Every finding on record at Aristacare at East Falls

Based on review of facility policy, staff interview and observations, it was determined the facility failed to ensure emergency equipment readily available related to ambu bag (a handheld device used to manually push air into the lungs) and tracheostomy set (a set of sterile, pre assembled medical supplies used to perform, maintain, or manage a tracheostomy (a surgical opening in the neck into the trachea (windpipe) that allows air to bypass the nose, mouth, and throat) for 15 of 25 residents reviewed. (Resident R21, R32, R53, R48, R27, R57, R37, R47, R29, R5, R15, R16, R28, R43, R55) Review of facility policy on Backup Trach, under section POLICY STATEMENT: Guidelines for Stocking and Availability of Spare Tracheostomy Tubes. Under section PROCEDURE: #A. Bedside spare tracheostomy tubes-every patient with a tracheostomy will have two spare tracheostomy tubes available to them. #1. One tube of the same size, type, and cuff configuration currently in use. #2. One tube that is one size smaller than the tube currently in use. Spare tubes are clearly labeled tracheostomy size, type, and unopened tubes will remain in their original packaging and unopened. #B. Facility Stock -Most Frequently Used Tracheostomy Size -The facility will maintain a par level of the most frequently used tracheostomy size to support routine replacement in emergency needs. The designated most used tracheostomy tube and required on-hand quantity will be maintained. #C. The Respiratory Director/Supply Manager will review utilization at least quarterly and revise the designated most used size and par level as needed. #D. The facility will maintain quantity needed of the most commonly used tracheostomy tube sizes in central supply. #E. Step-Down Tracheostomy Tube Stock- Step-Down tracheostomy tubes will be maintained in facility inventory at all times for emergency replacement when a smaller tube is needed. Step-down tubes will be compatible with the tracheostomy tubes commonly used in the facility and will include the appropriate configurations based on resident needs. If a step-down should be used it will be replaced ASAP. #F. Inventory Monitoring and Replacement -Respiratory staff will verify bedside spare tracheostomy tubes at the start of each shift and after any tracheostomy change. Central inventory will be checked at least weekly for required quantities, packaging integrity, correct sizes and configurations. any missing expired, damaged, open, or used tube must be reported immediately and replaced. Stock levels below the required minimum will be reported to the respiratory director slash supply manager. Review of Resident R21 MD orders revealed an order for Trach size 6, Trach type Shiley with an order date of [DATE]. Observation conducted on Resident R21 conducted on [DATE], at 11:27 AM, revealed that Resident R21 in bed with a Tracheostomy tube. Observation of Resident R21's room revealed that there was no Ambu bag on her bedside or near Resident R21's bed. Observation of Resident R21's bedside table revealed that a size 6 replacement trach set on in Resident R 21's bedside drawer. Furter, the size 6, trach replacement kit was open. Further observation of Resident R21's bedside drawers revealed that there was no trach replacement kit size smaller (size 4) than the tube currently in use. Interview conducted with Licensed staff Employee E13 confirmed that there was no Ambu bag in Resident R21's room. Further, Employee E13 also confirmed that the size 6 trach replacement kit in Resident R21's drawer was open and that there was no unopened size 6 trach kit in Resident R21's bedside drawer. Further Employee E13 also confirmed that there was no downsize trach replacement kit (size 4) in Resident R21's drawer. Observation conducted on Resident R32 conducted on [DATE], at 11:27 AM, revealed that Resident R32 was in bed with a Tracheostomy tube. Observation of Resident R32's room revealed that there was no Ambu bag on her bedside or near Resident R32's bed. Observation of Resident R32's bedside table revealed that a size 6 replacement trach set on in Resident R32's bedside drawer. Furter, the size 6, trach replacement kit was open. Further observation of Resident R32's bedside drawer revealed that there was no downsize trach replacement kit; (size 4) Interview conducted with licensed Employee E13 confirmed that there was no Ambu bag in Resident R32's room. Further, Employee E13 also confirmed that the size 6 trach replacement kit in Resident R32's drawer was open and that there was no unopened size 6 trach kit in Resident R32's bedside drawer. Further Employee E13 also confirmed that there was no downsize trach replacement kit (size 4) in Resident R32's drawer. Observation conducted on Resident R53 conducted on [DATE], at 11:27 AM, revealed that Resident R53 was in bed with a Tracheostomy tube. Observation of Resident R53's room revealed that there was no Ambu bag on her bedside or near Resident R53's bed. Observation of Resident R53's bedside table revealed that a size 6 replacement trach set in Resident R53's bedside drawer. Furter, the size 6, trach replacement kit was open. Further observation of Resident R53's bedside drawer revealed that there was no downsize trach replacement kit; (size 4) Interview conducted with licensed staff Employee E13 confirmed that there was no Ambu bag in Resident R53's room. Further, Employee E13 also confirmed that the size 6 trach replacement kit in Resident R53's drawer was open and that there was no unopened size 6 trach kit in Resident R53's bedside drawer. Further Employee E13 also confirmed that there was no downsize trach replacement kit (size 4) in Resident R53's drawer. Interview with licensed staff Employee E11 conducted on [DATE], at 12:16 PM confirmed that the facility did not have enough supply of tracheostomy set size 4 and size 6 for each resident using those sizes. Further interview with Employee E11 revealed that the facility only has two spare size #4 tracheostomy sets and seven spare size #6 tracheostomy sets. Observation of Resident R48's Room revealed that resident had two opened tracheostomy kits in size 6.0. No tracheostomy kit size 5.0 (size smaller). Review of Resident R48's physician orders revealed orders for size 6.0 Shiley flex tracheostomy and Spare trach at bedside, same size and a size down. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:20 a.m., confirmed findings. Observation of Resident R27's (room [ROOM NUMBER]B) bedside revealed that resident had one empty box for tracheostomy kit in size 5.0, two opened boxes size 6.0. Review of Resident R27's physician orders revealed order for size 6.0 Shiley XLT. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:22 a.m., confirmed findings. Observation of Resident R57's Room revealed that resident had an opened tracheostomy kit in size 6.0. No ambu bag (a handheld device used to manually push air into the lungs). No tracheostomy kit size 5.0. Review of Resident R57's physician orders revealed order for size 6.0 Shiley flex. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:23 a.m., confirmed findings. Observation of Resident R37's Room revealed one unopened tracheostomy kit size 6.0. No tracheostomy kit size 5.0. Review of Resident R37's physician orders revealed order for size 6.0 flex. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:35 a.m., confirmed findings. Observation of Resident R47's Room revealed an unopened tracheostomy kit size 5.0. No tracheostomy kit size 6.0. Review of Resident R47's physician orders revealed an order for size 6.0 Shiley. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:37 a.m., confirmed findings. Observation of Resident R29's room revealed that resident had an unopened tracheostomy kit size 6.0. No tracheostomy kit size 5.0. Review of Resident R29's physician orders revealed an order for size 6.0 flex. Interview with Employee E5, Director of Respiratory Therapy on [DATE], at 11:37 a.m., confirmed findings. Findings include: Observation of Resident R5's bedside revealed that resident had an unopened tracheostomy kit in size 7.5. No tracheostomy kit size 6.5. Review of Resident R5's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E2, Director of Nursing on [DATE], at 11:28 a.m., confirmed findings. Observation of Resident R15's bedside revealed that resident had an unopened tracheostomy kit in size 7.5. No tracheostomy kit size 6.5. Review of Resident R15's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E2, Director of Nursing on [DATE], at 11:22 a.m., confirmed findings. Observation of Resident R16's bedside revealed that resident had an unopened tracheostomy kit in size 6.0. No ambu bag (a handheld device used to manually push air into the lungs). No tracheostomy kit with the next size down. Review of Resident R16's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E4, Licensed Practical Nurse on [DATE], at 10:45 a.m., confirmed findings. Observation of Resident R28's bedside revealed that resident had an unopened tracheostomy kit in size 6.0 XLT. No tracheostomy kit size with the next size down Review of Resident R28's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E2, Director of Nursing on [DATE], at 11:22 a.m., confirmed findings. Observation of Resident R43's bedside revealed that resident had an opened tracheostomy kit in size 6.0 and No tracheostomy kit with the next size down. Review of Resident R43's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E3, Respiratory Nurse on [DATE], at 11:02 a.m., confirmed findings. Observation of Resident R55's bedside revealed that resident had an unopened tracheostomy kit in size 7.5. No tracheostomy kit size 6.5. Review of Resident R55's physician orders revealed Spare trach at the bedside, same size and size down. Interview with Employee E2, Director of Nursing on [DATE], at 11:22 a.m., confirmed findings.

Based on review of clinical record, review of facility policy, interview with staff and residents, it was determined that the facility failed to provide residents who are not able to communicate verbally with a communication device for one of thirty-one residents observed (Resident R8)Findings include: Review of Resident R8's clinical record revealed that Resident R8 was admitted to the facility on [DATE], with diagnosis of but not limited to traumatic subarachnoid hemorrhage, Traumatic Brain Injury, Tracheostomy status. Review of Resident R8's Social Services care plan initiated on October 24, 2026, revealed that Resident R8 has a communication problem related to being in a non-verbal. Review of Resident R8's Speech Therapy Evaluation and Plan of Treatment dated July 10, 2026, revealed that Resident R8 had diagnoses of but not limited to Cognitive-Communication Deficit and Aphonia (aphonia is the total or partial loss of the ability to produce voiced sound). The Speech Therapist Plan of Treat include Evaluation of speech sound production and language assessment. Objective Progress/Short Term Goals include Patient will increase ability to make needs known with 70% of attempts with minimal initiation difficulty in order to communicate basic wants needs. Objective Progress/ Long Term Goals include Patient will improve cognitive communication skills to 70% accuracy to communicate basic wants needs within environment. Patient Goal was to improve communication. Initial Assessment /Current Level of Function and Underlying Impairments, Reason for Therapy: Patient presents with moderate cognitive-communication impairment characterized by deficit, attention, memory and safety awareness. Patient presents with aphonia in the presence of trach. Review Speech Language and Pathology Recertification, Progress Report and Updated Therapy Plan for Certification for August 9, 2026, to October 7, 2026, revealed that Objective Progress/Short term Goals includes Patient will increase ability to make needs known with 70% of attempts with minimal initiation difficulty in order to communicate basic wants/needs (target date September 18, 2026). Objective Progress/Long Term Goals include Patient will improve cognitive communication skills to 70% accuracy to communicate basic wants/needs within current environment with a target date of September 11, 2026. Observation of resident conducted on August 11, 2026, at 11:24AM revealed that Resident R8 was in bed, alert and awake with tracheostomy tube in place. Further observation revealed that Resident R8 has a clipboard with a piece of paper on his bedside. Further observation revealed that there was no communication board on resident's bedside table and no pen or pencil within Resident R1's reach. Interview with resident R8 revealed that Resident R8 was not able to vocalize his words. Resident R8 started to make gestures and facial expressions which could not be understood by surveyor. Resident R8 started to attempt to forcefully speak. Garbled sound was coming out of Resident R8's tracheostomy and was unintelligible. Resident continued to attempt to communicate with surveyor verbally but was not able to do so. Resident was encouraged to write his message on the paper on the clipboard. However, there was no pen or pencil on his bed or his bedside table. Upon further inspection of Resident R8's room, a pen was found on an overhead table which was against the wall opposite from the foot of Resident R8's bed. Resident R8 was handed the pen, and Resident R8 proceeded to attempt to write on the paper however the writing was illegible. Resident appears frustrated and started waving the clipboard around. After 10 minutes of unsuccessful attempts to communicate with Resident R8, surveyor went to summon the DON (Director of nursing) Employee E2 to assist in communicating with a Resident R8. Observation revealed that Employee E2 attempted to read what Resident R8 had previously written on the clipboard but was not able to decipher the writing while Resident R8 was trying to vocalize something that was unintelligible. Employee E2 then proceeded to attempt to communicate with Resident R8 asking him what he was trying to say but Employee E2 also could not understand what Resident R8 was trying to communicate. Employee E8 continued to attempt to communicate with Resident R8 by guessing different words that sounded like the sound that was coming out of Resident R8's tracheostomy. After about 5 minutes of trial and error, Employee E2 was able to decipher a name but could not fully understand what Resident R8 was trying to say. Interview with Employee E2 conducted at the time of the observation confirmed that Resident R8 had difficulty verbalizing his needs. Further Employee E2 also confirmed that residents writing was Illegible. Further, Employee E2 confirmed that there was no communication board in the residence room. Interview with Speech Therapist Employee E12 August 13, 2026, at 1:05PM revealed that Residents R8 had difficulty with verbal communication because he does not have a Passy Muir Valve (A medical device that attaches to a patient's tracheostomy tube to help them speak). Further speech therapist also revealed that Resident R8 did not qualify for a Passy Muir Valve because he had difficulty clearing his secretions. Further interview with Employee E12 revealed that Resident R8 can benefit from a communication board. Further, speech therapist also revealed that she may have provided Resident R8 with a communication board in the past but that she was not sure. Follow up interview with Employee E2 conducted on August 14, 2026, at 11:45 AM reveal that Resident R8 has been provided with a communication board. Further Employee E2 also revealed that the communication board was effective in improving Resident R8's ability to communicate his immediate need. 28 Pa. Code 201.2(a)

Based on review of clinical record, review of facility policy it was determined that the facility failed to ensure that a person-centered baseline care plan was completed within 48 hours of a resident's admission for one of thirty-one residents observed (Resident R37)Review of facility policy on Care Plans revealed that under section Policy Statement- An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under section POLICY INTERPRETATION AND IMPLEMENTATION, the resident's care plan is developed using the completed resident's comprehensive assessment MDS (Minimum Data Set- a federally required resident assessment conducted at a specific interval) using the Baseline Care Plan is the template. Review of resident R37 clinical record revealed that Resident R37 was admitted to the facility on [DATE], with diagnoses of but not limited to End Stage Renal Disease (ESRD), Dependence on Renal Dialysis. Review of Resident R37's physician order revealed that resident R37 had and order for dialysis as follows:Order Summary: Dialysis performed Monday thru Friday at bedside. End Stage Renal Disease. Order date July 01.2026. Review of Resident R37 MDS (Minimum Data Set- a federally required resident assessment conducted at a specific interval) dated July 08,2026 section O0110, Special Treatments, Procedures, and Programs, J1 Dialysis revealed that Resident R37 was on dialysis. Review of Resident R37 care plan revealed that the resident R37 needs dialysis hemodialysis r/t renal failure Date Initiated: July 07, 2026. Revision on: July 07, 2026. Further review of Resident R37 clinical record revealed no documented evidence that Resident R37 had a baseline care plan related dialysis completed within 48 hours. 28 Pa Code 211.10 (c) Resident Care policies

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that the resident assessment accurately reflected the resident's status regarding tracheostomy tube removal for one of eight residents reviewed (Residents R3).Findings include:Clinical record review revealed Resident R3 was admitted to the facility on [DATE], with diagnoses including but not limited to respiratory failure, tracheostomy status (having tracheostomy tube in place as a means to breathe), dependence on respirator (ventilator) status (resident on a ventilator), and anoxic brain damage (brain damage caused by lack of oxygen to the brain).Observation conducted on August 12, 2026 at 9:15 AM revealed Resident R3 laying in bed, and having no tracheostomy tube in place (decannulated), on no oxygen, and having an unbandaged/uncovered, healing ostomy wound (hole where tracheostomy had formerly been) observed at the base of his throat.Review of clinical documentation revealed multiple nursing/respiratory notes dated July 18, 2026, indicating resident had self-decannulated (removed his tracheostomy tube), however, remained in stable respiratory condition, with oxygen saturations remaining in the high 90s% on room air, even without oxygen administration via nasal cannula (resident would not tolerate keeping nasal cannula on).Further review of clinical documentation revealed resident was admitted with a tracheostomy tube and utilizes a ventilator to breathe. This was indicated also under Section O - Special Treatments, Procedures, and Programs of the Quarterly MDS assessment dated [DATE], that Resident R3 was receiving Respiratory Treatments that included Oxygen therapy, suctioning, and tracheostomy care.Review of the clinical record pertaining to MDS data revealed a Significant Change in Condition MDS assessment had been started on August 2, 2026, which was incomplete as of August 13, 2026.Interview with Employee E6, MDS Coordinator, conducted on August 13, 2026 at 1:40 p.m. confirmed that Resident R3's tracheostomy status was incorrect according to the latest (Quarterly) MDS assessment completed May 29, 2026. Employee E6 did clarify that Resident R3 was still receiving wound care to the former site of the tracheostomy tube. 28 Pa. Code 201.14(a) Responsibility of licensee2 Pa. Code 211.5(f) Medical records

Based on observation, clinical record review, review of the Resident Assessment Instrument (RAI) User's Manual, and staff interview, it was determined the facility did not ensure to complete a comprehensive Significant Change in Status Assessment using the Minimum Data Set (MDS) after a significant change in physical functioning for one of eight residents reviewed (Resident R3).Findings include:According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual indicates a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.Clinical record review revealed Resident R3 was admitted to the facility on [DATE], with diagnoses including but not limited to respiratory failure, tracheostomy status, dependence on respirator (ventilator) status, and anoxic brain damage (brain damage caused by lack of oxygen to the brain).A Quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that section (C) relating to resident's cognition, did not complete a BIMS assessment (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, listed as a numerical score) due to Resident R3's being rarely/never understood. However, the assessment indicated in Section C1000, Cognitive Skills for Daily Decision Making that Resident R3 was Severely impaired, meaning he never/rarely made decisions.Review of clinical documentation revealed resident was admitted with a tracheostomy tube and utilizing a ventilator to breathe. This was indicated also under Section O - Special Treatments, Procedures, and Programs of the Quarterly MDS assessment dated [DATE], that Resident R3 was receiving Respiratory Treatments that included Oxygen therapy, suctioning, and tracheostomy care.Observation conducted on August 12, 2026 at 9:15 AM revealed Resident R3 laying in bed, asleep, and having no tracheostomy tube in place (decannulated), on no oxygen, and having an unbandaged/uncovered, healing ostomy wound (hole where tracheostomy had formerly been) observed at the base of his throat.Further review of clinical documentation revealed multiple nursing/respiratory notes dated July 18, 2026, indicating resident had self-decannulated (removed his tracheostomy tube), however, remained in stable respiratory condition, with oxygen saturations remaining in the high 90s% on room air, even without oxygen administration via nasal cannula (resident would not keep the nasal cannula on).Review of the clinical record pertaining to MDS data revealed an a Significant Change in Condition MDS assessment had been started on August 2, 2026, which was incomplete as of August 13, 2026.During an interview on August 13, 2026 at 1:40 PM, MDs Coordinator, Employee E6, confirmed that the Significant Change in Condition MDS should have been completed within the 14 days from July 18, 2026 and had not been. The MDS Coordinator acknowledged that Resident R3's decannulation met the criteria for a Significant Change in Condition in accordance with the RAI User's Manual. 28 Pa. Code 211.5 (f)(ii)(ix) Medical records28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of clinical record, and staff interview it was determined that the facility failed to notify the resident's representative of a significant change in the resident's condition for one of one resident reviewed (Resident R1). Findings Include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of advanced Amyotrophic Lateral Sclerosis (ALS - a progressive neurological disease that results in severe and irreversible muscle weakness, loss of voluntary movement, and loss of speech and swallowing function), tracheostomy status (a surgically created hole in your trachea that allows for breathing), and dependence on ventilator (machines that act as bellows to move air in and out of the lungs).Continued review of Resident R1's clinical record revealed the resident is fully dependent on staff for all care needs and receives nutrition and medications via a PEG tube (feeding tube placed directly into the stomach through the abdominal wall for long-term nutritional support).Resident R1's clinical record indicated communication is limited to eye blinking and head nods for yes/no responses.Record review for Resident R1 revealed documentation from the facility's contracted wound care company dated March 31, 2026, that revealed the resident's skin was documented as intact with no wounds observed during routine assessment.Further review of Resident R1's documentation from the facility's contracted wound care company dated April 28, 2026, revealed the presence of a sacral pressure injury (localized damage to the skin and/or underlying soft tissue).Review of Resident R1's clinical record and available documentation at the time of the survey revealed no documentation that the resident's family or representative was notified of the sacral pressure injury.Interview on June 9, 2026, with the Director of Nursing (DON), Employee E2, confirmed there was no documentation that the facility notified the resident's Power of Attorney (POA) when the sacral pressure injury was identified. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.19 (a) Resident Rights.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to ensure pressure ulcer interventions were documented as ordered by the physician for one of one resident reviewed (Resident R1).Findings Include:Review of undated facility policy Prevention of Pressure Ulcers revealed residents at risk for pressure ulcers include those who are bed and/or chair-fast. General preventative measures include changing position every one to two hours, or more frequently if needed.Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of advanced Amyotrophic Lateral Sclerosis (ALS - a progressive neurological disease that results in severe and irreversible muscle weakness, loss of voluntary movement, and loss of speech and swallowing function), tracheostomy status (a surgically created hole in your trachea that allows for breathing), and dependence on ventilator (machines that act as bellows to move air in and out of the lungs). Continued review of Resident R1's clinical record revealed the resident is bed/chair bound, fully dependent on staff for all care needs, and receives nutrition and medications via a PEG tube (feeding tube placed directly into the stomach through the abdominal wall for long-term nutritional support).Resident R1's clinical record indicated communication is limited to eye blinking and head nods for yes/no responses.Review of Resident R1's clinical record revealed a physician order dated April 23, 2026, to turn and reposition the resident every 2 hours and nurse aide documents completion every shift in Resident R1's medical record. Review of Resident R1's clinical record revealed no documented evidence nurse aides and/or nursing staff documented the completion of turning and repositioning every 2-hours as ordered. Interview on June 9, 2026, at approximately 1:00 p.m. with the Director of Nursing, Employee E2, confirmed there was no documented evidence to verify Resident R1 was turned and repositioned per the physician order. 28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observations, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that one out of eleven resident room maintained functional running water necessary for hygiene and provision of care. (room [ROOM NUMBER]) Findings include: Review of the Centers for Disease Control and Prevention (CDC), Guideline for Hand Hygiene in Health-Care Settings, MMWR Recommendations and Reports, Vol. 51, No. RR-16, October 25, 2002. revealed hand hygiene, including washing hands with soap and water, is essential for infection prevention during high-risk patient care activities such as wound care, toileting, tracheostomy care, and feeding tube management. Per CDC guidance, alcohol-based sanitizer alone is not sufficient when hands are visibly soiled or after exposure to bodily fluids, and proper handwashing is required to reduce the risk of infection transmission. Observations conducted at approximately 9:40 a.m. with the Director of Maintenance, Employee E6, in resident's room [ROOM NUMBER], it was noted that the sink was not functioning and there was no running water available. The shower was non-functional, with the faucet removed, and although the toilet was operational, the absence of running water in the sink and shower was confirmed. The Director of Maintenance, Employee E6 stated that the water supply to the room had been shut off for approximately two weeks due to a plumbing issue and confirmed that both the sink and shower were inoperable. He further stated that this was the only room on the unit affected by this issue. Review of facility document review revealed that an outside contracting company evaluated the issue and provided an estimate for repairs to room [ROOM NUMBER] dated February 9, 2026. However, the facility did not accept or proceed with the proposed work, and repairs had not been completed as of the date of the survey. Interview conducted at approximately 2:00 p.m. on March 30, 2026, with the Nursing Home Administrator, employee E1 confirmed awareness of a water issue in room [ROOM NUMBER] for approximately two weeks but stated he was unaware that the sink lacked running water. When questioned regarding the repair estimate dated February 8, 2026, approximately seven weeks ago, the Administrator indicated that the facility declined the external estimate and planned to complete the repairs internally; however, no definitive start date or timeline for completion was provided. Employee E1 further stated that hand sanitizer was available in the room as an interim infection control measure and did not identify the lack of running water as an infection control concern. He confirmed that no alternative accommodations had been implemented, despite the facility having available beds (66-bed capacity with a census of 61) and the ability to relocate the resident if necessary. Interview with Licensed nurse Employee E3 on March 30, 2016, at 1:10 PM, confirmed that the number one priority for infection control in patient care is proper hand hygiene. The Licensed nurse, Employee E3 stated that nursing staff must wash their hands, as it is crucial to patient care. In situations where water is not immediately available, the Employee E3 reported that staff would use hand sanitizer until they are able to wash their hands. Interview with Respiratory Therapist, Employee E4, on March 30, 2026, at 1:45p.m. revealed that infection prevention is very important, especially in a high-acuity environment. The therapist stated that, in her role, proper hand hygiene is critical to her work. Interview with Nursing Assistant, Employee E 5 on March 30, 2026, at 1:55 p.m. revealed that staff are educated to wash their hands all the time, especially before and after providing patient care, in order to prevent infections. 28 Pa. Code 201.14 (a)(g) Responsibility of Licensee 28 Pa. Code 201.18(e) (2.1) Management 28 Pa. Code 204.19 Plumbing, Heating, Ventilation, Air Condition and Electrical

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to ensure one resident was free from significant medication error for one of three residents reviewed (Resident R1).Findings Include:Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses of anoxic brain damage (oxygen is cut off from the brain), anxiety (intense, excessive, persistent worry or fear), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).Review of Resident R1's hospital record revealed an After Visit Summary dated November 4, 2025. Review of Resident R1's After Visit Summary revealed instructions to stop taking the following medications: clonazepam (used to treat seizures and panic disorders), Keppra (seizure treatment), Seroquel (antipsychotic), and Valproic Acid (primarily used to treat seizures)Review of Resident R1's clinical record revealed physician orders dated November 5, 2025, to administer Keppra 1000 milligrams (mg) every 12 hours for seizure, Clonazepam 25 mg two times per day, Seroquel 25 mg two times per day, and Valproate (valproic acid) 15 milliliters (mL) every 8 hours for seizures.Review of Resident R1's medication administration record revealed:Clonazepam was administered twice on November 5, 2025, and Seroquel was administered once on November 5, 2025.Keppra and valproic acid were administered as ordered from November 5, 2025, through November 11, 2025.Review of Resident R1's clinical record revealed a progress note dated November 6, 2025, by the Nurse Practitioner, Employee E3, that revealed [family] at bedside concerned about medications. Further review of the progress note dated November 6, 2025, revealed Resident R1 was noted to be lethargic and was awaiting proper medication list from the hospital.Interview on December 29, 2025, at 2:35 p.m. with Nurse Practitioner, Employee E3, revealed the facility did not have Resident R1's medication discharge list from the hospital when the resident was admitted . Nurse practitioner, Employee E3, indicated he/she adjusted the Clonazepam and Seroquel to be administered only as needed (versus standing orders) after medication concerns were brought to his/her attention by Resident R1's family.Continued interview on December 29, 2025, at 2:35 p.m. with Nurse Practitioner, Employee E3, revealed he/she kept reminding nursing staff to obtain an updated medication list from the hospital.Further interview with Nurse practitioner, Employee E3, revealed that he/she was unaware that the hospital gave instructions to discontinue the Valproic acid and Keppra.28 Pa Code 211.9(a)(1) Pharmacy services28 Pa Code 211.12(d)(5) Nursing services

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure safety interventions for falls were in place for two of four residents reviewed for falls (Resident R11, R20). Findings include:Clinical record review revealed Resident R11 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (condition that prevents airflow to the lungs, causing breathing problems), hemiplegia and hemiparesis (affects movement/sensation on one side of body), and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of Resident R11 ' s care plan, revised September 19, 2025, revealed the resident is at moderate risk for falls related to confusion, deconditioning, and unaware of safety needs. The resident subtantiated a fall that occurred on September 02, 2025 when resident slid out of wheelchair and another fall from bed on September 16, 2025. Further review of Resident R11 ' s care plan for falls revealed fall mats were to be applied to bilateral sides of the bed. Observation on November 03, 2025 at 10:12 a.m. revealed Resident R11 lying in bed and did not have bilateral floor mats on the floor next to the bed. Follow-up observation on November 03, 2025 at 1:10 p.m. revealed Resident R11 lying in bed and did not have bilateral floor mats on the floor next to the bed. Interview on November 03, 2025, at 1:22 p.m., with Employee E7, Nurse Aide, confirmed Resident R11 did not have bilateral floor mats on the floor while in bed. Review of clinical record revealed Resident R20 was admitted to the facility on [DATE], with a diagnose of amyotrophic lateral sclerosis (also known as [NAME] ' s Disease, a neurodegenerative disease affecting nerve cells in the brain and spinal cord, which leads to loss of muscle control) and myasthenia gravis (chronic autoimmune disorder leading to muscle weakness and fatigue).Review of Resident R20 ' s care plan, initiated May 17, 2025, revealed Resident R20 was at risk for falls and interventions included bilateral fall mats to be in place.Observation on November 05, 2025 at 11:30 AM revealed Resident R20 had one fall mat on the right side of the bed in place.Interview with Employee E8, Licensed Practical Nurse, confirmed Resident R20 only had the right-side fall mat in place. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on observation, interviews with residents and staff, and review of facility documentation, it was determined that the facility failed to ensure that call bells were functioning properly for 6 of 6 resident rooms. (Rooms-717 (A and B), 723, 720-(A and B), 728-B and 733-B) Findings include:Review of Facility ' s policy for Call Bells revealed (within Item 3 of Guidelines) that For any defective call lights, inform maintenance. Residents may be offered with a tap bell to use if and when applicable. Observations on November 5, 2025, at 11:30 AM and November 7, 2025, at 11:35 AM of call light of Residents ' call bell in room [ROOM NUMBER]-A and B, revealed that at both times call bell box had been pulled out of the wall and was therefore rendered defective/ineffective. Further observation revealed that the call bell did not illuminate outside room when the resident pushed call bell button, Resident R20 had not been provided with an alternative of a tap bell as per facility Call Bells Policy.Observation and interview with Resident R21 on November 4, 2025, at 12:00 p.m. stated the resident ' s call bell in room [ROOM NUMBER]-B has not worked in months. Observed was a small silver manual bell that the resident was told to use if staff attention was needed.Review of a grievance, dated October 17, 2025 family reported Resident R22 ' s call bell in room [ROOM NUMBER] has not worked in approximately two weeks since the resident ' s admission, instead was giving a manual bell. On November 6, 2025, at 11:00 a.m. during an interview with four residents (Resident R17, R18, R19 and R23), in rooms 720-A and B, 728-B and 733-B stated their call bells have not worked for weeks. They are given a small manual bell that the staff do not respond. On November 4, 2025, at 1:00 p.m. during an interview with the Nursing [NAME] Administrator, stated the facility does not have an effective process for informing maintenance when something needs repair. Maintenance is told verbally and that recently the staff was trained on how to use the computerized TELS system that goes directly to maintenance. 28 Pa Code 201.18(b)(3) Management

A review of the facility policy titled, Isolation-Initiating Transmission-Based Precautions undated, revealed Transmission-Based Precautions will be imitated when there is reason to believe that a resident has communicable infection disease. Transmissions-Base Precautions may include Contact Precautions, Droplet Precaution, or Airborne precautions:A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with a physician's order on the same date for tracheostomy and hemodialysis. The clinical record also included special instructions for enhanced barrier precautions due to open insertion sites related to these treatments.On October 16, 2025, at 9:19 a.m., a tour with the Assistant Director of Nursing and Infection Preventionist, Employee E2, revealed that the facility provides bedside hemodialysis to residents. All such residents have special instructions to follow transmission-based precautions, and all staff entering their rooms must wear personal protective equipment (PPE), including a gown, gloves, and mask, when providing care or treatment. It was further observed that four hand sanitizing dispensers near rooms 738, 735, 733, and 731 were empty. In addition, the public restroom on the east side of the nursing unit lacked soap and paper towels.On October 16, 2025, at 9:21 a.m., dialysis patient care technician Employee E3 was observed providing bedside dialysis treatment to Resident R2 without wearing appropriate personal protective equipment (PPE). This was confirmed by the Assistant Director of Nursing, Employee E2.On October 16, 2025, at 10:37 a.m. dialysis patient care technician Employee E3 was interviewed and confirmed that it was my mistake for not wearing the PPE.A review of Resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with a physician's order on the same date for a feeding tube and an indwelling urinary foley catheter. Continued review of Resident R3's clinical record included special instructions for enhanced barrier precautions.On October 16, 2025, at 9:27 a.m., observations were conducted with the Assistant Director of Nursing, Employee E2, who confirmed that licensed nurse Employee E4 was providing care to Resident R3 without wearing appropriate personal protective equipment (PPE).28 Pa. Code 211.10 (d) Resident care policies.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on observation, interviews with staff, review of clinical records revealed the facility failed to ensure a resident at risk for pressure ulcers received care, consistent with professional standards of practice, to prevent pressure ulcers for one of 14 resident records reviewed (Resident R12). Findings include: Review of Resident R12's clinical records revealed an admission date of March 6, 2025, with the diagnoses of nontraumatic intracranial hemorrhage (bleeding), dysphagia (unable to follow) following unspecified cerebrovascular disease, tracheostomy status, acute and chronic respiratory failure, hypertension (high blood pressure), and gastrostomy.Physician orders dated September 12, 2025, instructed to don Prevalon boots (offloads pressure to reduce skin injuries) in bed/chair every day and night shift. Review of Resident R12's nursing notes dated October 29, 2025, stated the resident was found with an open area noted to right posterior lower leg above the ankle. The wound was documented measurements were, length 5.0, Width 2.5, and roughly 0.5 in Depth. Observation of Resident on November 3, 2025, and November 4, 2025, at 9:00 a.m. revealed that there were no Prevalon boots worn by the resident. November 4, 2025, at 10:30 a.m. during an interview with nurses ' aides (NA) Employee E9 and E10, the resident continued to be observed without Prevalon boots. NAs Employee E9 and E10 stated that a blister formed on the resident ' s leg and it popped. The aides stated the resident likes to cross his legs. Due to the boots not being used the resident was able to cross his legs which the area the two legs met was in the same area where the wound was found. The Director of Nursing was made aware of the above findings on November 4, 2025 at 11:00 a.m.28 Pa. Code 211.12 (d)(5) Nursing Services.

A review of the clinical record for Resident CL1 indicated an admission date of April 18, 2025, with diagnoses including respiratory failure with hypoxia, chronic obstructive pulmonary disease, tracheostomy, and dependence on renal dialysis.Review of Resident CL1's Minimum Data Set (MDS a periodic assessment of care needs), dated August 25, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment.The clinical record also indicated that Resident CL1 had a Power of Attorney (POA) document on file, signed on February 17, 2025, granting the POA authority to make financial and insurance decisions on behalf of the resident.Continue review of the resident's clinical record revealed that the facility had Resident CL1 sign the insurance change form on September 29, 2025, instead of obtaining the signature or approval of the designated POA.On October 16, 2025, at 9:41 a.m., an interview was conducted with the Business Office Manager, who confirmed that the insurance change was signed by Resident CL1 and not by the POA. Although the POA documentation was present in the clinical record, the facility failed to involve the POA in the treatment decision related to the insurance change.On October 16, 2025, at 1:37 p.m. an interview with the Administrator and Assistant Director of Nursing confirmed that facility failed to have the Resident's CL1 representative in the decision related to an insurance change.28 Pa. Code 201.14(a) Responsibility of licensee.

Based on interviews with residents and staff and review of clinical records, it was determined the facility failed to provide residents who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene related to incontinence care for four of 14 resident records reviewed (Resident R12, R17, R18, and R19).Findings include:Review of Resident R12's clinical records revealed an admission date of March 6, 2025, with the diagnoses of nontraumatic intracranial hemorrhage (bleeding), dysphagia (unable to swallow) following unspecified cerebrovascular disease, tracheostomy status, acute and chronic respiratory failure, hypertension, and gastrostomy. Review of Resident R12's annual MDS (minimum data set-an assessment of resident care needs) dated August 24, 2025. assessed the resident ' s cognition as severely impaired and completely dependent on staff for all activities of daily needs. During observation of Resident R12 receiving care by Nurses Aides (NA) Employee E9 and E10 on November 4, 2025, at 10:30 a.m. NAs stated Resident R12 was checked every two for incontinence, then it was documented it the resident was incontinent and what type of care was provided.Review of Resident R12 Bowel and Bladder Diary initiated on August 21, 2024, instructed the NA to document the resident ' s incontinence status Upon rising, after meals, at bedtime and as needed, every day, every shift: day, night, evening, nights 10-6. Review of the documentation revealed on October 16, 2025, at 2208 (10:08 p.m.) was the last time Resident R12 was documented receiving incontinence care, and not until, approximately 24 hours later, on October 17, 2025, at 2228, (10:29 p.m.) the resident was found and documented wet with bowel movement. On November 6, 2025, at 11:00 a.m. during an interview with three residents (Resident R17, R18, R19), alert and oriented, dependent on staff for incontinence care revealed complaints/concerns related to untimely incontinence care. Resident R18 stated, This past weekend, I had to lay in a saturated brief until morning. It happens often. Resident R17 stated, Call bell response is horrible. 7-3 and 3-11 will walk right by and pretend they don ' t know you need them. 11-7 they are not even in sight. When they do come, they have an attitude. Resident R19 stated, I had a yeast infection from not being changed properly. Resident R17 and Resident R19 both stated they and their daughters have complained multiple times to the facility. They both agreed that the facility says they will, Look into it ' , do something, ' Talk to the staff ' , but nothing changes. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of two residents sampled for post-traumatic stress disorder(PTSD). (Resident R7).Findings include:A review of the clinical record revealed that Resident R7 was admitted to the facility on [DATE] with diagnoses to include traumatic subarachnoid hemorrhage (a collection of blood that accumulates between the inner layer of the skull), traumatic brain injury (occurs when external force causes damage to the brain), and post-traumatic stress disorder (PTSD) (a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss).Resident R7's care plan, initiated July 08, 2025, revealed no care plan was developed for history of traumatic events. Further review of the care plan did not address possible triggers that may cause re-traumatization.Interview with the Director of Nursing, Employee E2, on November 06, 2025 at 11:30 a.m., confirmed Resident R7 ' s care plan was developed for the resident ' s diagnosis of PTSD and possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services

Based on observation, interviews with staff and review of resident clinical records, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion related to splinting for one of 14 resident records reviewed (Resident R12).Findings include: Review of Resident R12's clinical records revealed an admission date of March 6, 2025, with the diagnoses of nontraumatic intracranial hemorrhage (bleeding), and tracheostomy status.Review of Resident R12 ' s physician orders dated August 22, 2025, instructed to place a clean rolled gauze in right hand for passive stretch and in the left hand a carrot orthosis up to six hours on for contracture management. Review of Resident R12's care plan revealed that a care plan was developed on October 30, 2023 for a resting hand splints to be worn during daytime for 6-8 hours.Observation of Resident R12 on November 4, 2025, at 10:30 a.m., with nurses ' aide (NA) Employee E9 and E10, revealed there was no rolled gauze in place on the resident's right hand.Interview with NA, Employee E9 at the time of the observation revealed that the gauze was for wound care and the wound care nurse would place the gauze in the residents hand. Interview conducted with the Director of Rehabilitation on November 6, 2025, at 10:00 a.m. revealed that the gauze that was to be placed on the resident's right hand was used for contractures not for wound care. 28 Pa. Code 211.12 (d)(5)(5) Nursing Services.

Based on a review of clinical records and facility policies, observations and staff interviews, it was determined that the facility failed to timely and consistently provide recommended and/or prescribed treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores related to turning and repositioning for three of seven residents reviewed. (Resident R52, R47 and R5)Findings include:Review of care plan for Resident R52 dated July 25, 2023, revealed that resident was totally dependent on staff to turn and reposition in bed every 2 hours.Review of physician order for resident R52 dated May 3, 2025, revealed an order to turn and reposition every 2 hours. Observation of Resident R52 on July 29, 2025, at 10:20 a.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand. There was a wedge cushion on the floor to the left side of the bed. Further observation of Resident R52 on July 29, 2025, at 12:22 p.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand, similar position as observed at 10:20 a.m. There was a wedge cushion still on the floor to the left side of the bed. Continued observation of Resident R52 on July 29, 2025, at 2:20 p.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand, similar position as observed at 10:20 a.m. There was a wedge cushion still on the floor to the left side of the bed. Observation of Resident R52 on July 30, 2025, at 10:03 a.m. revealed that the resident was lying on her back with wedge on left side and under the thigh and pillow on both sides. There was a wedge cushion on the floor to the left side of the bed. Observation of Resident R52 on July 30, 2025, at 12:00 p.m. revealed that the resident was lying on her back with wedge on left side and under the thigh and pillow on both sides. There was a wedge cushion on the floor to the left side of the bed. Continued observation of Resident R52 on July 30, 2025, at 1:01 p.m. revealed that the resident was at the same position from 12:00 p.m.Review of Nurse Aide documentation of Resident R52 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025 7am to 3pm shift and only one shift documentation available for July 30, 2025.Review of care plan for Resident R47 dated September 6, 2024, revealed that resident was at risk for impaired skin and staff to turn and reposition in bed every 2 hours.Review of physician order for resident R47 dated May 3, 2025, revealed an order to turn and reposition every 2 hours. Observation of Resident R47 on July 29, 2025, at 10:21 a.m. the resident was lying in bed on her back with no pillows or wedge cushion. There was wedge cushion and splints on the floor. Observation of Resident R47 on July 29, 2025, at 12:21 p.m. the resident was lying in bed on her back with no pillows or wedge cushion, similar position from 10:21 a.m. There was wedge cushion and splints on the floor. Continued observation of Resident R47 on July 29, 2025, at 2:20 p.m. revealed that the resident was at a similar position. Review of Nurse Aide documentation of Resident R47 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025, 7am to 3pm shift and only one shift documentation available for July 30, 2025.Review of care plan for Resident R5 dated February 24, 2024, revealed that resident actual skin impairment. There was no care plan intervention for turning and repositioning or heel offloading. Review of physician order for resident R5 dated May 3, 2025, revealed an order to turn and reposition every 2 hoursObservation of Resident R5 on July 29, 2025, at 10:22 a.m. revealed that the resident was lying in bed on her back. Resident did not have any heel offloading measures in place. Observation of Resident R5 on July 29, 2025, at 12:24 p.m. revealed that the resident was lying in bed on her back, similar position as observed at 10:22 a.m. Resident did not have any heel offloading measures in place. Continued observation of Resident R5 on July 29, 2025, at 2:21 p.m. revealed that the resident was lying in bed on her back, similar position as observed at 10:22 a.m. and at 12:24 p.m Resident did not have any heel offloading measures in place. Observation of Resident R5 on July 30, 2025, at 10:01 a.m. revealed that the resident was lying in bed on her back.Observation of Resident R5 on July 30, 2025, at 12:01 p.m. revealed that the resident was lying in bed on her back.Continued observation of Resident R5 on July 30, 2025, at 1:01 p.m. revealed that the resident was at the same position in bed as observed at 10:01 a.m. and at 12:01 p.m.Review of Nurse Aide documentation of Resident R5 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025, 7am to 3pm shift and only one shift documentation available for July 30, 2025.Interview with Nurse Aide, Employee E15 on July 29, 2025, at 2:20 p.m. she did not turn and reposition. Resident R52, R47 and R5 because the resident had tube feeding and contractures as wells as she was not able to get to them after morning care. Employee stated she did not receive any training from the facility about positioning of contracted residents and residents with tracheostomy and ventilator. Continued interview with Employee E15 on January 31, 2025, at 12:00 p.m. stated facility is a specialized trach and vent facility and most of the residents required 2 persons for ADL's. Employee E15 stated she had to provide care for 10 to 12 residents per day and it was not always possible to turn and reposition everyone every 2 hours, provide all ADL cares and showers assigned. Interview with the Director of Nursing, Employee E2 on July 30, 2025, at 1:30 p.m. confirmed that all residents should be turned and repositioned as tolerated every 2 hours. Employee E2 stated residents should be repositioned to back to both sides every 2 hours using pillows and wedge cushions. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(a)(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on the review of facility staffing schedule, clinical records, and interviews with staff, residents and resident representative, it was determined that the facility failed to ensure sufficient nursing staff to provide nursing related to interventions to prevent pressure ulcer and restorative nursing services for four of seven residents reviewed. (Residents R52, R47, R5, and R6)Review of an undated facility policy Prevention of Pressure Ulcers, revealed that Identify risk factors for pressure ulcer development 2. For a person in bed. a. Change position at least every two hours or more frequently if needed.Interview with Resident R14, R18 and R21 during resident council meeting held on July 29, 2025, at 11:00 a.m., stated the facility did not have sufficient staffing. Residents stated call bells often take longer to answer and sometimes it could even take one or two hours. Residents also stated activities of daily living (hygiene, mobility, dining-eating, communication) take longer due to low staffing.Interview with Resident R49's representative on July 31, 2025, at 3:08 p.m. stated resident was not getting her hair done at all and staff would not wash her hair as requested stated facility had severe staffing shortages. Review of care plan for Resident R52 dated July 25, 2023, revealed that resident was totally dependent on staff to turn and reposition in bed every 2 hours.Review of physician order for resident R52 dated May 3, 2025, revealed an order to turn and reposition every 2 hours. Observation of Resident R52 on July 29, 2025, at 10:20 a.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand. There was a wedge cushion on the floor to the left side of the bed. Further observation of Resident R52 on July 29, 2025, at 12:22 p.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand, similar position as observed at 10:20 a.m. There was a wedge cushion still on the floor to the left side of the bed. Continued observation of Resident R52 on July 29, 2025, at 2:20 p.m. revealed that the resident was lying in bed on her back with one pillow on the left side and one pillow under the right hand, similar position as observed at 10:20 a.m. There was a wedge cushion still on the floor to the left side of the bed. Observation of Resident R52 on July 30, 2025, at 10:03 a.m. revealed that the resident was lying on her back with wedge on left side and under the thigh and pillow on both sides. There was a wedge cushion on the floor to the left side of the bed. Observation of Resident R52 on July 30, 2025, at 12:00 p.m. revealed that the resident was lying on her back with wedge on left side and under the thigh and pillow on both sides. There was a wedge cushion on the floor to the left side of the bed. Continued observation of Resident R52 on July 30, 2025, at 1:01 p.m. revealed that the resident was at the same position from 12:00 p.m.Review of Nurse Aide documentation of Resident R52 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025 7am to 3pm shift and only one shift documentation available for July 30, 2025.Review of care plan for Resident R47 dated September 6, 2024, revealed that resident was at risk for impaired skin and staff to turn and reposition in bed every 2 hours.Review of physician order for resident R47 dated May 3, 2025, revealed an order to turn and reposition every 2 hours. Observation of Resident R47 on July 29, 2025, at 10:21 a.m. the resident was lying in bed on her back with no pillows or wedge cushion. There was wedge cushion and splints on the floor. Observation of Resident R47 on July 29, 2025, at 12:21 p.m. the resident was lying in bed on her back with no pillows or wedge cushion, similar position from 10:21 a.m. There was wedge cushion and splints on the floor. Continued observation of Resident R47 on July 29, 2025, at 2:20 p.m. revealed that the resident was at a similar position. Review of Nurse Aide documentation of Resident R47 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025, 7am to 3pm shift and only one shift documentation available for July 30, 2025.Review of care plan for Resident R5 dated February 24, 2024, revealed that resident actual skin impairment.Review of physician order for Resident R5 dated May 3, 2025, revealed an order to turn and reposition every 2 hoursObservation of Resident R5 on July 29, 2025, at 10:22 a.m. revealed that the resident was lying in bed on her back. Resident did not have any heel offloading measures in place. Observation of Resident R5 on July 29, 2025, at 12:24 p.m. revealed that the resident was lying in bed on her back, similar position as observed at 10:22 a.m. Resident did not have any heel offloading measures in place. Continued observation of Resident R5 on July 29, 2025, at 2:21 p.m. revealed that the resident was lying in bed on her back, similar position as observed at 10:22 a.m. and at 12:24 p.m Resident did not have any heel offloading measures in place. Observation of Resident R5 on July 30, 2025, at 10:01 a.m. revealed that the resident was lying in bed on her back.Observation of Resident R5 on July 30, 2025, at 12:01 p.m. revealed that the resident was lying in bed on her back.Continued observation of Resident R5 on July 30, 2025, at 1:01 p.m. revealed that the resident was at the same position in bed as observed at 10:01 a.m. and at 12:01 p.m.Review of Nurse Aide documentation of Resident R5 for turn and reposition revealed that there was no documented evidence for the completion of the task as ordered for July 29, 2025, 7am to 3pm shift and only one shift documentation available for July 30, 2025.Interview with Nurse Aide, Employee E15 on July 29, 2025, at 2:20 p.m. she did not turn and reposition. Resident R52, R47 and R5 because the resident had tube feeding and contractures as wells as she was not able to get to them after morning care. Employee stated she did not receive any training from the facility about positioning of contracted residents and residents with tracheostomy and ventilator. Continued interview with Employee E15 on January 31, 2025, at 12:00 p.m. stated facility is a specialized trach and vent facility and most of the residents required 2 persons for ADL's. Employee E15 stated she had to provide care for 10 to 12 residents per day and it was not always possible to turn and reposition everyone every 2 hours, provide all ADL cares and showers assigned. Review of the restorative aide documentation for Resident R6 revealed therapy was only conducted 7 out of the last 30 days in July 2025. Observation of Resident R6 on July 30, 2025, at 1:00 p.m. was observed lying in bed without the splint in use on the right arm. The resident who was nonverbal motioned she does not like the splint and does not like to use it. The resident also motioned that the resident receives therapy but not all of the time. Interview with the restorative aide Employee E11 on July 30, 2025, at 1:05 p.m. explained the RNP is not being done daily/consistently as ordered due to insufficient staffing. When there are not enough nursing assistants (NA) for resident care the RNP aide is taken off the RNP schedule and replaced as a NA. 28 Pa Code 201.18(a)(3) Management28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 211.12 (d)(4) Nursing services

Based on observations, review of facility documentation, staff and resident interviews, it was determined that the facility failed to provide an ongoing program of activities to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities for three of three residents reviewed. (Residents R14, R18 and R21).Findings include:Interview with residents during resident council meeting held on July 29, 2025, at 11:00 a.m. with Resident R14, R18 and R21 stated they do not have any activity program in the facility.Resident R21 stated the facility were supposed to provide his favorite group program like Bingo but the facility did not provide any group activities lately.Resident R18 stated the last activity program she attended was on July 4, 2025 and no other activity program since then.Resident R14 stated she did not attend any activity program.Review of July 2025 activity program revealed that there were no group activities on weekends, the only activity program listed on weekend was Independent Leisure.Observation of the facility on July 28, 2025, revealed there was no activity program and no activity staff available at the facility.Interview with the administrator on July 29, 2025, at 2:00 p.m. stated facility did not have any activity staff. Administrator confirmed that there was no activity program provided according to the activity calendar in July 2025.28 Pa. Code 201.18(e)(6) Management

Based on the review of clinical records, facility policies, review of professional standard of practice, observations, and interview with staff, it was determined the facility failed to provide treatment as ordered by the physician, to prevent pressure ulcers. This failure resulted in Immediate Jeopardy situation for Resident R2, Resident R3 and Resident R8 who developed pressure ulcers. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent infection of existing pressure ulcers. This failure resulted in actual harm to R1, R2, R3, R4, R5, R6, R7, and R8 whose pressure ulcers worsened and/or deteriorated for eight of nine residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, and R8) Findings Include: Review of US Department of Health and Human Services, Agency for Healthcare Research & Quality, revealed the pressure ulcer best practice incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. Review of the American College of Physicians (ACP) national organization of internists who specialize in the diagnosis, treatment, and care of adults revealed Clinical Practice Guidelines indicating the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of an undated facility policy Prevention of Pressure Ulcers, revealed the following: GENERAL GUIDELINES 1 The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 2. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 3. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 4. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. 5. Assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. 6. Once identified, the wound NP (Nurse Practitioner)/Physician is notified about the consult by DON (Director of Nursing)/designee. 6. Skin checks weekly are suggested. If done, document. INTERVENTIONS AND PREVENTIVE MEASURES: GENERAL General Preventive Measures 1. Identify risk factors for pressure ulcer development (see procedure entitled Pressure Ulcer Risk Assessment). 2. For a person in bed. a. Change position at least every two hours or more frequently if needed b. Determine if resident needs a special mattress c. If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 3. For a person in a chair: a. Change position at least every hour b. Use foam, gel, or air cushion as indicated to relieve pressure. 4. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. 5. Do not use donut-shaped cushions. 6. Refer resident to a rehabilitation program, or a restorative nursing program, as indicated. 7. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. 8. Ensure that the resident drinks plenty of fluids and eats a well-balanced diet. 9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 10. Immediately report any signs of a developing pressure ulcer to the supervisor. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. Risk Factor - Bed-fast: a. Change position at least every two hours and more frequently as needed. b. Use a special mattress that contains foam, air, gel, or water, as indicated. c. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. d. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees ( e.g., for residents with tube feeding or respiratory issues). e. Unless resident has both sacral and ischial pressure ulcers, avoid placing directly on the greater trochanter for more than momentary placement. Review of an undated facility policy revealed the following: Pressure Ulcer Treatment 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s). b. Managing tissue loads. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Operative repair of the pressure ulcers(s). f. Education and quality improvement. Pressure ulcer treatment requires a comprehensive approach, including: 1. Debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). 2. Managing infections. 3. Managing systemic issues (edema (swelling), venous insufficiency, etc). 4. Maximizing the potential for healing. 5. Pain control. 6. All wounds are to be seen weekly by wound Nurse Practitioner/Wound Nurse 7. All strategies for treatment are individualized. Stage II (ulcer involving loss of the top layers on the skin) Pressure Ulcer Interventions/Care Strategies Clean, shallow, minimal drainage: 1. Protect 2. Manage drainage 3. Promote moist wound healing 4. Treatment: a. Cleanse with normal saline or other skin cleanser in accordance with physician orders and facility protocol b. Apply barrier cream, or tx (treatment) c. Cover with non-adhesive light gauze or transparent dressing d. Change per physician order and manufacturer's directions. 5. Manage pain. Medium drainage: 1. Follow above procedure; consider the need for alginate or foam. Follow-up If wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist. STAGE III (ulcer involving full thickness of skin loss, exposing tissue) PROTOCOL Stage III Pressure Ulcer Interventions/Care Strategies 1. Protect 2. Fill dead space including tunnels and undermining 3. Manage drainage 4. Promote moist wound healing 5. Manage pain No drainage: 1. Treatment a. Irrigate wound with normal saline (NS) or other designated wound cleanser or use circular motion for cleaning from inside of wound to outer edges with NS soaked gauze. b. Apply tx to wound cavity c. Change per order and manufacturer's directions. d. Manage pain Medium to heavy drainage: 1. Follow above procedure. Consider substituting alginate or foam. STAGE IV (ulcer involving loss of skin layers, exposing muscle and bone) PROTOCOL Stage IV Pressure Ulcer Interventions/Care Strategies 1. Protect: a. Fill dead space including tunnels and undermining b. Manage drainage c. Promote moist wound healing. 2. Debride slough/eschar (hardened, dry, black or brown dead tissue, forms a scab-like covering over deep wounds. It acts as a protective barrier but can impede healing) a. Select the method of debridement most appropriate to the resident's condition and goals (note: this is a physician task/NP task) b. Sharp, mechanical, enzymatic, and/or autolytic (breaking down of cells or tissues by their own enzymes) debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue c. If there is urgent need for debridement, as with advancing cellulitis or sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), sharp debridement should be used. 3. Treatment: a. Irrigate wound with normal saline or other designated wound cleanser or use circular motion for cleaning from inside of wound to outer edges with NS soaked gauze. b. Apply treatment c. Cover with DSD (Dakin's solution) Review of clinical record for Resident R1 revealed Resident R1 was admitted to the facility on [DATE], with diagnoses including Anoxic Brain Damage (the brain is completely deprived of oxygen, leading to potential brain cell death) and Tracheostomy (surgical procedure where an opening is made in the neck to access the trachea) status. Review of Resident R1's physician orders dated March 18, 2025, revealed an order to turn and reposition every 2 hours - Nurse Aide to document the completion every shift in Nurse Aide charting. Further review of Resident R1's physician orders revealed the resident had a wound care order for sacral wound with calcium alginate and Medi honey and cover with border dressing. Review of Resident R1's Braden Scale (tool used to assess a patient's risk of developing pressure ulcers) assessment for Resident R1 dated March 19, 2025, revealed Resident R1 was at very high risk for developing pressure injuries. Review of skin assessment for Resident R1 dated March 19, 2025, revealed the resident had a skin tear to the sacrum which measured 4 x 0.5 with no depth. (No unit of measurement was included) Review of an admission MDS for Resident R1 (Minimum Data Set- periodic assessment of resident care needs) dated March 23, 2025, revealed that the resident did not have a pressure injury. Review of re-admission nursing note for Resident R1 dated March 27, 2025, revealed the resident had a wound on the sacrum, however, further review of nursing note failed to specify type, measurement, or any other wound characteristics. Review of Braden Scale assessment for Resident R1 dated March 27, 2025, following readmission revealed the resident was at very high risk for developing pressure injuries. Review of skin assessment for Resident R1 dated March 27, 2025, failed to identify if the resident had any wounds including the measurements. Review of an admission MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated April 3, 2025, revealed the resident was not able to complete BIMS (Brief Interview of Mental Status) assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS assessment revealed the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of two or more helpers is required for the resident to complete the activity) on staff for all ADLs (activities of Daily Living) including bed mobility. Additional review of Resident R1's MDS assessment revealed the resident was always incontinent of bowel and bladder. Continued review of MDS assessment revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. It was also revealed the resident was receiving tracheostomy/ventilator treatment. Review of wound care practitioner progress note for Resident R1 dated April 1, 2025, revealed Significant contributors for increased risk of wound incidence and/or impede healing include but not limited to vascular complicating factors, generalized muscle weakness, impaired mobility, and inevitable effects of aging. Education provided regarding pressure relief, general offloading, and frequent repositioning. Wound measurement was 6 cm (centimeters) length x 5cm width x 1 cm depth with an area of volume of 30 cubic cm. Additional review of the wound care practitioner's note dated April 1, 2025 for Resident R1 revealed a recommendation for wound care with Dakin's wound care solution. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, Pressure Redistribution Mattress per Facility Protocol, Wheelchair Pressure Redistribution Cushion per Facility Protocol and Offload heels per Facility Protocol. Review of April 2025's physician orders and April 2025's Treatment Administration Record (TAR) for Resident R1 failed to reveal documented evidence of an air mattress provided as recommended by the physician. Further review of April 2025 TAR revealed the resident received wound care treatment with Dakin's and there was treatment which was signed out as completed for Calcium Alginate and Medi honey and cover with border dressing. It was unclear which treatment the resident received. Interview with the Director of Nursing on May 2, 2025, at 1:00 p.m. confirmed the resident had two different orders for wound care and signed as administered, however the Director of Nursing was not able to specify which treatment the resident received. Review of wound care practitioner's note dated April 8, 2025, revealed that wound measurement was 5 cm length x 6 cm width x 2 cm depth with an area of volume of 60 cubic cm. The wound was staged as Stage 4 (ulcer involving full thickness of skin layers, exposing muscle and bone) pressure injury. There was also moderate amount of serosanguineous (type of wound drainage composed of blood serum and red blood cells) drainage. Further review of the wound care practitioner's note revealed a recommendation for wound care with Dakin's wound care solution, cover with alginate (highly absorbent, conformable, and fast-gelling dressings derived from seaweed, and are used to manage moderate to heavily exuding wounds) and border gauze daily and as needed. Continued review revealed additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, wheelchair pressure redistribution cushion per facility protocol and offload heels per facility protocol. Review of wound care practitioner's note dated April 15, 2025, revealed wound measurement was 5 cm length x 6 cm width x 3 cm depth with an area of volume of 90 cubic cm. The wound was staged as Stage 4 (ulcer involving loss of skin layers, exposing muscle and bone) pressure injury. There was also moderate amount of serosanguineous drainage. Further review of the wound care practitioner progress note revealed a recommendation for wound care with Dakin's wound care solution, cover with Alginate and border gauze daily and as needed. Review of wound care practitioner progress note dated April 22, 2025, revealed the wound measurement was 7 cm length x 6 cm width x 3 cm depth with an area of volume of 126 cubic cm. Undermining (condition where the tissue beneath the edges of a wound separates from the underlying structures, creating a cavity or pocket) has been noted at 12:00 and ends at 12:00 with a maximum distance of 4 cm. The wound was staged as Stage 4 pressure injury. Further review of the wound care practitioner progress note revealed a recommendation for wound care with Dakin's wound care solution, cover with Alginate and border gauze daily and as needed. Review of Resident R1's April 2025 TAR (Treatment Administration record) revealed Resident R1 received wound care treatment with Dakin's however Alginate was not added to the wound care order as instructed by the physican. Review of care plan of March 18, 2025 for Resident R1 failed to reveal a turning and repositioning intervention, air mattress or other off-loading measures. The only interventions noted were dietary consult and monitoring of skin injury. Interview with the Wound Care Practitioner, Employee E3, on May 6, 2025, at 11:34 a.m. revealed wound care with Calcium Alginate was prescribed for Resident R1 who had wound drainage. When Calcium Alginate is prescribed it was important to provide the wound care with Calcium Alginate to minimize the chances of infection and prevent the deterioration of wound. Employee E3 revealed he was not aware of the resident not receiving the ordered prescribed. Review of Resident R1's clinical record revealed the initial wound care order placed on April 1, 2025, was not changed by the facility as recommended by the wound care practitioner. Facility continued the same wound care, which was ordered on March 20, 2025, for the same wound. Review of Resident R1's clinical record and facility documentation failed to reveal evidence of turning and repositioning, pressure reducing devices including air mattress were provided as ordered by the physician. These failures resulted in worsening/deterioration of pressure ulcers for Resident R1 whose wound size increased from 4 x 0.5 with no depth on March 19, 2025, to 6 cm length x 5cm width x 1 cm depth with an area of volume of 30 cubic cm on April 23, 2025. The wound further deteriorated to 7 cm length x 6 cm width x 3 cm depth with an area of volume of 126 cubic cm. Review of clinical record for Resident R3 revealed that resident was admitted to the facility on [DATE], with diagnoses including anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to potential brain cell death) and tracheostomy (a surgical procedure where an opening is made in the neck to access the trachea) status. Review of quaterly MDS (Minimum Data Set-Assessment of resident care needs) for Resident R3 dated February 21, 2025, revealed that the resident was not able to complete BIMS (Brief Interview of Mental Status) assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS revealed that the resident was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLs (Activities of Daily Living) including bed mobility. MDS also revealed that the resident was always incontinent of bowel and bladder. Continued review of MDS assessment revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. The assessment further revealed the resident was receiving tracheostomy/ventilator treatment. The assessment documented the resident had one Stage 4 unhealed pressure ulcer at the time of assessment which was documented as present on admission. Review of Braden Scale (tool used to assess a patient's risk of developing pressure ulcers) assessment for Resident R3 dated September 26, 2024, revealed that the resident was at very high risk for developing pressure injuries. Review of skin assessment for Resident R3 dated March 24, 2025, revealed that the resident had no skin impairment. Review of skin assessment for Resident R3 dated March 27, 2025, revealed that the resident had skin impairment to sacrum and left toe. There was no type, measurement or other wound characteristics specified on the skin assessment report. Review of wound care practitioner's note for Resident R3 dated March 25, 2025, revealed that the resident had a total of three (3) wounds one of which was a sacral pressure injury which measured 2cm length x 1.8 cm width x 1 cm depth, with an area volume of 3.6 cubic cm. The wound had no tunneling or undermining. The wound was staged as Stage 4. The two other wounds were non-pressure injury related wounds. Further review of the wound care practitioner's note for Resident R3 revealed a recommendation for wound care with collagen, moistened gauze with normal saline and cover with dry dressing. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of March 2025 TAR, revealed no documented evidence that the facility provided air-mattress for Resident R3 as ordered by the physician. Review of wound care practitioner's note for Resident R3 dated April 1, 2025, revealed that the resident developed a new unstageable wound to the right ischial tuberosity (protuberance of a bone) which measured 1.0 cm x1. 0 cm x 0.1 cm. with an area of volume of 0.1 cm. The sacral pressure injury which measured 2cm length x 1.7 cm width x 1 cm depth, with an area volume of 3.6 cubic cm. Further review of the wound care practitioner's note for Resident R3 revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity wound care with honey gel and cover with border gauze. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of Resident R3's April 2025 TAR failed to reveal documented evidence the facility provided an air-mattress for Resident R3 as ordered by the physician. Review of wound care practitioner's note for Resident R3 dated April 8, 2025, revealed that the resident developed another new stage 2 (partial thickness skin loss) wound to the left buttocks which measured 2.0 cm x 2.0 cm x 0.1 cm. with an area of volume of 0.4 cm. The right ischial tuberosity which measured 3.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 0.9 cm. The sacral pressure injury which measured 2 cm length x 1.7 cm width x 1 cm depth, with an area volume of 3.4 cubic cm. Review of wound care practitioner's note for Resident R3 dated April 15, 2025, revealed that the left buttocks wound measured 5.0 cm x 2.5 cm x 0.1 cm. with an area of volume of 1.25 cm. The right ischial tuberosity which measured 3.0 cm x 5.5 cm x 0.1 cm. with an area of volume of 0.9 cm. The sacral pressure injury which measured 2cm length x 2 cm width x 1 cm depth, with an area volume of 4 cubic cm. Further review of the wound care practitioner's note for Resident R3 dated April 15, 2025, revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity wound care with honey gel, apply Alginate and cover with border gauze. The left buttock wound care with honey gel, apply Alginate and cover with border gauze. Additional review of wound care practitioner's note dated April 15, 2025 revealed additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, avoid direct pressure to wound site, protocol and offload heels per facility protocol. Review of Resident R3's April 2025 TAR failed to reveal documented evidence wound treatment was provided to left buttock wound for the month of April 2025. The right ischial wound care was not changed as recommended by the wound care practitioner. Review of wound care practitioner's note for Resident R3 dated April 22, 2025, revealed that the left buttocks wound measured 5.0 cm x 2.6 cm x 0.1 cm. with an area of volume of 1.3 cm. This wound was re-staged as Stage 3 (full thickness skin loss) pressure ulcer. The right ischial tuberosity which measured 8.0 cm x 8 cm x 0.2 cm. with an area of volume of 12.8 cm. The sacral pressure injury which measured 2.1 cm length x 2 cm width x 1 cm depth, with an area volume of 4.2 cubic cm. Further review of the wound care practitioner's notes for Resident R3 revealed a recommendation for sacral wound care with Alginate and cover with dry dressing. The right ischial tuberosity (bony prominence in the pelvis that serves as a key weight-bearing structure when sitting) wound care with Santyl, cover with Dakin's moistened gauze cover with border gauze. The practitioner documented the reason for change as Right ischial unstageable increased in size and eschar. Will change treatment to Santyl with 1/4 Dakin's moistened gauze and cover with border gauze daily. The left buttock wound care consisted of honey gel, apply alginate and cover with border gauze. Review of Resident R3's April 2025 TAR failed to reveal documented evidence treatment was provided to left buttock wound. The right ischial wound care was not changed as recommended by the practitioner. The recommended wound care in response to the wound deterioration was not implemented for the right ischial wound. Review of wound care practitioner's note for Resident R3 dated April 22, 2025, revealed that Right ischial unstageable increased in size and odor. Recommend x-ray of right ischium and hip to rule out Osteomyelitis (bone infection). No surrounding erythema (swelling), induration or purulence. Will continue with Santyl and 1/4 Dakin's moistened gauze and cover with border gauze daily and as needed, wound with high risk for worsening and infection due to critical care condition, immobility, impaired cognition, comorbid conditions. Continued review revealed that the left buttocks wound measured 5.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 1.5 cm. The right ischial tuberosity which measured 10.0 cm x 10 cm x 0.5 cm. with an area of volume of 50 cubic cm. There was also light amount of sero-sanguineous drainage with 80% eschar and 20% slough. The sacral pressure injury which measured 2.2 cm length x 2 cm width x 1 cm depth, with an area volume of 4.4 cubic cm. Review of Resident R3's clinical record and facility documentation revealed the facility did not provide wound care recommended by the wound care practitioner on April 15, 2025, April 22, 2025, and April 29, 2025 for right ischium wound. Facility documentation lacked evidence that air mattress were provided as ordered by the physician. These failures resulted in development and worsening/deterioration of the right ischium pressure ulcers for Resident R3 whose wound size increased from 3.0 cm x 5.5 cm x 0.1 cm. with an area of volume of 0.9 cubic cm on April 15, 2025, to 10.0 cm x 10 cm x 0.5 cm. with an area of volume of 50 cubic cm with light amount of sero-sanguineous drainage with 80% eschar and 20% slough. on April 29, 2025. It was also revealed that the facility did not provide wound care recommended by the wound care practitioner on April 8, 2025, April 15, 2025, April 22, 2025, and April 29, 2025, for left buttocks wound. Facility documentation lacked evidence an air mattress was provided as ordered by the physician. These failures resulted in the development and worsening/deterioration of the left buttock pressure ulcer wounds for Resident R3, who developed the wound and the wound size increased from 2.0 cm x 2.0 cm x 0.1 cm. with an area of volume of 0.4 cm. on April 8, 2025, to 5.0 cm x 3.0 cm x 0.1 cm. with an area of volume of 1.5 cm on April 29, 2025. Resident's wound deteriorated from Stage 2 to 3. Review of clinical record for Resident R2 revealed that resident was admitted to the facility on [DATE], with diagnoses including Anoxic Brain damage (occurs when the brain is completely deprived of oxygen, leading to potential brain cell death) and Tracheostomy (surgical procedure where an opening is made in the neck to access the trachea) status. Review of Resident R2's admission MDS January 27, 2025 revealed that the resident was not able to complete BIMS assessment which indicated that the cognitive status for the resident was severely impaired. Further review of the MDS assessment revealed the resident was dependent on staff for all ADL activities including bed mobility. The MDS assessment further revealed the resident was always incontinent of bowel and bladder. Continued review of MDS revealed the resident had an unstageable pressure injury and was at risk for developing pressure ulcers. It was also revealed that the resident was receiving tracheostomy/ventilator treatment. It was documented as the resident had one Stage 4 unhealed pressure ulcer at the time of assessment which was documented as present on admission. Review of Braden Scale assessment for Resident R2 dated March 11, 2025, revealed the resident was at very high risk for developing pressure injuries. Review of the physician order for Resident R2 dated March 12, 2025, revealed an order for Prevalon boot (devise use to help prevent pressure ulcers) when in bed. Review of wound care practitioner note for Resident R2 dated March 18, 2025, revealed that the resident had a sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. Further review of the wound care practitioner notes for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing. There were additional orders for off-loading, facility Pressure Injury Prevention Protocol, pressure redistribution mattress per facility protocol, wheel chair pressure redistribution cushion, and offload heels per facility protocol. Review of March 2025 TAR, revealed no documented evidence that the facility provided air-mattress for Resident R2 as ordered by the physician. Observation of the Resident R2 on May 2, 2025, at 12:00 p.m. revealed that the resident was lying flat in the bed, resident was not an air mattress. It was observed that the resident's heel was lying flat on the bed without any offloading measures. This observation was confirmed by the Wound Care Nurse, Employee E4. Review of wound care practitioner note for Resident R2 dated March 25, 2025, revealed that the sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. Further review of wound care documentation revealed that the resident developed a heel pressure ulcer on March 24, 2025, which measured 4 cm length x 4 cm width x 0.1 cm depth, with an area volume of 1.6 cubic cm. Review of wound care practitioner note for Resident R2 dated April 1, 2025, revealed that the sacral pressure injury which measured 6 cm length x 5 cm width x 3 cm depth, with an area volume of 90 cubic cm. The heel pressure ulcer measured 3 cm length x 3 cm width x 0.1 cm depth, with an area volume of 0.9 cubic cm. Further review of the wound care practitioner's note for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing. Continued review of the wound care practitioner's note for Resident R2 revealed a recommendation for sacral wound care with Vashe moistened rolled gauze and cover with border dressing and Alginate with border gauze for heel ulcer. Review of April 2025 TAR revealed that the heel ulcer was treated with Alginate with medihoney which was not according to the wound care practitioner's recommendation. Review of Nurse Aide Documentation revealed that from April 5, 2025, to May 5, 2025 only 8 shifts out of 240 shifts documented that the offloading of heel was provided. Review of wound care practitioner's note for Resident R2 dated April 8, 2025, revealed that the sacral pressure injury which measured 7 cm length x 5 cm width x 3 cm depth, with an area volume of 105 cubic cm. The right heel pressure ulcer measured 3 cm length x 3 cm width x 0.1 cm depth, with an area volume of 0.9 cubic cm. but noted with moderate amount of serosanguinous drainage. New right ischial (hip bone) pressure injury measured 3 x 3 x 0.1 with an area volume of 0.9 cubic cm. Continued review of Resident R2's wound care practit[TRUNCATED]

Based on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to timely assess, monitor and provide treatment consistent with professional standards to Resident R1's sacral pressure ulcer. This failure resulted in actual harm to Resident R1 who experienced a delay in treatment and healing to a sacral pressure ulcer for one of two residents reviewed for pressure ulcer. (Resident R1) Findings include: Review the facility policy on Pressure Ulcer Treatment revealed that under section Purpose stated that the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Under section General Guidelines #1. The pressure ulcer treatment program should focus on the following strategies, a. Assessing the resident and the pressure ulcers. b. Managing tissue loads. c. Pressure Ulcer care e. Operative repair of the pressure ulcer. f. Education and quality improvement. #2. When an eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Traumatic Subdural Hemorrhage (brain bleed), left hemiplegia/hemiparesis (paralysis/weakness to one side of the body), Muscle Weakness, Reduced Mobility. Review of Resident R1's admission MDS (Minimum Data Set - a federally required resident assessment completed at a specific interval) assessment dated [DATE], Section M0100 (Determination of Pressure Ulcer/Injury Risk) A., revealed that resident has a pressure ulcer, Section M150 (Risk of Pressure Ulcer/Injuries) revealed that Resident R1 was at risk of developing pressure ulcers/injuries. Section M0210 (Unhealed Pressure Ulcer/Injuries) revealed that Resident R1 had one or more unhealed pressure ulcers/injuries. M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage) F1 revealed that resident had unstageable pressure ulcer. Review of Resident R1's Nursing Admission assessment dated [DATE], revealed that under section URINARY Resident R1 was incontinent of bladder, Under section SKIN , Resident R1 had an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer on his sacrum. Continued review of the nursing admission assessment did not include the size of the pressure ulcer or any other description of the pressure ulcer. Further review of Resident R1's clinical record revealed the following Wound Weekly Observation Tool: Review of Wound Observation Tool dated July 29, 2024, revealed that Resident R1 had a pressure ulcer on his sacrum. Further the pressure ulcer was coded as Stage 1 (intact skin with a localized area of non-blanchable erythema (redness). Further, wound description as follow: Epithelial tissue (pink) was documented as present with 100% necrosis (black) on wound bed, wound size: 0.2 centimeters (cm) x 0. x 0.1 cm., peri wound intact. Wound Weekly Observation Tool dated August 12, 2024, identified a pressure ulcer on his sacrum. Further, the pressure ulcer was coded as Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (separation of dead tissue from living tissue) and/or eschar (dark, crusty tissue covering the wound) may be visible but does not obscure the depth of tissue loss.) Further, wound description as follow: 50% granulation and 50% slough observed, wound size: 2.4 cm. x 3.0 cm. x 0.1 cm., peri wound intact. Wound Weekly Observation tool dated August 19, 2024, revealed that Resident R1 had a pressure ulcer on his sacrum. Further, the pressure ulcer was coded as Stage 3. Wound description as follow: epithelial tissue, granulation and slough present, wound size: 2.5 cm. x 3.0 cm. x 0.1cm, peri wound intact. Wound Weekly Observation tool dated August 27, 2024, revealed that Resident R1 had a pressure ulcer on his sacrum. Further, the pressure ulcer was coded as Stage 3. Wound description as follow: epithelial tissue, granulation and slough present, wound size: 3.0 cm. x 3.1 cm. x 0.1cm., peri wound intact. Wound Weekly Observation tool dated September 3, 2024, revealed that Resident R1 had a pressure ulcer on his sacrum. Further. the pressure ulcer was coded as Stage 3. Wound description as follow: epithelial tissue, granulation and slough present, wound size: 4.4 cm. x 3.1cm. x 0.1cm., peri wound intact. Wound Weekly Observation tool dated September 14, 2024, revealed that Resident R1 had a pressure ulcer on his sacrum. Further, the pressure ulcer was coded as Stage 3. Wound size was 6.0 cm. x 4.0 cm. x 1.0 c.m, peri wound intact. Further review of Resident R1's clinical record revealed that Resident R1 was not seen by a wound specialist until September 16, 2024. Review of wound progress note from the wound specialist dated September 16, 2024, revealed the following: Sacral is an Unstageable Pressure Injury obscured full-thickness skin and tissue loss. Initial wound encounter measurements are 5.5 cm length x 4 cm. width x 0.5 cm depth. No tunneling. No sinus tract. No undermining. Light amount of serous drainage noted with Mild odor. Wound bed has 10%, granulation, 90% eschar: no slough and no epithelialization present. Review of wound progress note from the wound specialist dated September 23, 2024, revealed the following: Sacral is an Unstageable Pressure Injury obscured full-thickness skin and tissue loss. Subsequent wound encounter measurements are 6 cm. length x 4 cm. width x 1 cm. depth. No tunneling. No sinus tract. Undermining has been noted at 9:00 and ends at 12:00 with a maximum distance of 1cm. Light amount of serous drainage noted which has a Mild odor. Wound bed has 10%, granulation, 90% slough; no eschar and no epithelialization present. The wound is deteriorating. Further review from the wound specialist note dated September 23, 2024, revealed that sacral pressure ulcer was debrided (removal of damage tissue) with post debridement measurements: 6.1cm length x 4.2cm width x1.3cm depth. Post debridement stage noted as unstageable pressure injury obscured full-thickness skin and tissue loss. Review of physician's orders revealed that there was no treatment order until July 31, 2024, when an order was obtained for Medi honey Wound/Burn Dressing Paste (Wound Dressings) Apply to sacrum topically every dayshift for wound healing. Apply to wound bed after cleansing with NSS (normal saline solution). Cover with dry clean dressing and border gauze. D/C (discontinued) Date- August 19, 2024. Physician's orders dated August 20, 2024, revealed an order for Betadine Solution 10 % (Povidone-Iodine) Apply to sacrum topically every dayshift for wound healing. Apply to wound bad after cleansing with NSS. And cover with dry clean dressing. -D/C Date-August 27, 2024. Physician's order dated August 28, 2024, revealed an order for Hydrogel External Gel (Wound Dressings) Apply to sacrum topically every dayshift for wound healing. Apply to the wound bed after cleansing with NSS and cover with border gauze dressing-D/C Date-September 17, 2024. Physician's order dated September 18, 2024, revealed an order for clean sacral wound with normal saline. Apply Santyl to wound. Cover with clean, dry dressing. Change daily and PRN for soilage/dislodgement. Every dayshift for wound care. Review of physician's progress note dated July 16, 17, 18, 19, 21, 23, 24, 25, 26, 27, 29, 30, 31, 2024, revealed no evidence that Resident R1's wound was seen by the physician. Review of Resident R1's care plan revealed that there was no wound care plan until August 22, 2024, when Resident R1's care plan for actual impairment to the sacrum was initiated. Review of Nurse's Aides Task from July 15, 2024 to October 15, 2024, in resident's clinical record revealed no documented evidence that resident was turned and positioned. Interview with Director of Nursing Employee E2 conducted in October 16, 2024 at 11:46 a.m. confirmed that there was no documented evidence that the turning and positioning was conducted as a measure to prevent further deterioration in Resident R1's pressure ulcer. Further, Employee E2 revealed that she was not yet employed at the facility in July and August of 2024. Wound observation conducted on October 16, 2024, at 10:10 a.m. with licensed Practical Nurse (LPN) Employee E3 and Nurse Aide, Employee E4, revealed that Resident R1 had a sacral pressure ulcer. Further observation revealed that the wound bed appeared beefy red in color. Measurements were not taken at the time of observation. Interview with Employee E3 conducted at the time of the observation revealed that Resident R1's pressure ulcer was a Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Review of Resident R1's clinical record revealed that there was no documented evidence that Resident R1's sacral pressure ulcer was monitored and assessed after it was identified on admission on July 15, 2025. It was not until July 29, 2024, when a wound weekly Observation Tool was performed. There was no documented evidence that a plan of care was developed with interventions precautions to improve or prevent further deterioration of Resident R1's sacral pressure ulcer upon admission to the facility on [DATE]. Further review of Resident R1's clinical record revealed no documented evidence that wound treatment was initiated upon the identification of Resident R1's sacral pressure ulcer on July 15, 2024, until July 31, 2024. The facility failed to assess, monitor and provide timely treatment to Resident R1's unstageable pressure ulcer identified at admision resulting in actual harm to Resident's R1 who experienced a delay in treatment and healing to a sacral pressure ulcer. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received treatment and care in a timely manner related to high glucose levels and emergent transfer to a hospital. This failure resulted in Immediate Jeopardy to a Resident CL1 who had elevated blood sugar levels and was not emergently transferred to a hospital for one of five residents reviewed (Resident CL1). Findings Include: Review of Resident CL1's clinical record reveled that Resident CL1 was admitted to the facility on [DATE], with diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar (glucose). Review of Resident CL1's [DATE], physician's order revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML; Insulin Regular Human Injection Solution (Insulin Regular (Human) 30 unit subcutaneously one time only for DM (Diabetes Mellitus) for 1 day. If resident shows S/S (signs and symptoms) of fruity smelling breath vomiting, excessive hunger and thirst, rapid heartbeat- Perform BG (blood sugar), If BG (blood sugar) >400, immediately contact physician. Review of Resident CL1's nursing note revealed on [DATE], at 5:38 p.m. A call was placed to on call physician about [Resident's CL1's] elevated blood sugar, nurse check blood sugar for the evening check and it read high. On call physician told nurse to give resident 20 units of regular insulin and recheck in an hour. Review of Resident CL1's [DATE], Medication Administration Record revealed no evidence that 20 units of regular insulin was administered to the resident on [DATE]. Interview with the Director of Nursing, Employee E2 on [DATE], at 10:10 a.m. confirmed that there was not a physician order for 20 unit of regular insulin. Review of Resident CL1's nursing note revealed a nursing entry dated [DATE], at 8:06 p.m. nurse called on call physician again to inform that the Resident CL1's blood sugar remained elevated. The on-call physician stated to stop the Dextrose 5 percent and give her an additional 30 units of regular insulin and to recheck in an hour. Continued review of Resident's CL1's nursing note dated [DATE], at 9:01 p.m. indicated that the resident was in bed with hyperglycemia BG (blood glucose) checked at approx. (approximately) 19:30 (7:30 p.m.) result 507 and on Dextrose 5% percent IV (intravenous) immediately stopped. Regular insulin given per MD's orders to recheck and supervisor aware. Review of Resident CL1's medication administration record for the month of [DATE], revealed that regular insulin 30 units was given one time at 8:50 p.m. on [DATE], by night Supervisor, Licensed practical, Employee E5. Review of Resident CL1's nursing note written by Registered nurse, Employee E3 dated [DATE], at 12:25 a.m., revealed Patient (Resident CL1) presents on report with status change all day hyperglycemic, diaphoretic, tachycardic and in acute resp. Distress with blood glucose reading high. Blood glucose later read 507 after multiple attempts at approximately. 7:50 PM. Doctor [Employee E6] was notified by outgoing nurse and gave an order to stop patient Dextrose 5% at approx. 8 pm give 30 unit of regular insulin. Order was administered. After rechecking two times [Resident CL1] still read high. Supervisor was immediately called to assess patient at approximately 9:45 pm. Presented resident status to the supervisor [Registered nurse, Employee E4] and informed her that [Resident CL1] has to be sent out via 911 (Emergency Medical Services) to the hospital but supervisor [Employee E4] was dismissive refused to assess and evaluate the resident. Supervisor [Register nurse, Employee E4], became extensively aggressive argumentative, belligerent, condescending, rude, and yelling in the hallway in front of co-workers insisting [Resident CL1] does not need to be sent out to the hospital. Call placed to MD [Physician, Employee E6] at approximately 9:50 pm to inform [Resident CL1] status. R/T called in to resident's room for assistance while preparing [Resident's CL1's] paperwork and calling 911. Supervisor [Registered nurse, Employee E4] returned to the nursing station yelling at nurse [Register nurse, Employee E3] stating that by referring to [Resident's CL1]. this is her baseline per her mom she has always been diaphoretic and you are going to send the Resident's CL1 out just because she is diaphoretic?' [Supervisor Employee E4 repeatedly refused to listen to writer that this is a medical emergency for [Resident CL1] to be transported via 911 to the hospital. Doctor [Employee E6] returned phone call at approximately 10:20 PM to send [Resident CL1] out via 911. Supervisor Register nurse, Employee E4, interrupted writer on 911 call to go and give Dextrose 5% with DON on the phone again refusing to listen this is a medical emergency and the doctor has given an order to transport [Resident CL1] out, while the DON is on the phone in the midst of the emergency insisting not to transfer resident's out arguing. Supervisor [Registered nurse, Employee E4] repeatedly disregarding the doctors order and refused to speak to the doctor. The [Register nurse, Employee E3] tried to confirm the DON's directives again with the supervisor. Supervisor [Registered nurse, Employee E4] was dismissive, yelling out in the hallway refusing to listen. Supervisor [Register nurse, Employee E4], insisted the [Register nurse, Employee E3] come to her office and paged the [Register nurse, Employee E3] while calling 911 again at approximately 22:35 (10:35 p.m.) call placed to MD in the presence of the supervisor [Registered nurse, Employee E4], with the night supervisor [Licensed practical nurse, Employee E5], MD insisted to send [Resident CL1] out via medical emergency while supervisor [Registered nurse, Employee E4] still yelling and refused to speak to the doctor or attend to the resident. Night supervisor LPN attempted to get supervisor [Employee E4] to speak to the doctor but supervisor [Employee E4] was still belligerent and aggressively refused to speak to doctor arguing with the night supervisor [Licensed practical nurse, Employee E5], yelling at him. Supervisor [Register nurse, Employee E4] left the facility while [Resident CL1] was still in acute medical distress. 911 was immediately call at 22:50 (10:50 p.m.) [Register nurse, Employee E3] was with [Resident CL1] obtained sat at 99 percent on vent 60 percent setting and heart rate 168. [Resident CL1] coded at approximately 10:58 pm code blue immediately announced on overheard board CPR (cardiopulmonary resuscitation) immediately initiated with all nurses on board at approximately 11:02 with [Resident CL1] pulseless. At approximately 11:10 pm 911 called again and 911 paramedics arrived at facility at 11:25 pm and immediately took over. After multiple rounds of CPR 911 pronounced [Resident CL1] expiration at 11:51 pm. Review of nursing note dated [DATE], at 5:06 a.m. revealed Resident was found unresponsive by the nurse @ appr 2358 (11:58 p.m.) and immediately called code blue. CPR (Cardio Pulmonary Resuscitation) was initiated immediately and 911 called. EMT (Emergency Medical Technician) personnel got here at 2325 (11:25 p.m.). Eleven sets of chest compressions was completed before the EMT personnel got here and took over the process. Both the EMT personnel and RN declared resident at 2351 (11:51 p.m.) Review of the investigation statement from night Supervisor, Licensed practical nurse, Employee E5 on [DATE], revealed that [Resident's CL1's register nurse, Employee E3 told me that [Resident CL1] looked some sort of way, and she thinks the resident needs to be sent out. The residents were also already on fluids. Supervisor [Registered nurse, Employee E4] had told night supervisor [Licensed practical nurse, Employee E5], I don't think she needs to be sent out and director of nursing doesn't either. [Register nurse, Employee E3], came to night supervisor [Licensed practical nurse, Employee E5], and said the doctor wants to talk to the supervisor [Registered nurse, Employee E4], wasn't interested and said that because I'm also a night supervisor, that I could talk to on call doctor [Employee E6], and supervisor [Registered nurse, Employee E4], also state that director of nursing said the resident doesn't need to be sent out. Night supervisor [Licensed practical nurse, Employee E5], said to supervisor [Registered nurse, Employee E4], the doctor wants to send the patient out. Supervisor [Registered nurse, Employee E4], didn't talk to the doctor. Attempts made to conduct interviews with Registered nurse, Employee E3 and the night supervisor, Licensed practical nurse, Employee E5 were unsuccessful. Interview conducted with Supervisor, Registered nurse, Employee E4 on [DATE], at 12:00 p.m. revealed that on [DATE], the employee came for her ,d+[DATE] p.m. shift and stated to reviewed labs and reports. Around 8:00 p.m. she went to Registered nurse, Employee E3 to report that there was an order for Resident CL1 for D5 2L that needed to be giving. Registered nurse, Employee E3 didn't ' t want to give the D5 2L iv to the resident because of high blood sugars. [Registered nurse, Employee E3] refused to give D5 iv and wanted to call the MD to inform to change the order. 'I called DON to inform everything with [Registered nurse, Employee E3] not giving the D5 iv to resident but walked away. Wanted to call the doctor together with her but she walked away, and I couldn't ' t deal with her attitude and asked night supervisor to talk and take over [Registered nurse, Employee E3] and [Resident CL1]. I didn't ' t know anything about the blood sugar high for resident and I didn't ' t talk to the doctor. No call blue on my shift, I left my shift didn't ' t know that she went to the ER. But got a late text that resident passed away. Interview conducted with facility's prior Director of Nursing on [DATE],4 at 2:29 p.m. confirmed that she received a call from Supervisor, Registered nurse, Employee E4 to inform her that Registered nurse, Employee E3 was refusing to give the Dextrose 5 iv and that Registered nurse, Employee E3 wanted to cancel the order and contact the MD about the resident's high level of blood sugar levels. Interview with on-call physician, Employee E6, on [DATE], at 2:37 p.m. revealed that he got a call from a nurse about Resident CL1's high blood sugar level (still elevated) and order to stop the Dextrose 5 and give her an additional 30 units of regular insulin and to recheck in an hour. After one hour nurse informed that resident's blood sugar was high, and I order to be sent out to the hospital for more care. In the background I heard register nurse [Employee E3] was talking to supervisor [Registered nurse, Employee E4], why you're not send [Resident CL1] out to hospital. An Immediate Jeopardy situation was identified to the Nursing Home Administrator, Employee E1 and Regional Director of Nursing, Employee E8 on [DATE], at 10:33 a.m. for the facility's failure to ensure that a resident received treatment and care in a timely manner related to high glucose levels and failed to ensure that a resident was emergently transfer to the hospital. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Regional, Director of Nursing on [DATE], at 10:33 a.m. The following action plan was received and accepted on [DATE], 1:48 p.m. -Resident no longer resides at the facility. -Audited other residents who receive treatment and care related to high glucose level with no findings. -Current 7 a.m. -7 p.m. licensed nursing staff have been educated on the facility's significant change in condition and hyperglycemia policies. 100% of current in- house staff during this shift have been in serviced. The rest of the licensed nursing staff upcoming shift at 7p.m. -7 a.m. will be educated at the start of their shift. 100 percent of all staff will be in serviced by tomorrow [DATE]. -Facility also educated nurses in ensuring that the physician is notified timely of abnormal blood glucose levels for all residents with a diagnosis of diabetes mellitus. -NHA, DON and/ or Designee will conduct daily audits for a week, and weekly for 4 weeks, then monthly for 3 months to ensure care compliance. -Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and /or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward. Review of facility documentation revealed that the corrective action plan was immediately developed and initiated on [DATE]. Review of in-service records revealed that in-service training was provided to licensed nursing staff on the change in condition policy and the hyperglycemia policy. Interviews conducted with licensed nursing staff confirmed knowledge of the resident change in condition and hyperglycemia policies. The Immediate Jeopardy was lifted on [DATE], at 12: 01 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(ii)(iii) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on review of clinical records, review of facility policies, review of manufacturer's guidelines and interviews with staff, it was determined that the facility failed to perform a required pre-used test of a ventilator to ensure proper function which resulted in actual harm to Resident R1 whose ventilator did not alarm when the resident became disconnected from the ventilator and in the resident's death for one of three ventilator dependent residents (Resident R1) Findings include: Review of facility policy, Vent Checks dated April 1, 2018, revealed Ventilator monitoring shall be done on an ongoing basis by the RCP (Respiratory Care Practitioner) and nursing . Each day the RCP will be given an assignment and are then responsible for monitoring those patient's ventilators, the ventilator alarms and their overall status. Continued review revealed that monitoring ventilator care includes, Maintain a leak-free patient circuit by ensuring proper integrity of the circuit connections . Inspect the ventilator control panel for proper settings as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's Quarterly Minimum Data Set (MDS- a mandatory periodic assessment) dated February 22, 2022, revealed that the resident was admitted to the facility July 24, 2020, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that the resident was severely cognitively impaired and was totally dependent requiring the assistance of two or more staff persons for bed mobility. Further review revealed that the resident required oxygen therapy, suctioning, [CONDITION(S)] (an opening surgically created through the neck into the trachea to allow direct access to the breathing tube) care and invasive mechanical ventilation (breathing machine). Review of Resident R1's physician note, dated March 28, 2022, at 10:39 p.m. indicated that the resident was evaluated by a pulmonologist (a physician that specializes in respiratory conditions). The physician noted that the resident had chronic respiratory failure and that she required ongoing mechanical ventilation. Continued review of Resident R1's physician note, dated March 30, 2022, at 1:02 p.m. indicated that the physician went into Resident R1's room to assess the resident at 12:50 p.m. and that She was unresponsive, looks very pale, pulseless. The note indicated that there were no vent alarms. The resident was pronounced dead on March 30, 2022, at 12:50 p.m. Review of Resident R1's clinical record revealed a respiratory note, dated March 30, 2022, which indicated that the respiratory therapist was called into the resident's room by the physician and that the ventilator was disconnected and not alarming. Interview on March 31, 2022, at 4:53 p.m. with licensed nurse, Employee E4, confirmed that she was the nurse responsible for caring for Resident R1 on March 30, 2022, during the day shift. Employee E4 stated that she gave Resident R1's morning medications as per her routine and that the resident was at her usual baseline status at that time. Review of the respiratory note dated March 29, 2022 at 10:56 p.m. indicated that all alarms were set and functional. Respiratory note dated March 30, 2022 indicated that ventilator settings were verified, resident was suctioned, Spo2 99%, [CONDITION(S)] care was provided, and ballard was changed. RT was called into resident room by physician. Resident was pulseless, vent not alarming, pronounced by physician at 12:50 p.m. Interview on March 31, 2022, at 5:32 p.m. respiratory therapist, Employee E5, respiratory therapist revealed that she was the respiratory therapist responsible for caring for Resident R1 on March 30, 2022, during the day shift. Employee E5 stated that she provided routine morning respiratory care to Resident R1 at approximately 7:45 - 8:00 a.m. including suctioning, changing the resident's inner tracheal cannula (inner [CONDITION(S)] tubing), gauze and that she changed the Ballard (in-line suctioning device). Employee E5 stated that she checked the resident's oxygen levels which were within normal limits and that she checked the ventilator settings. Employee E5 stated that she was unable to remember if the ventilator alarmed while she disconnected the circuit during the provision of care. Employee E5 confirmed that while changing the Ballard and inner tracheal cannula, the ventilator circuit must be disconnected from the resident temporarily until care is completed. After providing care to Resident R1, Employee E5 stated that she continued on her rounds and that she did not have any further care interactions with the resident until she was informed that the resident was found unresponsive. Review of the facility investigation of the camera footage confirmed that on March 30, 2022, Resident R1 received medications by the assigned nurse at 9:39 a.m. at 10:00 a.m., the housekeeper stopped by the resident's room to take the trash, at 10:30 a.m.- 11:00 a.m. the assigned nurse aide provided morning care. Resident was alert, with no signs and symptoms of distress, at 11:09 a.m. -11:19 a.m. the housekeeper came in the room, at 11:44 a.m. the assigned nurse did visual check, and the resident was alert, with no signs of distress, 11:53 a.m. Respiratory Therapist did visual check and at 12:46 p.m. the physician entered room which at the time found the resident unresponsive. Review of documentation, Device Investigation Report, dated April 11, 2022, revealed that an investigation was conducted by the ventilator vendor related to Resident R1's death after she was found disconnected from the ventilator and the ventilator did not alarm. The investigation concluded that, The Patient Circuit Disconnect alarm did not activate because it was set to OFF. The investigation also concluded that, The Low Inspiratory Pressure and Low Minute Volume alarms did not activate because the Pre-Use Test was not performed to compensate for increased gas pathway resistance. The investigation also noted that the ventilator's internal bacterial filter was soiled from use, which resulted in an increased resistance in the patient gas pathway. Review of the ventilator alarm event usage report dated March 30, 2022, confirmed that the ventilator alarms were on and functioning as follows: 109 times from 6:00a.m.-9:00 a.m., 19 times form 9:00 a.m. to 12:00 p.m. and 4 times form 12:00 p.m. to 1:00 p.m. Review of the ventilator Clinical and Technical Manual dated 2021, revealed that the Patient Circuit Disconnect alarm activates when [ventilator] detects a large leak in the circuit. The Manual indicates to Always test the Patient Circuit Disconnect alarm before use to verify it detects disconnects and/or decannulations with the specific patient conditions. Continued review revealed, To ensure that therapy is delivered accurately, you must perform a Pre-Use test whenever prompted, the patient circuit is changed, or the device is powered on. Continued review revealed that the Pre-Use Test calculates the resistance and leak of the ventilator circuit and improves the accuracy of therapy delivered during ventilation. Further review revealed manufacturer recommendations to replace the internal bacterial filter whenever it may have become contaminated. The Manual noted that the ventilator may fail its Pre-Use Test if the internal bacterial filter becomes heavily contaminated. Further review of the manufacturer's recommendations revealed The secondary, low resistance, internal bacterial filter eliminates 99.99% of bacteria and viruses to protect against cross-contamination. Serviceable by trained technicians, typically during 10,000-hour scheduled maintenance. Review of the ventilator usage report revealed that Resident R1's ventilator had 2,847 hours until maintenance was to be due. Interview on March 30, 2022, at 5:15 p.m., Employee E3, Director of Respiratory Therapy, revealed that there was no documentation available for review related to ventilator system alarm testing as per the manufacturer recommendations. Employee E3 stated that ventilators are checked upon a resident's admission to the facility and whenever the tubing is completely changed in the ventilator. Further, the respiratory therapy staff are expected to verify ventilator settings every six hours. Review of Respiratory Treatment Administration Records (TARs) confirmed that Resident R1's Ballard device and inner cannula were changed on March 30, 2022. Continued review revealed that Resident R1's ventilator tubing was last changed on March 13, 2022. Interview on April 12, 2022, at 12:30 p.m. with the Nursing Home Administrator, Director of Nursing and Medical Director revealed that the facility was unaware that a pre-use test was not performed on Resident R1's ventilator once the resident was temporarily disconnected for the provision of care. Additionally, the facility was unaware that the device's internal bacterial filter was soiled. The facility failed to perform a required pre-used test on Resident R1's ventilator to ensure proper functioning which resulted in actual harm to Resident R1 whose ventilator did not alarm when the resident became disconnected from the ventilator. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.10(a) Resident care policies 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services