Every finding on record at Beacon Ridge

Based on review of facility policies, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to provide necessary treatment and services for a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) for one of 40 residents reviewed (Resident 43), resulting in a deterioration of the wound and delayed healing. Findings include: The facility's pressure ulcer policy, dated January 22, 2026, indicated that the facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new sore from developing. Document in the resident's record and the Treatment Administration Record (TAR) that wound care was administered as prescribed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated August 25, 2025, indicated that the resident was cognitively impaired, was dependent on staff for bed mobility, transfers, dressing/grooming and hygiene, was incontinent of bowel and bladder, had a Stage 3 pressure ulcer present on admission, had diagnoses including cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain), hemiparesis and hemiplegia (paralysis or weakness to one side of the body due to brain injury) affecting right dominant side, and wound infection. A care plan for the resident, dated August 19, 2025, revealed that the resident had a Stage 3 pressure ulcer to her right hip on admission and staff were to administer medications as ordered. Review of hospital documentation for Resident 43, dated August 17, 2025, revealed that the resident had a wound to her right hip with purulent discharge (a thick, opaque, and often foul-smelling fluid, ranging in color from yellow and green to brown or white, that indicates a likely bacterial infection) along with surrounding erythema (abnormal skin redness or rash caused by dilated blood vessels near the skin's surface, typically resulting from inflammation, infection, or injury) and warmth. A Computed Tomography (CT) scan of the right hip, completed on August 17, 2025, for suspected abscess (a localized collection of a mixture of white blood cells, bacteria, and dead tissue that forms in the body, often due to bacterial infections, viruses, or foreign objects) and infection showed subcutaneous fat stranding in the anterior pelvic wall, and lateral to the right hip, consistent with cellulitis (a common, potentially serious bacterial skin infection affecting deep dermis layers, often caused by Streptococcus or Staphylococcus bacteria entering through skin breaks). She was treated with vancomycin at the hospital to cover Methicillin-resistant Staphylococcus aureus (MRSA) (type of staph bacteria resistant to many antibiotics making treatment difficult). An admission screen for Resident 43, dated August 19, 2025, revealed that the resident had a Stage 3 pressure ulcer to her right lateral hip measuring 2.5 centimeters (cm) length x 1.5 cm width x 0.1 cm depth, and it was noted that a treatment was ordered. A physician's order for Resident 43, dated August 19, 2025, included orders to cleanse the right hip with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply adaptic (non-adhering wound dressing made of knitted cellulose acetate fabric impregnated with a petrolatum emulsion used to protect regenerating tissue in draining, partial- and full-thickness wounds) and cover with bordered dressing daily and as needed for soilage/dislodgement until resolved. Review of the resident's TAR for August 2025, revealed that the treatment order was not transcribed to appear on the TAR for the treatment to be completed as ordered. There was no documented evidence that the treatment was completed as ordered from August 19, 2025, through August 26, 2025, delaying treatment to the wound. A physician's note for Resident 43, dated August 21, 2025, revealed that the resident had a Stage 3 pressure ulcer over her right hip. A weekly skin assessment, completed August 23, 2025, indicated that the resident had no open areas or skin issues. A wound consultation note for Resident 43, dated August 26, 2025, revealed the resident was seen for a pre-existing ulcer of the right hip. The wound was classified as a Stage 3 pressure ulcer present on admission. The wound base contained 40 percent slough (dead tissue within a wound, often appearing as a yellow, tan, or white fibrous material) and a surgical wound debridement was completed and indicated removal of necrotic tissue (dead, non-viable tissue that impedes healing and increases the risk of infection, requiring prompt identification and removal). The wound prior to and after surgical debridement measured 7.5 cm x 6 cm x 0.3 cm, revealing that the wound worsened since admission to the facility on August 19, 2025. Interview with the Assistant Director of Nursing on April 22, 2026, at 10:42 a.m. confirmed that the treatment order, dated August 19, 2025, to Resident 43's right hip was not transcribed to appear on the TAR for the treatment to be completed as ordered, and that there was no documented evidence that the treatment was completed as ordered from August 19, 2025, through August 26, 2025. Interview with the Director of Nursing on April 23, 2026, at 2:31 p.m. revealed that Resident 43's wound to her right hip was not very big when she was admitted , about 0.1 cm deep and had no drainage or necrotic tissue. A physician's order for Resident 43, dated October 14, 2025, included orders to cleanse the right hip with 0.125 percent Dakins solution (a solution used to treat and prevent tissue infections) and pack with Dakins soaked rolled gauze and cover with silicone bordered super absorb dressing (designed for moderate to heavily exuding wounds, such as ulcers and surgical wounds) twice daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on November 17, 2025. A physician's order for Resident 43, dated November 24, 2025, included orders to irrigate the right hip with normal saline solution, apply Plurogel (designed to create a moist wound healing environment that promotes debridement, softens necrotic tissue/debris) to wound base, pack with normal saline moistened gauze and cover with silicone bordered super absorb dressing daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on December 8, 2025. A physician's order for Resident 43, dated December 9, 2025, included orders to irrigate the right hip with normal saline solution, apply Plurogel to wound base, pack with normal saline moistened gauze, apply calmoseptine (moisture barrier) to periwound and cover with silicone bordered super absorb dressing daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on December 14, 2025. A physician's order for Resident 43, dated December 14, 2025, included orders to irrigate the right hip with normal saline solution, apply calmoseptine to periwound, pack wound with Dakins 0.125% moistened rolled gauze, and cover with silicone bordered super absorb dressing daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on December 15, 2025. A physician's order for Resident 43, dated December 19, 2025, included orders to irrigate the right hip with acetic acid solution (topical antimicrobial agent used to treat infected wounds) 0.25 percent, sprinkle flagyl powder (antifungal used to treat wounds with infection, necrotic (dead) tissue, or bacterial growth) 500 milligram (mg) crushed tablet into wound bed, then pack wound with acetic acid 0.25% moistened rolled gauze, and cover with silicone bordered super absorb dressing twice daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on December 23 and December 27, 2025, on the night shift. A physician's order for Resident 43, dated January 27, 2026, included orders to irrigate the right hip with normal saline solution, then pack wound with calcium alginate rope (may cut in half to fit into wound bed) and cover with super absorb bordered dressing once daily and as needed for soilage/dislodgement. There was no documented evidence that the treatment was completed as ordered on March 13, 2026, and April 12, 2026. Interview with the Assistant Director of Nursing on April 22, 2026, at 10:42 a.m. confirmed that there was no documented evidence that the treatments to Resident 43's right hip were completed as ordered on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.Findings include: The facility's policy regarding food preparation, dated January 22, 2026, indicated that all foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or as state regulations requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. A dietary tracking form of tray delivery times revealed that on April 20, 2026, breakfast trays were delivered to Bayside at 7:40 a.m. Observations on Bayside on April 20, 2026, at 8:09 a.m. revealed a breakfast cart containing nine undelivered breakfast trays. Two trays had protective lids only covering half of the dish and the eggs were exposed. At 8:18 a.m. the Regional Dietary Manager arrived on unit, and the trays were still on the cart. The Regional Dietary Manager took temperatures of the uncovered eggs which were 103 degrees Farenheit. Eggs with the protective coverings temped at 112.8 degrees Farenheit. Interview with the Regional Dietary Manager on April 20, 2026, at 8:20 a.m. confirmed that the breakfast tray should have been covered and that the eggs were cold and not palatable and should not be served to the residents. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.6(c) Dietary Services.

Based on review of policies, observations and staff interviews, it was determined that the facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the kitchen.Findings include:The facility's policy for food temperatures, dated January 22, 2026, revealed the temperature of potentially hazardous cold foods must be served at a temperature of 41 degrees Fahrenheit or below.The facility policy regarding food storage, dated January 22, 2026, revealed that food should be stored in such a manner as to prevent contamination and to maintain the safety and wholesomeness of the food for human consumption.Observations on April 20, 2026, at 6:07 a.m. in the main kitchen walk in cooler revealed that the temperature inside the walk-in cooler was in the danger zone of 42 degrees Fahrenheit. Observations on April 20, 2026, at 6:07 a.m. in the main kitchen walk in cooler revealed that there were 56 cartoons of milk that expired on April 19, 2026, and were not discarded.Observations on April 20, 2026, at 6:10 a.m. in the main kitchen prep cooler revealed that there were six pies that were on Styrofoam plates that were open to the air. Interview with the Regional Dietary Manager on April 20, 2026, at 11:37 a.m. confirmed that the main cooler should have been below 41 degrees Fahrenheit, that the pies should have been sealed in such a way to prevent air from entering the food, and that expired food should have been removed from the main cooler.Observations on April 22, 2026, at 11:27 a.m. revealed a fan was blowing on three pans of apple crisp desert that were not covered. Interview with the Dietary Manager on April 22, 2026, at11:27 a.m. confirmed that there should not be a fan blowing on food prep area.28 Pa. Code 211.6(f) Dietary services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for two of 40 residents reviewed (Residents 44 and 73).Findings include:A facility policy for medication and treatment administration dated January 22, 2026, indicated that medications are administered in accordance with prescriber orders.A admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44 dated January 12, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnoses that included atrial fibrillation (a heart rhythm disorder characterized by a rapid and irregular heartbeat).A nursing note dated January 6, 2026, revealed that the resident was admitted to the facility as a hospice respite stay.Hospice medication orders for Resident 44 dated November 12, 2025, included physician's orders to administer 5mg of Jantoven (a blood thinner medication) once daily three times a week and administer 7.5 mg of Jantoven four times a week. A review of his Medication Administration Record (MAR) revealed that the facility did not clarify physician orders for Jantoven dose to be administered. The MAR revealed that the resident did not receive Jantoven on January 6, 2026, January 7, 2026, and January 8, 2026.Interview with the Director of Nursing on April 22, 2026, at 1:41 p.m. confirmed that Resident 44's Jantoven was not clarified by the physician and that the resident had missed three doses of Jantoven. A admission MDS assessment for Resident 73 dated April 14, 2026, revealed that the resident is cognitively intact, required assistance with daily care needs, and had medical diagnosis that included a nondisplaced fracture of right tibia (bone in lower leg). Physician orders for resident 73 dated April 9, 2026, included orders for the resident to receive 70 milligrams of Enoxaparin Sodium injection (an anticoagulant) to prevent deep vein thrombosis (a blood clot) one time a day. Observation on April 21, 2026, at 8:00 a.m. revealed that Licensed Practical Nurse 3 administered a prefilled 80 mg dose of Enoxaparin into Resident 73's abdomen.Interview with Licensed Practical Nurse 3 on April 21, 2026, at 8:05 a.m. confirmed that the Enoxaparin Sodium is an 80 mg prefilled syringe from pharmacy and that she administered the incorrect dose to Resident 73. Interview with the Director of Nursing on April 21, 2026, at 8:41 a.m. confirmed that the Licensed Practical Nurse 3 administered the Enoxaparin Sodium 80 mg prefilled syringe and did not follow physician's orders resulting in a medication error.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative in writing regarding the reason for transfer to the hospital for six of 40 residents reviewed (Residents 7, 8, 9, 43, 67, and 81).Findings include: A nursing note for Resident 7, dated February 11, 2026, revealed that at 12:00 p.m. the resident had an unwitnessed fall. Resident 7 was yelling for help which staff responded to and found her sitting on the floor near her dresser. Resident 7 did not appear to hit her head, but stated her right arm hurt. A new order was received to send to the emergency for evaluation and treatment. A nursing note for Resident 7, dated April 2, 2026, revealed that at 12:55 p.m. the x-ray results showed the right elbow and shoulder showed a subacute displaced fracture in the right humerus (upper arm bone). A new order was received to send to the emergency for evaluation and treatment. Review of Resident 7's clinical record revealed that there was no documented evidence that the resident's representative or emergency contact were notified in writing of the purpose for the resident's transfer regarding her hospitalization of February 11, 2026 and April 2, 2026. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 8, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included paralytic syndrome following cerebral infarction (persistent, bilateral muscle weakness or paralysis affecting both sides of the body as a long-term consequence of a stroke). A nursing note for Resident 8, dated March 12, 2026, revealed that at 12:10 a.m. the resident had increased shortness of breath and abdominal pain. The physician was notified and orders were obtained to transfer the resident to the hospital for evaluation. A nursing note dated March 12, 2026, at 5:10 a.m., revealed the resident was admitted to the hospital with a diagnosis of sepsis (a life-threatening reaction to an infection). Review of Resident 8's clinical record revealed that there was no documented evidence that the resident or the resident's responsible party were notified in writing of the reason for the resident's transfer to the hospital on March 12, 2026. A quarterly MDS assessment for Resident 9, dated February 12, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnoses that included dementia. A nursing note for Resident 9, dated April 16, 2026, at 11:09 a.m. the resident had abnormal lung sounds irregular breathing. The physician was notified and orders were received to transfer her to the hospital for evaluation. A nursing note dated April 16, 2026, at 6:25 p.m. revealed that the resident was admitted to the hospital with diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm) and urinary tract infection. Review of Resident 9's clinical record revealed that there was no documented evidence that the resident or the resident's responsible party were notified in writing of the reason for the resident's transfer to the hospital on April 16, 2026. A quarterly MDS assessment for Resident 43, dated February 20, 2026, indicated that the resident was cognitively impaired, had limited range of motion to her upper and lower extremity on one side, required assistance from staff for daily care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications), had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) present on admission, and had diagnoses including cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain) and hemiparesis and hemiplegia (paralysis or weakness to one side of the body due to brain injury) affecting right dominant side. A nursing note for Resident 43, dated March 24, 2026, at 1:02 p.m. revealed that the facility received a call from a nurse in the hospital emergency room stating that per the attending hospitalist, the resident had results of positive blood cultures of Staphylococcus epidermidis. The resident's physician was contacted, and orders were received to send the resident to the hospital for treatment of positive blood cultures. A nursing note for the resident, dated March 24, 2026, at 3:51 p.m. revealed that the resident was admitted with a diagnosis of bacteremia (the presence of bacteria in the bloodstream). Review of Resident 43's clinical record revealed that there was no documented evidence that the resident or the resident's responsible party were notified in writing of the reason for the resident's transfer to the hospital on March 24, 2026. A nursing note for Resident 67, dated April 15, 2026, revealed that at 9:15 a.m. the resident had a witnessed fall in the Bayside lounge and had no injuries at that time. A nursing note dated April 15, 2026, revealed that at 4:26 p.m. the therapy department reported that the resident was complaining of pain in her left hip during therapy. Physician was notified and ordered for the resident to have an x-ray of the left hip. A nursing note on April 15, 2026, at 7:38 p.m. revealed that had a left femoral neck fracture (left hip fracture) and was to be sent to the local hospital. Review of Resident 67's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer regarding her hospitalization of April 15, 2026. A quarterly MDS assessment for Resident 81, dated February 12, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnoses that included hemiplegia (severe or complete paralysis affecting one side of the body) or hemiparesis (one-sided muscle weakness) after a stroke. A nursing note for Resident 81, dated January 20, 2026, at 10:47 a.m. the resident was having stroke-like symptoms. She was evaluated by the physician, who provided orders to transfer the resident to the hospital for evaluation. A nursing note dated January 20, 2026, at 1:51 p.m. revealed that the resident was admitted to the hospital with diagnosis of stroke. Review of Resident 81's clinical record revealed that there was no documented evidence that the resident or the resident's responsible party were notified in writing of the reason for the resident's transfer to the hospital on January 20, 2026. Interview with the Nursing Home Administrator on April 22, 2026, at 11:02 a.m. confirmed that they were not completing written transfer letters to the families regarding the reason for transfer for the residents listed above. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to coordinate care with the hospice provider by failing to follow recommendations for changes in medications for one of 40 residents reviewed (Resident 38). Findings include: The Hospice contact, effective June 3, 2022, indicated that hospice and the facility shall communicate with one another regularly and as needed for each particular hospice patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of the hospice patients are met 24 hours per day. If there are physician orders that are inconsistent with the hospice plan of care or hospice protocols, a nurse with facility shall notify hospice. An authorized representative of hospice shall resolve differences directly with the physician and secure the necessary orders. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated March 20, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, received antipsychotic and antianxiety medications, received hospice services, and had diagnoses including dementia, psychotic disorder, anxiety and depression. A care plan for the resident, dated January 8, 2025, indicated that the facility would coordinate care with the resident's hospice provider. Physician's orders for Resident 38, dated June 18, 2024, revealed that the resident was receiving hospice services effective June 19, 2024. A current physician's order for Resident 38, dated March 14, 2025, included orders for the resident to receive ABHR cream (a compounded topical medication often used in hospice for terminal agitation, anxiety, or nausea) containing 1 milligram (mg) of Ativan (an antianxiety medication used to treat anxiety/agitation) per 12.5 mg of Benadryl (an antihistamine used to treat nausea) per 2 mg of Haldol (an antipsychotic medication used to treat nausea/agitation) per 10 mg of Reglan (used to treat nausea). Apply to inner wrist topically twice daily for anxiety and psychosis. A hospice order for Resident 38, dated February 16, 2026, included orders for the resident to receive ABHR cream containing 1 mg of Ativan per 25 mg of Benadryl per 2 mg of Haldol per 10 mg of Reglan. Apply one syringe to wrist or neck every a.m. and p.m. for anxiety and agitation with care. A hospice order for Resident 38, dated April 13, 2026, included orders for the resident to receive ABHR cream containing 1 mg of Ativan per 25 mg of Benadryl per 2 mg of Haldol per 10 mg of Reglan. Apply one syringe to wrist or neck every a.m. and p.m. for anxiety and agitation with care. There was no documented evidence in Resident 38's clinical record that the hospice orders, dated February 16, 2026, and April 13, 2026, were transcribed into the resident's orders. Interview with the Nursing Home Administrator, dated April 23, 2026, at 1:01 p.m. confirmed that there was no documented evidence in Resident 38's clinical record that the hospice orders, dated February 16, 2026, and April 13, 2026, were transcribed into the resident's orders and they should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for two of 40 residents reviewed (Residents 1, 2, and 43). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 3, 2026, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, received antipsychotic medications (medications used to treat mental health disorders), had a diagnosis of dementia, depression with severe psychosis and obsessive-compulsive disorder (a chronic mental health condition characterized by uncontrollable repeated thoughts and/or behaviors). A physician's order for Resident 1, dated January 16, 2026, included orders for the resident to receive o.25 milligrams (mg) of risperidone twice daily related to severe depression with psychotic features. There was no documented evidence that a care plan was developed to address Resident 1's use of antipsychotic medication. There was no documented evidence that a care plan was developed to address that the resident had dementia and cognitive impairment. Interview with the Assistant Director of Nursing on April 22, 2026, at 12:17 p.m. confirmed that Resident 1 did not have care plans developed to address her use of antipsychotic medication and to address her dementia with cognitive impairment. A quarterly MDS assessment for Resident 2, dated January 2, 2026, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had medical diagnosis that included dementia and high blood pressure. Physician's orders for Resident 2 dated December 4, 2025, included an order for the resident to receive 40 milligrams of Furosemide, a diuretic medication used for edema. There was no documented evidence that a care plan was developed to address Resident 2's diuretic medication. Interview with Licensed Practical Nurse Assessment Coordinator dated April 23, 2026, at 11:22 a.m. confirmed that Resident 2 did not have a diuretic care plan and that he should have in place. A quarterly MDS assessment for Resident 43, dated February 20, 2026, indicated that the resident was cognitively impaired, had limited range of motion to her upper and lower extremity on one side, required assistance from staff for daily care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications), had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) present on admission, and had diagnoses including cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain) and hemiparesis and hemiplegia (paralysis or weakness to one side of the body due to brain injury) affecting right dominant side. A physician's order for Resident 43, dated March 27, 2026, included orders for the resident to receive a 50 mg capsule of Nitrofurantoin Macrocrystal (an antibiotic) daily every Monday, Wednesday and Friday via her feeding tube for prophylaxis for urinary tract infections. There was no documented evidence that a care plan was developed to address Resident 43's long term use of antibiotic therapy for prophylaxis for urinary tract infections. Interview with the Nursing Home Administrator on April 23, 2026, at 11:39 a.m. confirmed that there was no documented evidence that a care plan was developed to address Resident 43's long term use of antibiotic therapy for prophylaxis for urinary tract infections. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for six of 40 residents reviewed (Residents 2, 10, 12, 34, 43, 57).Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415K1 Anticoagulant was to be checked if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 2, dated June 7, 2026, included an order for the resident to receive 500 milligrams (mg) of Divalproex Sodium (anticonvulsant) two times a day for seizure disorder. Review of the Medication Administration Record (MAR) for Resident 2, dated March 2026, revealed that staff administered the 500 mg of Divalproex two times a day from March 1 through March 31, 2026. However, a quarterly MDS assessment for Resident 2, dated, March 16, 2026, revealed that Section NO415K1 was not checked, indicating that the resident did not receive an anticoagulant medication during the seven-day look-back assessment period. Interview with Licensed Practical Nurse Assessment Coordinator on April 21, 2026, at 2:09 p.m. confirmed that Resident's 2 MDS was coded inaccurately. The RAI User's Manual, dated October 2025, revealed that Section P0100A Restraints used in bed: bedrails, was to be coded (0) if not used, (1) if used less than daily, and (2) if used daily during the seven-day look-back period. Review of Side Rail/Enabler Bar Assessments for Resident 10 dated January 30, 2026, and February 11, 2026, indicated that side rails/enabler bars were not indicated. There was no documented evidence that Resident 10 had side rails in place during the seven-day look-back period. However, a quarterly MDS assessment for Resident 10, dated February 12, 2026, revealed that Section P0100A was coded (2) to indicate that the resident used side rails daily. The RAI User's Manual, dated October 2025, revealed that Section N0415A1 Antipsychotic; N0415B1 Antianxiety; N0415G1; and N0415K1 was to be checked if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 12 dated November 3, 2025 included orders for the resident to receive 250 mg of Seroquel (a antipsychotic) at bedtime for schizoaffective disorder; orders for the resident to receive 5 mg of buspirone (a antianxiety) two times a day for anxiety; orders for the resident to receive 40 mg of Furosemide (a diuretic) one time a day for edema, and orders for the resident to receive 0.5 mg Clonazepam (a antianxiety and anticonvulsant) two times a day for anxiety. Review of the Medication Administration Record (MAR) for Resident 12, dated February 2026, revealed that staff administered 250 mg of Seroquel at bedtime, 5 mg of Buspirone two times a day, 40 mg of Furosemide one time a day, and 0.5 mg of Clonazepam two times a day starting February 1, 2026, through February 28, 2026. A quarterly MDS assessment for Resident 12, dated, February17, 2026, revealed that Section NO415A1, N0415B1, N0415G1, and N0415K1 were not checked, indicating that the resident did not receive an antipsychotic, antianxiety, diuretic and anticonvulsant medication during the seven-day look-back assessment period. Interview with Licensed Practical Nurse Assessment Coordinator on April 21, 2026, at 2:09 p.m. confirmed that Resident 10 and 12's MDS was coded inaccurately. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section N0415F1 Antibiotics were to be checked if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 34, dated January 31, 2026, included an order for the resident to receive 100 mg of Doxycycline Hyclate (an antibiotic) two times a day for two days for urinary tract infection, and an order dated February 4, 2026 for the resident to receive 2% of Mupirocin (an antibiotic) one time a day to the right great toe ulcer. Review of the MAR and Treatment Administration Record (TAR) for Resident 34, dated February 2026, revealed that staff administered 100 mg of Doxycycline Hylcate two times a day and 2% of Mupirocin one time a day starting February 1 through February 28, 2026. A quarterly MDS assessment for Resident 34, dated February 6, 2026, revealed that Section NO415F1 was not checked, indicating that the resident did not receive an antibiotic during the seven-day look-back assessment period. Interview with Licensed Practical Nurse Assessment Coordinator on April 21, 2026, at 2:09 p.m. confirmed that Resident's 34 MDS was coded inaccurately. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section O0110H1B intravenous medications was to be checked if the resident received intravenous medications while a resident during the 14 day look-back period. Review of the MAR for Resident 43, dated February 2026, revealed that staff administered 1 gram of Meropenem intravenously every eight hours from February 2, 2026, through February 6, 2026. However, a quarterly MDS assessment for Resident 43, dated February 20, 2026, revealed that Section O0110H1B was coded, indicating that the resident received intravenous medications during the 14 day look-back assessment period. Interview with Licensed Practical Nurse Assessment Coordinator on April 22, 2026, at 10:42 a.m. confirmed that Resident 43's MDS was coded in error. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section M0150 should be coded 0-'no' if the resident is not at risk for developing a pressure ulcer/injury, and coded 1- 'yes' if the resident is at risk for developing a pressure ulcer/injury. This answer is based on the items reviewed for determination of pressure ulcer risk in Section M0100 items A through Z; check M0100A if the resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; check M0100B if a formal assessment has been completed; check M0100C if the resident's risk for pressure ulcer/injury development is based on clinical assessment; and check M0100Z if none of the above apply. A quarterly MDS assessment for Resident 43, dated February 20, 2026, revealed that Section M0100A, M0100B, and M0100C were all checked indicating that the resident was at risk for developing a pressure ulcer/injury; however, Section M0150 was coded 0-'no', indicating that the resident was not at risk for developing a pressure ulcer/injury. Interview with the Nursing Home Administrator on April 23, 2026, at 2:15 p.m. indicated that the Licensed Practical Nurse Assessment Coordinator confirmed that Resident 43's MDS was coded in error. The RAI User's Manual, dated October 2025, revealed that Section N0415A1 Antipsychotic was to be checked (1) yes if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 57 dated August 27, 2025, included for the resident to receive 50 milligrams (mg) of Seroquel (an antipsychotic medication) daily at bedtime. Physician's orders dated March 6, 2026, included for the resident to receive 25 mg of Seroquel two times a day for bipolar disorder. Review of the MAR for Resident 57 dated March 2026 revealed that 50 mg of Seroquel was administered daily at 9:00 p.m. and 25 mg of Seroquel was administered at 9:00 a.m. and 2:00 p.m. daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 57 dated March 29, 2026, indicated that Section N0415A1 Antipsychotic was checked (0) no, indicating that the Resident did not receive an antipsychotic medication during the seven-day look-back period. Interview with Licensed Practical Nurse Assessment Coordinator on April 21, 2026, at 2:09 p.m. confirmed that Resident 57's MDS was coded inaccurately. 28 Pa. Code 211.5(f) Medical records

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for two of 40 residents reviewed (Resident 9, 34).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly MDS assessment for Resident 9, dated February 12, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs and had diagnoses that included dementia.Physician's progress note for Resident 9 dated April 7, 2026, included that the resident was to have routine Tylenol for pain control. Physician's orders for Resident 9 dated November 12, 2024, indicated that the resident was to receive 500 milligrams (mg) of Acetaminophen (generic name for Tylenol), two tablets every eight hours as needed for pain. There was no documented evidence that physician's orders for Tylenol to be given routinely were implemented. Interview with the Assistant Director of Nursing on April 22, 2026, at 1:15 p.m. revealed that the order for routine Tylenol in the physician's progress note was missed, therefore it was not added to the resident's medication orders, and it should have been. A quarterly MDS assessment for Resident 34 dated February 6, 2026, revealed that the resident is cognitively impaired, required assistance with daily care needs, and had medical diagnosis that included diabetes mellitus and cellulitis of the right lower limb.Physician's orders for Resident 34 dated February 4, 2026, included orders for 2% Mupirocin ointment apply to right great toe ulcer one time a day for wound care. Physician orders dated April 3, 2026, included orders to cleanse right great toe diabetic ulcer with wound cleanser, apply Iodosorb ointment to wound bed and surrounding callus area, and cover with dry dressing and secure with rolled gauze daily.A wound consultant note for Resident 34 dated April 1, 2026, indicated that the Certified Registered Nurse Practitioner recommended that staff cleanse the right great toe wound with wound cleaner, apply Iodosorb ointment to wound bed and surrounding callus area, then cover with a dry dressing and secure with rolled gauze change daily. Review of the Treatment Administration Record for Resident 34, dated April 2026, revealed that the resident was receiving two separate wound treatments to the same right great toe wound.Interview with the Director of Nursing on April 22, 2026, at 1:41 p.m. confirmed that Resident 34 was receiving two wound treatment orders and that the order for Mupirocin ointment should have been discontinued and the wound consultant recommendation should have been followed.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were provided with proper colostomy care for one of 40 residents reviewed (Resident 16).Findings include:The facility's policy regarding colostomy care (care for an artificial opening in the bowel), dated January 22, 2026, colostomy care will be provided per physician orders to provide the stoma with good skin care and check the condition of the stoma and surrounding skin.An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16 dated March 17, 2025,indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had medical diagnosis that included intellectual disabilities and had an ostomy (a surgically created opening in the abdomen for bowel elimination. A review of Resident 16's clinical record revealed that there was no physician order for the resident colostomy size or orders to change the colostomy appliance. Interview with the Nursing Home Administrator on April 22, 2026, at 9:35 a.m. confirmed that there was no physician order for the ostomy size and that there was no documented evidence that colostomy appliance was being changed for Resident 16.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings (delivers liquid nutrients directly into the stomach) received appropriate treatment and services to prevent complications for one of 40 residents reviewed (Resident 43). Findings include: A facility policy for feeding tubes, dated January 22, 2026, indicated that the licensed practical nurse will change feeding tube dressings at least every 24 hours unless the physician's orders say otherwise and they are to document the dressing change in the resident's chart. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated February 20, 2026, indicated that the resident was cognitively impaired, had limited range of motion to her upper and lower extremity on one side, required assistance from staff for daily care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications), had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) present on admission, and had diagnoses including cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain) and hemiparesis and hemiplegia (paralysis or weakness to one side of the body due to brain injury) affecting right dominant side. Physician's orders for Resident 43, dated August 19, 2025, included orders to cleanse the feeding tube site with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), pat dry and apply drain sponge (specialized wound gauze used around tubes, drains and catheters) daily and as needed for soilage or dislodgement. Review of Resident 43's Treatment Administration Record (TAR) for August 2025 through December 2025, and for March and April 2026, revealed that there was no documented evidence that the resident's feeding tube site care was completed as ordered on August 19, 20, 22, and 24; September 15, 16, 19, and 29; October 4, 5, 8, 9, and 13; November 30; December 27; March 21, 29, 31; April 9, 13, 17, and 19. Interview with the Assistant Director of Nursing on April 22, 2026, at 10:42 a.m. confirmed that there was no documented evidence that Resident 43's feeding tube site care was completed as ordered on the above-mentioned dates. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 40 residents reviewed (Residents 8 and 43).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 8, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included paralytic syndrome following cerebral infarction (persistent, bilateral muscle weakness or paralysis affecting both sides of the body as a long-term consequence of a stroke). Care plan for Resident 8 dated March 18, 2026, indicated that the Resident was receiving diuretic (medicines that help reduce fluid buildup in the body) therapy for edema (swelling caused by excess fluid trapped in the body's tissues) and staff were to administer diuretic medication as ordered by the physician. Review of the Medication Administration Record (MAR) for Resident 8 dated April 2026, revealed that the resident was not receiving diuretic medication during the time of the survey. Interview with the Director of Nursing on April 4, 2026, at 3:21 p.m. confirmed the Resident's care plan should have been revised when the diuretic was discontinued. A quarterly MDS assessment for Resident 43, dated February 20, 2026, indicated that the resident was cognitively impaired, had limited range of motion to her upper and lower extremity on one side, required assistance from staff for daily care needs, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications), had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) present on admission, and had diagnoses including cerebral vascular accident (an event caused by poor blood flow or bleeding to in the areas of the brain) and hemiparesis and hemiplegia (paralysis or weakness to one side of the body due to brain injury) affecting right dominant side. A care plan for Resident 43, dated March 24, 2026, indicated that the resident was receiving intravenous (administration of fluids and/or medications directly into a person's vein) medications related to an Extended-Spectrum Beta-Lactamase (ESBL-multi-drug resistant bacterial infection) infection in the urine. There was no documented evidence in the resident's clinical record that she was receiving intravenous medications. Interview with the Nursing Home administrator on April 23, 2026, at 11:39 a.m. confirmed that Resident 43's care plan should have been revised to reflect that she was no longer receiving intravenous medications. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations, and staff interviews, it was determined that the facility failed to provide a separately locked, permanently affixed compartment in the refrigerator for the storage of controlled drugs (medications with the potential to be abused) in one of two medication rooms reviewed. Findings include:Observations in the facility's medication room on the Landings unit on April 22, 2026, at 1:11 p.m. revealed one small, locked refrigerator containing five bottles of liquid Ativan (a controlled medication used to treat anxiety). The liquid Ativan was not in a secured, locked compartment separate from other non-narcotic medications. Interview with Licensed Practical Nurse 1 at the time of the observation confirmed that the five bottles of liquid Ativan were not in a secured, locked compartment separate from other non-narcotic medications. Interview with the Nursing Home Administrator on April 22, 2026, at 1:40 p.m. confirmed the five bottles of liquid Ativan were not in a secured, locked compartment separate from other non-narcotic medications. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for two of 40 residents reviewed (Residents 32 and 78).Findings include:A review of the facility policy for resident call system dated January 22, 2026, indicated that each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 32 dated February 6, 2026, indicated that the resident was sometimes understood and sometimes able to understand others, required assistance from staff for daily care needs and had diagnoses that included Parkinson's disease (brain condition that causes problems with movement, mental health, sleep, pain and other health issues) and dementia. Care plan for Resident 32 dated March 20, 2019, indicated that the resident had a self-care performance deficit and staff were to encourage the resident to use the call bell for assistance. An intervention dated February 10, 2021, indicated that staff where to assure the call pendant is in place and functioning properly. Observation of Resident 32 on April 20, 2026, at 9:00 a.m. revealed the resident lying in her bed with her call pendant on her nightstand on the left side of her bed, out of reach. An interview with the Director of Nursing at the time revealed that the resident was unable to use the call pendant and proceeded to place the call pendant in place around the resident's neck. During an interview with Resident 32 on April 20, 2026, at 9:05 a.m., when the resident was asked how she would call for a nurse, she replied push this button, and pointed to her call pendant.Interview with Resident 32 on April 21, 2026, at 3:21 p.m., when the resident was asked how she would call for a nurse, she replied they tell me there is a bell somewhere to use. Observations at that time revealed the resident was wearing a call pendant and had a tap bell on her overbed table that was not within reach. Interview with Licensed Practical Nurse 1 on April 22, 2026, at 1:04 p.m. revealed that the resident prefers to stay in bed and that she sometimes does use her call pendant to call for assistance if she wants something. An annual MDS assessment for Resident 78 dated March 20, 2026, indicated that the resident was usually understood and was usually able to understand others, required assistance from staff for daily care needs and had diagnosis that included dementia and stroke.Care plan for Resident 78 dated April 11, 2017, indicated that the resident had a self-care performance deficit and staff were to encourage the resident to use the call bell for assistance. Observation of Resident 78 on April 20, 2026, at 8:56 a.m. revealed the resident lying in his bed with his call pendant on his nightstand on the right side of his bed, out of reach. An interview with Nurse Aide 2 at the time of the observation revealed that the resident should have had his call pendant within reach. During an interview with Resident 78 on April 21, 2026, at 1:15 p.m., when the resident was asked how he would call for a nurse if needed, he showed me his call pendant hanging on his neck. Interview with the Director of Nursing on April 20, 2026, at 9:00 a.m. revealed that all residents that are able to use their call pendants should have them within reach. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory services were obtained as ordered by the physician for one of 40 residents reviewed (Resident 57).Findings include:Facility policy for Laboratory Services dated January 22, 2026, indicated that the facility will provide or obtain laboratory services to meet the needs of the residents, and will promote practices to ensure the quality and timeliness of laboratory services. The day shift unit nurse will fill out and send laboratory requests for newly ordered laboratory tests. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated March 29, 2026, indicated that the resident was cognitively intact, was independent with daily care needs, and had a history of urinary tract infection. Nurse's note for Resident 57 dated February 24, 2026, at 1:31 p.m. revealed that the resident complained of burning and pain on urination, that the physician was notified, and orders were received to obtain a UA flex to culture (diagnostic test that performs a standard urine analysis first, and automatically orders a urine culture if specific indicators of infection are present) to rule out a urinary tract infection.Nurse's note for Resident 57 dated February 24, 2026, at 5:58 p.m. revealed that the physician was notified of the urinalysis results and ordered 100 milligrams (mg) of Macrobid (an antibiotic) to be given twice a day for seven days pending the culture and sensitivity (C&S- laboratory procedure that identifies infectious germs (culture) and determines the most effective antibiotic (sensitivity) to treat the infection) results. Review of Resident 57's lab results for February 2026 revealed no documented evidence that a C&S was obtained from the resident's urine sample on February 24, 2026, as ordered by the physician. Interview with the Nursing Home Administrator on April 23, 2026, at 10:25 a.m. revealed that a urine C&S was not obtained for Resident 57 as ordered and it should have been. Interview with the Nursing Home Administrator on April 23, 2026, at 11:30 a.m. revealed that the order for laboratory services that were to be obtained on Resident 57's urine sample on February 24, 2026, was transcribed wrong and therefore a urine C&S was never completed by the lab.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for five of 38 residents reviewed (Resident 1, 13, 25, 29, 75). Findings include: The facility's policy regarding homelike environment, dated January 2, 2025, indicated that the facility staff and management were to the extent possible maximize the characteristics of the facility that reflect a personalized homelike setting including a clean, sanitary, and orderly environment. Observations of Resident 1's room on May 22, 2025, at 9:10 a.m. revealed that there was a large area of dried chipping paint, approximately 24 inches by 10 inches above the heating/cooling unit. Interview with the Maintenance Director on May 22, 2025, at 9:40 a.m. revealed that he was not aware of the chipping paint and indicated that with all the rain lately that moisture must be coming in the walls. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated December 2, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, was independent for care needs, and had diagnoses that included anxiety and manic depression. An admission MDS assessment for Resident 29, dated December 18, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required supervision to moderate assistance for care needs, and had diagnoses that included orthostatic hypotension (low blood pressure with changes in body position) and diabetes mellitus. Observations of Resident 13 and 29's room [ROOM NUMBER] on May 19, 2025, at 11:20 a.m. revealed that there was an area of broken dry wall, approximately 18 inches by 18 inches, near the packaged terminal air conditioner (PTAC - a self-contained through-the-wall heating and air conditioning unit). There was also a resident blanket rolled up sitting on the window sill and the wall was starting to bubble under the paint on either side of the window. In the corner of the window was a three-inch line of a black/grey, removable substance. The wall trim below the wall was pulling away from the wall and in some areas lying on the floor. The window sill was loose and breaking apart in the corner. Interview with Residents 13 and 29 at the time of the observations revealed that they put a blanket on the windowsill to block out the cold draft. A little bit ago some of the pieces of the wall fell on the floor, and maintenance staff cleaned it up, and said they would be back to clean it up. However they have not returned to fix anything. Observations of Resident 13 and 29's room on May 22, 2025, at 9:52 a.m. revealed the PTAC and window conditions were the same and the blanket was now wet. Interview with Resident 29 at the time of the observations indicated no staff have come in to fix the area. Interview with Maintenance Director on May 22, 2025, at 11:23 a.m. revealed that maintenance concerns from nursing are communicated with paper slips that are picked up daily. He confirmed that the areas of dry wall were in need of repair, water was coming in through the window causing water damage to the windowsill making it loose and breaking apart, the paint and wall trim had water damage, there was a black, removable substance on the corner of the window, and that the areas were not homelike. There was no work order that he was aware of in the system, and he was not aware this room needed such repairs. He also indicated that the flashing above the window may be a concern, which allows water to come in behind the stucco. Observations of Resident 25's room on May 22, 2025, at 9:21 a.m. revealed that there was an area of broken out drywall, approximately seven inches by seven inches on the wall below the window next to the floor. Observations of Resident 75's room on May 22, 2025, at 9:30 a.m. revealed that there was an area of dried visibly chipping paint, approximately 12 inches by 10 inches above the heating/cooling unit. Interview with the Maintenance Director on May 22, 2025, at 9:52 a.m. revealed that he was not aware of the chipping paint in rooms [ROOM NUMBERS], or the broken drywall in Resident 75's room. He indicated that it was unacceptable and that his staff would be correcting the concerns. 28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect a resident's specific care needs for three of 38 residents reviewed (Residents 35, 47, 50). Findings include: A facility policy regarding comprehensive person-centered care plans, dated January 2, 2025, indicated that comprehensive, person-centered care plans are developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change. A quarterly MDS assessment for Resident 35, dated February 26, 2025, indicated that the resident was cognitively intact, required assistance with care needs, and had a diagnosis of hypertension (high blood pressure). A care plan for Resident 35, dated September 16, 2024, indicated that the resident was receiving a diuretic (a medication used to treat fluid retention and hypertension) related to edema (fluid retention in body tissues) and hypertension. Review of Resident 35's clinical record, including review of the resident's Medication Administration Record (MAR), revealed no documented evidence that the resident was receiving a diuretic. Interview with the Nursing Home Administrator on May 21, 2025, at 2:02 p.m. confirmed that Resident 35's care plan should have been revised to reflect that he was not receiving a diuretic. A quarterly MDS assessment for Resident 47, dated March 1, 2025, indicated that the resident was cognitively intact, was understood, usually understands, was independent with care needs, and had a diagnoses of dementia, anxiety, depression, and bipolar disease (shifts in mood, energy, and activity levels, encompassing both periods of manic and depression). A care plan for Resident 47, dated March 3, 2023, indicated that the resident was an elopement risk and a wanderer with impaired safety awareness. The care plan included an intervention to have a code alert bracelet at all times numbered 9000-0434J with an expiration date of April 21, 2024. Physician orders for Resident 47, dated March 22, 2025, included an order to have code alert bracelet on at all times numbered 9000-0434M with expiration date October 25, 2025, and checked for placement every shift. Observations of Resident 47 on May 21, 2025, at 11:11 a.m. revealed that the resident was lying in bed. Licensed Practical Nurse 1 checked the alert bracelet and it was labeled 9000-0434M with an expiration date of October 25, 2025. Interview with the Nursing Home Administrator on May 21, 2025, at 2:01 p.m. confirmed that Resident 47's care plan should have been revised to reflect the correct code alert bracelet information. An annual MDS assessment for Resident 50, dated May 7, 2025, indicated that the resident was cognitively impaired, was usually able to make herself understood and was usually able to understand others, and required assistance with care needs. A care plan for Resident 50, dated February 17, 2025, indicated that the resident had a urinary tract infection with an intervention that included to give antibiotic therapy as ordered. Review of Resident 50's clinical record, including review of the resident's Medication Administration Record (MAR), revealed no documented evidence that the resident had a urinary tract infection and no documented evidence that she was receiving an antibiotic. Interview with the Nursing Home Administrator on May 22, 2025, at 10:11 a.m. indicated that she believed Resident 50's care plan should have stayed in effect related to her MDS. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters (a flexible catheter used to drain urine from the bladder into a drainage collection bag) for three of 38 residents reviewed who had an indwelling urinary catheter (Residents 4, 7, 10). Findings include: The facility's policy regarding urinary catheter care, dated January 2, 2025, indicated that staff are to be sure the catheter tubing and drainage bag are kept off the floor. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 7, 2025, revealed that the resident was severely cognitively impaired, required assistance with daily care, had an indwelling urinary catheter, and had a diagnosis of neuromuscular dysfunction of the bladder (nerve damage to the bladder). A care plan for Resident 4, dated March 19, 2023, revealed that the resident had an indwelling urinary catheter and staff were to ensure that the drainage bag was off the floor and below the level of the bladder. Observations of Resident 4 on May 21, 2025, at 10:32 a.m. revealed that the resident was sitting in her broda chair (customized wheelchair) in the Bayside lounge. Nurse Aide 3 entered the lounge and transported the resident approximately 18-20 feet back to her room to brush her hair prior to the resident's beautician appointment. Her indwelling urinary catheter drainage bag was connected underneath her wheelchair, as the resident was being transported, approximately four inches of the bottom of the dignity bag drug across the floor. Interview with the Director of Nursing, Infection Preventionist, and Nurse Aide 3 on May 21, 2025, at 10:35 a.m. confirmed that Resident 4's indwelling urinary catheter dignity bag should not have been in direct contact with the floor. All three staff remarked that it is a challenge to keep the dignity bags off the floor due to some of the chairs being so low to the floor. An annual MDS assessment for Resident 7, dated, May 5, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, and had an indwelling urinary catheter (a soft flexible tube inserted into the bladder to drain urine), Physician's orders for Resident 7, dated April 29, 2025, included an order for the indwelling catheter to be changed every 30 days. Review of Resident 7's Treatment Administration Record (TAR) for May 2025 revealed no documented evidence that the catheter change for May 5, 2025, was completed. Interview with the Nursing Home Administrator on May 21, 2025, at 10:41 a.m. confirmed that there was no documented evidence that Resident 7's indwelling catheter was changed every 30 days as ordered on May 5, 2025, and it should have been. A quarterly MDS assessment for Resident 10, dated March 2, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had an indwelling urinary catheter, and had a diagnosis of obstructive uropathy (blockage of the urinary tract). A care plan for Resident 10, dated March 16, 2022, revealed that the resident had an indwelling urinary catheter, and staff were to ensure that the drainage bag was off the floor, below bladder level, and that the tubing was secured to avoid pulling or trauma. Physician's orders for Resident 10, dated November 11, 2024, included an order for staff to check the resident's catheter bag and tubing every shift for proper positioning (below bladder level and off the floor) and cover for dignity. Observations of Resident 10 on May 19, 2025, at 11:34 a.m. revealed that the resident was sitting in her wheelchair in her room. Her indwelling urinary catheter drainage bag was connected underneath her wheelchair with the dignity bag half on and half off with part of the drainage bag exposed. The indwelling urinary catheter tubing was lying in direct contact with the floor. During an interview with Licensed Practical Nurse 4 on May 19, 2025, at 11:46 a.m., Resident 10 proceeded to wheel herself towards this writer and the nurse, dragging the indwelling urinary catheter tubing on the floor. The nurse indicated that she knew the catheter bag had to be off the floor and that her concern with the catheter tubing being on the floor was that the resident may step on it. Interview with the Nursing Home Administrator on May 19, 2025, at 3:15 p.m. confirmed that Resident 10's indwelling urinary catheter tubing should not have been in direct contact with the floor. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was created to reflect the resident's specific care needs for one of 38 residents reviewed (Resident 7). Finding include: A facility policy, dated January 2, 2025, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It will aid in preventing or reducing decline in the resident's functional status and/or functional levels and assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated, May 5, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of Parkinson's disease. Clinical record review for Resident 7 revealed that there was no documented evidence that a care plan was created to address specific care needs related to Parkinson's disease. Interview with the Nursing Home Administrator on May 21, 2025, at 10:48 a.m. confirmed that Resident 7 did not have a care plan developed to address her specific care needs related to Parkinson's disease, and it should have been. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to safely transfer one of 38 residents reviewed (Resident 62) who required assistance from staff for transfers. Findings include: An admission minimum data set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated March 4, 2025, indicated that he was alert and oriented, required moderate assistance for daily care needs, and assist of one for transfers with wheeled walker and gait belt. Observations of Resident 62 on May 22, 2025, at 8:24 a.m. revealed that Nurse Aide 2 transferred the resident from a seated position to his wheelchair by using the back of his pants while there was a gait belt on the back of his wheelchair. Interview with Nurse Aide 2 on May 22, 2025, at 8:26 a.m. revealed that she was aware of Resident 62's transfer status and that she did not use a gait belt for the transfer instead she used the back of his pants for the transfer. Interview with Nursing Home Administrator on May 22, 2025, at 2:08 p.m. confirmed that Resident 62 should have been transferred with the use of a gait belt and he was not. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of Department of Health files, policies, clinical records, and manufacturer's instructions, as well as staff interviews and observations, it was determined that the facility failed to ensure that the residents' environment remained free from accident hazards created by adding wedges to the sides of specialty air mattresses for three of five residents reviewed (Residents CR1, R3, R4) and resulting in harm for one resident. Findings include: Department of Health files revealed a report dated [DATE], indicating that on [DATE], Resident CR1 was on a specialty air mattress with built in bolsters, in addition to bilateral positioning wedges, when Nurse Aide 1 turned the resident away from her during care and the resident rolled out of bed. The report further indicated that the resident was admitted to the hospital with [REDACTED]. The facility's fall risk management policy dated [DATE] indicated that key elements of the program were to do an assessment, a reassessment, and evaluation of the resident's treatment plan. A physician order [REDACTED]. The manufacturer's instructions for use of the specialty air mattress, undated, contained a warning not to use any attachments not recommended by the manufacturer. Interview with the manufacturer's Executive Medical Director, Post Market Surveillance on [DATE] at 1:10 p.m. revealed that if a facility used any additional devices with any of their specialty air mattresses, then the facility assumed the responsibility of the resident's safety with the use of this additional equipment. The manufacturer's instructions, undated, for the Roll Control Bolsters (added wedges) indicated that they were designed to be used as positioning devices to support the resident on his/her side, to reduce the likelihood that the resident would roll off of the bed. A comprehensive assessment dated [DATE], for Resident CR1 revealed that the resident had a [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. She also had a history of [REDACTED]. Interview with Registered Nurse 2 on [DATE] at 2:35 p.m. confirmed that the resident was initially placed on the specialty air mattress on [DATE], due to having pressure ulcers upon admission to the facility. Review of an incident report and interdisciplinary team meeting notes dated [DATE], indicated that the resident fell out of bed and that due to her confusion and non-compliance she was identified to be at high risk for further falls and wedges held in place by velcro were placed on her bed. There was no documented evidence that the use of the velcro wedges along with the specialty air mattress was assessed for any possible safety hazards that adding the wedges to the air mattress may have created for the resident upon initiation of use of this additional equipment on the specialty air mattress. An incident report dated [DATE] revealed that the resident was found sitting beside her bed on a fall mat, having exited from the left side of the bed "over the velcro wedges." A quarterly fall review note dated [DATE], indicated to continue the present interventions. The documentation did not reflect that an assessment of the possible safety hazards created by continuing to use the wedges with the specialty mattress, or by the resident going over the velcro wedges, was completed. An incident report and nursing note dated [DATE] revealed that staff found the resident on the floor mat beside her bed, and that the resident stated she "slipped." At that time "new velcro wedges" were placed on her bed; however, there was no documented evidence that an assessment of the possible safety hazards created by adding the wedges to the specialty air mattress was completed. Interview with Registered Nurse 1 on [DATE] at 11:05 a.m. revealed that the resident had velcro wedges in place at the time of the incident on [DATE], and that they were secured to the bed, although one wedge was found leaning over toward the edge of the bed on the side she fell from. He further indicated that he felt the wedge appeared "soft"; therefore, he put new wedges on the bed, and he confirmed that he did not assess the resident's safety with the continued use of the wedges along with the specialty air mattress. A nursing note and incident report dated [DATE], revealed that the "resident rolled away from staff and rolled out of bed" and when Registered Nurse 4 entered the room the resident was supine on the floor mat on the right side of the bed. The resident had bleeding from both nostrils, an abrasion to the top of her forehead, and she complained of neck pain. Interview with Nurse Aide 3 on [DATE] at 11:55 a.m. indicated that prior to the fall she had the resident pulled close to her on the left side of the bed prior to placing her on her right side to finish incontinent care and during this care the velcro wedge on the right side of the bed slid down to the side of the bed, level with the top of the air mattress, and the resident fell out of the bed onto the mat on the floor. She indicated that the velcro wedge was checked and was secured to the bed frame after putting her back to bed prior to her incontinent care and was still secured to the bed after the incident. Observations of Resident CR1's bed on [DATE] at 11:45 a.m. revealed that the wedges were on the specialty air mattress and each wedge was secured with a strap going under and around the bed frame toward the center of the bed. The strap went through a slider and was tightened to an approximate 8 inch length strap on the left, and 4 inch strap on the right causing the edges of the air mattress to partially collapse. The left wedge was flat on the surface of the mattress inside the built-in bolster (approximately 2 inch height) of the mattress, and the right wedge was on top of the built-in bolster, leaning partially over to the edge of the mattress. The wedges were secured together by a velcro strap between the two wedges. The CAT scan report dated [DATE], indicated that Resident CR1 had a compound fracture of the C1 vertebral body, it was an unstable fracture through the base of the odontoid process with displacement and severe central canal compression (fracture of neck location of cervical area, C1-C2). Nursing notes dated [DATE], indicated that the resident died at 2:45 a.m. and that the Deputy Coroner informed the facility that the manner of her death was accidental. Interview with the Administrator on [DATE] at 1:30 p.m. confirmed that the facility did not have a policy regarding the use of specialty air mattresses. Interview with the Director of Nursing on [DATE] at 2:30 p.m. revealed that the facility does not complete a safety assessment when wedges are used with specialty air mattresses. The quarterly resident assessment dated [DATE], revealed that Resident R3 was confused, was dependent for bed mobility, and had impaired mobility of the upper and lower extremities. A physician order [REDACTED]. Incident logs and nursing notes dated [DATE], revealed that the resident climbed over the wedges and was found on his knees; on [DATE], the resident was found on the floor and the wedges had slid off the right side of the bed; on [DATE], the resident was found head first with his head on the floor and feet in bed and the wedge strap was ripped; on [DATE], the resident fell from bed and the velcro wedge was out of place beside him; on [DATE], the resident fell from bed and was sent to the emergency room for evaluation; and on [DATE], the resident fell from bed onto the floor and the velcro wedges were loose on the right side of the bed and he rolled over the top of the wedge. Observations on [DATE] at 2:58 p.m. revealed that the resident was on an air mattress with velcro wedges in place. There was no documented evidence that included what the rationale was for continuing to use the velcro wedges although they were not effective in preventing the resident from falling out of bed. There was no documented evidence that the continued use of side rails were assessed for possible safety hazards following these incidents. A quarterly resident assessment dated [DATE], revealed that Resident R4 was confused, was dependent for bed mobility, had impaired mobility of the upper and lower extremities, and had history of falls. A physician order [REDACTED]. On [DATE] the resident fell out of bed. Observations on [DATE] at 10:52 a.m. and 2:09 p.m. revealed that the resident was on an air mattress and had velcro wedges in place. Interview with the Director of Nursing on [DATE] at 3:30 p.m. revealed that he continued to use the velcro wedges for residents, even though they were not effective, because the velcro wedges were the best thing that they had. 28 Pa. Code 201.14 (a) Responsibility of license. 28 Pa. Code 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited [DATE], [DATE], [DATE].