Every finding on record at Belvedere Center, Genesis Healthcare, The

Based on a review of the facility's policy and the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure medications were properly labeled and stored on one of three units observed (South Unit Front Medications Cart, South Unit Middle Medication Cart, and South Unit Medication Room). Findings: A review of the facility policy titled Medications and Medication Labels, undated, revealed, Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws. A review of the manufacturer's medication guidelines revealed the following: A review of manufacturers' storage guidelines for Insulin Glargine (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. A review of manufacturers' storage guidelines for Lantus Insulin (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Humalog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Insulin Lispro (Humalog-fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. A review of the manufacturer's storage guidelines for Novolog Insulin (fast-acting insulin), revealed that the medication must be stored at room temperature and must be discarded within 28 days after opening. An observation of the South Unit Front Medication Cart was conducted on July 13, 2026, at 9:56 a.m., in the presence of licensed nurse Employee E5. The observation revealed the following: One Gargline insulin pen opened and undated; Two Lantus insulin pens opened and undated; and one Humalog Insulin pen opened and undated. Additional observations revealed 38 tablets with different sizes and colors were scattered on the second-row drawer of the medication cart. An observation of the South Unit Middle Medication Cart was conducted on July 13, 2026, at 10:05 a.m., also in the presence of Employee E5. The observation revealed one Insulin Lispro pen with a dated 6/8/26. An interview was conducted with Employee E5 on July 13, 2026, at 10:05 a.m. Employee E5 confirmed that the above insulins observed should have been dated once opened. An observation of the South Unit medication room refrigerator was conducted on July 16, 2026, at 1:00 p.m., in the presence of Employee E5. The observation revealed one Lantus insulin pen and one Novolog insulin pen. Both medications were opened and undated. An interview with Employee E5 was conducted on July 16, 2026, at 1:05 p.m. Employee E5 does not know when the medication was opened. Employee E5 confirmed that the insulin pens should have been dated when opened. The above findings were conveyed to the Director of Nursing on July 16, 2026, at 2:00 p.m. The facility failed to ensure medications were properly stored and labeled on the South Unit medication cart and room. 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a clinical records review and resident and staff interviews, it was determined that the facility failed to monitor a resident's behaviors and follow the psychiatrist's recommendations for one of five residents reviewed (Resident 8). Findings: A review of Resident 8's diagnosis list includes Psychosis (A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality), Major Depressive Disorder (Characterized by a low mood or loss of interest in activities that last for a long time that can interfere with normal functioning), and Schizoaffective disorder (A chronic mental health condition that combines symptoms of Schizophrenia with mood disorder). A review of Resident 8's Quarterly Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated June 12, 2026, revealed the resident's cognition was intact. A review of Resident 8's current care plan developed on September 18, 2024, revealed Resident was at risk for distress/fluctuating mood symptoms related to psychosis. Interventions include: Observe for signs of delirium (A sudden, severe change in mental state that causes confusion, and reduced ability to focus), including delusions( A fixed, false belief that persist despite clear, contradictory evidence)/hallucinations (Are sensory experiences that occur in the absence of an external stimulus); notify physician/advance practice practitioner as needed; Observe for signs/symptoms of worsening sadness/depression/ anxiety/fear/anger/agitation. A review of Resident 8's Psychiatry consult dated November 11, 2025, revealed the resident had a suicide attempt before being admitted to the facility. The same report revealed that the resident was currently not on psychotropic medications due to mumbling and concerns of sedation. Assessment revealed, Overall mood is stable, has some frustrations but is coping. No psychosis symptoms. Plan includes Redirect as able, Continue to document behaviors in EMR (Electronic Medical Records) to assist with medication adjustments and treatments, and Follow up as needed. A review of Resident 8's nursing progress notes from November 2025 until July 2026 failed to reveal any behavior monitoring of the resident's behaviors. A review of Resident 8's Psychiatry notes dated July 7, 2026, revealed: Asked to see by unit manager request, increased anger, was recently observed barking towards another resident, reports of banging their head on the wall and hitting themselves in the face. The same report revealed the plan as follows: Start Zyprexa (an antipsychotic medication) 2.5 mg at night for Schizophrenia, redirect as able, continue to document behaviors in EMR to assist with medication adjustments and treatments, blood work, and follow up in 2-4 weeks. The behaviors mentioned by the Psychiatrist during the July 7, 2026, consult were not documented on the resident's EMR. Also, there were no other behaviors documented on the resident's EMR after July 7, 2026. A review of Resident 8's physician order and Medications Administration Records revealed that the Zyprexa medication and blood work recommended on July 7, 2026, by the psychiatrist were not followed. An interview with licensed nurse Employee E6 was conducted on July 16, 2026, at 10:30 a.m. Employee E6 reported that Resident 8's behaviors were reported by the roommate. Employee E6 confirmed that those behaviors were not documented on the resident's EMR, but they requested a psychiatry consult. Employee E6 reported that after the consult, the provider informed them that they will think about the order. There was no behavior monitoring follow-up found on the resident's EMR. An interview with the Director of Nursing (DON) was conducted on July 16, 2026, at 10:45 a.m. The DON reported that Resident 8 did not have behavior monitoring due to residents not being on psychotropic medications. The DON also reported that the primary provider was responsible for writing the orders in the residents' EMR. The DON reported that the primary provider received the psychiatry consult/ recommendations on July 7, 2026, but forgot about it until the consult report was printed by the facility on July 16, 2026, and was shown to the primary provider. An interview was conducted with Resident 8 on July 16, 2026, at 11:00 a.m. The residents reported hitting their face with their hands and banging on the wall when they become frustrated and angry. The residents reported that frustrations usually occur during showers and when missing clothes in their drawer. An interview was conducted with the roommate, Resident 57, on July 16, 2026, at 12:15 p.m. Resident 57, a cognitively intact resident, reported that Resident 8 had an on-and-off behavior of hitting their head and banging on the wall. Resident 57 reported that the behavior occurs when they get mad; they stated [They] have a bad temper. Resident 57 also reported that Resident 8 would often talk to themselves and change voices with words that cannot be understood. They also reported hearing Resident 8 saying I wish I was dead. Resident 57 reported that they reported Resident 8's behaviors to the nursing staff a few weeks ago because it was getting worse. The above information was discussed with the DON on July 16, 2026, at 1:00 p.m. The facility failed to ensure Resident 8's behaviors were monitored and psychiatrist recommendations were timely followed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observation, clinical records review, and staff and residents' interviews, it was determined that the facility failed to ensure the resident's dignity was maintained for one of 26 residents reviewed (Resident 93). Findings Include: Review of Resident 93's diagnosis list includes: Spastic Hemiplegic Cerebral Palsy (A neurological condition affecting movement and muscle tone on one side of the body, including the arm, leg, and sometimes the face), Post Traumatic Stress Disorder (PTSD), and Anxiety Disorder (A mental health disorder characterized by feeling of worry, anxiety or fear that are strong enough to interfere with one's daily activities). A review of Resident 93's Annual Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated July 10, 2026, revealed the resident was cognitively intact. The same MDS revealed the resident required set-up with toileting. A review of Resident 93's active care plan developed on July 23, 2025, revealed Resident had previous trauma experience. Feeling upset when reminded of a stressful experience from the past. History of sexual assault during teenage years. An observation conducted on July 14, 2026, at 1:00 p.m., revealed Resident 93 was by themselves in a room with a shared bathroom (jack and [NAME]). An opposite gender resident (Resident 129) resides in the opposing room. Further observation revealed that the bathroom door can be locked on both sides. An interview was conducted with Resident 93 on July 14, 2026, at 1: 05 p.m. The resident verbalized concern that they must share the bathroom with Resident 129, an opposite gender resident. The resident reported that a few months ago (unable to tell the exact date), Resident 129 got into the bathroom while they were using it despite locking it; they claimed: they might have been broken. A review of the facility's grievance/concern dated April 12, 2026, revealed: Resident voiced concerns regarding security of locks due to jack and [NAME] bathrooms. Resolutions revealed: [Resident 129] on opposing side of bathroom agreed to use shower room bathroom moving forward to ensure this [resident] feels safe and secure. A review of Resident 129's clinical records census revealed resident was transferred to the room opposing Resident 93's room on February 3, 2026. An interview with Resident 129, a cognitively intact resident, was conducted on July 15, 2026, at 10:00 a.m. Resident 129 reported that they previously used the [NAME] and [NAME] bathroom but had to stop because Resident 93 made false accusations. Resident 129 reported that around March or April 2026, they were accused of banging the bathroom door. Resident 129 reported that they knocked on the bathroom door, but no one answered, so they got in while Resident 93 was in the bathroom. Resident further reported that to prevent further issues/concerns, they agreed to use the bathroom shower instead. An interview was conducted with the Nursing Home Administrator (NHA) on July 15, 20266, at 11:00 a.m. The NHA reported that it was the facility's set up (jack and [NAME] bathroom) and there were no other available rooms when Resident 129 was transferred. The facility failed to ensure dignity was maintained for Resident 93. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observation and staff interview, it was determined that the facility failed to ensure resident rooms had appropriate hot water temperatures and/or working hot water faucets on the Southside unit for ten of twenty rooms observed. (Rooms 319, 320, 321, 322,323, 324, 326, 328, 330 and the shower room)Findings include: During interview conducted with Resident 1 on July 14, 2026, at 1:34 p.m. the resident stated there had been no hot water in his/her room for several days. Resident 1 stated staff was made aware, but nothing had been done to alleviate the problem. Observations made on July 14, 2026, at 1:37 p.m., with Maintenance Director Employee E1 revealed water temperatures in nine rooms and the shower room on the Southside Unit did not have hot water with no water coming out of the hot water faucets in two rooms (319 and 320). During interview conducted with Unit Manager Registered Nurse Employee E2, on July 14, 2026, at 1:58 p.m., Employee E2 denied knowledge of rooms on the unit without hot water. On July 15, 2026, at 10:00 a.m., review of facility temperature logs for the evening of July 14, 2026, revealed hot temperatures for rooms on the South Unit ranged between 100 and 110. During interview conducted with Employee E1 on July 15, 2026, at 12:40 p.m. Employee E1 stated a [NAME] Valve (a high performance thermostatic mixing valve designed to blend hot and cold water to maintain a safe, consistent temperature) needed to be replaced, the part was already in-house, and a plumbing contractor was scheduled to come out tomorrow, July 16, 2026, between 10:00 a.m. and 12:00 p.m., to replace the part. Employee E1 stated the broken valve must be causing low hot water temperatures as the equipment was in an area underneath the affected unit. Observations made of hot water temperatures on July 16, 2026, at 12:45 p.m., with Employee E1, after the valve replacement was completed revealed hot water temperatures in rooms on the South Unit ranged between 82 and 87 degrees. The hot water temperature in the unit shower room was 91 degrees. The hot water faucets in rooms [ROOM NUMBERS] remained broken. Review of the plumbing contractor's service order dated July 16, 2026, documented the facility had the wrong parts for the mixing valve so he/she removed the existing thermostat and cleaned it up. The thermostat was reinstalled and adjusted. The loop was set to temperature no hotter than 110 at the facility's request. The facility will order the correct part for standby. There was no documentation related to the contractor coming back when the part was received. Interview conducted with Nursing Home Administrator (NHA) on January 16, 2026, at 12:20 p.m. when the above was presented, the NHA confirmed knowledge of the hot water situation. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) (e)(3) Management. 28 Pa. Code 207.2(a) Administrator's responsibility

Based on review of clinical records, the facility failed to provide an accurate initial assessment of a resident's vision status for one of 32 residents reviewed (Resident 13)Findings include:Review of hospital occupational therapy progress notes dated May 21, 2026, revealed that Resident 13's vision was noted as impaired and Reports seeing only shadows and light. Further review of the occupational therapy assessment and plan from the same date revealed patient presented in the ED (emergency department).with significant visual impairment.Review of Resident 13's admission MDS (Minimum Data Set - a mandatory assessment of a resident's care needs and medical condition) dated June 22, 2026, revealed that Resident 13 was admitted to the facility on [DATE], from the hospital. Review of MDS Section B- Hearing, Speech and Vision, item B1000 Vision Ability to see in adequate light (with glasses or other visual appliances) was coded as Adequate - sees fine detail, such as regular print in newspapers and books. Review of item B1200 Corrective Lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision was codes No.Review of Resident 13's care plan dated June 15, 2026 revealed the following, Resident 13 is at risk for falls. Impaired mobility, recent amputation of right toes, blindness and further review of Resident 13's care plan dated June 16, 2026 revealed, Resident 13 has vision impairment.The facility failed to accurately assess Resident 13's vision status on admission. This finding was shared with the Director of Nursing on July 16, 2026 at approximately 2:30 p.m. 28 Pa. Code 211.5(f) Clinical Records.

Based on staff interview, observation, and clinical record review, it was determined that the facility failed to develop and implement a person-centered care plan that included the minimum healthcare information necessary to properly care for a resident for one out of 32 residents reviewed (Resident 18).Findings include:Observation of Resident 13 on July 13, 2026, at approximately 11:30 a.m., revealed Resident 13 out of bed sitting in a wheelchair. When asked questions, Resident 13 did not respond.Interview with the LPN Unit Manager (E4) on July 17, 2026, at approximately 12:45 p.m. revealed that Resident 13 does not speak. Resident 13 responds with vocalizations and nodding of the head when staff asks Resident 13 about their needs such as food or a preferred music channel. Further interview revealed that there should be a communication board with pictures Resident 18 could point to in the room. Observation of Resident 18's environment on July 17, 2026, at approximately 12:50 p.m. revealed there was no picture board in the room.Review of Resident 18's hospital history and physical dated June 3, 2026, revealed Resident 13 presented to the ER (emergency room) as a stroke alert.patient unable to provide details of events leading up to admission due to speech difficulty/dysarthria (speech difficulty caused by a nerve defect).Review of Resident 18's admission MDS (Minimum Data Set - a mandatory assessment of a resident's care needs and medical condition) dated July 9, 2026, revealed that Resident 18 was initially admitted to the facility on [DATE]. Review of MDS Section B Hearing, Speech, and Vision Item B0600 Speech Clarity was coded No speech - absence of spoken words. Review of Item B0700 Makes Self Understood Ability to express ideas and wants, consider both verbal and non-verbal expression was coded Rarely/never understood. Review of Item B0800 Ability to Understand Others Understanding verbal content, however able (with hearing aide or device, if used) was coded Rarely/never understands.Review of Resident 18's care plan, initiated on June 16, 2026 revealed a diagnosis of aphasia following cerebral infarction (an inability to communicate after a stroke). Further review of Resident 18's care plan revealed no plan of care for Resident 18's communication deficit.The facility failed to create a care plan that included the minimum healthcare information necessary to properly address Resident 18's communication deficit.This finding was shared with the DON on July 17, 2026, at approximately 2:30 p.m. 28 Pa. Code 211.12(d)(5) Nursing services.

Based upon review of facility policy, clinical records review, facility documents and staff interview, it was determined the facility failed to ensure that a current smoking assessment for one of one resident reviewed (Resident 81).Findings include:Review of facility's policy OPS137 Smoking dated February 24, 2025, stated 2.3.1 Patients will be re-evaluated quarterly and with a change in condition. Review of Resident 81's diagnosis list revealed diagnoses including Chronic Obstructive Pulmonary Disease, unspecified (COPD- a common lung disease causing restricted airflow and breathing problems) and congestive heart failure (excessive body/lung fluid caused by a weakened heart muscle).Review of Resident 81's clinical record revealed Resident 81 is currently a smoking resident due to a grandfather clause in the facility's policy.Review of Resident 81's clinical record revealed a Smoking Safety Evaluation dated December 15, 2025.Further review of Resident 81's clinical record failed to reveal evidence that a current Smoking Safety Evaluation was completed since December 2025.Interview with the Director of Nursing on July 16, 2026, at 9:32 a.m. revealed that no Smoking Safety Evaluation was completed for Resident 81 since December 2025. 28 Pa. Code 201.18(c)(4) Management

Based on interview with staff and clinical record review, it was determined that the facility failed to maintain complete and accurate medical records related to medications and treatments for one of five residents reviewed (Resident 116).Findings include: Resident 116 had medical diagnoses that included history of disease of the digestive system, Gastronomy, Aphasia, and Severe Protein Calorie Malnutrition. Review of Resident 116's care plan revealed a focus dated June 27, 2026, for an enteral feeding tube (a soft, flexible tube that delivers nutritionally complete liquid feeds, including protein, carbohydrates, fats, vitamins, minerals, and water, directly into the gastrointestinal tract to meet nutrition and hydration needs) related to Cerebrovascular Accident (a condition that occurs when blood flow to a part of the brain is interrupted) with dysphagia (difficulty swallowing). Review of Resident 116's physician orders revealed an order dated June 29, 2026, for Enteral Feed Glucerna (a nutrition formular) 1.5 calorie, administer bolus (single large dose) 325 milliliters (ml) four times per day via peg (small flexible tube placed in abdomen) for total volume: 1300 ml four times a day for feedings. Review of Resident 116's physician orders revealed an order dated June 29, 2026, to flush tube with 125 ml before and after each bolus. Total volume of flush = 1000 ml every 24hrs. Total volume of nutrient + flush = 2300 ml every 24 hours four times a day. Review of Resident 116's June 2026 Medication Administration Report (MAR) revealed total daily flush amounts as follows:June 29, 2026, total volume of 6900 ml.June 30, 2026, total volume of 9200. Per Resident 116's June MAR, there were two days in June 2026, when the resident's total volume of flush exceeded the physician ordered amount. Review of Resident 116's July 2026 MAR revealed total daily flush amounts as follows:July 1, 2026, total volume of 9200 ml.July 2, 2026, total volume of 5600 ml.July 3, 3036, total volume of 3550 ml.July 4, 2026, total volume of 1000 ml.July 5, 2026, total volume of 1000 ml.July 6, 2026, total volume of 1000 ml.July 7, 2026, total volume of 1000 ml.July 8, 2026, total volume of 750 ml.July 9, 2026, total volume of 1000 ml.July 10, 2026, total volume of 1000 ml.July 11, 2026, total volume of 1000 ml.July 12, 2026, total volume of 1000 ml.July 13, 2026, total volume of 1000ml. Per Resident 116's July MAR, there were three days in July 2026, when the resident's total volume of flush exceeded the physician ordered amount. Per Resident 116's July MAR, there was one day in July 2026, when the resident's total volume of flush did not meet the physician ordered amount. Interview conducted with the Director of Nursing on January 16, 2026, at 1:20 p.m., when the above was presented, the DON confirmed there were days when the resident did not received the accurate daily total flush amounts. 28 Pa. Code: 211.5 (f) Clinical records 28 Pa. Code: 211.12 (d)(1)(5) Nursing services

Number of residents sampled: Number of residents cited: Based upon observation, it was determined the facility failed to ensure medications were properly labeled with open and expiration dates for three of four medication carts observed (North Back Hall Cart, North Front Cart and South Middle Cart).Findings include:Review of package insert instructions for Humalog (Lispro) Insulin Pens revealed unopened Humalog pens should be stored in the refrigerator.Further review of package insert instructions for Humalog Insulin Pens revealed that once opened, Humalog can be kept at room temperature for up to 28 days. Review of package insert instruction for Lantus Insulin revealed Lantus Insulin should be used within 28 days after opening. Review of package insert instruction for Lantus (glargine) Insulin revealed Lantus Insulin should be used within 28 days after opening.Observation of the North Back Hall Medication Cart on August 15, 2025, at 9:12 a.m. revealed one open Lispro Insulin Pen with no open or expiration date; three open Lantus Insulin Pens with no open or expiration date; one unopened and unrefrigerated Lispro Insulin Pen; two open Humalog Insulin Pens with no open or expiration date; one Glargine Insulin Pen with no resident name, no open or expiration date; and one unopened Glargine Insulin Pen unrefrigerated.Observation of the North Front Hall Medication Cart on August 15, 2025, at 9:16 a.m. revealed one unopened Lantus Insulin Pen unrefrigerated.Observation of the South Hall Middle Medication Cart on August 15, 2025, at 9:21 a.m. revealed one open Lantus Insulin Pen with no open or expiration date; one open Basaglar Insulin Pen with no expiration date and one unopened Humalog Insulin Pen unrefrigerated.The above information was conveyed to the Director of Nursing on August 15, 2025, at 11:00 a.m. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing ServicesPreviously cited 7/18/2024, 8/23/2024

Number of residents sampled: Number of residents cited: Based upon observation, it was determined that the facility failed to ensure medication carts were locked when a staff member was not in attendance for one of four medication carts observed (North Hall Front Cart).Findings include:Observation on August 15, 2025, at 9:16 a.m. revealed the North Hall Front Medication Cart to be open and unlocked with no staff members in attendance. Four residents were observed in the hallway at the time of the observation.During the observation, the cart was able to be opened, and medications were able to be viewed and examined by a surveyor. Licensed employee was observed in a resident room with employee's back to the cart and not able to observe the cart that was left unattended and unlocked.The above information was conveyed to the Director of Nursing on August 15, 2025, at 11:00 a.m. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing ServicesPreviously cited 7/18/2024, 8/23/2024

Based on facility policy, clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 1 of 26 residents reviewed (Resident 134). Findings include: Review of facility records revealed a policy titled Discharge and Transfer dated June 11, 2025, noting for patients transferred to a hospital for unplanned, acute transfers, the patient must be permitted to return to the facility. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form. Copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirement. A review of Resident 134's clinical record revealed the resident was transferred to the hospital on July 21, 2025, due to change of condition and decline in activities of daily living. There was no documented evidence to indicate that the facility provided a written notice to the Office of the State Long-Term Care Ombudsman regarding the resident's hospitalization. Review of the facility's discharge log for July 1, 2025, thru July 31, 2025, revealed Resident 134 was not listed as discharging to the hospital on July 21, 2025. Interview on August 15, 2025, at 2:25 p.m. with Nursing Home Administrator (NHA) and Director of Nursing (DON) when the above was presented the DON confirmed there was no documentation of the Ombudsman's Office being notified of the resident's hospital transfer. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Number of residents sampled: Number of residents cited: Based on clinical record review and interview with staff, it was determined that the facility failed to complete a comprehensive assessment within 14 days after a significant change in the resident's condition for one of 26 residents reviewed (Resident 90).Findings include:Review of Resident 90's physician's orders revealed an order on June 19, 2025, for Compassus Hospice for evaluation and treatment. Review of the resident's progress note of June 20, 2025, revealed resident assessed by Compassus Hospice and has been admitted to their services. Further review of clinical record revealed that a significant change MDS (Minimum Data Set - periodic assessment of resident needs) was completed on June 20, 2025; however, Section O0110 - Special Treatments, Procedures, and Programs indicated that the resident was not receiving hospice care. Review of Resident 90's progress note of June 23, 2025, revealed that Compassus Hospice nurse stated that resident's admission on [DATE], was voided and resident was admitted to hospice on June 23, 2025. Further review of the clinical record revealed a significant change MDS had not been completed after the resident was admitted to hospice.Interview with licensed staff Employee E3 on August 15, 2025, at 12:10 p.m. revealed that hospice was voided on June 20, 2025, because hospice could not admit the resident until seen face to face. Employee E3 also confirmed that hospice started on June 23, 2025, and that a significant change MDS had not been completed. 28 Pa. Code: 211.12(d)(3) Nursing servicesPreviously cited 7/18/24

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for two of 26 residents reviewed (Residents 95 and 113).Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for two of 26 residents reviewed (Residents 95 and 113). Findings include: Review of Resident 95's clinical record revealed the resident was receiving dialysis. Review of Resident 95's quarterly MDS assessment (MDS - periodic assessment of resident care needs) dated July 3, 2025, Section O0110 – Special Treatments, Procedures, and Programs indicated that the resident was not receiving dialysis. Interview with licensed staff Employee E3 on August 15, 2025, at 11:50 a.m. confirmed Resident 95 was receiving dialysis and the resident's MDS was coded incorrectly. Review of Resident 113's clinical record revealed the resident was receiving hospice care. Review of Resident 113's admissions MDS assessment dated [DATE], Section O0110 – Special Treatments, Procedures, and Programs indicated that the resident was not receiving hospice care. Interview with licensed staff Employee E3 on August 15, 2025, at 2:25 p.m. confirmed Resident 113 was receiving hospice care and the resident's MDS was coded incorrectly. 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 7/18/24

Number of residents sampled: Number of residents cited: Based on policy review, and clinical records review, it was determined that the facility failed to follow physician orders regarding administration of medications for one of 26 resident (Resident 3) Findings include: Review of medication administration general guidelines section 7.1 dated 01/25-page three of six Medication Administration section 1. Medications are administered in accordance with written orders of the prescriber. Review of Resident 3's clinical record revealed there was a current physician's order for the resident to be receiving Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) (Midodrine is used to treat low blood pressure), Give 1 tablet via PEG-Tube (Peg tube A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach.) three times a day for Hypotension Hold for SBP (Systolic blood pressure also known as SBP is the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats. It is measured in millimeters of mercury (mm Hg) and is crucial for assessing cardiovascular health.) Greater than or equal to130.Review of Resident 3's Medication administration record revealed that Midodrine was administered 11 times in the month of June 2025 outside of parameters with a systolic blood pressure greater than/equal to 130. Review of the Medication administration record revealed that Midodrine was administered 9 times outside of parameters in July 2025 with a systolic blood pressure greater than/equal to 130.Informed health care administrator of deficient practices on August 15, 2025, at 1:44 PM. PA Code 211.10(c) Resident Care PoliciesPreviously cited 7/18 2024 PA code S 211.9(a)(1) Pharmacy Services Pa code S 211.12(d)(5) Nursing servicesPreviously cited 7/18 2024

Based on a review of the facility's policy, facility documentation, clinical records, and staff interview, it was determined that the facility failed to monitor resident's skin condition and follow wound physician's treatment orders/recommendations resulting in harm to Resident CL1 of discovering the wound at an advanced Stage 3 (full thickness loss of skin that extends into the subcutaneous tissue but does not cross the fascia beneath), wound deterioration, and unnecessary pain/discomfort for one of two residents reviewed (Resident CL1). Findings include: Review of the facility's policy titled Skin Integrity and Wound Management, reviewed May 1, 2024, revealed that nursing assistants will observe skin daily and report any changes or concerns to the nurse. The licensed nurse will evaluate any reported or suspected skin change or wounds and perform daily monitoring of wounds or dressing for the presence of complications or declines. Implement wound care treatments/techniques as indicated and ordered. Review of Resident CL1's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Urinary Tract Infection (UTI), and Peripheral Vascular Disease (PVD- circulatory condition that causes blood vessels outside the heart and brain to narrow, block, or spasm). Review of Resident CL1's clinical admission assessment revealed resident was admitted to the facility on [DATE]. Further review of admission assessment under section skin assessment revealed the presence of scabs on both lower extremities. Additional review of the clinical admission assessment failed to reveal any skin wounds to the sacral area (tailbone). Review of Resident CL1's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 22, 2024, revealed Resident CL1 had severe cognitive impairment. Further review of the admission MDS assessment revealed Resident CL1 was rating as always being incontinent of both bowel and bladder and was dependent on bed mobility. Additonal review of the MDS revealed resident did not have pressure ulcer upon admission and was at risk for developing a pressure ulcer. Review of Braden Scale Assessment (scale used for predicting pressure sore risk) dated March 1, 2024, revealed a score of 14 indicating Resident CL1 was moderately at risk for developing a pressure ulcer. Review of Resident CL1's skin and incontinent care plans revealed interventions including observing skin for signs of skin breakdown (redness, cracking, blistering, decreased sensation, and skin that does not blanche easily), and monitoring for skin redness/irritation and reporting as indicated. Review of Resident CL1's clinical record revealed that weekly skin assessments were conducted but issues with skin integrity were not noted. Review of Resident CL1's nursing progress notes dated March 7, 2024, at 12:24 p.m., revealed a new open area was discovered on Resident CL1's sacrum. Upon further assessment, a new Stage 3 was noted on the sacrum. The wound was assessed, treatment was applied, all parties were notified, the care plan was updated, and a new treatment order was placed. Review of Resident CL1's skin assessment dated [DATE], revealed Resident CL1's sacrum Stage 3 wound was determined to be in-house acquired, measuring 3.3 x 1.7 x 0.1 cm. with light serosanguinous drainage (type of wound drainage that is a combination of blood and serum). Review of Resident CL1's physician orders dated March 7, 2024, revealed a wound treatment to cleanse the wound with wound cleanser, apply Thera honey (wound dressing saturated with Manuka Honey, used to maintain a moist environment conducive to wound healing while permitting the passage of exudate into a secondary dressing), and cover it with foam dressing. Change every other day and as needed if soiled or dislodged. Review of the facility's documentation, including Incident Report dated March 7, 2024, revealed wound nurse was notified of the new Stage 3 wound discovered on the resident's sacrum. The investigation failed to reveal why the resident's sacral wound was discovered at an advanced Stage 3 level. Review of Resident CL1's wound consult report dated March 18, 2024, revealed Resident CL1's sacral wound was a Stage 3 measuring 2.5 x 3.5 x 0.2 cm. with 60% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The wound order was to cleanse the sacral wound with normal saline and apply Medi honey to the wound cover with border dressing change daily and as needed. Review of Resident CL1's March 2024, Treatment Administration Record (TAR) revealed that the March 18, 2024, treatment recommendation/order of the wound doctor was not followed. Resident CL1's Stage 3 sacral wound was treated every other day instead of daily as ordered by the physician. Review of Resident CL1's wound consult report dated March 24, 2024, revealed Resident CL1's sacral wound continued to be categorized as Stage 3 wound with measurements of 3.2 x 3.5 x 0.5 cm. with 60% slough. The wound recommendation/order was to cleanse the sacral wound with normal saline and apply Medi honey to the wound cover with border dressing change daily and as needed. Review of Resident CL1's March 2024, Treatment Administration Record (TAR) revealed the March 24, 2024, treatment recommendation/order of the wound doctor was not followed. Resident CL1's Stage 3 sacral wound was treated every other day instead of daily as ordered by the physician. Interview on August 22, 2024 at 11:00 a.m. with the wound nurse, licensed Employee E3 revealed that Employee E3 does wound rounds with the wound doctor on a weekly basis. Employee E3 indicated the attending physicians automatically approve the recommendations of the wound physician. Employee E3 reported that he/she was responsible for reviewing the wound doctor's consult and placing the order. Employee E3 confirmed that the wound doctor's treatment order/recommendation made on March 18, and 24, 2024, was not followed. Review of the wound consult dated April 3, 2024, revealed Resident CL1's sacral wound is now categorized as Unstageable (obscured full-thickness skin and tissue loss) measuring 2.8 x 3.9 x 0.8 cm with 60% slough. The wound treatment order was to cleanse the sacrum with wound cleanser, pack the wound lightly with 1/4 Dakin's moistened gauze, and cover with border dressing daily and as needed. Review of Resident CL1's March and April 2024, TAR revealed from March 18, 2024, until April 4, 2024, Resident CL1's sacral wound was documented as administered/treated on March 20, 21, 22, 26, 28, 30, and April 1, 2024. Review of Resident CL1's wound consult dated April 11, 2024, revealed Resident CL1's sacral wound was categorized as Unstageable with measurements of 4.5 3 x 1 cm. Undermining has been noted at 9:00 and ends at noon with a maximum distance of 1.2 cm. There is a moderate serosanguinous drainage which has a strong odor. 80% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). The wound is deteriorating. Review of Resident CL1's physician's notes dated April 11, 2024, revealed resident was examined after evaluation by the wound care team. The sacral wound was worsening with malodorous discharge with concern for Osteomyelitis (Bone infection). A transfer to the hospital was ordered by the physician. Review of Resident CL1'S hospital records revealed that in the ER (emergency room ) patient was found to have a mucopurulent (combination of mucous and pus), malodorous sacral wound. The same note revealed that the patient had a sacral wound for about one month that had become progressively painful. The pain was burning, non-radiating, and worse with the pressure shown. MRI (Magnetic Resonance Imaging - medical imaging that uses strong magnetic fields and radio waves to generate images of the organ of the body) revealed early Coccygeal Osteomyelitis. The wound was debrided and washed out by surgery and was placed on IV antibiotics (Intravenous- medications administered in the vein). The above information was discussed with the Nursing Home Administrator on August 22, 2024, at 12 p.m. The facility failed to ensure Resident CL1's skin was appropriately monitored, and the physician's order was followed resulting in a harm of discovering an advanced Stage 3 sacral wound, further wound deterioration, and pain. 28 Pa. Code 211.11(d) Resident care plan Previously cited 7/18/24 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited 7/18/24 28 Pa. Code 211.10 (d) Resident care policies Previously cited 7/18/24

Based on review of clinical records and staff interviews, it was determined the facility failed to ensure a baseline care plan was developed for one of the 30 residents reviewed (Resident 110). Findings include: Review of Resident 110's clinical record revealed the resident was readmitted to the facility on [DATE], with a diagnosis of Acute Diastolic (Congestive) Heart Failure, Hypertension (high blood pressure), and Absence of Left Leg Above Knee. Review of Resident 110's clinical records revealed physician orders dated July 3, 2024, documenting the following orders: Pulse Oxygen every shift to keep oxygen sats greater than or equal to 90%. Clean external filter on oxygen concentrator. Oxygen tube change weekly, label each component with date and initials. Oxygen at 2L/min via Nasal Cannula, continuously. Review of Resident 110's clinical records revealed a Minimum Data Set (MDS) assessment dated [DATE], documenting the resident required oxygen therapy on admission and while in the facility. Review of Resident 110's care plan failed to reveal that a baseline care plan was developed for the resident receiving oxygen. The facility failed to ensure Resident 110's baseline care plan for oxygen was developed. Interview conducted with the Director of Nursing on July 18, 2024, at 1:55 p.m. when the above findings were reviewed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on observation and staff interview, it was determined the facility failed to maintain resident dignity for one of one residents (Resident 80). Findings include: Review of Resident 80's Minimum Data Set (MDS, Standardized assessment used to collect information about a resident for quality measure) with a date of completion of May 9, 2024, revealed Resident 80 possesses a BIMS (Brief Interview for Mental Status) of 8 (indicating moderate cognitive impairment). Additional review of Resident 80's MDS revealed under section 8 (Hearing, Speech, and Vision) that Resident 80 has difficulty understanding others and difficulty communicating with others. Review of Resident 80's medical diagnosis revealed an active diagnosis of Other Nontraumatic Intracerebral Hemorrhage (brain bleed caused from a stroke that caused memory loss, difficulty speaking and understanding .). Observations conducted on July 15, 2024, at 9:45 a.m. revealed a sign on Resident 80 [NAME] indicating, Resident 80 FALL RISK. Observations conducted on July 16, 2024, at 10:13 a.m. revealed the sign remained on Resident 80's door. Observations conducted on July 17, 2024, at 8:30 a.m. revealed the sign remained on Resident 80's door. Interview conducted with Nursing Home Administrator (NHA) on July 18, 2024, at 12:15 p.m. reported the facility did not have the consent of Resident 80 or Resident 80's POA (Power of Attorney). The NHA confirmed the facility failed to respect Resident 80's dignity. 28 Pa. Code 201.29 (j) Resident Rights

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure the advanced directives were accurately reflected in residents' records for one of 30 residents reviewed (Resident 79). Findings include: Review of Resident 79's clinical records revealed that the resident was admitted to the facility on [DATE], and review of clinical record revealed diagnoses including Chronic Kidney Disease, Malignant Neoplasm of Prostate (prostate cancer), Bradycardia (slow heart rate), Cardiac Arrhythmia (irregular heartbeat), Urethral Stricture (narrowing of the urethra), Obstructive and Reflex Uropathy (blockage in urinary tract), Urine Retention, Benign Prostatic Hyperplasia (enlarged prostate), Hypertension (high blood pressure) and Abnormalities of Gait and Mobility (changes in walking pattern). Continued review of Resident 79's clinical record revealed the resident had a BIMS (Brief Interview for Mental Status) scored of five which indicating the resident was severely cognitively impaired. Review of Resident 79's clinical records revealed a care plan dated January 24, 2023, documenting the resident has an established advanced directive of Full Code (life sustaining measures). Further review of Resident 79's clinical records revealed a care plan dated April 12, 2024, documenting the resident was admitted into hospice care due to end stage diagnosis of Senile Degeneration of the Brain, with the goal being the resident will achieve the highest possible level of acceptance and readiness for death by the time of death. Review of Resident 79's active physician orders, revealed an order, dated April 10, 2024, indicated the resident's advanced directive to be Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not Hospitalize (DNH). Review of progress notes from April 10, 2024, through July 18, 2024, for Resident 79 revealed no indication as to reason the physician's orders did not match the resident's care plan. Interview conducted on July 18, 2024, at 1:55 p.m. with Director of Nursing confirmed the above information. 28 Pa Code 211.12(d)(3) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure residents had comprehensive care plans for one of 26 residents reviewed (Resident 113). Findings include: Review of Resident 113's admission elopement assessment dated [DATE], revealed the resident scored a 6, indicating the resident was an elopement risk. Review of Resident 113's elopement assessment dated [DATE], revealed the resident scored a 1, indicating the resident was an elopement risk. Review of Resident 113's care plan failed to reveal a plan of care addressing the resident's risk for elopement. The above findings were discussed with and confirmed with the Director of Nursing on July 18, 2024, at 10:05 a.m. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and facility documentation, it was determined the facility failed to ensure one of two residents reviewed for elopement was provided adequate supervision to prevent elopement (Resident 113). Findings include: Review of Resident 113's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, altered mental status, Schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and homelessness. Review of Resident 113's admission Minimum Data Set (MDS - periodic assessment of resident care needs) dated April 8, 2024, revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment at the time of admission. Review of Resident 113's quarterly MDS dated [DATE], revealed the resident had a BIMS score of 12, indicating mild cognitive impairment. Review of Resident 113's clinical record revealed the resident signed a transportation agreement on April 5, 2024, which stated that the facility does not provide staff escorts for appointments. Review of Resident 113's admission elopement assessment dated [DATE], revealed the resident scored a 6, indicating the resident was an elopement risk. Review of Resident 113's elopement assessment dated [DATE], revealed the resident scored a 1, indicating the resident was an elopement risk. Review of Resident 113's progress notes revealed a nurse's note on June 17, 2024, revealed Resident out to Vascular appointment. Per [physician] appointment needs to be rescheduled with family present to make decisions concerning below knee amputation. Further review of Resident 113's progress notes revealed a care plan meeting note dated June 19, 2024, which stated that the resident's Power of Attorney stated that she could escort Resident to her medical appointments. Interview with the Director of Nursing on July 15, 2024, at approximately 11:00 a.m. revealed Resident 113's appointment was scheduled for 10:30 a.m. on July 9, 2024. Review of information submitted by the facility revealed on July 9, 2024, at 11:00 a.m., the facility received a call from the vascular surgery center that Resident 113 left the building after checking in at 10:15 a.m. The resident's Power of Attorney arrived at the appointment at 10:22 a.m. Review of the witness statement from the transport driver revealed the driver witnessed the resident walking down the street. The above findings were discussed with the Director of Nursing on July 19, 2024, at 10:05 a.m. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility policy, facility investigative documentation, clinical and hospital records, it was determined that the facility failed to ensure one of 24 residents was free from neglect, which resulted in actual harm to Resident 120, through Employee E3's failure to report a fall to registered nurse, the resident experienced a delay in assessment, treatment, and subsequent hospitalization for intracranial hemorrhage (brain bleed) resulting in death. Findings include: Review of facility policy, Abuse Prohibition, last revised [DATE], revealed: Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between Center, patient, practitioners, and patient representatives. Review of Resident 120's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia, Abnormalities of Gait and Mobility, muscle weakness, history of falls, unspecified lack of coordination, and altered mental status. Review of Resident 120's Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident had a BIMS score of 09, indicating moderate cognitive impairment. The MDS further indicated the resident required supervised, one person physical assist for all activities of daily living, including transfers, walking in their room, and walking in the corridor on the unit. Review of Resident 120's care plan revealed the resident was identified as at risk for decreased ability to perform activities of daily living, with an intervention added on [DATE], to provide the resident with cuing for safety, and an intervention added on [DATE], to provide the resident with supervision transfers using a stand and pivot transfer. Further review of Resident 120's care plan revealed the resident was identified as a risk for falls on [DATE], with interventions added on the same date to monitor for changes in the resident's condition, keep the resident's environment free of clutter, and encourage the resident to attend activities to maximize their full potential. Review of facility investigation revealed a witness statement from licensed nurse Employee E10 dated [DATE], which stated that Around 8am I went into her room to give her her medication and she was still asleep. I called her name to notified [(sp.)] her I was there to give her medication and she would not respond or wake up. Due to resident not responding to verbal stimuli I touched her knee and she yelled ouch .I asked her if she could sit up to take her pills she stated 'yes' but would not sit up, so I asked if she want me to come back and she shook her head yes. I returned around 8:30 to attempt to give her her pills again. She would not respond to verbal stimuli so I touched her other knee and she yelled ouch again. I then assisted resident to a sitting position to assess why she kept yelling ouch. During assessment I noted bruising to both her knees. Due to bruising I assessed skin and noted abrasions to her left pinky and ring finger. Resident tried to lay down during assessment and her sleeve went up that's when I noted bruising to her right shoulder going down her arm MD was notified and made aware of new findings. I was ordered to put in x-rays which were placed and later canceled due to resident being sent to the hospital. Review of Resident 120's progress notes revealed a physician's note on [DATE], at 1:55 p.m. which stated: I was asked to see patient by nursing staff today. The patient is noted to have lethargy today. She is also noted to have bruising on right shoulder, bilateral knees. She is not responsive to verbal stimuli but responds to physical stimuli. Further review of the physician's note revealed the resident had been on Eliquis (anticoagulant - blood thinning medication) in the past but not at the time of the change in condition. The physician ordered the resident be sent to the hospital as soon as possible. Further review of Resident 120's progress notes revealed a nurse's note on [DATE], at 8:14 a.m., following up with hospital, which stated the resident had been admitted to the hospital with a diagnosis of altered mental status. Review of facility investigation documentation revealed a witness statement from licensed nurse Employee E3 dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Review of Employee E3's witness narrative indicated, On [DATE] resident was sitting at nurse's station until 10:30 p.m. Resident was eating watermelon and drinking water. At 10:30 p.m. I assisted resident to her room and helped her into bed. I left resident's [wheelchair] beside her bed because that is where she normally keep it. During the night the resident yelled out a few times but when checked on resident was still in bed and did not require any assistance. No bruises were noticed on resident. Further review of facility investigation documents revealed a witness statement from nurse aide Employee E4, dated [DATE], which indicated the employee became aware of Resident 120's injury on [DATE], at 5:00 p.m. Employee E4's witness statement revealed the employee last cared for Resident 120 on [DATE], when the employee assisted the resident with a meal on the ,d+[DATE] shift. Review of facility documentation revealed a timeline which indicated the facility was informed on [DATE], at 1:30 p.m. by the hospital that Resident 120 had a brain bleed. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with nurse aide Employee E9 on [DATE], at 4:55 p.m. Employee E9 was asked if any residents fell on the ,d+[DATE] shift on [DATE]. Employee E9 stated: No one fell but there was a lady who was laying on the floor. When asked who was laying on the floor, Employee E9 identified Resident 120 and stated this happened around 7:30 p.m. Employee E9 stated: Before I went into the room I called for help and the nurse came down and so did [Nurse Aide, Employee E4.] Employee E9 stated that the nurse did not ask her for a statement and Employee E9 did not know if the nursing supervisor was notified. Review of facility investigation documentation revealed an interview conducted by the Nursing Home Administrator and Director of Nursing with licensed nurse, Employee E11 on [DATE], at 5:40 p.m. Employee E11 was identified as the nursing supervisor for the ,d+[DATE] shift on [DATE]. Employee E11 indicated that no one reported any falls, incidents, or behaviors from Resident 120 on [DATE]. Employee E11 was asked if any staff member made Employee E11 aware of anything occurring with Resident 120, and Employee E11 stated: No, the aides did not reach out to me and I saw [Licensed Nurse Employee E3] Monday night when I was down there and she mentioned nothing. Further review of facility investigation documents revealed a follow up witness statement from licensed nurse Employee E10 on [DATE], which stated: [Employee E3] relieved me from the cart on [DATE] at 5 pm. I gave her report on the incident that occurred with [Resident 120.] I asked her if anything happened to her knowledge. She stated, 'No.' Further review of facility investigation revealed a follow up interview conducted with nurse aide Employee E4 by the Nursing Home Administrator and Director of Nursing on [DATE], at 5:00 p.m. Employee E4 admitted to helping pick Resident 120 off the floor on [DATE] at 7:30 p.m. Employee E4 stated that they were not asked to write a statement and they did not know if licensed nurse Employee E3 notified the supervisor. Additional review of facility investigation revealed a follow up interview conducted with licensed nurse Employee E3 by the Nursing Home Administrator and Director of Nursing on [DATE], at 3:00 p.m. Employee E3 admitted that Resident 120 was found on the floor on [DATE], at approximately 7:15 or 7:30 p.m. Employee E3 admitted to not completing an incident report or alerting the supervisor of Resident 120 being found on the floor. Review of Resident 120's hospital records from [DATE], through [DATE], revealed that CT scans showed the resident had multiple brain bleeds. The resident was then transported to a trauma center, started on comfort measures, and died on [DATE]. The hospital discharge summary listed that death was due to intracranial hemorrhaging. Interview with the Nursing Home Administrator on [DATE], at 11:50 a.m. confirmed the facility substantiated neglect allegations against licensed nurse Employee E3 and nurse aide Employee E4 for failing to report Resident 120's fall. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.29 (c) Resident Rights

Based on review of the facility's policy, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor and provide wound treatment timely and consistently resulting in harm of a new pressure ulcer discovered at an advanced stage (Stage 3- Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) for one of nine residents reviewed (Resident 54). Findings include: Review of facility policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed the purpose is to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. Further review of the facility's policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed residents will be observed by the NA (nurse aide) daily. Changes or concerns will be reported to the licensed nurse, who will evaluate any reported or suspected skin changes or wounds, and document newly identified skin/wound impairments as a change in condition. Review of Resident 54's current diagnosis list revealed injury of the left hip with ORIF, (open reduction and internal fixation), a surgery used to stabilize and heal a broken bone. Additional review of Resident 54's clinical record included an Admission Nursing Evaluation which revealed Resident 54 was readmitted to the facility on [DATE], with no other skin impairments other than a left hip surgery wound. Review of the Significant Change/Readmission Minimum Data Set (MDS- Standardized assessment tool that measures health status in long-term care residents) dated September 9, 2023, revealed the resident had no pressure ulcers. Review of Resident 54's care plan initiated October 6, 2019, revealed a care plan focus of risk for skin breakdown related to advanced age (greater than [AGE] years). The skin breakdown care plan interventions were listed as follows: observe skin for signs/symptoms of skin breakdown i.e., redness, cracking, blistering, and skin that does not blanche easily, and provide preventative skin care i.e., lotions, barrier creams as ordered. Further review of Resident 54's clinical record failed to reveal additional interventions were added to the care plan upon readmission on September 12, 2023, after Resident 54's right hip ORIF, (open reduction with internal fixation). Review of Resident 54's clinical record including assessment notes dated September 11, 2023, (4:35 p.m.), revealed a skin check was performed and the following skin injury/wound(s) were previously identified and were evaluated as follows: discoloration(s): description: multiple marks left forearm, right upper arm, right forearm, abrasion(s): description: dime size scratch on right side of face near lower corner of eye. Other wound(s): location(s): sutures left thigh. Review of Resident 54's care plan revealed a revision dated September 12, 2023, documenting the resident being at risk of falls, cognitive loss, lack of safety awareness and previous fall with right hip ORIF, (open reduction with internal fixation), as well as alteration in comfort related to left hip ORIF, (open reduction with internal fixation). Review of the Braden Scale (tool used to predict risk for pressure sore development) dated September 12, 2023, revealed Resident 54 was AT RISK for developing a pressure sore. Further review of Resident 54's care plan revealed a revision dated September 19, 2023, documenting the resident having impaired skin integrity. Resident 54's care plan also revealed a revision dated September 26, 2023, documenting the resident having risk for skin breakdown related to advanced age, with a September 18, 2023, left heel wound. Further review of Resident 54's clinical record including assessment notes dated September 18, 2023, (6:16 p.m.) revealed a skin check was performed and the following new skin injury/wound(s) were identified: pressure area(s): location(s): (left) heel. Further review of skin assessment dated [DATE], failed to reveal measurements or condition of left heel wound. Skin assessment further revealed the area was cleansed, foam dressing applied, wound team consulted, and heel boot obtained to offload heel. Review of Incident Report dated September 18, 2023, revealed that during morning care a nurse aide reported blood on resident's sock and bed. During assessment a stage 3 ulcer to the left heel with a small amount of blood was discovered. Review of Resident 54's progress notes dated September 19, 2023, revealed a nutrition note indicating the resident has a Stage 3 wound and recommended addition of Liquid Protein 30 ml (milliliter) daily. Review of Resident 54's wound care notes dated September 25, 2023, revealed the heel wound measured 1.9 cm (centimeter) x 1.7 cm x 0.1 cm. The pressure ulcer has moderate amount of drainage. The drainage is serosanguineous, (discharge that contains both blood and serum, a clear yellow liquid.) Interview with the Director of Nursing (DON) and E1 Skin Health Team Lead on September 29, 2023, at 10:11 a.m., confirmed Resident 54's left heel wound was not identified until September 18, 2023, and the wound was diagnosed as Stage 3 upon identification. E1 stated that staff did not recognize the wound until Stage 3 and staff failed to properly prop the resident's heels, which caused the wound. The Director of Nursing confirmed investigation was performed and education was provided to staff. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services