Every finding on record at Aurora Nursing and Rehab Center

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 19 residents reviewed (Residents 26 and 40).Findings include:The facility's policy regarding psychotropic medication use, dated September 24, 2025, indicated that non-pharmacological approaches would be used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 26 dated October 1, 2025, indicated that the resident had moderate cognitive impairment, was dependent on staff for most daily care needs and had diagnoses that included cancer and dementia.Physician's orders for Resident 26 dated November 15, 2025, included an order for the resident to receive 0.5 milligrams (mg) of Ativan every six hours as needed for restlessness/agitation for 14 days.Review of the Medication Administration Record (MAR) for Resident 26 dated November 2025 revealed that 0.5 mg of Ativan was administered to the resident on November 17 at 1:45 a.m.; on November 19 at 7:18 p.m.; on November 20 at 7:21 p.m.; on November 21 at 8:49 p.m.; on November 22 at 7:00 p.m.; on November 23 at 10:11 p.m.; and on November 29 at 7:09 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times. A nursing note for Resident 40, dated December 8, 2025, revealed the resident was admitted to the facility on this date, was receiving hospice services, and had diagnoses that included dementiaPhysician's orders for Resident 14, dated December 9, 2025, included orders for the resident to receive 0.5 milliliters (ml) of Ativan concentrate every two hours as needed for restlessness/anxiety for 14 days.Review of the MAR for Resident 14, dated November 2025, revealed that 0.5 ml of Ativan was administered to the resident on December 9 at 7:08 p.m.; December 11 at 8:55 a.m.; December 13 at 11:27 p.m.; and December 14, 2025, at 10:18 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed doses of Ativan on these dates and times.Interview with the Director of Nursing on December 17, 2025, at 10:17 a.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted before administering Ativan to Resident 26 and 40 on the above-mentioned dates and times and there should have been.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an implanted venous port (a medical device placed under the skin in your chest, arm or belly that allows for easy access to a vein for administering fluids or medications) was flushed according to facility policy for one of 19 residents reviewed (Resident 9) and failed to ensure that a peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm for long term access) was flushed according to facility policy for one of 19 residents reviewed (Resident 41). Findings include:The facility's policy regarding flushing and locking an implanted venous port dated September 24, 2025, indicated that the purpose of the procedure was to maintain patency of the implanted port, to prevent mixing of incompatible medications and solutions, and to ensure the entire dose of a solution or medication is administered into the venous system. When the port is used intermittently for medication administration, flush (procedure involving the injection of saline into a catheter using a small syringe to clear or maintain patency) with preservative free 0.9 percent sodium chloride (normal saline-a sterile mixture of salt and water) before and after infusion/medication administration in addition to daily flushing. Steps for flushing when giving medication include to document location of catheter, and type and amount of flush used. An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated, 2025, revealed that the resident was cognitively intact, had diagnoses that included cancer, and had intravenous access.Physician's orders for Resident 9, dated December 5, 2025, included an order for the resident to receive one gram of ertapenem sodium solution (an antibiotic medication) intravenously every evening for a urinary tract infection for 10 days. Review of Medication Administration Records (MARs) for Resident 9, dated December 2025, revealed that staff documented administering the one gram of ertapenem sodium solution intravenously every evening from December 5, 2025, at 8:00 p.m. through December 14, 2025, at 8:00 p.m. However, there was no documented evidence that staff flushed Resident 9's implanted venous port before and after the administration of the ertapenem sodium solution.Interview with the Director of Nursing on December 17, 2025, at 10:17 a.m. confirmed that there was no documented evidence that Resident 9's implanted venous port was flushed before and after the administration of the ertapenem sodium solution on the above-mentioned dates per facility policy.The facility's policy regarding the flushing of peripheral and midline intravenous catheters (a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication), dated September 24, 2025, indicated that the peripheral or midline catheter was to be flushed with 10 milliliters (ml's) of normal saline (sterile salt and water solution) before and after each use. A nursing note for Resident 41, dated December 12, 2025, at 5:00 p.m. revealed the resident was admitted to the facility from the hospital and had a PICC line in place.Physician's orders for Resident 41, dated December 12, 2025, included an order for the resident to receive 1.25 grams of Vancomycin solution (an antibiotic) intravenously (IV) daily for 26 days and 4.5 grams of Zosyn Solution (antibiotic) intravenously every eight hours for 26 days for left foot cellulitis (bacterial skin infection).Review of the MAR for Resident 41 for December 2025 revealed that the resident received IV Vancomycin daily and Zosyn every eight hours; however, there was no documented evidence that the resident's PICC line was flushed before and after receiving the medication per the facility's policy. Interview with the Director of Nursing on December 17, 2025, at 10:17 a.m. confirmed that there was no documented evidence that Resident 41's PICC line was flushed before and after its use for medication administration per facility policy.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 19 residents reviewed (Resident 6, 14).Findings include: The facility's policy regarding medication administration, dated September 24, 2025, indicated that staff are to document the administration of controlled substances in accordance with applicable law. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6 dated December 1, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnosis that included chronic obstructive pulmonary disease and high blood pressure Physician's orders for Resident 6, dated October 6, 2025, included an order for the resident to receive 0 .5 milliliters (ml) of Morphine (a controlled narcotic pain medication) orally every 4 hours for moderate pain or shortness of breath. A review of Resident 6's-controlled drug record (used to keep count of narcotic medication) for October 2025 revealed that staff signed out 0.5 ml Morphine on October 9, 2025, at 1:20 p.m., October 13, 2025, at 8:00 p.m., October 14, 2025, at 11:53 p.m. However, review of the resident's MAR, dated October 2025, revealed no documented evidence that the 0.5 ml of Morphine was administered to the resident on those dates. Physician's orders for Resident 6, dated October 6, 2025, included an order for the resident to receive 1 ml of Morphine orally every 2 hours for sever pain or shortness of breath. A review of Resident 6's-controlled drug record for October and November 2025 revealed that staff signed out 1 ml Morphine on October 18, 2025, at 7:00 p.m., October 22, 2025, at 7:45 p.m., and November 17, 2025, at 1:55 p.m. However, review of the resident's MAR, dated October and November 2025, revealed no documented evidence that the 1 ml of Morphine was administered to the resident on those dates. Interview with the Director of Nursing on December 17, 2025, at 11:14 a.m. confirmed that there was no documented evidence that Resident 6 received the 0.5 ml or 1 ml of Morphine as ordered on the above referenced dates. A quarterly MDS assessment for Resident 14, dated December 30, 2025, revealed that the resident had moderate cognitive impairment, had occasional pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April 11, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol (narcotic pain reliever) every six hours as needed for moderate pain to severe pain.A review of Resident 14's controlled drug record for October and November 2025 revealed that staff signed out 50 mg of Tramadol on October 25 at 7:27 p.m., October 30 at 6:22 p.m., November 18 at 6:40 p.m., and November 26, 2025, at 6:28 p.m. However, review of the resident's MAR, dated October and November 2025, revealed no documented evidence that the 50 mg of Tramadol was administered to the resident on those dates.Interview with the Nursing Home Administrator on December 17, 2025, at 2:28 p.m. confirmed that there was no evidence of the Tramadol being administered to Resident 14. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include: Review of a facility policy for administering medications dated September 24, 2025, included that the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication, and the individual administering the medication initials the resident's medication administration record on the appropriate line after giving each medication and before administering the next one. Observations made during medication administration on December 15 and 16, 2025, revealed that two medication administration errors were made during 26 opportunities for error, resulting in a medication administration error rate of 7.69 percent. Physician's orders for Resident 9, dated November 12, 2025, included for the resident to have one spray in each nostril of fluticasone propionate (steroid nasal spray that can be used to treat allergy symptoms) 50 micrograms per actuation suspension one time a day for allergies. Physician's orders dated November 20, 2025, included for the resident to receive 500 milligrams (mg) of sodium chloride (medication containing a specific dose of salt or sodium chloride used to replenish lost electrolytes or treat low blood sodium) one time a day. Physician's orders dated December 15, 2025, included for the resident to receive two sprays of saline spray nasal solution in both nostrils every six hours as needed for dryness, may self-administer it. Observations during the medication administration on December 16, 2025, at 7:34 a.m. revealed that Licensed Practical Nurse 3 administered a 1000 mg tablet of sodium chloride and provided the resident with saline spray nasal solution for the resident to self-administer one spray in each nostril. After completion of the medication administration, Licensed Practical Nurse 3 returned to the medication cart and documented that he administered 500mg of sodium chloride and one spray to each nostril of fluticasone propionate 50 micrograms per activation suspension. Interview with Licensed Practical Nurse 3 on December 16, 2025, at 8:35 a.m. confirmed that he did administer 1000 mg of sodium chloride tablet when he should have cut it in half and gave 500 mg, and he confirmed that he did administer the as needed saline spray, however, he thought he had administered the ordered fluticasone propionate, also reporting at the time of this interview that he did not believe that the fluticasone propionate was in his medication cart. Interview with the Director of Nursing on December 17, 2025, at 8:47 a.m. confirmed that medications are to be administered as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 19 residents reviewed (Resident 32).Findings include: A review of the facility policy for resident call system dated August 24, 2025, indicated that each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Clinical record review for Resident 32 revealed that the resident was admitted to the facility on [DATE], for hospice respite (temporary, short-term inpatient care in a facility like a nursing home, for patients with a terminal illness) care. Nurse's note for Resident 32 dated December 12, 2025, at 7:47 p.m. revealed that the resident's admission assessment was completed and that staff reviewed verbally with the resident the use of the call bell system and using it for a need. The resident did show that he was able to call for the nurse effectively after staff showing him how to use the call bell. Observation of Resident 32 on December 15, 2025, at 11:48 a.m. revealed that Nurse Aide 1 assisted the resident by adjusting his bed and setting up his lunch meal tray. The nurse aide completed the task and walked out of the room. The resident's call bell was on the floor on the left side of his bed in front of his bedside table. Interview with Nurse Aide 1 on December 15, 2025, at 11:48 a.m. confirmed that Resident 32's call bell was not within his reach and the call bell should have been clipped to his bed so he could use it if needed. Interview with the Director of Nursing on December 15, 2025, at 12:42 p.m. confirmed that Resident 32's call bell should have been within his reach. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete a significant change Minimum Data Set assessment for one of 19 residents reviewed (Resident 6).Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) dated October, 2025 revealed that 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 revealed that staff should complete a significant change MDS when a resident has a decline that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the resident's care plan. The RAI Manual revealed that staff should complete a significant change MDS when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. A quarterly Minimum Data Set (MDS) assessment (mandated assessments of a resident's abilities and care needs), dated August 31, 2025, revealed Resident 6 was cognitively intact, required assistance from staff for daily care needs, was on hospice services and had active diagnoses that included chronic obstructive pulmonary disease (COPD-a progressive lung condition characterized by persistent airflow limitation). Physician's orders for Resident 6 dated August 15, 2025, included an order to admit to hospice care with an admitting diagnosis of COPD. A review of Resident 6's clinical record revealed that a significant change MDS was not completed per the RAI Manual. An interview with the Registered Nurse Assessment Coordinator on December 16, 2025, at 1:55 p.m. confirmed that a significant change MDS assessment should have been completed per the RAI Manual and was not. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible by failing to ensure that fall/injury prevention interventions were in place for one of 19 residents reviewed (Resident 26).Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 26, dated October 1, 2025, revealed that the resident was cognitively impaired, was dependent on staff for most daily care needs, and had a diagnosis of dementia. The care plan for Resident 26 dated April 7, 2025, indicated that the resident had a history of falling and included an intervention dated May 1, 2025, that the resident was to have bilateral fall mats in place. Physician's orders for Resident 26 dated April 30, 2025, included an order for the resident to have fall mats to bilateral sides of his bed and staff were to check placement of the fall mats every shift. Observations of Resident 26 on December 16, 2025, at 12:22 p.m. revealed that the resident was lying in bed and there were no fall mats on the floor on either side of his bed. An interview with Nurse Aide 2 at the time of the observation confirmed that Resident 26 should have had bilateral fall mats in place, however, he did not. Interview with the Director of Nursing on December 16, 2025, at 12:22 p.m. confirmed that Resident 26 should have had bilateral fall mats in place while in bed. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcer care/prevention treatments were provided as ordered for one of 19 residents reviewed (Resident 3). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 6, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, was at risk for pressure ulcer (skin impairment caused by pressure) development, and had one Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone) pressure ulcer present on admission. Physician's orders for Resident 3, dated February 19, 2025, included an order for the resident to have her coccyx cleansed with wound cleanser, pat dry, apply collagen powder and triad paste onto rolled gauze and gently pack the wound. Apply silver sulfadiazine, zinc, hydrocortisone and nystatin 1% cream to the peri wound and apply bordered foam daily and as needed. A review of Residents 3 September, November 2025 Treatment Administration Record (TAR) was reviewed and there is no documented evidence her treatment was completed per physician orders on September 23, 28, 29 and November 14, 2025. Physician's orders for Resident 3, dated November 25, 2025, included an order for the resident to have her coccyx cleansed with wound cleanser, pat dry, apply betadine soaked rolled gauze and gently pack wound. Apply silver sulfadiazine, zinc, hydrocortisone, and nystatin 1% cream to the peri wound and apply bordered foam daily and as needed. A review of Resident 3's December 2025 TAR was reviewed and there is no documented evidence her treatment was completed per physician orders on December 10, 2025. An interview with the Director of Nursing on December 17, 2025, at 11:14 a.m. confirmed that there was no documented evidence that wound treatments were completed as ordered for Resident 3 on the above dates. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 19 residents reviewed (Residents 4, 6, and 27).Findings include: A facility policy for Comprehensive Care Planning, dated September 24, 2025, included that the facility would review and revise the care plan as needed based on the patient's changing condition and at least quarterly with completion of a Minimum Data Set assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), for Resident 4, dated November 12, 2025, indicated that the resident had moderate cognitive impairment, required assistance with daily care needs, and had active diagnosis that included diabetes and heart disease. Care plan for Resident 4, dated September 12, 2025, indicated that the resident was receiving oxygen therapy. A review of Resident 4's December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation that the resident was receiving oxygen services. Interview with the Registered Nurse Assessment Coordinator on December 17, 2025, at 11:36 a.m. confirmed that Resident 4 was not receiving oxygen therapy and her care plan should have been revised to reflect that, however it was not. An annual MDS assessment for Resident 6 dated December 1, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnosis that included chronic obstructive pulmonary disease and high blood pressure Care plan for Resident 6 dated October 28, 2024, indicated that the resident was receiving an anticoagulant medication. Review of the Medication Administration Record (MAR) and nurses notes for Resident 6 dated December 2025 revealed no documented evidence that the resident was anticoagulant medication. An interview with the Registered Nurse Assessment Coordinator on December 17, 2025, at 11:36 p.m. revealed that Resident 6 was not receiving anticoagulant medication and her care plan should have been revised to reflect that, however it was not. A quarterly MDS assessment for Resident 27 dated October 22, 2025, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included diabetes and dementia. Care plan for Resident 27 dated May 29, 2025, indicated that the resident was taking antidepressant medication. Review of the MAR for Resident 27 dated December 2025 revealed that the resident did not receive any antidepressant medication in December. An interview with the Registered Nurse Assessment Coordinator on December 17, 2025, at 10:34 a.m. confirmed that Resident 27 was not receiving antidepressant medication and her care plan should have been revised to reflect that, however, it was not. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policy and clinical records, as well as interviews with staff it was determined that the facility failed to develop and implement a comprehensive person-centered care plan related to anxiety and the use of antibiotics for one of 19 residents reviewed (Resident 40). Findings include:The facility's policy regarding care plans, dated September 24, 2025, revealed that to complete a care plan, you were to conduct a thorough resident assessment, identify relevant health problems, set measurable goals, choose appropriate interventions, and regularly monitor progress to adjust the plan as needed. Care plans were to be reviewed/revised as needed based on the resident's changing condition, and at least quarterly.A nursing note for Resident 40, dated December 8, 2025, revealed the resident was admitted to the facility on this date, was receiving hospice services, and had diagnoses that included dementiaPhysician's orders for Resident 40, dated December 9, 2025, included an order for the resident to receive 0.5 milliliters (ml) of Ativan concentrate every two hours as needed for restlessness/anxiety for 14 days. A nursing note for Resident 40, dated December 11, 2025, at 4:08 p.m. revealed the resident continued to have redness to the right eye and a new order was received for 0.5% Erythromycin ointment be applied to the right eye four times a day for one week.The Medication Administration Record (MAR) for December 2025 revealed that Resident 40 was receiving Ativan as needed, and Erythromycin ointment to the right eye four times a day from December 11 through December 17, 2025.Review of the resident's current care plan revealed that there was no documented evidence that a care plan was developed to address Resident 40's care needs and interventions related to receiving antibiotic medications or having restlessness/anxiety.Interview with Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for the development of care plans) on December 16, 2025, at 2:30 p.m. confirmed that Resident 40's care plan did not address restlessness/anxiety.Interview with the Director of Nursing on December 17, 2025, at 10:17 a.m. confirmed that Resident 40's care plan did not include the use of antibiotic medications and should have.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 19 residents reviewed (Residents 11, 14, and 15).Findings include: The Long-Term Care Facility RAI User's Manual, dated October 2025, indicated that Section N0415E1 (Anticoagulant-medications that prevent blood clots from forming or growing), was to be checked if the resident was taking an anticoagulant medication during the seven day look back period, Section N0415F1 (Antibiotic) was to be checked if the resident was taking an antibiotic medication during the seven day look back period, Section N0415H1 (Opioid-medicines that helps reduce moderate to severe pain) was to be checked if the resident was taking an opioid medication during the seven day look back period, and Section N0415I1 (Antiplatelet-medication that prevents platelets from clumping together and forming blood clots) was to be checked if the resident was taking an antiplatelet medication during the seven day look back period. Physician's orders for Resident 11, dated December 1, 2025, included orders for the resident to receive 50 milligrams (mg) of Tramadol (opioid) four times a day as needed for pain.Review of Resident 11's Medication Administration Record (MAR), dated December 2025, revealed that the resident received Tramadol during the assessment period.However, an admission Minimum Data Assessment (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated December 2, 2025, revealed that Section N0415H1 was not checked, indicating that the resident did not receive an opioid during the look back period. A nursing note for Resident 14, dated October 14, 2025, at 3:22 p.m. revealed that the resident complained of burning/itching to her buttocks and the area was noted to have excoriation (skin damage) and dermatitis (skin inflammation). A physician's order for Resident 14, dated October 14, 2025, included an order for the resident to have Magic Mix (contains Silvadene (antibiotic) that is used to prevent wound infections) applied to the buttocks three times a day.Review of Resident 14's Treatment Administration Record (TAR), dated October 2025, revealed that Magic Mix was applied to the resident's buttocks three times a day.However, a quarterly MDS assessment for Resident 14, dated October 30, 2025, revealed that section N0415F1 was not checked, indicating that the resident did not receive an antibiotic medication during the look back period.Interview with Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for the completion of MDS assessments) on December 16, 2025, at 2:16 p.m. confirmed that Resident 11 and 14's mentioned MDS assessments were coded inaccurately. Physician's orders for Resident 15 dated October 22, 2025, included for the resident to receive 81 mg of aspirin (an antiplatelet medication) once every day and 2.5 mg of Apixaban (an anticoagulant medication) once every day. Review of the MAR for Resident 32 dated November 2025 indicated that the resident received 81 mg of aspirin and 2.5 mg of Apixaban daily during the seven day look back period and did not receive any opioid medication during the seven day look back period. However, a quarterly MDS for resident 15 dated November 22, 2025, revealed that Section N0415E was not coded (1), indicating that the resident did not take an anticoagulant during the seven day look back period, Section N0415H was coded (1), indicating that the resident did take an opioid during the seven day look back period, and Section N0415I was not coded (1), indicating that the resident did not take an antiplatelet during the seven day look back period. An interview with the Registered Nurse Assessment Coordinator on December 16, 2025, at 2:30 p.m. confirmed that Resident 15's MDS assessment dated [DATE], was coded incorrectly. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending November 19, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 17, 2025, identified repeated deficiencies related to accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), the development of individualized care plans, care plan timing and revision, and preventing issues with the accountability of controlled medications (drugs with the potential to be abused). The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending November 19, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding the development of individualized care plans, cited during the survey ending November 19, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were developed for their individual needs. The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending November 19, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan timing and revision. The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the survey ending November 19, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications. Refer to F641, F656, F657, F755 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to report timely allegations of abuse to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for three of 30 residents reviewed (Residents 131, 132, 133). Findings include: The Older Adults Protective Services Act, 1997-13, Section 701 (a)(1)(2), indicated that it was mandatory to report to the Protective Services agency. An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b). An employee shall notify the administrator immediately following the report to the agency. Within 48 hours of making the oral report, the employee or administrator shall make a written report to the agency. The agency shall notify the administrator that a report of abuse has been made with the agency. The facility's policy regarding reporting and investigating abuse, neglect, exploitation, or misappropriation, dated December 7, 2023, revealed that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility's medical director. Immediately is defined as within two hours of an allegation involving abuse or results in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or results in serious bodily injury. An admission Minimum Data Set (MDS) assessments (a federally-mandated assessment of a resident's abilities and care needs) for Resident 131, dated August 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included a hip fracture. A care plan for the resident, dated August 5, 2024, revealed that the resident required limited to extensive assistance from staff. An interview statement with Resident 131, undated, revealed that Nurse Aide 1 was like a [NAME] Sergeant, she is nasty. She asked if Nurse Aide 1 could put her leg up because it was falling, and the nurse aide told her do it herself, to lift her foot up. She then asked for the bed control, and the nurse aide told her she could not have it to put her head up and down. The resident said that she always had it. Nurse Aide 1 said if they found out that she gave it to the resident, she would be fired, and she continued to be argumentative. The resident said that she just wanted Nurse Aide 1 out of her room. So, she told Nurse Aide 1 that her son lives right down the road, and she will call him and have him come and take her out of here. She said that she does not want Nurse Aide 1 to take care of her because she was scared of her. An admission MDS assessment for Resident 132, dated August 2, 2024, revealed that the resident was understood, could understands others, and had diagnoses that included a fractured tibia (the shinbone, the larger of the two bones in the lower leg). A care plan for the resident, dated July 26, 2024, revealed that the resident required limited to extensive assistance from staff. A statement completed by Nurse Aide 2, dated August 14, 2024, revealed that on August 13, 2024, while responding to Resident 132's light, the resident was telling her how she has not seen her in a while, and she had missed her. The nurse aide told her that she missed her too and asked how she has been. The resident told her how her therapy was helping her and how everyone but one person was nice to her. The nurse aide responded with, Oh no, I'm sorry to hear that. The nurse aide asked her if she wanted to or felt comfortable speaking to her. The resident then told the nurse aide that she had an accident the night prior and Nurse Aide 1 went in and was being rude to her. She said that Nurse Aide 1 was upset with her and stated, I'm done, I'm so f*****g done, and as the nurse aide put her table back beside her bed, Nurse Aide 1 knocked her pop down to the floor and did not pick it back up. Resident 132 had to pick up the soda. An interview statement with Resident 132 completed by Registered Nurse 3, dated August 14, 2024, revealed that Nurse Aide 1 came in after the resident had an accident. Nurse Aide 1 came in all huffy and puffy because she had to change the resident's bed. Nurse Aide 1 told the resident you have to get out of bed, because I am not going to roll you, so then she knocked over the pop and stated, I'm f*****g done. So, the resident cleaned up the pop and then Nurse Aide 1 came in to care for her roommate and was rude with her roommate and told her that she could not put the head of her bed up, and told her she could be fired if she gave her roommate the remote. As per the resident, this was not the first time. The first time it happened, she let it go. She just figured Nurse Aide 1 was tired or did not feel good. An admission MDS assessment for Resident 133, dated July 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and gastrostomy (a surgical procedure that creates an opening in the abdomen that allows a feeding tube to be inserted directly into the stomach). A care plan for the resident, dated September 10, 2024, revealed that the resident required extensive assistance from staff. A statement completed by Nurse Aide 2, dated August 15, 2024, revealed that that night while helping Resident 133 into bed, the resident's wife had asked the Nurse Aide 2 if it was okay if she helped her husband with his urinal when he has to go. Nurse Aide 2 told her that if she wanted to, she was allowed to help him with his urinal. She then told Nurse Aide 2 that Nurse Aide 1 had come into his room one time as she was helping him with his urinal and snatched it out of her hand, and as she snatched out it out of her hand she was yelling at the resident's wife. The resident's wife also told Nurse Aide 2 that Nurse Aide 1 was always very aggressive with him and whips him back and forth in the bed. Nurse Aide 2 immediately came out of the room and notified the supervisor about the statement/accusations that the resident's wife had said. Interview with Registered Nurse 3 on November 14, 2024, at 9:35 a.m. revealed that she interviewed Resident 131 on August 14, 2024, after learning that the resident had concerns with Nurse Aide 1 while interviewing Resident 132 after learning that she had care concerns with Nurse Aide 1. There was no documented evidence until August 20, 2024, that the facility reported the allegations of possible abuse for Residents 131, 132, and 133 to the State Survey Agency (Department of Health), Protective Services agency, and the local police department. Interview with the Director of Nursing on November 14, 2024, at 10:55 a.m. confirmed that the allegations of possible abuse for Residents 131, 132, and 133 were not reported to the State Survey Agency (Department of Health), Protective Services agency, or the local police department until August 20, 2024. She indicated that she was on vacation when the incidents occurred. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 12, 22, 26). Findings include: The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse was to document all medications administered to each resident on the resident's medication administration record (MAR). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was understood and could understand others, required assistance with daily care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs). Physician's orders for Resident 12, dated September 11, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (Lorazepam - a controlled medication used to treat anxiety) every four hours as needed for anxiety/restlessness for 14 days (end date of September 25, 2024). A review of Resident 12's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for September 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on September 13, 2024, at 8:00 p.m. and September 23, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.5 mg doses of Lorazepam were administered to the resident on these dates and times. A review of Resident 12's controlled drug record for October 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on October 26, 2024, at 12:00 a.m. and on October 27, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence of an active physician's order for Lorazepam or that the signed-out doses were administered to the resident on these dates and times. Physician's orders for Resident 12, dated April 11, 2024, included an order for the resident to receive 50 mg of Tramadol (narcotic pain reliever) every six hours as needed for moderate to severe pain. A review of Resident 12's controlled drug record for August, September, and November 2024 revealed that a 50 mg tablet of Tramadol was signed out for the resident on August 10, 2024, at 6:30 a.m.; August 17, 2024, at 4:58 p.m. and 10:58 p.m.; August 23, 2024, at 7:35 a.m.; August 24, 2024, at 9:05 a.m.; September 2, 2024, at 1:37 p.m.; September 5, 2024, at 8:00 p.m.; September 8, 2024, at 8:10 a.m.; September 23, 2024, at 8:30 p.m.; September 24, 2024, at 12:17 a.m.; and on November 5, 2024 at 6:24 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 50 mg tablets of Tramadol were administered to the resident on these dates. Interview with the Director of Nursing on November 13, 2024, at 2:35 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 12 on the above-mentioned dates and times. An admission MDS assessment for Resident 22 dated October 4, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included anemia, high blood pressure, and chronic obstructive pulmonary disease. Physician's orders for Resident 22, dated September 27, 2024, included an order for the resident to receive 0.25 milliliters (ml) of Morphine Sulfate (controlled pain medication) every two hours as needed for pain. A review of Resident 22's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for October and November 2024 revealed that 0.25 ml of Morphine was signed out for the resident on October 8, 2024, at 2:53 a.m.; October 31, 2024, at 1:00 a.m.; November 4 2024, at 12:23 a.m.; November 7, 2024, at 2:25 a.m.; November 13, 2024, at 3:55 a.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.25 ml doses of Morphine were administered to the resident on these dates. An interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 22 on the dates mentioned above. An admission MDS assessment for Resident 26, dated October 8, 2024, revealed that the resident was cognitively intact, had pain, received routine and as needed pain medications, and received an opioid (narcotic pain medication). Physician's orders for Resident 26, dated October 2, 2024, included an order for the resident to receive 5 mg of oxycodone (narcotic pain medication) every six hours as needed. The resident's controlled drug record for October and November 2024 indicated that one dose of oxycodone was signed-out for administration to the resident on October 2 at 10:30 p.m., October 26 at 4:00 a.m., October 28 at 8:42 a.m., October 30 at 9:00 p.m., November 2 at 10:15 a.m., and November 8, 2024, at 9:00 p.m. However, the resident's clinical record, including the Medication Administration Records (MAR's) and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times. Interview with the Director of Nursing on November 13, 2024, at 1:58 p.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 26 on the above dates and times. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer medications and obtain weights as ordered by the physician for two of 30 residents reviewed (Residents 5, 17). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively intact, required assistance from staff for daily care needs and had diagnoses that included heart failure. Physician's orders for Resident 5, dated October 7, 2024, included an order for the resident to receive 5 milligrams (mg) of Midodrine (a medication that treats low blood pressure) three times a day for hypotension (low blood pressure) and was to be held if the systolic blood pressure (the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg). A review of Resident 5's Medication Administration Record (MAR) for October and November 2024 revealed that staff administered the 5 mg of Midodrine when the resident's blood pressure was 138/76 mmHg at 8:00 a.m. on October 8; 135/76 mmHg at 8:00 a.m. on October 14; 132/82 mmHg at 2:00 p.m. on October 14; 140/90 mmHg at 2:00 p.m. on October 30; 134/80 mmHg at 8:00 p.m. on October 30; 138/78 mmHg at 8:00 a.m. on November 1; 132/78 mmHg at 2:00 p.m. on November 1; 142/68 mmHg at 8:00 a.m. on November 2; 144/76 mmHg at 2:00 p.m. on November 2; 138/74 mmHg at 2:00 p.m. on November 5; 133/74 mmHg at 2:00 p.m. on November 11; and 138/71 mmHg at 8:00 p.m. on November 8, 2024. Interview with the Director of Nursing on November 14, 2024, at 10:50 a.m. confirmed that Resident 5 received the Midodrine on the above dates and that staff should have held the medication as ordered. A quarterly MDS assessment for Resident 17, dated October 10, 2024, indicated that the resident was cognitively impaired, required assistance with daily care needs, was on a diuretic medication, and had diagnoses that included chronic kidney disease Stage 3 (moderate to severe loss of kidney function) and congestive heart failure (the heart cannot pump blood as well as it should, causing weight gain due to fluid build up in the lungs and lower legs). A physician's note for Resident 17, dated April 8, 2024, at 8:56 p.m., indicated that the resident had increased left upper extremity edema and bilateral lower extremity edema. Physician's orders for Resident 17, dated April 17, 2024, included orders to increase the Lasix to 60 milligrams daily, obtain bloodwork in a week, and to weigh the resident weekly on Thursdays. A review of Resident 17's MAR for May, June, August, September, October and November 2024 revealed that the resident was not weighed as ordered on May 2, June 13, June 20, June 27, August 8, August 29, September 5, October 10, October 17, October 31, and November 7, 2024, and no documentation in the clinical record to indicate that the weights were attempted and refused by the resident on those days. Interview with the Director of Nursing on November 13, 2024, at 1:33 p.m. confirmed that Resident 17's weights were not obtained as ordered on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for seven of 30 residents reviewed (Residents 1, 5, 9, 14, 22, 23, 24.). This deficiency was cited as past noncompliance. Findings include: A nursing note for Resident 1, dated February 5, 2024, at 1:39 p.m., revealed that Resident 1 was being admitted to the hospital for osteomyelitis. There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. Nursing notes for Resident 5, dated September 26, 2024, at 3:06 a.m. and 5:36 a.m., revealed that the resident had a change in mental status with increased confusion, garbled speech, and bad chest pain. The physician was notified and the resident was sent to the hospital for evaluation. She was admitted to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis (high white blood cell count). There was no documented evidence that a written notice of Resident 5's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. A nursing note for Resident 9, dated October 11, 2024, at 11:22 p.m., indicated that the resident was very lethargic and her pulse oximetry (measures blood oxygen levels) initially was 78 percent on room air. Oxygen was applied at 4 liters per minute via nasal cannula (a small tube that delivers oxygen through the nasal passages) and her pulse oximetry increased to 91 percent. Her oxygen was turned up to 8 liters per minute via nasal cannula and her pulse oximetry increased to 99 percent. The resident was transferred to the emergency room for an evaluation. There was no documented evidence that a written notice of Resident 9's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. A nursing note for Resident 14, dated April 6, 2024, revealed that the resident had chest pain that was radiating to the left upper extremity. The CRNP was notified and ordered the resident to be transferred to the local emergency room . There was no documented evidence that a written notice of Resident 14's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. A nursing note for Resident 22, dated October 21, 2024, at 2:33 p.m., revealed that the resident had fallen in the bathroom. After the fall, the resident rolled to her right side because she was having pain to her left hip and wrist. The resident's left wrist was swollen and very painful to touch and the resident was unable to straighten her leg. The CRNP was notified and ordered the resident to be transferred to the local emergency room . A nursing note, dated October 21, 2024, at 11:59 p.m., revealed that Resident 22 was admitted with a left hip fracture and a left wrist fracture. There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. Nursing notes for Resident 23, dated October 1, 2024, at 9:38 a.m. and 12:37 p.m., revealed that the resident had severe left knee pain that was red/purple in color, was hot to tough, and had drainage from the incision site. She was transferred to the hospital and admitted with cellulitis (bacterial skin infection). There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. A nursing note for Resident 24, dated July 18, 2024, at 3:04 p.m., revealed that the resident had gastrointestinal pain with diarrhea, pain, and intermittent fever. An order was obtained to transfer the resident to the local emergency room . A nursing note, dated July 18, 2024, at 9:32 p.m., revealed that Resident 24 was being admitted with colitis and urinary tract infection. There was no documented evidence that a written notice of Resident 24's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer. Interview with the Director of Nursing on November 13, 2024, at 11:18 p.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital. She also confirmed that the facility did not notify the state ombudsman of transfers to the hospital. The Director of Nursing indicated that they had identified the issue of not providing written notices of the transfers to the hospital on October 25, 2024. Following the identification on October 25, 2024, that they were not providing the written notices to the resident and/or the resident's representative and state ombudsman when the resident was transferred to the hospital, the facility's corrective actions included: Education was provided to staff regarding the required written notice that was to be given to the resident and/or the resident's representative when the resident was transferred to the hospital. Education was provided to staff regarding the required notice to the state ombudsman when the resident was transferred to the hospital. Audits were started on all residents that were transferred to the hospital. The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F623 on November 11, 2024. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for four of 30 residents reviewed (Resident 10, 11, 18, 29). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 10 had an ARD of August 9, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 8, 2024. A quarterly MDS assessment for Resident 11 had an ARD of August 3, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was two days late. A quarterly MDS assessment for Resident 18 had an ARD of August 2, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was three days late. A quarterly MDS assessment for Resident 29 had an ARD of August 4, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 3, 2024. An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that the above referenced quarterly MDS assessments were not completed within the required time frames. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for four of 30 residents reviewed (Residents 181, 182, 183, 184). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admitted + 13 calendar days) following admission. A comprehensive admission MDS assessment for Resident 181, dated July 29, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 7, 2024, which was 16 days after admission. A comprehensive admission MDS assessment for Resident 182, dated August 11, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 19, 2024, which was 15 days after admission. A comprehensive admission MDS assessment for Resident 183, dated August 18, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 26, 2024, which was 15 days after admission. A comprehensive admission MDS assessment for Resident 184, dated June 18, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on June 26, 2024, which was 15 days after admission. An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that Residents 181, 182, 183 and 184's admission MDS assessments were not completed within the required time frames. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 30 residents reviewed (Residents 5, 22, 23). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415J1 Hypoglycemic Medications was to be coded if the resident took hypoglycemic medication during the seven-day look-back period and Section N0415K1 was to be coded if the resident took anticonvulsant medication during the seven-day look-back period Physician's orders for Resident 5, dated October 3, 2024, included orders for the resident to receive 500 milligrams (mg) of Metformin (medication used to lower blood sugars) one time a day for diabetes. There was no physician's order for the resident to receive an anticonvulsant medication. Review of the Medication Administration Record (MAR) for Resident 5, dated October 2024, revealed that staff had administered the Metformin during the seven-day look-back period. A quarterly MDS assessment for Resident 5, dated October 9, 2024, revealed that Section N0415J1 was not coded, indicating that the resident did not receive hypoglycemic medication during the seven-day look-back assessment period and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back period. Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 5 received a hypoglycemic medication during the look-back period, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately. The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident. An admission MDS assessment for Resident 22, dated October 4, 2024, revealed that Section N0300 indicated that the resident received an injection on one day of the assessment period. A review of Resident 22's Medication Administration Record (MAR) for September and October 2024 revealed that the resident did not receive any injections. Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:18 p.m. confirmed that Resident 22 did not receive an injection during the look-back period and that the assessment was coded inaccurately. The RAI User's Manual, dated October 2023, revealed that Section N0415E1 (Anticoagulant Medications - medications that thin the blood) was to be coded if the resident received an anticoagulant medication during the seven-day assessment period; Section N0415H1 Opioid Medications (narcotic medications used to treat pain) was to be coded if the resident used an opioid during the seven-day assessment period; and Section N0415K1 (Anticonvulsant Medications- used to treat seizure disorder) was to be coded if the resident used an anticonvulsant during the seven-day assessment period. Physician's orders for Resident 23, dated October 8, 2024, included orders for the resident to receive 40 mg of Enoxaparin (an anticoagulant medication) subcutaneously (beneath the skin) one time a day and 5-325 mg of Percocet (a narcotic pain medication) every four hours as needed for pain. There was no physician's order for an anticonvulsant medication. The resident's MAR for October 2024 revealed that the resident received Enoxaparin and Percocet during the assessment's look-back period. A significant change MDS assessment for Resident 23, dated October 14, 2024, revealed that sections N0415E1 and N0415J1 were not coded, indicating that the resident did not receive anticoagulant and opioid medications during the seven-day look-back assessment period, and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back assessment period. Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 23 received anticoagulant and opioid medications, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately. 28 Pa. Code 211.5(f) Clinical Records.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of one of 30 residents reviewed (Resident 5). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively impaired, was always incontinent of urine, and received an antibiotic. Physician's orders, dated July 24, 2024, included orders for the resident to receive 100 milligrams (mg) of Macrobid (an antibiotic) twice a day for five days for a urinary tract infection (UTI). Physician's orders, dated August 4, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) four times a day for 10 days for a UTI. Physician's orders, dated October 19, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) one time a day for seven days for a UTI. A nursing note, dated October 19, 2024, at 12:43 p.m., revealed that Resident 5's daughter was concerned about the resident's frequent UTI's. There was no documented evidence that a care plan was developed to address Resident 5's specific and individualized care needs related to frequent UTI's. Interview with the Director of Nursing on November 14, 2024, at 1:45 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 5's frequent UTI's. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records and facility investigative documents, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, by failing to follow a resident's care plan while providing care for one of seven residents reviewed (Resident 1), resulting in harm due to a fall from bed with a fracture. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 10, 2021, revealed that the resident was blind, alert and oriented, able to make her needs known, and required the extensive assistance of two staff for daily care activities, including bed mobility. The resident's care plan, dated December 28, 2020, revealed that she was at risk for falls. The kardex (nurse aide instructions for each resident's care) for Resident 1, dated May 27, 2020, revealed that she was to have the assistance of two staff for care. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note for Resident 1, dated October 22, 2021, at 6:35 a.m. revealed that at 6:05 a.m., a nurse aide called the nurse to the resident's room, and the resident was observed lying prone (face down) on the floor between her bed and the wall. The resident was screaming to get her up and send her to the hospital. Upon assessment, bleeding was noted from a laceration to left lower leg, as well as from her nose and mouth. The resident was stabilized, the physician was notified, and an order was given to send the resident to the hospital for evaluation. A hospital report for Resident 1, dated October 22, 2021, at 8:39 a.m. revealed that the resident had a complex, comminuted fracture (broken into many pieces) with deformity involving the right maxillary sinus (the cheek area beside the nose). Blood was noted in the right maxillary sinus related to this trauma. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall investigation for Resident 1, dated October 22, 2021, revealed that the resident was on an air mattress, was turned onto her side for care, continued to roll, and rolled off the bed. An interview statement from Nurse Aide 1, dated October 25, 2021, revealed that on October 22, 2021, she was completing a bed bath for Resident 1. She rolled the resident on to her side to change her sheets. At that time, Nurse Aide 1 indicated that the resident began to wiggle her legs, then fell out of bed. Nurse Aide 1 admitted that she knew to check the residents' kardex for the appropriate transfer status. She also indicated that she knew Resident 1 required the assistance of two staff members with bed mobility; however, the other nurse aide was working with another resident and she decided not to wait. Interview with Resident 1 on November 1, 2021, at 4:15 p.m. confirmed that on October 22, 2021, Nurse Aide 1 came in to give her a bed bath. The resident asked why there was not another aide because there were always two, and Nurse Aide 1 told her she did not need another person, that she could do the care on her own. The resident stated that Nurse Aide 1 seemed to be in a hurry and kept rolling her back and forth. The resident told the nurse aide that she was getting dizzy and could not hold on, but the nurse aide did not seem to care. The resident stated that she rolled out of the bed, had to go to the hospital, and her mouth and cheek were sore, and her leg hurts. Interview with the Nursing Home Administrator and Director of Nursing on November 1, 2021, at 4:30 p.m. confirmed that Nurse Aide 1 was aware that Resident 1 was to have two staff present for care but chose to do it alone, resulting in a fall with fracture for the resident. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.