that the following elements should be in place for the facility to demonstrate satisfactory compliance: a specific written smoking policy which is implemented; evidence of smoking safety assessments, quarterly reviews and plans of care; resident specific interventions, that residents do not have smoking material in personal possession and that smoking activity is supervised per policy. Review of Resident 10's clinical record revealed [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment (MDS-a tool used to assess a resident's care needs) dated June 20, 2014, indicated that Resident 10's cognitive status is scored as a 6, with 15 being the highest score attainable, indicating Resident 10 was not cognitively intact. Resident 10's care plan, initiated March 15, 2013, and which remains current, indicated the resident forgets things and has the potential to make poor choices. Resident 15's care plan included interventions for smoking and indicated he was at risk for smoking related injuries and smokes with supervision and is to wear a smoking apron. Review of Resident 10's interdisciplinary progress notes dated April 27, 2014, revealed that the resident was outside smoking the previous evening, dropped his cigarette, his shirt started smoking and Resident 10's shirt was removed by a Licensed Practical Nurse (LPN). An observation on July 14, 2014, at 4:20 p.m., revealed that the resident was sitting outside smoking without a smoking apron or supervision by staff. Review of Resident 10's Smoking Safety Assessment, dated April 28, 2014, indicated that the resident had no history of smoking related incidents and that he had been instructed on the facility's smoking protocol and understood the facility smoking policy. Observations of Resident 10's room on July 14, 2014, at 7:45 p.m. and on July 15, 2014, at 9:00 a.m., revealed that the resident's pack of cigarettes was sitting on his dresser in his room. Observations of Residents 7, 10, 14 and 23, on July 14, 2014, at approximately 1:25 p.m., revealed that the residents were smoking independently in the facility's designated smoking area. Residents 10, 14, and 23, were observed not to be wearing smoking safety aprons. Resident 23 had ashes noted on her clothing. There were no staff observed outside. The facility failed to ensure that the residents had interventions in place to effectively maintain safety while smoking. The facility failed to ensure that interventions were implemented and effective for the safe supervision of the residents. On July 14, 2014, at 4:20 p.m., the Nursing Home Administrator and the Directors of Nursing were notified that Immediate Jeopardy had been identified related to resident smoking. The Nursing Home Administrator and the Directors of Nursing were then asked to provide a corrective action plan. Observation July 16, 2014, outside the building revealed that by a side entrance to the 300 hall, there was an ash tray with cigarettes disposed in it and the garbage can. The loading dock entrance area also had cigarettes on the ground. Interview on July 17, 2014, at 8:30 a.m., with the Nursing Home Administrator and the Director of Nursing 2 revealed the areas are not designated smoking areas and that no smoking should occur in these areas. During observation of the facility court yard on July 14, 2014, at approximately 3:45 p.m., a railing was observed. Upon further inspection it was revealed that the railing separated the common area of the courtyard from the concrete steps leading into the facility basement. At the furthest point, next to the ground level building where the railing was attached to the wall, there was observed to be an approximate drop of eight to eight and a half feet to the concrete steps. The railing extended from the wall approximately 10 feet, turned at a 90 degree angle and re-attached to the perpendicular wall at approximately four feet. The four foot section was comprised of a gate and more railing. The railing was observed to have gaps between the ground to the first horizontal rail, and from the first horizontal rail to the second/top horizontal rail each of approximately two feet. It was also observed that laying alongside the concrete footing to which the railing was attached to the ground surface, were multiple pieces of vinyl and aluminum siding that had mulch and other plant debris on top of them. The pile of siding was approximately 6 to 8 feet in length and extended its width of approximately one to one and a half feet, perpendicular to the railing. When the siding was stepped on, the siding created an uneven, unsecured footing. At the time of the observation, it was raining and the siding was also wet, which made it slippery. On July 14, 2014, at 4:40 p.m., the Nursing Home Administrator and the Directors of Nursing were notified that Immediate Jeopardy had been identified related to the courtyard railing. The Nursing Home Administrator and the Directors of Nursing were then asked to provide a corrective action plan. During an interview on July 14, 2014, at approximately 4:40 p.m., the NHA and Director of Maintenance revealed that the residents, the staff, and the family of residents had access to the courtyard. The Director of Maintenance revealed that the railing was identified approximately one month prior, and that the facility had already purchased privacy fencing to block off the railing from the courtyard. At approximately 7:00 p.m., an observation of the railing revealed that the siding was removed from the side of the steps and that the facility attached wire mesh to and around the railing to prevent any access to the gaps in the railing. At this time observations were made that two metal fence posts used laterally, had exposed ends approximately four and a half feet above ground. The Immediate Jeopardy for the hot water dispensers, resident smoking and courtyard railing was lifted on July 14, 2014, at 10:00 p.m., when corrective plans of action were accepted by the survey team. Review of Resident 4's July 2014, physician's orders [REDACTED]. pumping action), hypertension (high blood pressure) and a history of falls. A review of the clinical record for Resident 4 revealed impaired safety awareness and judgment and a history of falls. Review of the fall reports revealed the resident had a fall on January 10, 2014. The report indicated that Resident 4 was in her bare feet and the area on the report for when the resident had last been toileted was left blank. An intervention written on the fall report was for a physical therapy assessment to be done. Review of Resident 4's clinical record revealed there was no evidence that the physical therapy assessment was done following the January 10, 2014 fall. Resident 4 also experienced two falls on June 28, 2014, and no new interventions were put into place to prevent additional falls. Resident 4 fell on [DATE], and there were no new interventions put into place. The care plan for Resident 4 revealed a focus area for risk for falls initiated on August 21, 2012, and current. Review of the clinical record for Resident 4 revealed that the resident had falls on January 10, 2014, two falls on June 28, 2014 and a fall on June 29, 2014. There were no new interventions added to the care plan after the multiple falls. Review of Resident 5's July 2014, physician's orders [REDACTED]. Clinical record review revealed that Resident 5 sustained falls from her bed on April 4, 2014, and June 18, 2014. One of the interventions for the fall dated April 4, 2014, was a physical therapy referral for bed positioning. Review of facility documentation revealed that the referral was not completed until May 30, 2014, and did not address safe positioning for the resident in her bed. Review of the fall dated June 18, 2014, revealed an intervention of a physical therapy referral for bed positioning with bolsters. The referral was completed the following day on June 19, 2014. While the referral mentioned the safety measures in place, it did not address safe positioning in bed for the resident with the bolsters. Review of Resident 13's July 2014, physician's orders [REDACTED]. Review of Resident 13's quarterly MDS assessment dated [DATE], identified that the resident was able to ambulate with extensive assistance of one person. The resident was to receive a restorative nursing program twice daily for ambulation. Review of the facility's Verification of Investigation dated April 30, 2014, revealed that Resident 13 was being ambulated with the assistance of one staff person when another resident who was in a wheelchair ahead of them, was blocking their path. The staff person went to push the other resident out of their path, leaving Resident 13, when the resident lost her balance and fell . Results of the x-ray reports of the resident's left hand, dated April 30, 2014, reveal that Resident 13 sustained fractures involving the second through fourth metacarpal necks (broken fingers) with mild displacement and associated swelling. In an interview with the Director of Nursing 1 on July 17, 2014, at 1:00 p.m., she stated that the staff person should not have left Resident 13 and that education has been provided to that staff person. Review of the July 2014, physician's orders [REDACTED]. Review of Resident 15's current care plan revealed impaired safety awareness and judgment. Review of the quarterly MDS assessment dated [DATE], revealed that Resident 15 requires the assistance of one person when transferring and eating. Review of the facility fall reports revealed that Resident 15 fell on [DATE], while sitting at the side of the bed, eating breakfast and on June 25, 2014, after Resident 15 was sitting at the bedside eating breakfast. The care plan for Resident 15, initiated on August 15, 2012 and current, revealed a focus area for risk for falls. Review of the current care plan revealed there were no new interventions added to the care plan following Resident 15's March 5, 2014, and June 25, 2014 falls. Review of the clinical record for Resident 15 revealed that the resident had falls on March 5, 2014, June 4, 2014 and June 25, 2014, and the care plan was not revised with new interventions after the falls. Observation on July 16, 2014, at 9:10 a.m., of the facility laundry area revealed that the first washing machine upon entering the washing room from the left side had a large amount of water on the floor at the left side of the washer which is accessible to staff. An interview with the Environment Director 1 at 9:20 a.m. revealed the water should not be there. Observation on July 16, 2014, at 9:20 a.m., of boiler room number 2 revealed chemical bottles, an aerosol spray can and half a plastic garbage can with paper trash in it with rags on top. An interview with the Environment Director on July 16, 2014, at 9:20 a.m., revealed that there should be nothing stored in the boiler room. An interview on July 17, 2014, at 8:30 a.m., with the Nursing Home Administrator and the Director of Nursing 2 revealed that the water should not be by the washer and there should be no trash, chemicals or rags stored in the boiler room. During the initial tour of the 100 Unit on July 14, 2014, the soiled utility closet door was observed to be unlocked from approximately 10:20 a.m. until 11:07 a.m., but had a sign indicating the door should be kept locked at all times. During an interview with Licensed Practical Nurse (LPN) 6, it was confirmed that the soiled utility closet door should be locked at all times and LPN 6 locked the door. During an interview with the Director of Nursing 1 on July 17, 2014, at 12:40 p.m., it was confirmed that soiled utility closet doors should be locked at all times. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 07/21/2012. 28 Pa. Code 201.18(b)(1) Management Previously cited 07/27/2012, 08/22/2013, 02/24/2014, 04/18/2014, 06/25/2014. 28 Pa. Code 211.11(a) Resident care plan. Previously cited 07/27/2012, 02/24/2014. 28 Pa. Code 211.11(c)(d) Resident care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 07/27/2012, 07/02/2013, 08/22/2013, 11/14/2013, 02/24/2014, 04/18/2014, 06/25/2014.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide assessment, treatments and services to prevent and promote optimal healing of pressure ulcers for 3 of 19 sampled residents (Residents 5, 7, and 19). Findings include: Review of Resident 5's July 2014, physician's orders [REDACTED]. Review of Resident 5's quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident needs) dated June 10, 2014, revealed that the resident was at risk for pressure ulcers. Review of physician orders [REDACTED]. Review of the nurses' notes dated September 26, 2013, at 11:01 a.m., revealed that Licensed Practical Nurse 3 (LPN 3) documented, "no open areas noted to sacral region, Duoderm continued as preventative measure." A nurses' note dated October 22, 2013, at 12:38 a.m., revealed, "2 pressure areas noted on bottom (one on each buttock)." A treatment order was obtained. Review of Resident 5's July 2014, physician's orders [REDACTED]. There is no further assessment of the areas. On July 10, 2014, there was a wound evaluation sheet for the sacrum that showed there was an open area. There was no evidence of further assessment of the sacral open area. During an interview on July 17, 2014, at 10:00 a.m., the Nursing Home Administrator and the Director of Nursing 2 (DON 2) confirmed that there was no assessment of the open areas identified on October 22, 2013. On October 22, 2013, the dietician recommended that the facility add nutritional juice with breakfast and a Mighty Shake (type of nutritional supplement) with lunch and dinner (for a total of three times a day) to promote wound healing. At that time the facility only added the supplements two times per day instead of the recommended three times per day. During an interview on July 17, 2014, at 9:30 a.m., the Registered Dietician confirmed that the supplement was only administered to the resident two times per day instead of three until it was discontinued in April 2014. Review of Resident 7's March, April, May, June and July 2014, physician's orders [REDACTED]. Review of the wound evaluation sheet dated March 14, 2014, revealed that Resident 7 had a 5.0 centimeter by 5.0 centimeter open area to the left ischial (lower part of the hip bone) area and a 6.0 centimeter by 6.0 centimeter area to the right ischial area. Review of the Wound Evaluation Flow Sheet dated March 16, 2014, revealed that the resident did not have any open areas to the sacrum or the buttock. Review of Resident 7's clinical record did not reveal any evidence of a treatment order for the identified open areas. The Consultation Report dated May 12, 2014, by the wound clinic physician, revealed that Resident 7 arrived at the wound clinic without his wound vac (device used to promote wound healing) applied. Observation of the dressing change to Resident 7's right and left ischial open areas on July 16, 2014, at 2:55 p.m., by Registered Nurse 4 (RN 4) revealed that spray cleanser was applied to the buttock areas which ran into the open wound beds. RN 4 applied skin prep to the border of the wounds without washing their hands. RN 4 touched the wound bed of the open area with gloves that were soiled. RN 4 placed clean scissors in the work field which contaminated the scissors and then cut the drape and sponges, which are sterile (material used in dressing change), with the contaminated scissors. RN 4 inserted suction tubing into sponges with ungloved hands that were not washed. Interview with the Nursing Home Administrator and the Director of Nursing 2 revealed the dressing was improperly completed and hand washing should have been done. Review of the clinical record for Resident 19 revealed admitting [DIAGNOSES REDACTED]. Review of Resident 19's physician's orders [REDACTED]. Review of Resident 19's April 2014 Treatment Administration Record (TAR) revealed an order dated April 23, 2014, to cleanse the sacral wound with wound cleanser, apply Cellerate (treatment for [REDACTED]. The TAR revealed that the treatment was first applied April 27, 2014, 4 days after the physician order [REDACTED]. Interview with the Director of Nursing 1 on July 17, 2014, revealed the expectation that the treatment should be done. The facility failed to provide evidence of communication regarding the development, assessment, and treatment of [REDACTED]. 28 Pa. Code 211.12(a) Nursing services. Previously cited 07/02/2013. 28 Pa. Code 211.12(c) Nursing services. Previously cited 07/02/2013, 08/22/2013, 04/18/2014, 06/25/2014. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 07/27/2012, 07/02/2013, 08/22/2013, 11/14/2013, 02/24/2014, 04/18/2014, 06/25/2014.

Based on observation, clinical record review and staff interviews, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development and promote optimal healing for 2 of 11 residents reviewed (Residents 8 and 9) Findings include: Review of clinical record for Resident 8 revealed a [DIAGNOSES REDACTED]. Clincal record revealed Resident 8 had a stage IV pressure ulcer. Review of wound evaluation flow sheet revealed that the would has not been assessed for measurement or other characteristics about the wound since September 2, 2014. Review of weekly skin checks revealed no skin assessment has been done since September 19, 2014. Review of treatment record for September 2014 revealed that on September 19, 22, 24, and 27 of 2014 the treatment to the pressure ulcer was not done. Interview with DON on October 2, 2014 at 11:10 a.m. confirmed that the weekly skin sheets should be addressed every week and the pressure ulcer wound evaluation should be assessed weekly and with dressing changes. DON also stated that education will continue for staff to document refused if Resident 8 refused a dressing change. Review of Resident 9's September 2014 physician orders [REDACTED]. Review of Residnet 9's September 2014 Treatment Administration Record (TAR) revealed Staff continued to sign off that Duoderm was being applied every 72 hours beginning September 8, 2014 through September 29, 2014. Interview with LPN 2 revealed that on September 18, 2014, without a physician order, staff stopped the Duoderm, applied [MEDICATION NAME] barrier paste, and left right buttock open to air even though documentation indicated the Duoderm was being applied. Observation of Resident 9 both on October 1, 2014 at 1:35 p.m. and October 2, 2014 at 11:30 a.m. revealed Resident 9's buttock area open to air and without Duroderm.