Every finding on record at Barnes-Kasson County Hospital

Based on clinical record review, facility policy review, observation, and staff interviews, it was determined that the facility failed to consistently implement interventions to prevent the development and worsening of pressure injuries for one of 12 residents reviewed (Resident 2). This failure resulted in actual harm when Resident 2 developed a Stage 2 pressure injury that subsequently deteriorated and was identified as an unstageable pressure injury.Findings include: According to the National Pressure Injury Advisory Panel (NPUAP) September 2025 a pressure injury is localized damage to the skin and underlying soft tissue. The skin injury occurs due to intense and/ or prolonged pressure or pressure in combination with shear. Preventive measures include various interventions such as the use of high-quality static pressure-reducing mattress (a mattress specially designed to spread body weight evenly to prevent high-pressure spots such as the hips, shoulders, and tailbone), staff assisting and encouraging mobility, and applying barrier creams. Review of the facility policy titled Skin Assessment/Braden Scale, last reviewed July 1, 2026, revealed the facility evaluates residents for risk of impaired skin integrity and pressure injury development using the Braden Scale, a standardized tool used to identify pressure injury risk. The Braden scale is a standard instrument to evaluate the risk for skin breakdown due to pressure; the total score is 6-23. The lower the score the higher the risk for pressure injury development. Review of the facility policy titled Pressure Sore Staging and Treatments, last reviewed July 1, 2026, revealed the resident's plan of care was to include preventive measures to maintain skin integrity and interventions to address identified skin problems. The policy also required routine skin assessment by a Registered Nurse and documentation of identified skin problems and the effectiveness of interventions. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included obesity (general term used to describe a condition in which a person has an excessive amount of body fat). Resident 2 was admitted to an acute care facility on May 2, 2026, and returned to the facility on May 11, 2026. A Skin Only Evaluation dated May 12, 2026, identified multiple pressure injuries involving Resident 2's gluteal and buttock-fold areas, including a Stage 2 (Stage 2 pressure injury involves partial-thickness loss of skin with exposed underlying skin tissue) pressure injury to the right gluteal fold measuring 0.8 centimeter (cm) by 0.6 cm. A Braden Scale assessment dated [DATE], identified Resident 2 as at moderate risk for developing pressure injuries with a score of 12. Identified risk factors included moisture, limited mobility, inability to independently reposition, and the need for moderate to maximum assistance with movement. A review of Resident 2's reentry Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 18, 2026, revealed that Resident 2 had severe cognitive impairment with a BIMS score of 5 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 means severe cognitive impairment, significant difficulties with knowing the year, month, weekday and/or delayed memory recall) and indicated Resident 2 required the assistance of two staff members for repositioning in bed and transfers from bed to the chair and vice versa. The MDS indicated the resident had two Stage 2 pressure ulcers upon reentry to the facility. A physician's order dated April 13, 2026, directed staff to turn and reposition Resident 2 hourly from side to side. A physician's order dated May 2, 2026, directed use of an alternating air mattress for pressure reduction. Resident 2's care plan, revised May 2, 2026, identified the resident as having impaired skin integrity and being at risk for additional skin injury. Interventions included hourly side-to-side repositioning, use of an alternating air mattress to redistribute pressure, routine skin monitoring, and encouraging adequate nutrition and fluid intake. Nursing documentation dated June 21, 2026, indicated that all remaining Stage 2 pressure injuries involving Resident 2's left and right gluteal folds had resolved. Despite the physician's order and care-planned intervention directing staff to reposition Resident 2 hourly from side to side, review of the July 2026 Documentation Survey Report revealed multiple hourly repositioning checks between July 1 and July 15, 2026, when staff documented Resident 2 lying on their back rather than positioned from side to side as ordered. A Skin Only Evaluation dated July 15, 2026, completed by Employee 2, Licensed Practical Nurse (LPN), identified a painful Stage 2 pressure injury to Resident 2's right gluteal fold/buttock measuring 6.2 cm in length by 4.8 cm in width by 0.1 cm in depth. Treatment included cleansing the pressure injury with Vashe (a wound-cleansing solution), applying Triad paste (a protective wound dressing paste applied to damaged skin to help protect the area and manage wound moisture), and covering the area with a bordered dressing (a protective wound covering with an adhesive border) every Monday, Wednesday, and Friday, and as needed if the dressing became soiled. The treatment also directed staff to apply barrier cream (a protective cream used to shield the skin from moisture and irritation) with every incontinence product change. Despite the development of the Stage 2 pressure injury and the existing physician's order for hourly side-to-side repositioning, staff continued to document Resident 2 lying on their back during 60 separate hourly repositioning checks between July 15 and July 23, 2026, rather than positioned from side to side as ordered. A Skin Only Evaluation dated July 23, 2026, completed by Employee 2, LPN, documented that the affected area had changed in appearance. Employee 2 classified the area as a suspected deep tissue pressure injury (DTI) involving the right thigh/gluteal fold measuring 4 cm by 4 cm, with the depth unable to be determined. A DTI is damage to underlying tissue that may appear as persistent dark red, maroon, or purple discoloration. The July 23, 2026, treatment directed staff to cleanse the area and apply Balmex (a barrier cream used to protect the skin from moisture and irritation) every shift and to apply barrier cream with every incontinence product change. Between July 23 and July 27, 2026, staff documented Resident 2 lying on their back during an additional 32 separate hourly repositioning checks rather than positioned from side to side as ordered. A Skin Only Evaluation dated July 27, 2026, completed by Employee 2, LPN, documented further deterioration of the affected area and classified the pressure injury as unstageable, measuring 4.8 cm by 5.2 cm. An unstageable pressure injury involves full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because the wound is obscured by dead tissue. The July 27, 2026, evaluation also documented placement of a urinary catheter, a tube inserted into the bladder to drain urine, to assist with keeping the affected area dry and support healing. Despite the documented deterioration of the pressure injury, staff continued to document Resident 2 lying on their back during an additional 58 separate hourly repositioning checks between July 27 and August 5, 2026, rather than positioned from side to side as ordered. On August 4, 2026, at 11:13 AM Resident 2 was observed lying on their back in bed on the ordered alternating air mattress. The control unit responsible for operating the alternating air mattress was turned off. The mattress control was set for a resident weight of 320 pounds. Resident 2's documented weight on July 22, 2026, was 203 pounds. According to the manufacturer's guidelines, proper weight setting supports pressure redistribution and comfort. Setting the mattress at the proper weight helps prevent pressure ulcers by keeping pressure levels within a safe range while offering alternating pressure cycles, typically around every 10 minutes to shift loading points. An August 5, 2026, Skin Only Evaluation, completed by Employee 2, LPN, documented continued deterioration of Resident 2's skin condition. The unstageable pressure injury involving the right thigh/gluteal fold measured 9.6 cm by 11.2 cm. The evaluation also documented deep tissue damage to the posterior right thigh and seven additional Stage 2 open areas. Treatment was changed to cleansing the affected area with Vashe and applying Triad paste every shift. A physician's order also directed that Resident 2 be evaluated by an outside wound clinic. On August 5, 2026, at 10:30 AM during an observation with Employee 1, RN, Resident 2's posterior thigh/lower buttock area contained a large bright red and purple area with seven open areas within the affected area. The open areas appeared bright red. No drainage or odor was observed.The measurements for the seven Stage 2 pressure injuries contained within the DTI included:2.3 cm (length) x 0.3 cm (width) x 0.2 cm (depth)0.7 cm (length)x 0.4 cm (width)x 0.2 cm (depth)0.4 cm (length)x 0.3cm (width) x 0.2 cm (depth)0.6 cm (length)x 0.2 cm (width) x 0.2 cm (depth)0.2 cm (length)x 0.2 cm (width) x 0.2 cm (depth)0.3 cm (length)x 0.1 cm (width) x 0.2 cm (depth)0.4 cm (length)x 0.5 cm (width)x 0.2 cm (depth) During an interview on August 5, 2026, at 11:40 AM the Director of Nursing confirmed that the clinical record did not demonstrate consistent implementation of interventions, including repositioning, to prevent further deterioration of Resident 2's skin condition. The Director of Nursing was unable to explain why the alternating air mattress control unit was turned off or why the mattress was set for 320 pounds when Resident 2's documented weight was 203 pounds. During an interview on August 5, 2026, at 11:40 AM the Director of Nursing confirmed that Employee 2, LPN, completed the facility's wound evaluations and that an RN was expected to oversee the evaluations and agree or disagree with the findings. During an interview on August 6, 2026, at 10:00 AM Employee 2 confirmed that she completed Resident 2's wound evaluations, including wound staging and treatment recommendations, and confirmed that Resident 2's pressure injury continued to deteriorate following its identification on July 15, 2026. The clinical record lacked evidence that an RN assessed Resident 2's pressure injury as required by facility policy as the pressure injury changed in appearance and deteriorated. Employee 2, LPN, completed the documented wound evaluations on July 15, July 23, July 27, and August 5, 2026. The facility's failure to consistently implement ordered and care-planned pressure-relieving interventions resulted in actual harm to Resident 2, as evidenced by the development of a painful Stage 2 pressure injury and subsequent deterioration of the affected area to an unstageable pressure injury, with continued deterioration and additional areas of skin breakdown. The findings were reviewed during an interview on August 6, 2026, at 1:45 PM with the Director of Nursing and Nursing Home Administrator. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, resident observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan intervention intended to promote resident safety by failing to ensure an electronic wandering safety device was in place for one of 12 residents reviewed (Resident 9).Findings include: A review of the facility policy titled Care Plan Process, last reviewed July 1, 2026, indicated the facility will promote coordinated interdisciplinary care through an individualized plan of care based on assessment, planning, treatment, services, and interventions. The policy indicated care will be complete, current, realistic, time-specific, and appropriate to each resident's individual needs.Clinical record review revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included traumatic brain injury (damage to the brain caused by a sudden blow, jolt, or other injury to the head).Review of Resident 9's comprehensive care plan revealed a care plan initiated October 3, 2024, and most recently revised November 18, 2025, identifying Resident 9 as being at risk for wandering. The care plan established a goal for Resident 9 to remain safe and not leave the facility unattended.The care plan included an intervention, initiated October 3, 2024, and most recently revised February 4, 2025, directing staff to maintain a Wander Guard attached to Resident 9's chair. A Wander Guard is an electronic safety device used to alert staff when a resident who is at risk for wandering approaches a monitored area or exit.Observation on August 4, 2026, at 11:28 A.M. revealed Resident 9 seated in the resident's Broda chair (specialized supportive positioning and mobility chair) in a community room in the presence of two activity staff members. The Wander Guard identified in Resident 9's comprehensive care plan was not attached to the Broda chair. The two activity staff members checked Resident 9, including the resident's ankles, and were unable to locate the Wander Guard on the resident or the chair.During an interview on August 5, 2026, at 11:30 P.M., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident 9's comprehensive care plan directed staff to maintain a Wander Guard attached to the resident's chair and confirmed that the care-planned safety intervention was not implemented as directed.28 Pa Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, resident observation, and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set (MDS), accurately reflected the residents' clinical status for two of 12 residents reviewed (Residents 2 and 9).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical record review revealed Resident 2 was admitted to the facility on [DATE] with diagnoses that included but not limited to obesity (general term used to describe a condition in which a person has an excessive amount of body fat), pressure ulcers (injury to the skin and underlying tissue caused by prolonged pressure), peripheral vascular disease (a condition that reduces blood flow through blood vessels outside the heart and brain), and cellulitis (bacterial infection of the skin and underlying tissue) of the right lower leg. A review of a clinical record titled Skin Only Evaluation, dated May 12, 2026, documented that Resident 2 had a Stage 3 pressure injury of the coccyx (a pressure-related wound over the tailbone involving full-thickness loss of skin). A review of Resident 2's reentry admission Minimum Data Set (MDS), with an Assessment Reference Date of May 18, 2026, revealed Section M, Skin Conditions, was coded with a 0 (zero) for Stage 3 pressure injuries, indicating the resident did not have any Stage 3 pressure injuries during the applicable assessment period. The MDS did not capture the Stage 3 pressure injury of the coccyx documented in the clinical record on May 12, 2026. During an interview on August 6, 2026, at 9:30 A.M., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident 2's MDS was not coded accurately and did not capture the presence of the Stage 3 pressure injury. A review of the clinical record revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included traumatic brain injury (damage to the brain caused by an external force to the head). A review of a physician's order dated September 23, 2025, directed that Resident 9 remain NPO (nothing by mouth), meaning the resident was not to receive food, fluids, or medications by mouth. A review of the clinical record revealed Resident 9 received nutrition and medications through a gastrostomy tube (G-tube, a tube inserted directly into the stomach to provide nutrition and medications). A physician's order dated April 17, 2026, directed staff to administer 1.2 liters of Jevity 1.5 (a liquid nutritional formula) through the feeding tube at a continuous rate of 65 milliliters (mL) per hour by pump until the prescribed amount was delivered. A review of Resident 9's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of May 18, 2026, revealed Section GG, Functional Abilities and Goals, item GG0130A, Eating, was coded 01, Dependent, indicating the helper completed all of the effort for the activity. According to the RAI Manual, item GG0130A, Eating, addresses the resident's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. The RAI Manual directs staff to use Code 88, Not Attempted Due to Medical Condition or Safety Concerns, when the resident does not perform the activity because of a medical condition or safety concern. The clinical record documented that Resident 9 was NPO and received nutrition through a G-tube. Therefore, the MDS coding of 01, Dependent, for item GG0130A did not accurately reflect the resident's functional status related to eating. During an interview on August 6, 2026, at 9:30 A.M., the Nursing Home Administrator and Director of Nursing confirmed that Resident 9's MDS was not coded accurately and did not accurately reflect the resident's functional status related to eating. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of facility policy, and staff interview, it was determined that the facility failed to implement procedures to maintain complete and accurate records of the receipt, administration, and disposition of controlled medications to permit accurate reconciliation for two of 12 residents reviewed for medication administration (Residents 11 and 35).Findings include: A review of the facility policy titled Controlled Substances, last reviewed July 1, 2026, revealed that the facility will comply with applicable laws, regulations, and other requirements related to the handling, storage, disposal, and documentation of controlled medications. The policy indicated that the nurse administering a controlled medication is responsible for documenting the name of the resident receiving the medication; the name, strength, and dose of the medication; the time and method of administration; the quantity of medication remaining; and the signature of the nurse administering the medication. A clinical record review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a condition in which blood sugar levels remain too high) and a pressure ulcer of the sacral region (an area of damaged skin and underlying tissue caused by prolonged pressure over the sacrum, the bone at the base of the spine). A review of Resident 11's physician orders revealed an order, initiated March 31, 2026, for hydrocodone-acetaminophen 5 milligrams/325 milligrams, one tablet by mouth every 12 hours as needed for breakthrough pain rated 7 through 10 on a pain scale (a tool used to rate pain intensity, typically from 0, meaning no pain to 10, meaning the worst pain possible). Hydrocodone-acetaminophen is a combination opioid pain medication containing hydrocodone and acetaminophen. Hydrocodone-containing combination products are Schedule II controlled substances, medications with accepted medical uses that have a high potential for misuse and dependence. Review of facility records revealed that the facility used a Controlled Drug Receipt/Record/Disposition Form to account for the receipt, use, remaining quantity, and disposition of controlled medications.The facility also used a Medication Administration Record (MAR), the clinical record used to document medications administered to a resident, including the medication, date and time of administration, and the staff member who administered the medication. Comparison of Resident 11's Controlled Drug Receipt/Record/Disposition Form with the MAR from April 3 through August 4, 2026, identified seven instances in which the controlled-drug record documented that a hydrocodone-acetaminophen tablet was removed from the available supply; however, the MAR contained no corresponding documentation that the medication was administered:April 12, 2026, at 4:45 PMApril 25, 2026, at 3:35 PMJune 20, 2026, at 3:45 PMJune 27, 2026, at 6:45 PMJuly 23, 2026, at 3:30 PMJuly 30, 2026, at 3:40 PMAugust 2, 2026, at 5:30 AMComparison of Resident 11's Controlled Drug Receipt/Record/Disposition Form with the MAR from April through August 2026 identified three instances in which the MAR documented that hydrocodone-acetaminophen was administered; however, the Controlled Drug Receipt/Record/Disposition Form contained no corresponding documentation that the medication was removed from the controlled-drug inventory:April 25, 2026, at 8:36 PMJune 23, 2026, at 4:40 PMJuly 23, 2026, at 8:31 PMTherefore, the facility's two records used to account for the administration and disposition of Resident 11's Schedule II controlled medication could not be reconciled. A review of Resident 35's physician orders revealed an order, initiated May 8, 2025, for Xanax 0.25 milligram, one tablet by mouth three times daily for anxiety. Xanax, the brand name for alprazolam, is a benzodiazepine medication used to treat anxiety and is classified as a Schedule IV (lower potential for abuse) controlled substance.Comparison of Resident 35's Controlled Drug Receipt/Record/Disposition Form with the MAR from June 1 through August 5, 2026, identified eight instances in which the controlled-drug record documented that a Xanax 0.25 milligram tablet was removed from the available supply; however, the MAR contained no corresponding documentation that the medication was administered:June 4, 2026, at 2:00 PMJune 18, 2026, at 9:00 PMJune 19, 2026, at 9:00 PMJune 21, 2026, at 9:00 PMJune 28, 2026, at 9:00 PMJuly 23, 2026, at 9:00 PMJuly 25, 2026, at 9:00 PMJuly 30, 2026, at 9:00 PMThe facility's records did not provide a complete and accurate account of the administration and disposition of Resident 35's controlled medication and could not be accurately reconciled.During an interview on August 6, 2026, at 9:05 AM, the Director of Nursing (DON), reviewed the discrepancies identified between the Controlled Drug Receipt/Record/Disposition Forms and the Medication Administration Records for Residents 11 and 35. The facility failed to maintain controlled-medication records in sufficient detail to provide an accurate accounting and reconciliation of hydrocodone-acetaminophen for Resident 11 and Xanax for Resident 35. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on a review of clinical records, staff interview, facility policy, and the facility's infection assessment tool, it was determined the facility failed to consistently implement its antibiotic stewardship protocols for initiating antibiotic use in accordance with the established infection prevention and control guidelines for two residents out of 12 sampled (Resident 14 and Resident 34) Findings included: Review of a facility policy entitled Antibiotic Stewardship last reviewed March 2024, indicated that antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available along with a completed Revised McGeer's Criteria for Infection Surveillance Checklist (an algorithm that uses criteria to make an empiric diagnosis of UTI in nursing home residents. For resident's that do not have an indwelling urinary catheter and with at least three of the following signs and symptoms must be present prior to a practitioner prescribing antibiotic therapy include a fever (temperature of at least 100.4 F), new or increased frequency, urgency, or burning on urination, new flank or suprapubic pain or tenderness, change in character of urine, and worsening of mental or functional status) form that includes the following data: signs and symptoms, when symptoms were first observed, resident's hydration status, current medication list, allergy information, infection type, any order for warfarin (blood thinning medication) and results of last INR (is a laboratory test that measures international normalized ratio (INR) and indicates how long it takes blood to clot), last creatine clearance or serum creatine (if available), and time of the last ATB dose. A review of nursing progress notes for Resident 14's completed by Employee 1, a Licensed Practical Nurse (LPN), dated November 14, 2024, at 10:59 AM, revealed the resident had increased confusion and complaints of burning upon urination with NON (new orders noted) for a (urinalysis) and C & S (culture and sensitivity - a urine culture is considered positive if it shows the presence of more than 100,000 colony-forming units (CFUs) of bacteria per milliliter of urine and indicates the presence of an infection. The sensitivity test helps select the best medicine to treat the infection). C&S results dated November 18, 2024, at 7:07 AM identified Citrobacter murliniae (a species of bacteria) 70,000-90,000 CFU/mL and Proteus mirabilis (gram-negative rod-shaped bacteria) 20,000-30,000 CFU/mL and was susceptible (responsive to treatment) to nitrofurantoin, gentamicin, and trimethoprim/sulfamethoxazole (antibiotics). A review of the revised McGeer's Criteria for Infection Surveillance checklist completed for resident 14 determined that UTI criteria were not met as the resident did not present with the minimum required clinical signs or symptoms for UTI diagnosis. Despite this, Macrobid 100 milligrams was prescribed. November 18, 2024, based on urine culture results that did not meet diagnostic criteria for antibiotic use. The 72-Hour Antibiotic Time-Out form confirmed the antibiotic appropriateness was marked as no and facility staff failed to justify the continuation of treatment. Resident 14 received 13 of 14 prescribed doses of Macrobid without evidence of clinical necessity. During an interview on January 16th, 2025, at 10:15 AM the infection preventionist IP confirmed the failure to adhere to antibiotic stewardship protocols including ensuring criteria were met before initiating treatment. The facility also failed to follow its antibiotic stewardship protocol when initiating and continuing antibiotic therapy for Resident 34. A review of Resident 34's clinical record of nurses' progress notes completed by Employee 2, a LPN, dated December 3, 2024, at 10:18 AM and 1:09 PM, revealed that the resident had increased lethargy and weakness, leading to physician orders for urinalysis and C&S testing. Macrobid 100 mg (an antibiotic that fights bacteria in the body) oral capsule 100 mg (milligrams), twice daily was prescribed the same day. A review of a facility form entitled Newly diagnosed Infection Report dated December 3, 2024, completed by the Director of Nursing (DON) indicated a diagnosis of UTI; the resident was transferred to the ER (emergency room ) and returned on Macrobid 100 mg orally twice daily for 7-days. A review of the revised McGeer's Criteria for Infection Surveillance Checklist form was incomplete for this resident. Evidence supporting a UTI diagnosis was not documented before initiating Macrobid therapy on December 3rd, 2024. Further review of physician's orders dated December 4, 2024, at 5:51 PM, revealed an order for Rocephin (ceftriaxone sodium an antibiotic administered via injection and used to treat many kinds of bacterial infections) Sodium Injection Solution Reconstituted, inject 1 gm (gram) intramuscularly two times a day related to UTI until December 9, 2024, at 1:00 PM. Additionally, physician's orders were obtained on December 4, 2024, at 9:27 PM, to discontinue IM Rocephin and change to IV (intravenous therapy is a medical technique that administers fluids, medications, and nutrients directly into a person's vein) Rocephin Solution Reconstituted 1 gm (gram) intravenously every 12 hours for infection related to UTI. A review of culture results dated December 6, 2024, at 7:59 AM, revealed Resident 34's final urinalysis and C & S results that were 80,000-90,000 CFU/mL of E. coli (is bacteria from the intestines is present in fecal matter and trace amounts of fecal matter make their way into the urinary tract through the urethra opening and begin to multiply).Despite this, the 72-Hour Antibiotic Time-Out form indicated the resident did not meet McGeer's criteria for antibiotic treatment. Despite inconclusive diagnostic evidence, Macrobid therapy was initiated, followed by additional orders for intramuscular IM Rocephin, later revised to intravenous IV Rocephin on December 4th, 2024. The 72-hour antibiotic timeout form confirmed the resident did not meet McGeer's criteria for antibiotic treatment. Resident 34 received 2 doses of Macrobid, 1 dose of I am Rocephin, and four doses of IV Rocephin without documented evidence of clinical necessity. During an interview on January 16th, 2025, at 11:05 AM, the nursing home administrator acknowledged the facility's failure to implement antibiotic stewardship protocols for residents 14 and 34. This failure contributed to the initiation and continuation of antibiotic therapy without documented evidence of clinical necessity, inconsistent use of infection surveillance tools, and noncompliance with infection prevention and control guidelines. Refer F757 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, the facility failed to ensure documented evidence of clinical necessity for the administration of antibiotic medications in accordance with established guidelines for two of five sampled residents for unnecessary medication prescribing practices (Resident 14 and 34). Findings included: A review of Resident 14's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including psychotic disorder with delusions (type of serious mental illness called a psychotic disorder and people who have it can't tell what's real from what is imagined) and history of UTI (urinary tract infection - an infection in any part of the urinary system). A review of nursing progress notes for Resident 14's completed by Employee 1, a Licensed Practical Nurse (LPN), dated November 14, 2024, at 10:59 AM, revealed the resident had increased confusion and complaints of burning upon urination with NON (new orders noted) for a (urinalysis) and C & S (culture and sensitivity - a urine culture is considered positive if it shows the presence of more than 100,000 colony-forming units (CFUs) of bacteria per milliliter of urine and indicates the presence of an infection. The sensitivity test helps select the best medicine to treat the infection). C&S results dated November 18, 2024, at 7:07 AM identified Citrobacter murliniae (a species of bacteria) 70,000-90,000 CFU/mL and Proteus mirabilis (gram-negative rod-shaped bacteria) 20,000-30,000 CFU/mL and was susceptible (responsive to treatment) to nitrofurantoin, gentamicin, and trimethoprim/sulfamethoxazole (antibiotics). A review of a facility provided form entitled Revised McGeer's Criteria for Infection Surveillance Checklist (an algorithm that uses criteria to make an empiric diagnosis of UTI in nursing home residents. For resident's that do not have an indwelling urinary catheter and with at least three of the following signs and symptoms must be present prior to a practitioner prescribing antibiotic therapy include a fever (temperature of at least 100.4 F), new or increased frequency, urgency, or burning on urination, new flank or suprapubic pain or tenderness, change in character of urine, and worsening of mental or functional status) determined that UTI criteria was not met for an ATB to be prescribed. Despite results not meeting McGeer's criteria for a UTI diagnosis, the physician prescribed Macrobid 100 mg twice daily for 7 days on November 18, 2024, at 12:54 PM. A review of a facility provided form entitled 72-Hour Antibiotic Time-Out form indicated antibiotic appropriateness as no and confirmed that the resident did not meet McGeer's criteria for antibiotic treatment. The resident received 13 of 14 prescribed doses of Macrobid without documented justification for the antibiotic's use. During an interview on January 16, 2025, at 10:15 AM the Infection Preventionist (IP) confirmed the prescribing physician was aware the criteria were not met, and the facility failed to prevent unnecessary antibiotic use. A review of Resident 34's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities and the symptoms may interfere with individual's daily lives) and a history of UTI. A review of Resident 34's clinical record of nurses' progress notes completed by Employee 2, a LPN, dated December 3, 2024, at 10:18 AM and 1:09 PM, revealed that the resident had increased lethargy and weakness, leading to physician orders for urinalysis and C&S testing. Macrobid 100 mg (an antibiotic that fights bacteria in the body) oral capsule 100 mg (milligrams), twice daily was prescribed the same day. A review of a facility form entitled Newly diagnosed Infection Report dated December 3, 2024, completed by the Director of Nursing (DON) indicated a diagnosis of UTI; the resident was transferred to the ER (emergency room ) and returned on Macrobid 100 mg orally twice daily for 7-days. However, the Revised McGeer's Criteria for Infection Surveillance Checklist form was incomplete and did not provide evidence supporting the UTI diagnosis. Further review of physician's orders dated December 4, 2024, at 5:51 PM, revealed an order for Rocephin (ceftriaxone sodium an antibiotic administered via injection and used to treat many kinds of bacterial infections) Sodium Injection Solution Reconstituted, inject 1 gm (gram) intramuscularly two times a day related to UTI until December 9, 2024, at 1:00 PM. Additionally, physician's orders were obtained on December 4, 2024, at 9:27 PM, to discontinue IM Rocephin and change to IV (intravenous therapy is a medical technique that administers fluids, medications, and nutrients directly into a person's vein) Rocephin Solution Reconstituted 1 gm (gram) intravenously every 12 hours for infection related to UTI. A review of culture results dated December 6, 2024, at 7:59 AM, revealed Resident 34's final urinalysis and C & S results that were 80,000-90,000 CFU/mL of E. coli (is bacteria from the intestines is present in fecal matter and trace amounts of fecal matter make their way into the urinary tract through the urethra opening and begin to multiply).Despite this, the 72-Hour Antibiotic Time-Out form indicated the resident did not meet McGeer's criteria for antibiotic treatment. The resident received two doses of Macrobid, one dose of intramuscular (IM) Rocephin, and four doses of intravenous (IV) Rocephin without documented evidence of clinical necessity. During interviews on January 16, 2025, at 10:30 AM, the IP and the Nursing Home Administrator (NHA) confirmed the prescribing physician and staff failed to ensure adherence to prescribing guidelines, and nursing staff inconsistently completed the surveillance checklist. During an interview on January 16th, 2025 at 11:05 AM, the nursing home administrator (NHA) confirmed the facility failed to ensure adherence to antibiotic prescribing criteria for Residents 14 and 34. This failure resulted in the administration of unnecessary medications, inconsistent completion of infection surveillance documentation and non compliance with the established guidelines for the prevention of unnecessary medication use. 28 Pa. Code 211.2 (3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa. Code 211.12 (d)(1)(3) Nursing Services 28 Pa. Code 211.5 (f)(ix) Medical records

Based on a review of clinical records and select facility investigative reports and resident and staff interview it was determined that the facility failed to consistently provide care and services to prevent the development and promote healing of pressure sores for one of 12 residents sampled (Resident 21). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that 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. A review of the clinical record revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses to include diabetes and urinary retention, with a foley catheter (a flexible tube inserted into the bladder to drain urine into a collection bag). A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident was moderately cognitively impaired with a BIMS score of 19 ( Brief interview for Mental Status score is a test which is used to evaluate a person's cognitive status, a score of 8-12 indicated moderate cognitive impairment), required assistance for activities of daily living and was at risk for developing pressure sores. A review of a facility investigation report dated August 19, 2024, at 10:30 A.M. revealed, on August 18, 2024, at 10:30 A.M., during a resident bath, Employee 3 Nurse Aide (NA) noted Resident 21, developed a 2cm-by-2cm open area on the right labia and an excoriation in the vaginal area presumed by Employee 3 to be caused by the Foley catheter tubing rubbing against the area. The skin finding was reported to Employee 4 a licensed practical nurse (LPN) The intervention put into place at that time including included alternating the Foley catheter tubing between the right and left legs daily. However, there was no evidence provided at the time of the survey that this intervention was consistently documented or implemented. Despite these measures, the facility failed to prevent the development of further pressure related skin issues. A review of a facility investigation report dated October 9, 2024, at 7:30 P.M., Employee 7 (NA) identified a blister on resident 21's right inner thigh presumed to be caused by pressure from the Foley catheter. Employee 7 (NA) placed a disposable washcloth between the residents foley catheter tubing and the blister and reported the blister to the nurse. The Physician was contacted, and new orders noted for skin prep (a skin barrier) to be applied every shift. A review of a skin assessment dated [DATE], at 1:54 A.M. revealed, the outer labia was slightly excoriated, the skin was red and intact. An intact blister measuring 1 cm x 0.4 cm was present on the right inner thigh. The presumed cause was noted as pressure from the foley catheter tubing. Preventative measures in place at the time the blister was discovered included alternating the Foley catheter tubing from the right leg to the left leg daily and ensuring a protective barrier was consistently placed between the residence skin and the catheter tubing. However, there was no evidence these measures were consistently implemented as required. This failure to follow established preventative interventions contributed to the development of additional pressure related skin issues. To address this issue staff was reeducated to ensure that all preventative measures and interventions were consistently implemented and documented to prevent further complications. A review of facility investigative documentation dated November 15, 2024, at 12:00 AM revealed Employee 5 identified blood the resident's peri area while assisting her with care. Employee 6 an agency RN assessed the resident and noted. The resident had bleeding from her vaginal area and there were scratches to both her right and left labia. The resident reported itching and scratching in that area. The presumed cause of the skin issue was from the resident's scratching in the area. Despite prior preventative measures to alternate the catheter tubing and use of protective layer, there was no evidence these measures were consistently followed. There was no evidence provided at the time of the survey that interventions to prevent pressure sores for Resident 21 including alternating the foley catheter tubing from the right leg to the left was documented as completed. There was no evidence at the time of the survey that effective interventions were put into place to prevent continuing pressure areas related to the residents foley catheter tubing. During an interview on January 16, 2025, at approximately 11:00 AM the director of nursing (DON) was unable to provide documented evidence the facility had implemented timely interventions and treatment to prevent the continued pressure areas related to the foley catheter tubing. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing service

Based on a review of clinical records and select facility policy and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by five of 13 sampled residents (Resident CR1, 9, 3, 10 and 20). Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed February 2023, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic steward ship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. There was no evidence at the time of the survey ending March 7, 2024, of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on August 15, 2023, included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections. According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests. There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections. Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, lifelong. A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid. There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE] with diagnosis to include a history of urinary retention and a history of urinary retention. A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity. The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, prophylaxis (to prevent UTIs) with no stop date. Admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections. A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, but no date or time indicated on the form. The Physician documented ok on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID. An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria). Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs. A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was currently taking Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year. A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily. A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily. The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily. During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by mouth daily and no dose reduction was completed until November 3, 2023. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time. A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures. A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg. A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, the state is requiring followup for MRSA in the spine. {Resident 10} was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for ??. ( no reason noted). Labs ordered, Infectious disease follow up not needed. There were no additional recommendations on the form. There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline. A review of the clinical record revealed that Resident 3 was admitted into the facility on [DATE], with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection). A review of record titled Newly diagnosed Infection Report dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound). A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site. A review of a record titled Weekly Skin Documentation Flowsheet from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy. A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily. There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024. During an interview March 7, 2024 at 1 P.M., the Director of Nursing confirmed that the facility did not implement protocols to monitor antibiotic use that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and a facility-wide system to monitor the use of antibiotics. Refer F757 28 Pa. Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 211.2 (d)(3)(5)(10) Medical director 28 Pa. Code 211.10 (a)(d) Resident Care Policies

Based on observations, clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 13 residents sampled (Residents 8 and 30). Findings include: A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired. Further review of Resident 8's clinical record revealed that the resident exhibited multiple behaviors, including physical aggression with staff and medication and treatment refusals. Resident 8 refused medications on an almost daily basis, throughout the months of January 2024, through end of the survey March 07, 2024, according to a review of nursing progress notes. Review of Resident 8's care plan, initiated by the facility on February 24, 2023, indicated that the resident has behavioral problems. Review of care plan interventions revealed an intervention seek MD/psych consult, as needed, for medication and behavioral management. When reviewed during the survey ending March 7, 2024, the resident's clinical record revealed no documented visits from psychological services and no indication that the resident's physician had been notified of the resident's almost daily refusal of medications. Review of the clinical record revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and opioid dependence (dependence occurs when an opioid drug is used for more than six months to manage pain associated with a medical condition). An admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) A review of the resident's current behavioral care plan dated January 6, 2024, revealed that the resident requires psychosocial interventions for bipolar disorder, opioid dependence, and pain. The planned interventions for the resident's behaviors included seeking physician/psychological consult, as needed, for medication and behavioral management. An interview with Resident 30 on March 5, 2024, at 10:05 AM revealed that the resident has not received any psychological services since admission to the facility. The resident stated that her psychiatrist retired a few years ago and she has not been able to find another doctor. She stated that her previous psychiatrist prescribed her Neurontin and Ativan, medications, for her bipolar disorder and anxiety, which seemed to help her. She stated that she has been having increased anxiety especially prior to going to wound care to have debridement (a procedure to remove debris, infected/dead tissue from a wound) treatments during her stay at the facility. The resident stated that she has mentioned her concerns to several staff members without any resolution to date. There was no documented evidence that the facility had developed and implemented individualized interventions related to the resident's diagnosed conditions, including psychological services and community substance use services, as noted in the resident's behavioral health care plans. During an interview with the Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM confirmed that Resident 30 had not received any psychological services since admission to the facility. During an interview with the Nursing Home Administrator (NHA), on March 7, 2024, at approximately 10:00 a.m., the NHA was unable to provide evidence that Residents 8 and 30 were being provided the necessary behavioral health services. Refer F561 28 Pa. Code 211.10 (d) Resident care policies

Based on review of clinical records, and staff interview, it was determined that the facility failed to timely consult with the resident's physician regarding the potential need to alter treatment due to repeated refusals of medication administration prescribed for one resident out of 12 sampled (Resident 8). Findings include: A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired. Nursing notes dated between January 1, 2024, through the end of survey March 7, 2024, revealed Resident 8 was refusing at least one prescribed medication on a daily basis. There was no documented evidence that the facility had consulted the resident's attending physician regarding the resident's repeated and ongoing refusal of prescribed medications, which was confirmed during interview with the Director of Nursing on March 7, 2024, at approximately 12:50 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on review of clinical records, the facility's infection control data, clinical records and the facility's infection control policy it was determined that the facility failed to develop and implement infection control procedures for tracking and managing chronic infections as evidenced by four of 13 residents sampled (Residents 10, 9, 20, CR1) Findings include: A review of the facility's current infection control policy dated as reviewed by the facility February 24, 2024, revealed that it is the policy of the facility will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The objectives to include, to maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual agreement based upon the facility assessment conducted according to and following accepted national standards. A review of facility infection control logs dated from July 2023 through February 2024 revealed that there were four chronic infections treated by ongoing antibiotics among residents of the facility. These logs did not include any attempt to monitor the need for the ongoing use of the antibiotic medications, including evidence that these specific lifelong or chronic infections were reassessed and tracked to determine the need for ongoing antibiotic usage. A review of the facility's infection data dated July 2023 through September 2023, and September 2023 through February 2024 revealed that Residents 10, 9, 20 and CR1 had chronic infections which were identified in the facility's infection data each month. There was no evidence of re-evaluation or scheduled monitoring for these residents identified with chronic infections to evaluate the effectiveness and continued appropriateness of continued prophylactic antibiotic therapy. There was no descriptive information on the resident listings to include diagnostic criteria used. There was no data indicated on the monthly infection control logs indicating periodic assessment or evaluation of any of the four residents on the logs with lifelong/chronic infections requiring daily administration of antibiotic therapy to prevent infections. Interview on March 6, 2024, at 10 AM with the facility Infection Control Nurse confirmed that the facility's current infection control program did not include procedures to address those residents diagnosed with lifelong/chronic infections and clinical criteria to be used to determine best practices for treatment and any monitoring or surveillance related activities that may be required. Refer F881 28 Pa Code 211.10 (a)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(5) Nursing services

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for six of 13 residents sampled (Resident CR1, 3, 9, 10, 20 and 30). Findings included: Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE] and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on August 15, 2023, included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections. According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests. There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections. Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, lifelong. A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid. There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE] with diagnosis to include a history of urinary retention and a history of urinary retention. A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity. The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, prophylaxis (to prevent UTIs) with no stop date. Admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections. A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, but no date or time indicated on the form. The Physician documented ok on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID. An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria). Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs. A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was currently taking Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year. A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily. A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily. The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily. During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by mouth daily and no dose reduction was completed until November 3, 2023. Clinical record review revealed that Resident 10 was admitted to the facility on [DATE], with a diagnosis of osteoarthritis. A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time. A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures. A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg. A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, the state is requiring followup for MRSA in the spine. {Resident 10} was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for ??. ( no reason noted). Labs ordered, Infectious disease follow up not needed. There were no additional recommendations on the form. There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline. A review of the clinical record revealed that Resident 3 was admitted into the facility on [DATE], with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection). A review of record titled Newly diagnosed Infection Report dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound). A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site. A review of a record titled Weekly Skin Documentation Flowsheet from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy. A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily. There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024. A review of the clinical record revealed that Resident 30 was readmitted into the facility on [DATE], with diagnoses including MRSA infection, chronic venous hypertension with ulcers and local infection of skin and subcutaneous tissue. A review of record titled Newly diagnosed Infection Report dated October 13, 2023, revealed that there were new orders for Ceftin (antibiotic medication) 500 mg by mouth twice daily for 10 days and Rifampin (antibiotic medication) 300 mg by mouth twice a day for 10 days to treat MRSA in wounds. A review of the undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the SSTI met McGeer's criteria by having symptoms of fever (oral temperature greater than or equal to 100.0 degrees Fahrenheit), heat, redness and serous (clear to yellow fluid that leaks out of wound) drainage at the infected site. Further review of the clinical record revealed the resident's temperature was 97.0 degrees Fahrenheit on October 13, 2023, and there was no documentation of this resident having a fever, failing to meet the McGeer criteria for infection. A review of laboratory test results for culture and sensitivity of left ankle wound dated October 13, 2023, at 7:54 AM revealed that the identified organism was resistant to the prescribed Cefuroxime Axetil (Ceftin). A review of the resident's October 2023 MAR revealed that the resident received Ceftin 500 mg by mouth twice daily for 10 days receiving 20 unnecessary doses. A review of record titled Newly diagnosed Infection Report dated December 31, 2023, revealed that there were new orders for one dose of Vancomycin (antibiotic medication) 500 mg by mouth and one dose of Septra DS (antibiotic medication) for Escherichia coli ([E. Coli] bacteria that produces powerful toxins), extended-spectrum beta-lactamases ([EBSL] enzymes that confer resistance to most beta-lactam antibiotics) Enterobacter (a serious infection known to cause infections affecting parts of the body) and MRSA. Also, a new order to send the resident to the emergency department (ED). A review of undated Revised McGeer Criteria for Infection Surveillance Checklist revealed that the resident had heat, redness, swelling and tenderness at the affected site. There was no documentation provided showing evidence that the SSTI criteria was met. There was no corresponding physician documentation to indicate the clinical necessity of initiating antibiotic treatment to treat the resident's suspected SSTI. A review of the resident's December 2023 MAR revealed that the resident received Vancomycin 500 mg by mouth one dose and Septra DS by mouth one dose receiving 2 unnecessary doses. Consultation Notes from the hospital dated January 1, 2024, at 11:08 AM, revealed that the resident was admitted for an infectious disease consultation secondary to venous stasis ulcers. Wound cultures dated December 27, 2023, revealed MRSA plus EBSL E. coli. In summary, there is no cellulitis (bacterial infection of the skin), the wounds have colonized multidrug-resistant organisms ([MDRO] bacteria that resist treatment with more than one antibiotic) due to being in and out the hospital and long-term care facilities. At this point all antibiotic therapy should be discontinued. During an interview March 7, 2024 at 10 A.M, the Director of Nursing (DON) confirmed that the above noted residents were not free from unnecessary medications (antibiotics). Refer F880, F881 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.2 (d)(3)(5) Medical director 28 Pa. Code 211.5 (f) Medical records

Based on a review of clinical records and staff interview it was determined that the physician failed to act on a drug irregularity the pharmacist identified in the drug regimen of one resident out five of sampled residents (Resident 4). Findings include: A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of anxiety disorder, depression, and delusional disorder. A monthly pharmacist medication review dated on May 20, 2023, revealed that the pharmacist identified that the need for Resident 4's attending physician to evaluate the use of opioids prescribed for chronic pain greater than six months. The pharmacist noted that the resident was prescribed an opioid pain medication, Tramadol, 50 mg three times per day for pain since April 25, 2022, and recommended that the physician evaluate/reduce routine analgesic therapy with Tramadol with an end goal of discontinuation when the cause of pain had resolved, or the clinical status had changed. The resident's attending physician failed to act upon the the identified drug irregularity and did not respond to the identified drug irregularity of Resident 4's continued use of an opioid analgesic medication for pain. A pharmacist medication review dated June 10, 2023, indicated that Resident 4 was prescribed Duloxetine [(Cymbalta) a medication used to treat depression and anxiety] 20 mg by mouth daily for depression since June 2022 and recommended that the attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. The attending physician failed to act on the drug irregularity in the resident's medication regimen of the lack of a GDR during the first year in which a resident was prescribed a psychopharmacological medication. A pharmacist monthly medication review dated July 23, 2023, indicated that the resident was prescribed Quetiapine [(Seroquel) a psychotropic medication used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder] 75 mg by mouth in the morning and 50 mg by mouth at bedtime for diagnosis of delusional disorder since July 2020 and recommended that the attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. The attending physician failed to act on the pharmacist's identified drug irregularity of the lack of attempting a GDR of an antipsychotic medication, Seroquel. An interview with the Director of Nursing (DON) on March 7, 2024, at 9:15 a.m., confirmed that Resident 4's attending physician failed to act on the irregularities identified in Resident 4's drug regimen. Refer F758 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.2 (d)(3)(8) Medical Director.

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely assess declines in skin integrity, consistent with professional standards of practice, for for two residents out of 13 sampled residents with pressure ulcers (Residents 15 and 27). Findings include: According to Title 49 Chapter 21 49 Pa. Code S 21.145. Functions of the LPN S 21.145. Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and the patient ' s health care team members to seek guidance when: (i) The patient ' s care needs exceed the licensed practical nursing scope of practice. (ii) The patient ' s care needs surpass the LPN ' s knowledge, skill or ability. (iii) The patient ' s condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance. (2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures. (3) An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act. Resident assessment is outside the scope of an LPN. However, at the time of the survey ending March 7, 2024, the facility was utilizing an LPN to conduct resident pressure wound assessments. A review of a facility policy entitled Pressure Sore Strategies and Treatments that was reviewed by the facility on January 24, 2024, indicated that documentation was to include weekly assessment and charting. The assessment is to include the specific skin problem, location, wound characteristics and drainage. Review of Resident 15's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included hypertension (high blood pressure), type II diabetes (is a condition results from insufficient production of insulin, causing high blood sugar), and shortness of breath. Resident 15's plan of care initiated on October 19, 2021, at 7:58 a.m., identified that the resident was at risk for developing skin breakdown due to comorbidities (more than one illness at once) with planned interventions that included to document changes in skin condition and report to charge nurse, encourage turning and repositioning, and to apply treatments to areas as ordered. A physician order dated August 16, 2023, was noted for Silver Sulfadiazine 1% Cream [(Silvadene) a medication used with other treatments to help prevent and treat wound infections in patients with serious burns], apply topically to the bilateral buttocks prophylactically. A review of a Wound Assessment Report completed by Employee 1, a licensed practical nurse (LPN) and facility's wound care nurse, dated January 10, 2024, revealed that Resident 15 had a new wound, sheering (skin impairment caused by pulling that creates stress on the soft tissue layers (fat and muscle) and could lead to a tearing of the tissue depending on how high the shearing force becomes) to the sacrum that was originally identified on January 7, 2024. Employee 1 noted that the area was to the whole sacral area with skin peeling off and indicated that the resident wanted to be pulled up in the bed causing friction. The area was cleansed, Silvadene (medication is used with other treatments to help prevent and treat wound infections in patients with serious burns) was applied as per TAR (treatment administration record), and no signs or symptoms of infection and that the area would be monitored weekly. Resident 15's clinical record weekly Wound Assessment Report completed by Employee 1, dated January 31, 2024, revealed that the resident continued to have sheering to the coccyx area and no drainage and to continue with Silvadene and monitor weekly. A review of a new wound assessment report completed by Employee 1, dated February 14, 2024, revealed that a new pressure ulcer was identified on February 12, 2024, to Resident 15's right great toe that was indicated to be an unstageable due to suspected deep tissue injury. Employee 1 noted that the resident continued with a red area to the right great toe that measured 0.6 cm in length by 1.0 in width and no signs or symptoms of infection. Bed cradle applied to bed and keep blankets and all pressure off toe and will monitor until healed. Resident 15's clinical record failed to reveal that a registered nurse (RN) timely assessed the newly identified to the sacrum and right great toe and that the identified areas were assessed as per professional nursing standards that included measurements or description of the area, and that weekly wound monitoring was completed. Additionally, the clinical record failed to reveal that the resident's attending physician was timely notified of the new areas and that the resident's care plan for skin breakdown was reviewed and revised for adequacy and continued appropriateness to promote healing and prevent further skin impairments. A review of Resident 27's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pain. A review of a nursing progress note completed by Employee 2, a LPN, dated February 15, 2024, at 9:37 a.m., revealed that Resident 15 had a new reddened area to his left second toe that measured 0.5 cm in length by 0.3 cm in width with and skin prep applied, family aware. Further review of Resident 15's clinical record weekly wound assessment completed by Employee 1, LPN, dated February 28, 2024, at 10:27 a.m., revealing that the reddened area to his left second toe was now an unstageable area [underneath the discolored surface, this ulcer could be as deep as a stage 3 or stage 4 wound and may also form as a blood blister or be covered with eschar (a dry, dark scab or falling away of dead skin)] that measured 0.5 cm in length by 0.4 cm in width, non-blanchable, with a white center and tender to touch. No signs or symptoms of infection and to continue with skin prep and monitor weekly and as needed until heeled. Resident 15's clinical record failed to reveal documented evidence that a RN assessed the resident's skin impairment to his left great toe and failed to reveal that the facility had promptly reviewed and revised the resident's care plan to assure effective interventions to maintain/improve skin integrity. An interview with the facility's Director of Nursing (DON) on March 6, 2024, at 11:25 a.m., revealed that new pressure injuries and/or skin impairments should be immediately assessed and their origin investigated to plan care accordingly. The DON confirmed that the facility failed ensure timely assessment of newly identified skin impairments by a registered nurse and assessment of healing progress by a registered nurse. 28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued dose of an antipsychotic drug prescribed for one resident out of five sampled (Resident 4) and failed to attempt a gradual dose reduction of the antipsychotic drug. Findings include: A review of Resident 4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included anxiety disorder and delusional disorder. The pharmacist conducted a medication review on July 23, 2023, that indicated that the resident had been receiving the antipsychotic drug Quetiapine (Seroquel - a psychotropic medication used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) 75 mg by mouth in the morning and 50 mg by mouth at bedtime for diagnosis of delusional disorder since July 2020. The pharmacist requested that the resident's attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record. At the time of the survey ending March 7, 2024, there was no documentation from the physician to support the lack of attempts at a gradual dose reduction of Resident 4' dose of the antipsychotic drug. An interview with the Director of Nursing (DON) on March 7, 2024, at 9:30 a.m., confirmed that the facility could not provide documented evidence Resident 4's attending physician had documented individualized clinical rationale for Resident 4's ongoing need for the current dosage of Seroquel and the physician had not attempted a gradual dose reduction. 28 Pa. Code 211.2 (d)(3) Medical Director. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.9 (k) Pharmacy services.

Based on clinical record and select policy review and interview with facility staff, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for of one resident out of 13 sampled (Resident 7). Findings included: Review of a facility policy entitled Urinary Catheterization care and maintance reviewed February 24, 2024 indicated that, the purpose of urinary catheterization is to facilitate urinary drainage when medically necessary. Urinary catheters should be evaluated every day for the need and removed promptly when no longer necessary. a. On admission to the skilled nursing facility, a resident will be assessed for need for catheterization based on a list of acceptable clinical justification to include, urinary retention that cannot be otherwise teated; The resident is unable to pass urine due to an enlarged prostate; need for accurate output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring; Assistance for the healing of coccyx and sacral wounds stage 3 or greater; comfort or palliative care, if requested by the resident. b. If a resident is catheterized on admission to the facility and does not present with a clinically justifiable reason for catheterization, then the nursing staff will contact the attending Physician either to obtain written clinical justification for the catheter use or an order to remove the catheter. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses to include atrial fibrillation, heart failure and an indwelling foley catheter. Admission physicians orders dated December 11, 2023, included an indwelling foley catheter, 16 fr, 10 cc balloon and 1800 cc fluid restriction. A review of a facility form, entitled clinical justification for foley catheter dated December 11, 2023 revealed Urinary catheters are deemed medically necessary for the following reason in the facility: Need for accurate hourly output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring. The form was signed by the resident's attending physician. A review of the residents admission urinary continence evaluation dated December 21, 2023 revealed that the resident was continent of urine. The evaluation findings dated December 21, 2023 indicated that the resident remains continent and incontinent of bowels with a 16 fr/10 cc balloon foley catheter. Will start routine toileting (for bowels) at this time. Monthly physician progress notes dated January 2024 and February 2024 failed to address the ongoing clinical necessity for continued use of the indwelling foley catheter. A review of fluid intake documentation dated December 11, 2024, to the time of the survey ending March 7, 2024, revealed that the facility staff documented the resident's daily intake per shift. There was no indication that the resident's hourly urine output was being monitored and documented as noted on the clinical documentation for the foley catheter. The DON confirmed during interview on March 7, 2024, that there was no physician documentation to clinically support the use of the indwelling Foley catheter for accurate hourly urine output measurement for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring. 28 Pa. Code: 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.10 (a)(c)(d) Resident care policies

Based on resident and staff interviews and review of clinical records, it was determined that the facility failed to ensure that residents are afforded the right to make choices about aspects of their lives that were significant to them, including medication treatment options, for one resident out of 13 sampled (Resident 30). Findings include: Review of the clinical record revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and vitamin deficiency. An admission MDS (minimum data set-federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 17, 2024, revealed that the resident was cognitively intact with a BIMS (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 14. Interview with Resident 30 on March 5, 2024, at approximately 9:45 AM revealed that the resident stated that she has been requesting specific medications that she had received in the past. She stated that she was prescribed Neurontin for bipolar disorder by her psychiatrist in the community and that she felt as though she was doing much better when receiving that medication. The resident mentioned that she has been experiencing increased anxiety, especially prior to going for debridement treatment on her wounds, and in the past she would receive the antianxiety drug Ativan, as needed, which she no longer receives. The resident also expressed concerns that she was no longer taking vitamin D and a multivitamin (MVI) supplements. The resident stated that she has voiced these concerns to multiple facility staff members but her concerns have not been addressed. A review of the resident's medication administration record (MAR) for the month of March 2024 revealed that the resident was not current prescribed any the above medications or vitamin supplements that she mentioned during the interview, Neurontin, Ativan, Vitamin D, or multivitamin. An interview conducted on March 5, 2024, at approximately 10:30 AM with Employee 3, a nurse aide, confirmed that the resident has mentioned her medication concerns in the past. She stated that she was unaware of the resident's increased anxiety, but would convey the resident's complaints to the licensed nurse. An interview with Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM revealed that Resident 30 was scheduled to see a behavioral health specialist in the community on April 18, 2024, at 1:00 PM to evaluate the resident's mental health and review the resident's medications. Interview with the Nursing Home Administrator (NHA) and DON on March 7, 2024, at 1:45 PM, confirmed that the facility failed to demonstrate that the resident was timely afforded the right to participate in making choices about health care and treatment options. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 201.18 (e)(1) Management

Based on a review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized fall prevention interventions planned to meet resident's safety and supervision needs based on known risk factors, history of falls and displays of unsafe behaviors to prevent falls for two residents (Resident 10 and 33) resulting in a serious injury, a fractured hip, to one resident (Resident 10) and failed to maintain an environment free of potential accident hazards in one resident's room (Resident 26) out of 13 sampled residents. Findings include: The facility policy entitled Falls dated as reviewed March 29, 2023, indicated that a care plan will be developed to address the resident's specific factors which may contribute to the resident's risk for falls. At the beginning of each shift, all nurse aides will participate in walking rounds where they will also check to be sure safety alarms are in place and functioning appropriately. If a resident should sustain a fall, the resident will be re-evaluated by the Physical Therapist for new recommendations to prevent further falls. Review of Resident 10's clinical record revealed admission to the facility on [DATE], with diagnoses to have included senile dementia [is a group of symptoms that affects memory, thinking and interferes with daily life], anxiety, depressive disorder, and general deconditioning. The resident's care plan to address the resident's safety needs, initiated on September 3, 2020, indicated that the resident would remain safe and free from falls and injury with noted interventions that included assist of one with transfers, orient to call system as needed, bed to floor - locked in position and bilateral pressure alarm mats and bilateral floor mats. Review of Resident 10's quarterly Minimum Data Set (MDS a federally mandated standardized assessment process completed periodically to plan resident care), dated October 12, 2022, revealed that the resident was moderately cognitively impaired. The resident required extensive assistance of two plus-person physical assistance for bed mobility and transfers and required total dependence of two plus persons physical assist with toilet use. The resident was not steady and only able to stabilize with staff when moving from seated to standing position and with surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident was always incontinent of bladder and bowel. The MDS also noted that the resident had fallen in the last month and had fallen in the last 2-6 months without fracture related to a fall in the last 6 months. A facility Incident Investigation Form dated November 4, 2022, at 7:40 AM, revealed that Resident 10 had an unwitnessed fall in the doorway of her room. Employee 1, a nurse aide, reported that the resident was walking down the hallway and that she helped her to get into her chair. Resident 10 climbed out of her chair and walked towards her room, into the doorway, and fell . The sustained a 4.0 cm x 4.0 cm scrape to her right knee and a 2.0 cm x 2.0 cm bruise on her left lower leg. The planned preventative measure was for the resident not to be left in the hallway near her room and the resident should be either in her room, or the dining/activities room, or by the nurse's station. The investigation form noted that the resident's safety plan of care was updated. There was no indication that therapy performed a re-evaluation after Resident 10's fall on November 4, 2022, as indicated in the facility's Fall policy. Review of Incident Investigation Form dated November 9, 2022, no time indicated, revealed that the resident had a witnessed fall in the dining room. The investigation noted that the witness to Resident 10's fall was Resident 26. Resident was severely cognitively impaired with a BIMS score 6. However, Resident 26 stated that she witnessed Resident 10 slide out of her chair and land on the floor of the dining room. Resident 26 stated that she tried to help Resident 10 get up and off the ground, but she could not help her. Additionally, Resident 26's witness statement indicated that someone picked her up and took her maybe to the bathroom but she did not know the name of the staff member who picked Resident 10 up from the ground. The Incident Investigation Form further revealed that the Director of Activities saw Resident 26 flailing her arms and pacing back and forth and went to investigate the situation. When the Director of Activities arrived at the area where the residents were assembled, at the other end of the activities/dining room, Resident 10 was sitting on the edge of her Geri Chair and presumed that she climbed back into her chair before she arrived at the area and assisted Resident 10 to sit back in her chair to prevent a fall. The Activities Director assumed that Resident 10 was about to fall out of her chair and did not realize that she already had fallen and was getting herself back into her chair when observed. There was no evidence that the resident's chair alarm was in place and sounding. The facility's investigation also noted that the activities aide, that was working on November 9, 2022, at the time Resident 10's fall was on lunch from 1:45 PM until 2:15 PM. There was no evidence of any staff supervising these residents assembled in the dining/activities room, including Resident 10, who was unsupervised at the time of the fall. Review of Employee 2's, Activity Aide, statement dated November 11, 2022, at 9:00 AM, revealed I was on my lunch break at 1:45 PM to 2:15 PM and when I came back at 2:15 PM, Resident 26 told me that Resident 10 fell out of her chair and how scared she was. Employee 2 noted that she asked Resident 10 about the fall and Resident 10 confirmed that she fell out of her chair. Employee 2's statement indicated that the incident happened in the dining/activity room and that Resident 10 did not report any pain until 6 PM that evening when she took the resident to the bathroom. On November 9, 2022, the resident complained that her right leg was bothering her and Employee 2 reported the incident to the charge nurse, Employee 5, a night shift RN. Review of a statement that was completed by Employee 3, a nurse aide, dated November 9, 2022, and signed by the employee on November 12, 2022, revealed that Resident 10 kept telling us she fell earlier. Employee 3 noted that she didn't witness the fall, but when she took the resident to the bathroom around dinner time the resident had more trouble standing and turning to go to the bathroom. The resident told Employee 3 that she had fallen earlier that day and that her leg hurt a little bit. According to Employee 3's statement Resident 10 claimed that she fell on the previous shift and the two girls had picked her up. The resident also stated that one girl had a ponytail and glasses and the other girl she couldn't remember. Employee 3's statement noted that the resident was not in a ton of pain, just said that her leg hurt. Employee 5 contacted the Director of Nursing (DON) at 8:15 PM on November 9, 2023, and reported that she checked Resident 10 over and that there was discomfort to the resident's leg, but the resident was able to lift the leg, and no deformities were noted to the leg. The preventative measure planned was to apply a pressure sensor alarm in the resident's chair. An Incident Investigation Form dated November 10, 2022, (no time indicated) revealed that Resident 10 had an unwitnessed fall in her room the night prior (November 9, 2022 - the same date as the resident's fall in the dining/activity room witnessed by Resident 26) and didn't report the fall to any staff until November 10, 2022, in the afternoon. Resident 10's attending physician assessed the resident and indicated that the resident stated that she had right leg pain and that she had fallen last night and put herself back into bed. Resident 10 was given a PRN (as needed) Tylenol and the attending MD ordered an X-ray of her right hip and femur. There was no indication of any alarms sounding at the time of the resident's reported fall from bed on November 9, 2022, although the resident's care plan identified that bilateral pressure alarm mats were to be placed on the resident's bed and floor mats on the sides of the bed. Review of the radiology report November 10, 2022, at 12:54 PM, revealed that the impression of the x-ray was an acute impacted fracture of the right femoral neck. At that time, Resident 10's attending physician ordered the resident be sent to the Emergency Department. Review of nursing documentation dated November 11, 2022, at 1:20 AM, revealed that Resident 10 was admitted to the acute care hospital and that the resident was to have a pre-op evaluation for repair of the right hip. Review of Resident 10's alarm monitoring records dated November 2022 revealed that the resident had a pressure sensitive alarm in place on the chair and bed, which were noted to be functioning at the time of her two falls on November 9, 2022. Interview with Employee 4, a unit clerk, on April 12, 2023, 1:00 PM, reported that Resident 10 had alarms in place prior to her falls on November 9, 2022, and prior to sustaining the fracture. Employee 4 confirmed that the facility's alarm records reflected that staff documented alarms were already in place and functioning at the time of the resident's fall. Employee 4 was unable to explain why the incident report noted the addition of a chair alarm on November 9, 2022, since it was already care planned and documented as in place. During an interview with the Nursing Home Administrator (NHA) on April 12, 2023, at 2:23 PM, it was revealed that the facility was unable to determine which staff members, if any, were in the dining/activity room supervising the residents at the time of Resident 10's fall from her chair in that area on November 9, 2022. The NHA confirmed that the facility failed to ensure supervision of a resident with a history of falls to prevent a fall with major injury, a fracture. Also, the NHA reported that based on the information gathered and staff statements obtained regarding Resident 10's two falls on November 9, 2022, the facility was not able to identify the staff members who may have assisted the resident back into her chair when she was on the floor in the dining/activity room and whether an alarm was present on the resident's chair at the time as noted on the alarm monitoring records. The NHA also verified that the facility failed to re-evaluate Resident 10 after each fall as indicated in the facility's Fall policy. Clinical record review revealed that Resident 33 was admitted to the facility on [DATE] with diagnoses to include after care following a fracture. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status a tool used to screen and identify the cognitive condition of residents) and was independent for transfers, locomotion and toileting. A review of a facility incident investigation report dated March 16, 2023 at 12:40 P.M. revealed that staff observed Resident 33 in the hallway outside her room. Employee 5 (RN unit manager) heard Resident 33 yell out and fall to the floor, hitting her elbow. Employee 5 assessed the resident and helped the resident back to her bed. The resident was instructed to be more careful when walking. The resident, when interviewed, stated there was a chair in the hallway for me to sit on. When I was walking to the chair, I was holding onto the door and then the handrail, but the floor in my room and the hallway was so slippery that I fell . I had these socks (non-skid) on and still fell on my butt and hit my elbow. The facility investigation noted that the floor of Resident 33's room was found to be very dirty and slippery and outside of the resident's room, a slippery residue was found on the floor. The non-skid socks the resident wearing at the time of the fall were found to be worn and were replaced after the fall. A review of nursing documentation dated March 16, 2023 at 9:23 P.M. revealed, Resident 33 complained of right pelvic pain. She was noted to be very unsteady on her feet, her knees were buckling. The physician was notified and bilateral hips and pelvis xrays were ordered and completed. There were no fractures noted at that time. There were no additional interventions developed or implemented at that time to prevent falls to address the resident's unsteadiness during ambulation. A review of a nurses note dated March 17, 2023, at 9:21 P.M. revealed, Resident 33 was walking poorly, needed assistance to walk. A review of an incident report dated March 19, 2023, at 10:20 A.M. revealed Resident 33 was self ambulating to the bathroom. ( The bathroom is located across the hallway from the resident room. It is a communal resident bathroom) The resident began yelling out and her roommate rang her call bell. Employee 6, a nurse aide, stated that she went into the bathroom and found Resident 33. Resident 33 stated that she fell in the doorway of the bathroom while trying to get back to bed. The resident stated that she was able to get up from the floor and sat back on the toilet. Employee 6 called the licensed nurse who assessed the resident. Resident 33 was complaining of right knee and right hip/pelvis pain. Resident 33 was noted with unsteady ambulation. Upon assessment, the resident's right knee was reported with swelling and she was complaining of discomfort. The Physician was called and the resident was sent to the emergency room . A review of an xray report dated March 19, 2023 revealed, subtle nondisplaced fractures of the right sacral area and right pubic bones, but no acute fracture. New interventions planned after this fall were a therapy evaluation for transfer and ambulation status. There was no evidence at the time of the survey that interventions were implemented after the resident's March 16, 2023, fall and observed unsteadiness and difficulty ambulating on March 17, 2023, to include a therapy screening or evaluation for ambulation as noted in facility policy. Staff observed that Resident 33 exhibited unsteady ambulation and transfers and the resident incurred another fall 3 days later. During an interview March 13, 2023 at 11 A.M., the Director of Nursing confirmed that the facility failed to ensure the resident's non-skid socks were in good condition and not worn/threadbare, and that the resident was not timely referred to therapy for ambulation screening, as noted in facility policy, following the resident's fall on March 16, 2023, and prior to the resident's fall on March 19, 2023, which the resident also incurred while ambulating. Observation of resident room [ROOM NUMBER] on April 11, 2023, at 10:40 AM revealed that Resident 26 presently resided in the bed located by the door of this room. Resident 26, the resident assigned to the bed by the door, was fully ambulatory, but not present in the room at the time of the observations. Continued observation revealed that maintenance/hardware supplies were observed on the overbed table and unoccupied bed located by the window, on the window sill, and the floor of resident room [ROOM NUMBER]. On the overbed table, there was a glass framed wall plate with a side of the glass exposed, 4 white pieces of wood with loose screws, a black basket, and a white cable with ends exposed. There was a long piece of wooden wall molding on top of the unoccupied bed. On the window sill there were 4 metal shelf brackets, hard plastic baseboard molding, and a plastic outlet wall cover. On the floor beside the unoccupied bed there were pieces of grey plastic baseboard molding. Interview with the Nursing Home Administrator on April 12, 2023, at approximately 11:00 AM confirmed that the maintenance items left unattended in resident room [ROOM NUMBER] were a potential accident hazard to Resident 26, the ambulatory resident currently residing in that room. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies 28 Pa. Code 207.2 (a) Administrator's responsibility 28 Pa. Code 211.11 (d)(e) Resident care plan

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of the current facility policy entitled Policy for Dating Leftovers and Dairy Products indicated that all leftovers will be put in containers or plastic bags and dated and then used within 72-hours. Dry storage area, walk-in coolers and walk-in freezers, and coolers will be checked and logged for cleanliness and for dating of items at the beginning and at the end of operation by the supervisor or designee. Review of the current facility policy entitled Container Policy: Resident Food Storage indicated that resident items are to be placed in a closed container and the container will be labeled with the resident's name, date, and room number. Perishable food will be kept in the unit refrigerator no longer than consumably desirable, as determined by the nursing staff. Observation in the reach-in tray line refrigerator that there was a stainless-steel pan of cherry fruited gelatin that was dated [DATE], and scheduled for service on [DATE], and on [DATE]. The food service manager stated that the prepared item should be discarded in 3-days and confirmed that the fruited gelatin should not be served on [DATE] (> 3-day). Observation in the tray line cooler revealed that there was a deep stainless pan of lettuce and 7 containers of foods intended for the salad bar, which were not dated. There were three plastic clamshell containers of scones that were not dated. There were three shallow trays (one pizza, one brussels sprouts, and one with potatoes) that were not dated and a half shallow stainless pain that contained cherry gelatin that was uncovered and open to air. Observations in the walk-in dairy cooler revealed a 5 lb. container of cottage cheese that was opened and dated [DATE]. The manager confirmed the container should have been discarded. Observations of the dry storage area revealed a garbage can with trash inside that did not have a lid to cover the trash. In the area that housed snacks and cases of canned soda, there was a bucket on the top shelf of a wired rack and placed underneath an open ceiling tile that exposed a repaired broken pipe. The dietary manager stated there was a broken sewage/waste disposal pipe and that it was repaired and that the bucket was placed there in case of another break. Observation of the area that housed dietary's paper products revealed that there were several cases of product stored too close to the ceiling. Observation of the walk-in produce cooler revealed that there was a 12.84-ounce bottle of balsamic glaze that was not dated Observation revealed an accumulation of dust in the light fixture and vent grates with cobwebs present on the hood above the stove. The ceiling fan inside of the dish room had an accumulation of dust and debris. During an observation of the unit pantry area on [DATE], at 10:55 AM, revealed that the following concerns were identified: there was a container of cheesecake that was dated [DATE], (expired by 20-days), a jar of nacho dip that was not labeled or dated, an open jar of cheese dip that was not labeled or dated, a packet of sour cream with a manufacturer's expiration date of [DATE] (expired by 4-days), and a quart of half and half with a listed expiration date of [DATE]. A significant build-up of ice crystals was observed in the freezer and there was a package of frozen pizza that had significant ice crystals inside of the packaging and was not dated. Interview with the Nursing Home Administrator on [DATE], at 1:15 PM, confirmed that the dietary department and unit pantry area were to be maintained in a sanitary manner and that food/beverages should be stored in a sanitary manner. 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa Code 211.6(c) Dietary services

Based on observations and clinical record review it was determined that the facility failed to ensure that residents were free of chemical restraints used to most readily control resident behavior for one resident out 13 sampled residents (Resident 19). Findings include: A review of the clinical record revealed that Resident 19 was admitted to the facility on [DATE], with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) anxiety and chorea-like movements ( Chorea is a movement disorder that occurs in many different diseases and conditions. Dozens of genetic conditions, autoimmune and infectious diseases, endocrine disorders, medications and even pregnancy can have chorea as a symptom. Treatment is based on cause of the chorea). A significant change MDS Assessment (Minimum Data Set - a federally mandated assessment completed periodically to plan resident care) dated March 27, 2023, revealed that Resident 19 was moderately cognitively impaired and exhibited physical and verbal behaviors. A review of Resident 19's monthly behavior tracking flow records dated August 2022 through April 2023 revealed that the resident displayed behaviors to include anxiety, restlessness, verbal aggression and throwing objects. A review of the resident's current care plan for the resident's problem of behaviors initiated February 20, 2020 revealed that the Resident requires psychosocial interventions, receives Venlafaxine (an antidepressant medication), Buspirone (an antianxiety medication), Xanax ( a benzodiazepine, anxiety medication) and Depakote (an antiseizure medication used as a mood stabilizer). Resident 19 gets frustrated with staff if they do not immediately understand her or know what she wants. She can be needy at times, and occasionally is restless, verbally aggressive, yells and throws objects. Care planned interventions were to administer medications as per physician orders, encourage activity involvement (type of activity preferred by the resident was not identified) and socialization with others, seek Physician/Psychological consult as needed for medication and behavioral management, provide reading material for the resident and provide one on one if needed. A physician order, nurses notes and monthly Medication Administration Records dated from August 26, 2022 through September 12, 2022, revealed that the resident received Klonopin (an antianxiety agent, Benzodiazepines/Anticonvulsant) ODT (dissolves in the mouth) 0.25 mg, one by mouth twice a day. The medication was increased September 12, 2023 to Klonopin (ODT) 0.5 mg in the AM and 0.25 mg at HS (at bedtime). Nurses notes dated November 28, 2022 at 11:19 A.M. revealed that the certified registered nurse practitioner was aware of the resident's increased behaviors and safety concerns. The CRNP discontinued the Klonopin ODT dose of .5 mg in the AM and .25 mg in the PM and ordered the start Klonopin ODT 0.5 mg by mouth twice a day. A review of nurses notes dated December 14, 2022 at 2:41 P.M. revealed The nurse was walking down the hall, observed the resident sitting on the edge of her chair. The chair flipped and she fell to the floor. Nursing assessed the resident and no injuries were noted. Nurses note dated December 14, 2023 at 12:50 P.M. revealed that the nursing notified the CRNP that the resident was displaying continued outbursts and yelling. Nursing noted that Resident 19 continued to throw objects and swearing. The CRNP ordered an increase in the resident's dose of Celexa (an antidepressant medication) to 40 mg by mouth every day and also increased the resident's dose of Klonopin (ODT) to .5 mg, by mouth to three times a day. Resident 19 was admitted to the hospital December 15, 2022, and readmitted to the facility on [DATE]. The order for Klonopin (ODT) .5 mg TID was not re-ordered upon the resident's readmission to the facility. Upon readmission to the facility on [DATE], the physician ordered Buspirone HCL (antianxiety medication) 10 mg tablet, give one by mouth twice daily for anxiety. On January 5, 2023 at 12:30 PM, nursing called the physician to Resident 19's room. Resident 19 was flailing her arms and screaming at staff. Nursing noted that the resident was unable to sit still at that time. Redirection given, food and beverages offered, change of scenery given, one to one preformed. Resident continues to flail and scream at staff. New order noted, Haldol (an antipsychotic medication) 1 mg by mouth, give now and Haldol 1 mg by mouth twice a day. A review of a monthly medication administration record (MAR) revealed that Resident 19 received Haldol 1 mg BID daily from January 5, 2023, through January 18, 2023. A review of nurses notes dated January 18, 2023, at 2:23 PM revealed that nursing noted that Resident 19 continued with agitation, restlessness and the physician was made aware. A new order was noted to discontinue the Haldol and order Depakote ( an antiseizure medication sometimes used as a mood stabilizer) 250 mg by mouth three times a day. A nurse's note dated February 8, 2023 at 9:57 A.M. revealed that Resident 19 displayed increased anxiety and restlessness. Nursing noted that the resident was yelling out and throwing things. Refused meals and liquids this morning due to increased anxiety. Re approached. Dark area provided. Resident taken for a walk. No good effects noted. The physician was notified and a new order noted for Xanax (an antianxiety medication) 0.5 mg, take 2 tabs by mouth now and Xanax 0.5 mg, take 2 tabs by mouth every day. Nursing noted on February 9, 2023 at 2:33 P.M., that Resident 19 displayed increased anxiousness and restless movements this afternoon. Refused lunch. Yelling out. Dark quiet area provided. No good effects noted and the physician was made aware. A new order was noted for Xanax 0.5 mg, give 2 tabs by mouth now. A nurses note dated February 10, 2023 at 2:49 revealed that Resident 19 was extremely agitated and unruly, cussing, flailing her arms and legs. Staff placed the resident in a broda chair. The resident was repeatedly trying to bounce in her chair and get out of her chair. Resident very animated, will not calm down. Nursing noted on February 10, 2023 at 4:36 A.M., that Resident 19 displayed unrelenting episodes of agitation and restlessness with acting out and inability to calm down after repeated measures were tried. Nursing noted that the resident has an indwelling urinary catheter and was provided catheter care. Resident does not appear to understand about the catheter and lack of need to be toileted for urination although this was repeatedly verbalized to her. Resident was put into her broda chair and placed at the nurses station but kept trying to [NAME] herself out of the chair. Nursing called the physician regarding the resident's behaviors and the physician ordered Xanax 0.5 mg by mouth now. Resident 19 was admitted to the acute care hospital and readmitted to the facility on [DATE]. Upon readmission the physician ordered Xanax .5 mg by mouth every 8 hours as needed for 14 days. A pharmacy request to the physician dated February 20, 2023, revealed that the pharmacist requested that the physician re-evaluate the resident's need for Xanax 0.5 mg, every 8 hours by mouth as needed. The physician re-ordered Xanax 0.5 mg every 8 hours as needed every 14 days beginning February 20, 2023. On March 18, 2023, the pharmacist requested that the physician re-evaluate the resident's need for Xanax 0.5 mg, every 8 hours by mouth as needed. The pharmacist noted Please note that renewal of an as needed order requires a physician explaination and documentation. Based on the narcotic order sign out sheet, it may be appropriate to make Xanax a straight order at bedtime. The physician response was noted by the CRNP dated March 22, 2023, noting Xanax changed to straight order at 2 A.M for anxiety disorder. Nurses notes dated March 21, 2023 at 3:58 A.M. revealed that PRN Xanax 0.5 mg tablet given after continuous attempts to calm resident. Nurses notes dated March 21, 2023, at 1:33 PM revealed that the 14 day, as needed, Xanax order was reevaluated by Physician with a new order noted, Xanax 0.5 mg by mouth every day at 2 A.M. There was no documented evidence at the time of the survey of a documented physician evaluation regarding the resident's need for the administration of the Xanax at 2 AM daily. In response to the resident's behaviors nursing staff notified the physician/physician extender and multiple psychoactive medications were ordered and administered to this resident concurrently. There was no documented evidence at the time of the survey that the facility had used the least restrictive alternative for the least amount of time, that the prescribing practitioners had conducted ongoing re-evaluation of the need for the medications and consistently demonstrated these drugs were not used for staff convenience to most readily control the resident's behavior with least amount of staff effort. The facility administered multiple psychotropic drugs including Klonopin, Buspar, Depakote, Haldol, and Xanax to control the resident's behaviors. An interview with the Director of Nursing on April 13, 2023, at approximately 12:00 PM confirmed that the resident's clinical record lacked documented evidence that the staff and prescribing practitioners had identified and addressed to the extent possible, potential underlying causes for the resident's behaviors and had attemped to rule potential causes for the resident's behaviors to include possible physical causes such as pain or potential adverse consequences associated with the resident's current medication regimen or possible environmental factors, such as staffing levels, over stimulating noise or activities, under stimulating activities, alteration in the resident's customary location or daily routine, temperature of the environment, and crowding to ensure the medical necessity of the administration of these psychoactive drugs. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.8 (b) Use of restraints 28 Pa. Code 211.2(a) Physician Services

Based on a review of clinical records, select incident reports and select facility investigative reports and staff and resident interview it was revealed that the facility neglected to provide the care necessary to prevent physical harm, a serious injury, a fractured femur, sustained during an avoidable fall, by one of 13 residents reviewed (Resident 7). Findings include: A review of the clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 7's quarterly (MDS) Minimum Data Set Assessment (a federally mandated standardized assessment tool completed at various intervals to plan resident care) dated May 17, 2021, revealed that the resident was cognitively intact and required extensive assistance of two staff members with all activities of daily living, including bed mobility and transfer. A review of the resident's current comprehensive care plan and Kardex (a desktop file system that gives a brief overview of each patient), in effect at the time of the incident described below, revealed that Resident 7 required the assistance of two staff members for all activities of daily living (ADLs), including transfers and ambulation. A review of a Pennsylvania Department of Health PB-22 report form for investigation of alleged abuse, neglect and misappropriation of property and information submitted by the facility dated June 16, 2021, at 3 PM revealed that on Tuesday June 15, 2021, at 5 PM, Employee 5 (nurse aide), was attempting to transfer Resident 7 from the resident's recliner to the resident's bed with her walker when the resident's leg gave out. Employee 5 lowered the resident to the floor and called additional nursing staff for assistance. The report noted that Resident 7 was in moderate to severe pain, unable to move bilateral (both) lower extremities without significant pain. Her right leg was noted to be externally rotated, cool to touch, weak pedal pulse in the right foot. the residents vital signs were within normal limits. She vomited at that time. The Physician and responsible party notified. The resident was transferred to the hospital. Narcotic pain medication was ordered, [MEDICATION(S)] 60 mg IM (intramuscularly) , [MEDICATION(S)] 2.5/325 mg (oral narcotic pain medication) times 4 pills and [MEDICATION(S)] 8 mg times one dose (an antiemetic medication) all given at the time of the transfer to the hospital. The resident was transferred to the hospital on June 15, 202 at 8:05 PM. The facility's findings of the PB22 investigation report revealed that Resident 7's transfer status was the assistance of two staff. The facility interviewed Employee 5, the nurse aide who transferred the resident without the assistance of another staff member, which revealed that the employee stated that he failed to check his assignment sheet and did not realize that the resident's transfer status had changed. Resident 7's statement regarding the incident also verified that the employee just failed to check (the Kardex or care plan). The facility incident investigation report dated June 15, 2021, at 7 PM revealed that Employee 6 (LPN) stated that resident was found on the floor in her room with {Employee 5} standing behind her, both the resident and Employee 5 NA were leaning against the recliner chair. {Resident 7} was yelling in pain and unable to move her bilateral lower extremities, complaining of severe pain. The resident had vomited. The physician was contacted, the resident was transferred to the hospital for xray and ct scan after lifting with the mechanical lift back into her recliner. A review Employee 5's witness statement dated June 15, 2021, at 7 PM revealed, I was transfering {Resident 7} from her recliner chair to her bed with a walker. We got a foot away from the edge of the bed, when her right leg gave out. Once she wouldn't move anymore, then I slid {Resident 7} down the front of me, where she landed softly on her butt. Once she got to the floor, I gave her oxygen and waited for the other aides to show up to assist her off the floor. The employee's witness statement further indicated that Employee 5 was doing regular adl's, (activities of daily living) getting her ready for bed. The facility's investigation conclusion stated Employee 5 failed to check his assignment sheet and was unaware of Resident 7's transfer status. Employee 5 was relieved of duty and immediately sent home pending facility investigation. A review of a radiology diagnostic report dated June 15, 2021, at 10:34 PM revealed a CT scan (computed tomography scan is a medical imaging technique used in radiology to get detailed images of the body noninvasively for diagnostic purposes) of the right lower extremity. The results of this diagnostic test revealed there is an acute, comminuted (A fracture in which a bone is broken, splintered, or crushed into a number of pieces) distal right femoral (the long bone in the leg) fracture, involving the distal one third femoral diaphysis and supracondylar (the top of the leg, hip) region. The resident required hospitalization and surgical repair of the fracture and returned to the facility on [DATE]. The findings of the facility's investigation concluded that Resident 7 was an assist of 2 staff with all ADLs. The facility concluded that Employee 5 did not check the level of care the resident required in the Kardex or care plan, or ask any other staff about Resident 7's care. Employee 7 admitted to providing care independently without the assistance of other staff and verified that he did not check the resident's Kardex or care plan. The facility's investigation report revealed that Employee 5 was providing care independently to the resident and the employee was suspended. Interview with Resident 7 on September 8, 2021, at 1 PM revealed that the resident relayed that Employee 5 stood her up and was helping her get back to bed by himself. The resident stated that her leg gave out and she fell to the floor. The resident stated that she had a lot of pain. Resident 7 also stated that usually 2 people would transfer her. When interviewed on September 10, 2021, at 1 p.m. the Nursing Home Administrator confirmed that Employee 5 had neglected to provide the care planned for Resident 7 during transfer by failing to ensure the presence of another staff member resulting in an avoidable fall and serious injury to the resident. 483.13 Resident Behavior and Facility Practices 10-1-1998 Edition 28 Pa. Code 201.18(e)(1) Management Previously cited 4/16/19, 3/13/20 28 Pa. Code 201.29(a)(c)(d) Resident Rights Previously cited 3/13/20 28 Pa. Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 4/16/19, 6/19/20, 3/13/20

Based on a review of clinical records, incident investigations and select facility policy and staff interviews it was revealed that the facility failed to timely identify and act upon a change in resident condition, to assure the resident received timely and necessary treatment and prompt medical intervention at level required, which compromised the condition and caused ongoing pain for one resident out of 12 sampled (Resident 20). Findings include: A review of clinical records revealed Resident 20 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (The Minimum Data Set Assessment - a federally mandated standardized assessment process used to plan resident care) dated May 10, 2021 revealed that the resident required the assistance of one person with ambulation. A review of a facility provided incident investigation form revealed that the resident fell on [DATE]. According to this report, the nursing assistant providing the resident's care exited the bathroom door in front of the resident, and as the resident was exiting the bathroom with her rollator walker, she tripped over the threshold of the bathroom floor. The resident's walker was noted to be on her left side. Resident 20 immediately complained of left knee pain. Further review of the resident's clinical record revealed an order dated June 14, 2021, for a CT scan (scan or computed tomography scan is a medical imaging technique used in radiology to get detailed images of the body noninvasively for diagnostic purposes) of the left lower extremity and [MEDICATION(S)] (is a nonsteroidal anti-[CONDITION(S)] drug (NSAID) to reduce pain and inflammation) 30 mg three times a day as needed times 3 days. A review of the CT scan results showed no fracture. A review of nursing documentation dated June 15, 2021, revealed multiple entries on that date indicating that the resident had continued pain with prn (as needed) pain medication (Tylenol 325 mg two tablets once every four hours as needed) administered and the presence of swelling to the resident's left lower extremity. A review of a physical therapy progress note dated June 15, 2021, revealed that the resident had moderate pain and swelling in left anterior knee, had pain when weight bearing, and required moderate assistance of two with rollator walker. A review of nursing documentation dated June 16, 2021, revealed that the resident had continued pain with prn pain medication administered and continued swelling to left lower extremity. A review of nursing documentation dated June 17, 2021, again revealed that resident had continued pain with prn pain medication administered and swelling remained to left lower extremity. A review of nursing documentation dated June 18, 2021, revealed that the resident had unbearable pain not helped with prn Tylenol and increased anxiety. A new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of nursing documentation dated June 19, 2021, revealed that the resident had continued pain with prn pain medication administered and continued swelling to left lower extremity. A review of nursing documentation dated June 21, 2021, revealed that the resident had continued pain with prn pain medication administered and swelling remained present to left lower extremity. A review of nursing documentation dated June 22, 2021, revealed that the resident had continued pain with prn pain medication administered and the presence of swelling to left lower extremity. Nursing also noted that the resident did not want to participate in therapy on that date due to pain. A physician note dated June 22, 2021, revealed that the physician had removed 10 ccs of fluid from Resident 20's knee. Resident 20's clinical record revealed that on June 23, 2021, the facility made an appointment with Orthopedic services scheduled for June 29, 2021. On June 24, 2021, the facility scheduled an x-ray of the resident's left knee and ankle. Nursing documentation between June 15, 2021, and June 29, 2021, revealed that the resident continued to have pain, swelling and tenderness to the left leg. Review of the orthopedic consult dated June 29, 2021, revealed that the resident was diagnosed with a closed fracture to the distal femur (the thighbone directly above the knee), of the left leg. Further review of Resident 20's clinical record revealed no professional nursing assessment of the resident and pain assessments conducted after the resident's fall on June 14, 2021. An interview with the Director of Nursing on September 10, 2021, at approximately 10:00 a.m., revealed that the nursing progress note after the resident's fall was considered the assessment of the resident and that pain is only assessed when a pain scale number is obtained when a resident receives a prn medication. Review of the nursing progress note immediately after the resident's fall, referenced by the DON in the above interview, revealed that it was completed by a Licensed Practical Nurse and failed to reflect a comprehensive assessment of the resident's status. The facility's fall policy Assessment of Fall Risk last reviewed by the facility March 10, 2020, revealed that the the status post [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence at the time of the survey ending September 10, 2021, that the facility had timely and sufficiently acted upon the resident's consistent and daily complaints of pain and presence of swelling, which caused the resident increased anxiety and a decline in participation and functional abilities to perform activities of daily living. The resident displayed signs of injury following a fall on June 14, 2021, and the resident's fracture was not diagnosed until June 29, 2021, during an orthopedic consult. An interview with the DON (director of nursing) and NHA (Nursing Home Administrator) on September 10, 2021, at 12:30 p.m., were unable to provide evidence that the resident received timely treatment and necessary services from June 14, 2021, when the resident fell and June 24, 2021, when additional diagnostic imaging services were ordered by the physician and subsequently the fracture was identified on June 29, 2021, 15 days after the resident's fall during which the resident experienced ongoing pain and discomfort. 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 4/16/19, 3/13/20 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services Previously cited 4/16/19, 6/19/19, 3/13/20

Based on a review of clinical records, select facility policy and incident investigations and staff interviews, it was determined that the facility failed to implement individually planned and/or effective approaches to prevent a fall for a resident identified at high risk for falls, which resulted in a [MEDICAL CONDITION] for one resident out of 13 sampled (Resident 20). Findings include: A review of the facility policy entitled, Assessment of Fall Risk, last reviewed by the facility (MONTH) (YEAR), indicated that the facility's main components of an effective Fall Prevention Program include: thorough assessment, appropriate intervention, rigorous documentation and regular evaluation. Each employee will prioritize and assist with the prevention of falls. Utilizing the nursing process, plans of care will be developed by the nurse addressing the resident's specific factors which may contribute to the resident's risk for falls. A review of Resident 20's Quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 30, (YEAR), revealed that the resident's BIMS (Brief Interview for Mental Status - a tool to assess cognitive function) was a three, indicating severe cognitive impairment. The resident was totally dependent on two persons for transfer assistance and bed mobility. A review of the resident's fall risk assessment dated (MONTH) 4, (YEAR), revealed that the facility identified the resident as being at high risk for falls. A review of the resident's care plan revised (MONTH) 20, (YEAR), revealed the goal of keeping the resident free from falls and injury and a planned intervention was to keep the remote to the resident's recliner on the table, not in the chair. A review of a facility incident investigation form dated (MONTH) 29, (YEAR), at 4:00 PM indicated that while the resident was in her room, she used the remote control to adjust her recliner chair and elevated it to a standing position. The resident slid out of the chair onto her buttocks and had complaints of pain in her right leg. The physician was made aware at that time and ordered the resident to be sent to the hospital on (MONTH) 29, (YEAR). The resident was diagnosed with [REDACTED]. The facility's investigation indicated that the remote to the recliner chair was kept in the lower pocket of the chair, clipped to the chair and that the resident does not use the remote. The staff used the chair remote control to transfer the resident out of the chair. According to the Director of Nursing (DON), an intervention was put in place to have the remote to the recliner out of the resident's reach due to a past history of the resident reaching for the remote. Further review of the facility's investigation revealed no documented evidence of identification of the staff members who had placed the resident in the recliner chair and the location of remote control at the time the resident was transferred into the chair prior to the fall on (MONTH) 29, (YEAR). The new intervention the facility planned after the fall on (MONTH) 29, (YEAR), was to ensure that the recliner chair is unplugged from the wall outlet after transferring the resident into the recliner. During an interview with the DON on (MONTH) 12, (YEAR), at 11:00 AM the DON confirmed that there was no statement from the staff who had placed the resident in the chair and evidence of the location of the remote control after staff had transferred the resident into the recliner. The DON also stated that unplugging the chair from the wall outlet would have prevented the resident from using the remote to raise the chair, which had resulted in the fall with serious injury. 483.25(d)(1)(2) Free of Accident Hazards/supervision/devices Previously cited 3/10/17, 3/2/16 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services Previously cited 3/10/17, 5/4/16