Every finding on record at Bradford Hills Nursing & Rehabilitation Center

Based on closed clinical record review and staff interview it was determined that the facility failed to implement interventions to promote pressure ulcer healing for one of two residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed that the facility admitted her from the hospital on May 14, 2026. Review of nursing documentation from hospital staff dated May 13, 2026, at 12:42 PM indicated that Resident CR1 had a skin wound on her coccyx (last bone at the base of the spine) that, looks like a skin tear to coccyx. Resident CR1 discharged from the hospital on May 14, 2026, at 1:46 PM. Hospital discharge summary documentation dated May 14, 2026, did not include an assessment of the coccyx wound (e.g., size, color, drainage) or physician orders for treatment. Nursing documentation dated May 14, 2026, at 3:59 PM revealed that Resident CR1 arrived at the facility with a, wound on the sacrum (triangular bone at the base of the spine above the coccyx) that has been ongoing, per resident. There was no description of the wound or indication of treatment interventions. A facility electronic Admission/re-admission Evaluation assessment dated [DATE], noted that Resident CR1 had a Sacrum wound, however, there was no description of the site (e.g., stage, size, color, drainage). A facility electronic Skin Observation/check assessment dated [DATE], noted an area of skin integrity alteration on the coccyx; however, included no other description. A physician's order dated May 15, 2026, at 1:52 PM (almost 24 hours after Resident CR1's admission to the facility) instructed staff to, Cleanse coccyx wound with normal saline, pat dry. Apply medical grade honey to base of wound, zinc oxide (a mineral compound used to protect and support skin recovery; acts as a physical shield, soothing irritated skin and allowing underlying damage to heal naturally) to peri wound (area around wound). Cover with bordered gauze one time only for wound care for one day and every day shift for wound care and as needed for if dressing becomes wet, soiled or dislodged. Review of Resident CR1's TAR (treatment administration record, electronic documentation completed by licensed staff for the completion of treatments) dated May 2026 revealed that staff initialed completion of the coccyx treatment for the first time on May 15, 2026, at 4:22 PM. Review of documentation by the facility's contracted wound consultant provider for a service date of May 18, 2026, noted Resident CR1 had a pre-existing ulcer of the sacrum for less than 30 days, the previous treatment included barrier cream, and the previous care for the wound was provided by a hospitalist. The assessment of the wound on Resident CR1's sacrum was described as a stage III (stage III pressure ulcers involve full-thickness tissue loss where the epidermis and dermis (top two layers of skin) are completely lost, and the wound extends into the fat layer), 3 cm (centimeters) by 1.5 cm by 0.2 cm, with exposed subcutaneous tissue (the deepest layer of skin, composed primarily of fat and connective tissue), 100 percent slough (unhealthy, non-viable, tissue), and the peri wound area was intact, with erythema (redness) and fragile. The planned wound treatment was changed to hydrogel (water-rich, gel-based dressings that maintain a moist environment to promote healing, relieve pain, and support tissue repair) with zinc oxide to peri wound and secured with bordered gauze daily. Review of Resident CR1's TAR dated May 2026 revealed that staff did not implement the new wound treatment orders; but continued to treat Resident CR1's sacral wound with the medical grade honey until her transfer to the hospital on May 21, 2026. The surveyor confirmed the above findings regarding Resident CR1's pressure ulcer treatment with the Nursing Home Administrator and the Director of Nursing on June 8, 2026, at 3:15 PM. 483.25(b)(1)(i)(ii) Treatment/svcs to Prevent/heal Pressure UlcerPreviously cited deficiency 12/12/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, and staff interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered treatments for three of three residents reviewed (Residents 1, 2, and 3).Findings include: A review of current physician orders for Resident 1 revealed an order dated May 19, 2026, for staff to use Acetic Acid Irrigation Solution (a rinse to aid in the prevention of bacteria), one dose every night shift for wound care, and cleanse right hip wound with acetic acid, pat dry, and apply Santyl (topical ointment used to remove dead or damaged tissue from wounds to promote healing) to the base of the wound, and secure with bordered dressing. A review of Resident 1's TAR (treatment administration record, a form utilized to document the administration of resident treatments) dated May 2026, revealed the treatment was not completed per the physician order on one of the three days reviewed. May 21, 2026: no documentation on the TAR; blank A review of current physician orders for Resident 2 revealed an order dated April 7, 2026, for staff to cleanse Resident 2's left lower posterior thigh with normal saline, pat dry, apply collagen (a dressing used to promote tissue regeneration, stop bleeding, and maintain moisture) to the base of the wound, and secure with abdominal pad every night shift for wound care. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on three of 26 days reviewed. May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank May 20, 2026: no documentation on the TAR; blank A physician order dated April 27, 2026, instructed staff to cleanse Resident 2's right buttock with normal saline solution, pat dry, apply calcium alginate (a protective, healing, wound dressing) to the base of the wound and zinc oxide paste to peri wound every night shift for wound care. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on three of 26 days reviewed. May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank May 20, 2026: no documentation on the TAR; blank A physician order dated April 6, 2026, instructed staff to place Interdry (a moisture wicking, antimicrobial fabric designed to protect skin in folds) in Resident 2's abdominal folds to prevent skin to skin contact every day and night shift to maintain skin integrity. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on four of 26 days reviewed. May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank May 20, 2026: no documentation on the TAR; blank May 21, 2026: no documentation on the TAR; blank A physician order dated March 4, 2026, instructed staff to apply Triamcinolone Acetonide Cream (topical steroid used to reduce inflammation, itching, redness, and swelling) to Resident 2's left posterior thigh topically every day and night shift for wound care. The physician order also instructed staff to cleanse Resident 2's posterior thigh with normal saline, pat dry, apply Triamcinolone cream to the base of the wound and secure with abdominal pad. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on three of 26 days reviewed. May 10, 2026: no documentation on the TAR; blank May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank A physician order dated January 20, 2026, instructed staff to cleanse Resident 2's left abdomen with normal saline solution, apply zinc and nystatin, and leave open to air every day and night shift for Resident 2's abdomen wound. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on two of 26 days reviewed. May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank A physician order dated January 21, 2026, instructed staff to apply Nystatin external cream to Resident 2's abdomen topically every day and night shift for wound care. A review of Resident 2's TAR dated May 2026, revealed the treatment was not completed per the physician order on three of 26 days reviewed. May 10, 2026: no documentation on the TAR; blank May 18, 2026: no documentation on the TAR; blank May 19, 2026: no documentation on the TAR; blank A review of current physician orders for Resident 3 revealed an order initiated on April 28 and in place until it was discontinued on May 4, 2026, instructed staff to cleanse Resident 3's left ischium (the curved bone forming the base of the pelvis) with normal saline, pat dry, apply Silvasorb gel (used to treat partial and full thickness wounds) to the base of the wound, zinc oxide to peri wound, and secure with bordered gauze dressing every day shift for wound care. A review of Resident 3's TAR dated May 2026, revealed the treatment was not completed per the physician order on one of four days reviewed. May 3, 2026: no documentation on the TAR; blank A physician order dated May 4, 2026, instructed staff to cleanse Resident 3's left ischium with normal saline, pat dry apply Silvasorb gel to the base of the wound, zinc oxide to peri wound, and secure with bordered gauze dressing every day and night shift for wound care. A review of Resident 3's TAR dated May 2026, revealed the treatment was not completed per the physician order on two of 23 days reviewed. May 20, 2026: no documentation on the TAR; blank May 21, 2026: no documentation on the TAR; blank The facility failed to provide the highest practical care regarding physician ordered treatments for Residents 1, 2, and 3. The findings were reviewed with the Nursing Home Administrator and the Director of Nursing on May 27, 2026, at 2:21 PM. 483.25 Quality of CarePreviously Cited 12/12/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on closed clinical record review and staff interview, it was determined that the facility did not honor the right of a resident representative to make decisions regarding a residents transfer to the hospital for one of three residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident had an MDS (Minimum Data Set, an assessment completed at periodic intervals of time to determine care needs) completed on November 18, 2025, in which facility staff assessed the resident has having a BIMS (brief interview of mental status) score of seven, indicating severe cognitive impairment. Review of a court order in Resident CR1's closed record dated December 23, 2025, revealed the resident was noted as an incapacitated (not able to make decisions for himself) person and the resident's son was the permanent guardian for the resident. The son was listed as the resident's responsible party. Resident CR1 sustained a fall on December 25, 2025, at 9:16 AM. The resident was found sitting on the floor in his room and indicated he was attempting to go to the bathroom. The resident requires the use of an assistive device and one person assistance. It was noted that the resident attempted to self-transfer. Assessments were noted as completed on Resident CR1 with no injuries noted. Nursing documentation revealed that staff left a message for Resident CR1's responsible party regarding the fall at 11:21 AM on December 25, 2025. It was later noted the responsible party returned the call to the facility at 12:00 PM, and he had no questions regarding the incident. At 12:45 PM on December 25, 2025, facility staff received a call from the 911 dispatch center indicating Resident CR1's responsible party had called 911 indicating the resident had a fall earlier that day and felt the resident needed checked on. Facility staff indicated the resident was being monitored per protocol and upon checking on the resident the resident denied any pain or hurts. The 911 facility did not dispatch to the facility nor was the resident transferred to the hospital. There was no evidence of any follow up or attempted communication from facility staff to Resident CR1's responsible party after the call from the 911 center to discuss the resident condition or desire for the resident to receive emergency services/transfer to the hospital as the responsible party self-initiated for the resident. There was no evidence that facility staff provided the right to the resident's responsible party to transfer the resident to the hospital as desired. The above information was reviewed with the Nursing Home Administrator on February 9, 2026, at 5:15 PM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 13 and 17).Findings include: The facility's medication error rate was 23 percent based on 38 medication opportunities with nine medication errors. Interview with Employee 1 (registered nurse) on December 10, 2025, at 9:24 AM during the observation of the preparation of medications for administration to Resident 17, revealed that Employee 1 did not have artificial tears (liquid medication administered in the eye for lubrication to treat dryness of the eye) or Lidocaine patches (topical anesthetic to treat pain) included with the medications for the 9:00 AM medication pass because they were not available in the medication cart. Employee 1 did not report any other medications held due to unavailability. Employee 1 verified that she prepared 11 tablets of medication for Resident 17 on December 10, 2025, at 9:26 AM, which agreed with the quantity recorded by the surveyor.Clinical record review for Resident 17 revealed active physician orders to receive the following: Pyridoxine HCL (vitamin B6 supplement) tablet 100 mg (milligrams) give one tablet by mouth one time a dayLoratadine oral tablet (antihistamine used to relieve allergy symptoms, no milligram dose specified; however, is provided as a stock over-the-counter medication as a 10 mg per tablet dose) one tablet by mouth one time a dayFluticasone Propionate (Flonase, steroidal nasal spray used to treat allergy symptoms) nasal spray give two sprays in both nostrils every dayFluticasone-Umeclidin-Vilant (Trelegy Ellipta, combination steroidal medication inhaled to open airways and treat obstructive lung disease) inhalation aerosol powder one inhalation one time a day Review of Resident 17's medication administration record (MAR, electronic system used by the facility to document the administration of medications) revealed that the above four medications were scheduled for 9:00 AM daily. Interview with Employee 1 on December 10, 2025, at 11:40 AM confirmed that she did not initial the administration of the four above medications for Resident 17, she did not give them. Employee 1 indicated that the electronic medication administration system automatically entered, U-SA, for the administration of the Flonase nasal spray as it is indicated as self-administered by Resident 17 and kept at her bedside. Observation of Resident 17's bedside stand and interview with Resident 17 on December 10, 2025, at 11:53 AM revealed that she did not have the Flonase medication in her room. Resident 17 stated that she did not take the Flonase medication that morning. Employee 1 located a bottle of Ipratropium Bromide (generic Atrovent, short-acting anticholinergic medication used to dilate airways) nasal spray in an unlocked drawer in Resident 17's bedside stand. Resident 17 stated that she would use that nasal spray if she needed it. Review of Resident 17's clinical record revealed no physician orders for Resident 17 to self-administer the Ipratropium Bromide nasal spray.The surveyor reviewed the above four medication errors for Resident 17 during an interview with the Nursing Home Administrator and the Director of Nursing on December 10, 2025, at 2:00 PM.Interview with the Director of Nursing on December 11, 2025, at 12:20 PM revealed that the facility had no evidence of an assessment completed to confirm Resident 17 was capable of self-administration of medications. The interview confirmed that the maintenance staff supplied Resident 17 a key to a lockable drawer in her bedside stand after the surveyor's medication administration observation. The Ipratropium Bromide medication was removed from Resident 17's room.Observation of the medication administration pass for Resident 13 on December 10, 2025, at 9:42 AM revealed Employee 1 prepared medications that included: Amlodipine Besylate (medication used to lower blood pressure, hypertension) 10 mg, one tabletCarvedilol (medication used to lower blood pressure) 6.25 mg, one tabletAcetaminophen arthritis pain (Tylenol, extended release over-the-counter pain medication) 650 mg, two tabletsSodium bicarbonate (chemical compound that neutralizes stomach acid and acts as an antacid) 325 mg, one tabletIron 65 Fe (iron supplement that contains 65 mg of elemental iron which is equivalent to 325 mg of ferrous sulfate), five tablets Interview with Employee 1 on December 10, 2025, at 9:52 AM verified that she prepared a total of 25 tablets of medication, which agreed with the number recorded by the surveyor. Resident 13 then took the medications handed to her. Clinical record review for Resident 13 revealed the following active physician orders: Tylenol Eight Hour Arthritis Pain Oral Tablet Extended Release 650 mg one tablet by mouth twice daily for pain management.Sodium Bicarbonate Oral Tablet 650 mg give one tablet by mouth two times daily for hyperkalemia (elevated potassium levels in the blood)Ferrous Sulfate Tablet 325 (65 Fe) mg give one tablet by mouth one time a day for supplementationCarvedilol Tablet 6.25 mg give one tablet by mouth two times a day for hypertension; hold if systolic blood pressure (the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) is less than 100Amlodipine Besylate Tablet 10 mg give one tablet by mouth one time a day for hypertension; hold if systolic blood pressure is less than 100 Interview with Employee 1 on December 10, 2025, at 11:47 AM revealed that she did not have a blood pressure assessment for Resident 13 as required by the physician orders for the Amlodipine and Carvedilol medications. Employee 1 stated that the electronic medication administration system typically requires her to enter an assessment if ordered as a parameter by the physician; however, for the two medications administered that morning for Resident 13, it did not. Employee 1 also confirmed that she administered two tablets of the Tylenol arthritis medication instead of the one tablet ordered by the physician. Employee 1 confirmed that she administered one tablet of the Sodium Bicarbonate when she should have administered two to equal the 650 mg dose ordered. Employee 1 confirmed that she believed that she needed to administer five tablets of the 65 Fe supplement to equal 325 mg of iron as she did not review the labeling on the bottle that noted there was 65 mg of elemental iron extracted from 325 mg of ferrous sulfate; or noted that the physician's order that instructed to administer one tablet included both the 325 mg and 65 mg labeling. Employee 1 administered five tablets of the iron supplement instead of one tablet to Resident 13.The surveyor reviewed the above five medication errors for Resident 13 during an interview with the Nursing Home Administrator and the Director of Nursing on December 10, 2025, at 2:00 PM. 483.45(f)(1) Free of Medication Error Rates Five Percent or MorePreviously cited deficiency 11/22/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, review of select facility policies and procedures, and staff and resident interview, it was determined that the facility failed to ensure that pain management was provided that was consistent with professional standards of practice for one of two residents reviewed for pain (Resident 3).Findings include: The facility policy entitled Pain-Clinical Protocol, last reviewed without changes April 2, 2025, revealed the physician and staff will identify individuals who have pain, or who are at risk for having pain. The nursing staff will assess residents for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. The staff will reassess the individual's pain and related consequences for acute pain or significant changes in levels of chronic pain or if pain medications are not providing acceptable pain relief. If there are more than occasional analgesic requests, or the resident is not having pain relief of as needed analgesics, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN (as needed) use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures. If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. Interview with Resident 3 on September 30, 2025, at 1:36 PM revealed that she has pain daily, and she stated at times the pain can be severe. Clinical record review revealed the facility admitted Resident 3 on February 27, 2025. The facility developed a care plan initiated on February 27, 2025, that noted Resident 3 has pain related to a femur fracture of her right lower extremity. Resident 3's clinical record revealed the following medications to address her pain on the July and August 2025 Medication Administration Records (MAR, a form utilized by the facility to document the administration of medications): Buprenorphine Transdermal patch (pain patch used to treat and persistent pain) weekly 10 mcg (microgram) every TuesdayTylenol 650 milligrams (mg) every four hours as needed for mild pain (1-3)Hydromorphone HCl (opioid medication used to treat moderate to severe pain) 4 mg, one tablet every 12 hours as needed for moderate to severe pain (4-10) Resident 3 received the Hydromorphone 50 times for moderate to severe pain from July 1 to 31, 2025. The routine pain rating assessment by staff every 12 hours on these dates revealed that 32 out of the 62 times Resident 3 assessed her pain as moderate to severe at the time of the assessment. Resident 3 received the Hydromorphone 48 times for moderate to severe pain from August 1 to 31, 2025. The routine pain rating assessed by staff every 12 hours on these dates revealed that 37 out of the 62 times Resident 3 assessed her pain as moderate to severe at the time of the assessment. The facility failed to ensure Resident 3's pain was managed consistent with professional standards of practice. The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on December 12, 2025, at 10:37 AM 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide comprehensive skin assessments that are consistent with professional standards of practice to promptly identify and promote healing of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 1).Findings include: Clinical record review for Resident 1 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated November 11, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 7, which indicated cognitive impairment. The MDS revealed that the resident had a pressure ulcer. The MDS dated [DATE], also revealed the resident had a pressure ulcer. Current physician orders for Resident 1 dated August 21, 2025, at 8:00 AM instructed staff to treat the resident's sacral region wound every day shift every other day. A review of the Treatment Administration Record (TAR) for November 2025 revealed that staff were documenting the treatment as being completed. Resident 1's current care plan revealed that the resident has actual skin breakdown related to a right buttock pressure ulcer / sacral wound that was initiated on June 26, 2025. Review of Resident 1's clinical record revealed no documentation that the resident's pressure ulcer was comprehensively assessed (i.e. wound measurements, signs of infection, drainage, appearance, etc.) on a routine basis. A request for wound assessments for Resident 1 from August 2025 to November 2025 revealed the following assessments: August 5, 2025: admission / re-admission evaluation revealed a previous sacrum / coccyx pressure wound per the documentation. There was no comprehensive evaluation documented. August 15, 2025: Skin observation / check at 3:31 AM revealed an existing area of alteration in skin integrity of the coccyx (a small bone at the base of the spine) described as small open area with treatment in place. August 19, 2025: Skin observation / check at 9:54 AM revealed an existing area of alteration in skin integrity of the coccyx described as small open area with treatment in place. August 20, 2025, at 11:45 AM revealed wound care center documentation that noted a Stage 2 (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure injury to the sacrum. The wound was measured as 2.5 centimeters (cm) by 1.6 cm x 0.1 cm (length x width x depth). There was light serous exudate (a type of wound drainage). The peri-wound (tissue surrounding a wound) skin was intact. August 26, 2025, at 1:21 PM: Skin observation / check revealed an existing area of alteration in skin integrity of the coccyx described as small open area with treatment in place. September 9, 2025, at 12:35 PM: Skin observation / check revealed an existing area of alteration in skin integrity of the coccyx described as small open area with treatment in place. September 10, 2025, at 1:30 PM revealed wound care center documentation that noted a Stage 2 pressure injury to the sacrum. The wound was measured as 1.7 cm by 1 cm x 0.1 cm. There was light serous exudate. The peri-wound skin was intact. October 8, 2025, at 9:15 AM revealed wound care center documentation that noted a Stage 2 pressure injury to the sacrum. The wound was measured as 1.5 cm by 0.5 cm x 0.1 cm. There was moderate serous exudate. The peri-wound skin was erythematous (reddened) and macerated. November 26, 2025, at 8:00 AM revealed wound care center documentation that noted a Stage 2 pressure injury to the sacrum. The wound was measured as 0.8 cm by 0.5 cm x 0.5 cm. There was moderate serous exudate. The peri-wound skin was erythematous and macerated. An interview with the Nursing Home Administrator on December 12, 2025, at 12:53 PM to discuss the findings revealed that Resident 1's pressure ulcer should have been assessed weekly by the facility. Employee 5, registered nurse, was also present and stated there was no further documentation to indicate that the resident's pressure ulcer was routinely and comprehensively assessed for the dates selected of August 2025 to November 2025. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's rights to secure and confidential personal and medical information for one of six units reviewed for privacy concerns (Nursing Unit Two East; Resident 93).Findings include: Clinical record review for Resident 93 revealed an order for silver sulfadiazine cream one percent (a topical cream used to treat various skin wounds). The physician order instructed staff to apply the cream to bilateral lower extremities topically every day and night shift for wound care. The order was marked as discontinued. A nursing progress note for Resident 93 dated October 17, 2025, at 11:34 PM revealed a new order for silver sulfadiazine cream one percent; apply bilaterally to lower extremity topically every day and night shift for wound care and cleanse area; apply Silvadene cream to bilateral lower extremity rashes. Observation on the Nursing Unit Two East on December 12, 2025, at 10:30 AM revealed two wound care carts near the nurse's station. A plastic trash receptacle with a lid was affixed to the side of both carts. There were clear garbage bags in each receptacle that were partially filled with trash. One cart had the trash receptacle lid most of the way open and a discarded sulfadiazine box was visible with the pharmacy label still attached. Resident 93's name and order instructions for Resident 93 were visible. An interview with Employee 4, nurse aide, on December 12, 2025, at 10:34 AM confirmed the bins were used for regular garbage. Employee 4 was unclear if the medication box for Resident 93 should be in the trash because the employee reported that the nurses deal with the resident medications. The Nursing Home Administrator (NHA) was shown the cart by the surveyor on December 12, 2025, at 10:35 AM and the NHA informed the surveyor that Resident 93's labeled medication should not be in the regular garbage receptacle and the label should be shredded. 28 Pa. Code: 201.18(e)(1) Management

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to investigate and report to the appropriate agencies an allegation of potential resident-to-resident sexual abuse for three of three records reviewed for abuse (Residents 26, 43, and 49). Findings include: The facility policy entitled Resident Abuse and Neglect Prevention Program, last reviewed without changes April 2, 2025, revealed immediately upon discovery of an allegation of abuse or situation with the potential for abuse or harm, the facility will take reasonable measures to separate the alleged perpetrator from access to the alleged victim. Upon receiving a report of abuse or alleged abuse, the registered nurse supervisor, Director of Nursing, assistant director of nursing, or Nursing Home Administrator will begin the investigation. Upon receiving information concerning a report of abuse, the Director of Nursing or assistant director of nursing will inform the social service department. A representative from social services will visit the resident immediately to provide reassurance, support, and address the resident's psychosocial needs related to the alleged incident. The interdisciplinary team will initiate a plan of care addressing the impact of the incident on the resident's psychosocial status. The facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies, and/or local authorities per federal and state requirements. Clinical record review revealed the facility admitted Resident 43 on March 17, 2025. Review of Resident 43's most recent MDS (Minimum Data Set, an assessment tool completed at specific interval to determine care needs) dated November 18, 2025, revealed nursing staff assessed Resident 43 as severely cognitively impaired. Nursing documentation dated July 28, 2025, at 10:58 AM noted Resident 43 was making out with Resident 26. Review of Resident 26's clinical record revealed her most recent MDS dated [DATE], indicated that staff assessed Resident 26 as severely cognitively impaired. Clinical record review revealed nursing documentation dated September 24, 2025, at 1:14 PM that staff noted Resident 43 had Residents 26 and 49 in his room, making out with them. Nursing documentation dated September 24, 2025, at 1:16 PM revealed Resident 43 and Resident 26 were in the back lounge making out, and when redirected Resident 43 got very upset with staff. Clinical record review revealed social service documentation dated September 25, 2025, at 10:43 AM that revealed Resident 43 may exhibit the behavior of sexual advances described as making out with female residents on his unit. Resident 43 was placed on 15-minute checks. Nursing documentation dated September 25, 2025, noted Resident 43 was reported with behaviors of making sexual advances toward others and placed on every 15-minute checks. Interview with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not complete an investigation, obtain witness statements, notify law enforcement, or notify the Department of Health related to Resident 43's potential resident to resident sexual abuse. 483.12 (b) Development and Implementation of Abuse PolicyPreviously cited 11/22/24 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(8) Personnel policies and procedures

Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for three of 27 residents reviewed (Residents 17, 75, and 150).Findings include: Clinical record review for Resident 150 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 26, 2025, in which facility staff assessed the bed rails as being used as a physical restraint. Further clinical record review revealed no evidence that Resident 150 was ordered any restraints. The above information for Resident 150 was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on October 1, 2025, at 2:35 PM and again on December 10, 2025, at 2:35 PM. An interview with Employee 2, registered nurse assessment coordinator, on December 12, 2025, at 9:56 AM revealed that the facility does not utilize restraints and the MDS assessment was marked as an error for Resident 150 and was corrected. Clinical record review for Resident 17 revealed a quarterly MDS assessment dated [DATE], that indicated Resident 17 received insulin (hormone injected to lower blood sugar) on three days during the seven days reviewed. A physician order dated May 1, 2025, discontinued Humalog insulin injections (fast-acting insulin used to lower blood sugar) for Resident 17 that were administered before meals based on blood glucose assessments. Review of Resident 17's clinical record revealed no evidence of an active physician's order to administer insulin in July or August 2025. The surveyor reviewed the above information for Resident 17 during an interview with the Nursing Home Administrator and the Director of Nursing on October 1, 2025, at 2:00 PM and on December 9, 2025, at 2:36 PM. Interview with Employee 2 on December 12, 2025, at 9:53 AM confirmed that any coding for insulin injections on Resident 17's quarterly MDS assessment dated [DATE], was an error. Clinical record review for Resident 75 revealed an annual MDS dated [DATE], that facility staff assessed Resident 75 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 75 received an anticoagulant medication during the assessment period for the MDS noted above. Interview with Employee 2 on December 9, 2025, at 1:19 PM confirmed that Resident 75's June 16, 2025, MDS was coded in error regarding receiving an anticoagulant medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to develop a comprehensive care plan regarding dental needs that were identified in the comprehensive assessment for one of 27 residents reviewed (Resident 45).Findings include: Interview with Resident 45 on October 1, 2025, at 12:40 PM revealed that she had only broken natural teeth left. Observation of Resident 45's mouth on the date and time of the interview revealed several blackened pieces of teeth in her lower jaw. Clinical record review for Resident 45 revealed nursing documentation dated September 30, 2025, at 2:27 PM that staff noted Resident 45 was edentulous (no natural teeth). The surveyor requested evidence that Resident 45 received professional dental services, or declined such services, during an interview with the Nursing Home Administrator and the Director of Nursing on October 1, 2025, at 2:00 PM. Oral/Dental Inspection documentation signed by licensed practical nurse staff dated October 1, 2025, at 4:46 PM (following the surveyor's questioning) assessed Resident 45 as having obvious or likely cavities or broken natural teeth. An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated September 23, 2025, revealed that on October 6, 2025, at 9:34 AM the registered nurse assessment coordinator confirmed that Resident 45 had obvious, or likely, cavities or broken natural teeth. The care assessment area related to dental concerns triggered the facility to proceed to a care plan. Review of Resident 45's plans of care revealed no plan of care to address the identified dental concern. The surveyor reviewed the above concerns regarding Resident 45's care plan with the Nursing Home Administrator on December 9, 2025, at 12:09 PM. Interview with the Nursing Home Administrator on December 12, 2025, at 9:15 AM confirmed that the facility did not develop a plan of care to address Resident 45's dental concerns until following the surveyor's questioning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of four residents reviewed for activities of daily living concerns (Resident 9). Findings include: Clinical record review for Resident 9 revealed an MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff determined Resident 9 was independent with set up help only for bed mobility and transfers. Resident 9's next MDS assessment dated [DATE], revealed staff assessed Resident 9 as now requiring one person, limited physical assistance for bed mobility and transfers. There was no documented evidence in Resident 9's clinical record to indicate that the facility identified or assessed Resident 9's decline in his ability to perform these activities of daily living. The surveyor reviewed the above findings for Residents 9 with the Director of Nursing and the Nursing Home Administrator on December 12, 2025, at 9:42 AM. Resident 9 required staff physical assistance on four occasions for bed mobility and five occasions for transfers during the seven day look back period. The facility was unable to provide any further documentation that the facility assessed Resident 9's decline in bed mobility and transfer ability or implemented any measures to mitigate the decline. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of one resident reviewed (Resident 11).Findings Clinical record review revealed the facility admitted Resident 11 on February 21, 2025. Further review of Resident 11's clinical record revealed the following physician ordered medications initiated February 21, 2025, to promote Resident 11's bowel movements: Milk of Magnesia (MOM, laxative that pulls water into bowel to soften bowel contents) give 30 ml (milliliters) by mouth as needed (PRN) for bowel management if no bowel movement in two days (evening shift). Dulcolax suppository (a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation, if MOM is ineffective and as needed for bowel management on day three (evening shift). Review of bowel elimination records for Resident 11 revealed that staff documented no bowel movements for July 5, 6, 7, 8, and 9, 2025 (5 days). There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 11 refused, any PRN medications during this time. These findings were reviewed during an interview with the Director of Nursing on December 11, 2025, at 12:31 PM483.25 Quality of CarePreviously Cited 11/22/202428 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for one of one resident reviewed for smoking concerns (Resident 33).Findings include: Review of the facility policy reviewed on August 14, 2025, titled Tobacco Product Usage and Smoking Policy Posting, revealed that the facility maintains a resident's rights to smoke while ensuring activities remain safe and do not infringe upon the health, safety, welfare, or rights of others. The policy further noted that the safety delivery of quality health care is the goal of each and every employee and in order to provide for an optimum, safe environment in which to meet the goal, the facility will observe a tobacco usage and smoking policy for all residents, staff, visitors, and volunteers. Section L noted that, Smoking aprons will be worn by all residents while smoking. The smoking policy was signed and dated by Resident 33 and social services staff on September 9, 2025. Clinical record review for Resident 33 revealed a diagnosis list that included hemiplegia (paralysis or weakness on one side of the body) and hemiparesis (weakness on one side of the body). Review of the current physician orders for Resident 33 revealed an order dated January 31, 2023, that noted the resident may smoke cigarettes with staff supervision. Resident 33's care plan revealed that the resident wishes to smoke and is at risk of injury due to the desire to smoke. Some interventions included the following: provide and review the smoking policy to the resident and clearly review the facility guidelines for smoking dated January 31, 2023; reassess the resident immediately following any violation of the smoking policy dated January 31, 2023, and revised on October 18, 2023; staff to provide adaptive safety devices when applicable and noted a smoking apron dated January 31, 2023, and revised on October 18, 2023. Clinical record review for Resident 33 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated October 30, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 8, which indicated cognitive impairment. The MDS also noted upper and lower extremity impairment on one side. Observation of Resident 33 on December 10, 2025, at 10:30 AM revealed the resident was in the facility designated smoking area (a shed located in the rear of the facility). The resident was observed sitting in a wheelchair and smoking a cigarette. The resident did not have a smoking apron on as indicated in the facility policy and resident's care plan. The smoking aprons were observed hanging on the wall of the shed. Employee 3, Director of Housekeeping, was observed standing outside the shed with the doors open. Further review of the smoking area located outside of the shed revealed multiple partially smoked cigarette butts on the ground around a smoking receptacle. The smoking receptacle had a piece of plastic discarded in the cigarette disposal receptacle, which blocked the cigarettes from entering the receptacle. Several partially smoked cigarettes were observed sitting on top of the plastic. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 10, 2025, at 2:35 PM. A follow-up interview with the Nursing Home Administrator on December 12, 2025, at 10:10 AM revealed that the resident should have a smoking apron and if in violation of the facility smoking policy the resident should be immediately reassessed and brought back into the building. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to hand hygiene for one of 27 residents reviewed (Resident 13).Findings include: The facility policy entitled, Handwashing/Hand Hygiene, last reviewed without changes on April 2, 2025, revealed that all personnel will follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The procedural steps in the policy included performing hand hygiene before applying non-sterile gloves and after removing gloves. Observation of the medication administration pass for Resident 13 on December 10, 2025, at 9:42 AM revealed Employee 1 prepared medications that included Olopatadine Hydrochloride (Pataday, antihistamine, itch relief, liquid eye drops), artificial tears (over-the-counter liquid medication administered to the eye to relieve dryness), and Flonase (Fluticasone Propionate, steroidal nasal spray used to reduce allergy symptoms). Observation of Employee 1's administration of the eye drops and nasal spray to Resident 13 on December 10, 2025, at 9:57 AM revealed the following procedural steps:Employee 1 donned disposable gloves and administered one drop of the Olopatadine eye medication into Resident 13's right eye.Employee 1 removed the disposable gloves and donned a new pair of disposable gloves.Employee 1 did not perform hand hygiene before donning the new pair of gloves.Employee 1 administered one drop of the Olopatadine eye medication into Resident 13's left eye.Employee 1 removed her gloves.Employee 1 did not perform hand hygiene.Employee 1 donned another pair of disposable gloves and administered two sprays of the Flonase medication into Resident 13's right and left nostrils.Employee 1 removed her gloves, did not perform hand hygiene, and obtained the vial of artificial tears from the medication's box packaging. Employee 1 donned a pair of disposable gloves and administered one drop of the artificial tears into Resident 13's right eye.Employee 1 removed those gloves and donned another pair of disposable gloves without performing hand hygiene before she administered one drop of the artificial tears into Resident 13's left eye. Interview with Employee 1 on December 10, 2025, at 10:07 AM confirmed that she was aware of the steps for disposable glove use and that she should have performed some kind of hand hygiene between glove changes, however, she did not do so. The surveyor reviewed the above hand hygiene concerns with the Nursing Home Administrator and the Director of Nursing on December 10, 2025, at 2:00 PM. 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlPreviously cited deficiency 11/22/24 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area. Findings include: Observation of the facility's main kitchen on June 20, 2025, at 10:28 AM with Employee 1 (dietary clerk) and Employee 2 (dietitian) revealed the following: The dishwashing area had multiple smaller winged insects flying around. Two dead cockroach appearing insects were observed in the overhead wooden cupboards in the dishwashing area. These cupboards contained several loose unused trash bags and multiple boxes of surgical masks. An opening between the wall splash guard and the underlying wall was observed. This opening was located under the stainless-steel counter in the dishwashing area. Further observation of this area revealed the plastic splash guard was not securely affixed to the wall as noted while pushing in the center of the splash guard. While tapping on the splash guard, there was obvious insect activity noted as evidenced by a cockroach appearing insect being observed just inside the opening to the area between the splash guard and wall. Further observation revealed a thick, black colored, greasy, and sticky substance that coated the bottom of the stainless-steel table in the dishwashing area. Observation of the cook area located on the opposite side of the kitchen from the dishwashing area revealed three dead cockroach appearing insects on the floor behind various cooking appliances. There was unidentified debris on the floor. An interview with Employee 3, cook, on June 20, 2025, at 10:37 AM revealed sightings of cockroaches under the floor mats in the cook area in the morning. Further observation of this area revealed four live cockroach appearing insects coming from underneath a wheeled cart against the wall (adjacent to the floor mats) that was used for storing clean pots and pans. There was also a dead cockroach appearing insect on the floor and an extensive build-up of dirt and debris along the perimeter of the wall. Multiple air vents above a double set of egress doors to the kitchen contained a significant build-up of dust. Pest control documentation dated June 3, 2025, revealed a visit for general pest control - maintenance. Targeted pests included cockroaches with bait applicators, aerosol, and compressed sprayer in the steamer motor compartment and baseboards in food prep with noted activity found on June 3, 2025, at 12:22 PM. Pest control documentation dated June 10, 2025, revealed a visit for general pest control - maintenance. The pest control company noted the dishwashing area was inspected for cockroach activity and treated the problem area as needed. The documentation noted pest control staff followed up on the last visit with an inspection of the elevator, hallway, and dishwasher area for cockroach activity and found no activity, but treated all areas noted above to prevent future problems from occurring and to resolve any current issues. The facility provided no further pest control documentation that the pest control service was notified of cockroach activity after their last visit. An interview with the Director of Nursing on June 20, 2025, at 2:05 PM revealed the pest control company was contacted again today to advise of the surveyor findings and the pest control company will return this Saturday. The facility failed to maintain an effective pest control program so that the facility is free of pests. There was no evidence that the facility sealed openings where pests can move or nest such as between the wall and splash guard in the dishwashing area, removed any dead insects, ensured a clean and sanitary environment (such as the floor and vents), and followed-up with staff to ensure current measures are effective at eradicating any pests. The above information was reviewed in a meeting with the Director of Nursing and Employee 4 (Assistant Director of Nursing) on June 20, 2025, at 2:15 PM. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(3) Management

Based on a review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure dependent residents received bathing assistance for four of six residents reviewed (Residents 1, 3, 4, and 6). Findings include: The facility policy entitled, Preferences Requests Policy, issued December 1, 2024, revealed that it is the nursing staff's responsibility to obtain a resident's bathing preferences (such as shower or bath, morning or afternoon, and how many times a week). Clinical record review for Resident 1 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 20, 2025, that assessed him as being dependent upon staff for shower/bathing assistance. Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 1's preference was to receive a shower one time a week in the evening. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 1's shower between April 23, 2025, to May 7, 2025. During this period, Resident 1 missed a shower on April 30, 2025. The documentation did not indicate that Resident 1 refused a shower. Clinical record review for Resident 3 revealed an annual MDS dated [DATE], that determined Resident 3 required setup and/or clean up assistance with bathing. Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 3's preference was to receive a shower one time a week in the morning. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 3's shower between April 21, 2025, to May 12, 2025. During this period, Resident 3 missed a shower on April 28, 2025, and May 5, 2025. The documentation did not indicate that Resident 3 refused a shower. Interview with Resident 3 on May 13, 2025, at 1:05 PM revealed that he was to receive staff assistance with showering weekly, on Mondays; however, once in a while they ain't got enough staff. Clinical record review for Resident 4 revealed a quarterly MDS dated [DATE], that assessed Resident 4 required partial to moderate staff assistance for showering/bathing. Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 4's preference was to receive a shower one time a week in the evening. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 4's shower between April 21, 2025, to May 5, 2025. During this period, Resident 4 missed a shower on April 28, 2025. The documentation did not indicate that Resident 4 refused a shower. Clinical record review for Resident 6 revealed a quarterly MDS dated [DATE], that assessed Resident 6 as dependent on staff for showering/bathing. Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 6's preference was to receive a shower two times a week in the evening. Review of the task documentation for bathing revealed that staff documented the provision of a shower for Resident 6 weekly (April 18 and 25, 2025; and May 2 and 9, 2025), not twice a week as per Resident 6's preference. The documentation did not indicate that Resident 6 refused a shower. Interview with Resident 6 on May 13, 2025, at 1:20 PM confirmed that she prefers a shower twice a week, especially in the summer. The surveyor reviewed the above findings regarding Residents 1, 3, 4, and 6, during an interview with the Nursing Home Administrator and the Director of Nursing on May 13, 2025, at 1:36 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to implement procedures to exercise reasonable care for the protection of residents' property from loss for three of five residents reviewed (Residents CR1, CR3, and CR4). Findings include: The facility policy entitled, Personal Property, last reviewed/revised [DATE], revealed that a documented inventory of all residents' personal belongings will be completed upon admission by the nursing department, or another department identified by the facility. The inventory sheet will be updated when new items are acquired if the facility has been notified by the responsible party. The resident's personal belongings and clothing will be inventoried and documented upon admission and as such items are replenished. Missing items should be reported immediately to a staff member on the unit and placed on a concern/grievance form with follow through based on the concern grievance policy. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Personal belongings will be sent home with the resident upon discharge or within 30 days of discharge. Closed clinical record review for Resident CR1 revealed that the facility admitted him on [DATE]. A Disposition of Resident's Personal Effects form revealed that the facility inventoried items (e.g., wallet, dentures, and glasses); however, did not inventory clothing on this form. Items noted as acquired after Resident CR1's original admission included a phone (without description of type) and charger. Resident CR1 signed this form on [DATE]. Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the facility does not record personal clothing on the Disposition of Resident's Personal Effects form; but sends all clothing to the laundry department who inventories the clothing and begins a different form. Only the laundry staff sign this form. The resident/responsible party do not acknowledge the accuracy of the inventory. An untitled graph form provided by the facility with Resident CR1's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (more than a month after Resident CR1's admission to the facility). Nursing documentation dated February 18, 2025, at 8:09 AM revealed that Resident CR1 experienced mental status changes, staff contacted his physician, and the physician provided an order to send Resident CR1 to the emergency department for evaluation. Nursing documentation dated February 18, 2025, at 9:52 PM revealed that the emergency department admitted Resident CR1 to the hospital. Review of Resident CR1's census information revealed that the facility discharged him on February 22, 2025. Resident CR1's closed clinical record contained no documentation as to the disposition of Resident CR1's property. Neither Resident CR1 or his representative signed the Disposition of Resident's Personal Effects form after his discharge from the facility. A Resident Grievance/Complaint form dated [DATE], at 1:00 PM indicated that Resident CR1 was missing his phone. Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the Director of Nursing interviewed a nurse aide who stated that Resident CR1's responsible party picked up Resident CR1's personal property. Resident CR1's responsible party later reported that Resident CR1's phone was unaccounted for. The Director of Nursing confirmed that no staff had Resident CR1's responsible party attest to the collection of his property on discharge, there was no date when she came, and no progress note in the closed clinical record. Closed clinical record review for Resident CR3 revealed that the facility admitted him on [DATE]. A Disposition of Resident's Personal Effects dated [DATE], indicated that Resident CR3 had no property (e.g., clothing). An untitled graph form provided by the facility with Resident CR3's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (four days after Resident CR3's admission to the facility). Neither Resident CR3 or his representative attested to the accuracy of the clothing inventory. Census information for Resident CR3 revealed that the facility discharged him on [DATE]. A late entry progress note created by the registered nurse the next day on [DATE], at 7:28 AM revealed that Resident CR3's family arrived for his discharge. The documentation indicated that Resident CR3 stated that he had all his belongings. Resident CR3's closed clinical record did not contain evidence that Resident CR3, or his representative signed the Disposition of Resident's Personal Effects form upon his discharge. Interview with the Director of Nursing on [DATE], at 2:10 PM confirmed the above findings for Resident CR3. Closed clinical record review for Resident CR4 revealed that the facility admitted him on February 12, 2025. Nursing documentation dated February 12, 2025, at 3:19 PM indicated that the transport company left Resident CR4's belongings in the facility's reception area. Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's property on a Disposition of Resident's Personal Effects form. Nursing documentation dated February 23, 2025, at 10:09 PM revealed that Resident CR4 expired at the facility. Documentation by the Nursing Home Administrator dated February 24, 2025, at 12:52 PM revealed that the writer received a telephone call from Resident CR4's responsible party that she would be at the facility to pick up Resident CR4's belongings. The same documentation indicated that Resident CR4's sister confirmed that she received all his belongings that included pictures in his room. Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's property upon his discharge or that staff or Resident CR4's responsible party signed a Disposition of Resident's Personal Effects form. Interview with the Director of Nursing on [DATE], at 2:27 PM confirmed the above findings for Resident CR4. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited deficiency [DATE] 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.24(e)(5) Admission policy 28 Pa. Code 211.12(d)(3) Nursing services

Based on a review of select facility policies and procedures, closed clinical record review, review of personnel certifications, and staff interview, it was determined that the facility failed to ensure properly certified personnel provided basic life support, including cardiopulmonary resuscitation (CPR), to a resident who required emergency care (Employee 1; Resident CR2). Findings include: Review of the facility policy POLST (Physician Orders for Life Sustaining Treatment, form used to document a resident/responsible party wishes in the event of a medical emergency such as the absence of a heart rate or respirations), last revised [DATE], revealed that the facility assists the resident/responsible family member (RP) in completing a POLST upon admission. If the resident/responsible family member is not ready to complete the POLST, the facility informs the resident/RP that until a decision is made, the resident will be considered a Full Code (CPR, medical intervention such as chest compression and artificial breaths to restore circulatory and/or respiratory function that has ceased, is provided). The resident will receive all resuscitation efforts. Review of the facility policy, CPR: Defibrillation, last revised [DATE], revealed that defibrillation (use of an electrical current to help your heart return to a normal rhythm sometimes provided by an AED (automated external defibrillator) machine) is the most effective treatment for ventricular fibrillation (rapid, unsynchronized, contractions of the heart that can cause cardiac arrest and sudden death; requires immediate CPR and AED). The success of resuscitation of patients with ventricular fibrillation relates to how fast electrical defibrillation can be applied. The longer the duration of fibrillation, the greater the deterioration of the myocardium (heart muscle) because a fibrillating heart consumes a very large amount of oxygen. The chance of successful defibrillation is reduced as the fibrillation time increases. The procedural steps include: Call a code green, call 911, and notify the physician stat (immediately) Initiate CPR until the defibrillator is available Prepare the resident for defibrillation CPR continues until the defibrillator detects a change in the heart rhythm that may be shockable Evaluate and maintain CAB (chest compression, airway, breathing) and continue CPR until an ambulance arrives with EMTs who provide relief, signs of life are observed, or a physician determines it should be stopped. The facility policy entitled, Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], stipulated that is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Guidelines included that CPR certified staff will be available at all times, and staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification, which includes an online knowledge component, yet still requires in-person skills demonstrations to obtain certification or recertification, is also acceptable. Closed clinical record review for Resident CR2 revealed nursing documentation dated February 22, 2025, at 9:25 AM that Employee 1 (registered nurse supervisor) was called to Resident CR2's bathroom. Resident CR2 had decreased respirations to six (average normal range 12 to 20 breaths) and a thready, pulse of 45 (average normal range 60 to 100). The documentation indicated that the on-call physician was notified, and staff obtained an order to send Resident CR2 to the emergency room . Staff then noted that Resident CR2 was without a pulse and respirations. Staff called 911 (emergency medical personnel) and nursing staff started CPR. CPR continued until paramedics intubated (inserted a tube into the airway to perform artificial respirations) Resident CR2, started an intravenous line, and assumed ACLS (Advanced Cardiac Life Support, refers to a set of clinical interventions established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions). The paramedics obtained a physician's order to stop CPR and pronounce Resident CR2 deceased . Order administration documentation dated February 22, 2025, at 9:35 AM revealed that Employee 2 (licensed practical nurse) noted that Resident CR2 was deceased at 9:25 AM. A Code (CPR) Documentation form (document the facility utilized to record the sequence of events during a CPR event) dated February 22, 2025, for Resident CR2 revealed that Employee 1 recorded the sequence of events during Resident CR2's medical crisis on February 22, 2025. Employee 1 was the registered nurse in charge. Staff initiated CPR at 8:31 AM, and the AED was delivered at 8:45 AM. Comments documented on the form indicated that, Code called at 8:31 AM, CPR initiated at 8:31 AM, 911 activated at 8:31 AM, CPR continued, and paramedic and EMS arrived at 8:45 AM, AED applied, CPR continued. The available documentation did not indicate that facility staff applied the AED to Resident CR2, but that the AED was applied after EMS personnel arrived. Review of available facility personnel documentation for Employee 1 revealed that she completed the American Red Cross CPR/AED online training and was eligible for the skills session within 90 days; however, there was no indication that she completed the skills portion of the training to obtain her certification. Interview with the Nursing Home Administrator on February 25, 2025, at 3:02 PM confirmed that Employee 1 did not have CPR/AED certification. The interview with the Nursing Home Administrator indicated that the facility had an AED machine on each of the three floors of the building. The facility did not provide evidence that facility staff, not EMS personnel, applied the AED timely to Resident CR2. Telephone interview with the Nursing Home Administrator on February 26, 2025, at 9:35 AM confirmed the above findings. The facility failed to ensure that licensed nursing staff maintained current CPR certification for healthcare providers through a CPR provider whose training included hands-on practice and in-person skills assessment. 201.19(3) Personnel policies and procedures 201.20(a)(1)-(6) Staff development 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure self-determination for resident's choices related to shower preference for bathing for one of four residents reviewed (Resident 1). Findings include: A review of the census revealed that Resident 1 was admitted to the facility on [DATE]. An interview with Resident 1 on February 18, 2025, at 12:20 PM revealed that the resident stated that he had not received a shower since arrival in the facility and he and staff utilize wipes to bathe him. Clinical record review for Resident 1 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 8, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 14, which indicated no cognitive impairment. The MDS revealed that the resident was dependent on staff for bathing. Further review of the MDS noted that the resident indicated that choosing between a tub bath, shower, bed bath, or sponge bath, was somewhat important. Review of the current care plan for Resident 1 revealed an activities of daily living (ADL) self-care deficit. The care plan noted that the resident is total dependence on staff for bathing and listed an intervention as a Shower Tuesday and Saturday during the day. Nursing documentation dated January 7, 2025, at 7:44 AM noted the resident prefers a shower Tuesday and Saturday. The task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 1 indicated shower/bath on Tuesdays/Saturdays and the resident's preference is a shower. A review of the task list for Resident 1 for the last 30 days revealed staff documented the resident as receiving a Bed/Towel Bath on the following dates: January 21, 2025, at 5:23 AM January 23, 2025, at 3:29 PM January 25, 2025, at 3:29 PM January 26, 2025, at 3:29 PM February 2, 2025, at 2:42 PM February 6, 2025, at 10:51 PM February 9, 2025, at 2:56 PM February 17, 2025, at 11:29 PM There were no showers given, as per resident preference, documented under the task list. Further review of the clinical record revealed no evidence was documented to indicate Resident 1 refused a shower, there was a wound preventing a shower, an injury preventing a shower, or any other rationale. An interview with the Director of Nursing on February 18, 2025, at 2:05 PM revealed that the facility could not provide any evidence why Resident 1's preference for a shower was not honored. The Nursing Home Administrator and Director of Nursing were informed of the above findings on February 18, 2025, at 3:45 PM. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.12 (d)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of seven residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], at 4:30 PM and signed out of the facility against medical advice on January 26, 2025, at 9:13 PM. Closed clinical record review for Resident CR1 revealed a diagnosis list that included Type Two Diabetes Mellitus (a condition where the body cannot properly regulate blood sugar which results in an abnormally high blood sugar levels). Clinical record review for Resident CR1 revealed a physician's order on the Medication Administration Record and Treatment Administration Record (MAR/TAR where staff document the administration of medications and treatments) dated January 26, 2025, at 9:00 AM that instructed staff to obtain a blood sugar four times a day for diabetes monitoring. Further review of the MAR/TAR revealed that staff documented with a checkmark (which indicated completed) on January 26, 2025, at 9:00 AM, 12:00 PM, and 5:00 PM. However, there were no values noted. Facility documentation titled Weights and Vitals Summary, noted a blood sugar documented as 210 mg/dL(milligrams per deciliter) on January 26, 2025, at 6:15 PM. However, the facility could not provide any evidence of the values of the other two blood sugars that were documented as obtained. An interview with the Nursing Home Administrator on February 18, 2025, at 12:15 PM revealed that the facility could not provide documentation on the additional two missing blood sugar values that were documented as obtained. An interview with Employee 1, licensed practical nurse, on February 18, 2025, at 12:32 PM revealed Employee 1 had documented the blood sugars as measured, which was indicated with a checkmark on the MAR/TAR at the specified times in the electronic health record. However, was unable to pull up the values of the missing blood sugar measurements that Employee 1 also stated were entered at the specified times. The facility failed to ensure a complete and accurate clinical record for Resident CR1. The Nursing Home Administrator and Director of Nursing were informed of the above on February 18, 2025, at 3:45 PM. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse from another resident that resulted in actual harm with a serious injury of a left femoral neck fracture for one of two residents reviewed for resident-to-resident interactions. (Resident 399 [Resident 90], Unit 1 East). Findings include: Clinical record review for Resident 399 revealed that she was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other mental functions related to brain cell connections and the cells degenerate and die). Clinical record review for Resident 399 revealed a progress note dated October 24, 2024, at 2:02 PM that indicated a nurse aide witnessed Resident 399 get kicked in the right side and she was threatened by Resident 90. Resident 399 was immediately removed from the room to the lounge area. Resident 90 was interviewed as to what happened and she indicated that she was defending herself. Further clinical record review for Resident 399 revealed a nursing progress note dated October 24, 2024, at 2:43 PM that indicated she was kicked in her right torso by Resident 90. No injuries were noted to the resident, and she denied complaints of pain or discomfort. The note also indicated that Resident 399 had no recollection of the event. Review of the facility's investigation into the Resident-to-Resident event involving Resident 399 and Resident 90, dated October 24, 2024, at 1:35 PM revealed that the two residents were separated, and 15-minute checks were initiated. Review of the 15-minute check monitoring form provided by the facility revealed that they were completed and have been ongoing since the event of October 24, 2024. Review of the witness statement provided by the nurse aide that reported the above noted event revealed that she was walking by Resident 399 and Resident 90's room when she heard screaming. She stopped and went into the room, and she noted Resident 399 was on Resident 90's side of the room confused and stated that she needed help getting her daughter out of the wall because she was stuck. At that time Resident 90 kicked Resident 399 in the right side and said that she was going to kill her if she didn't leave her alone. The nurse aide provided reassurance to Resident 399 as she led her out of the room. The nurse aide also indicated in her statement that Resident 90 continued to kick at Resident 399 and tell her she was going to kill her if she came back into the room. Further clinical record review for Resident 90 revealed a physician's order dated October 24, 2024, that indicated she was to be one-to-one every shift for monitoring. The order was discontinued on November 9, 2024. When the surveyor requested documentation of the one-to-one monitoring for Resident 90, on November 22, 2024, at 12:30 PM the Nursing Home Administrator (NHA) revealed that they had initiated one-to-one on October 24, 2024, but she verbally discontinued it with the RN supervisor later that evening because Resident 90 calmed down. She also indicated that 15-minute checks remained in place and were being completed. Clinical record review for Resident 90 revealed a progress note dated October 25, 2024, at 4:04 PM that indicated Resident 90 was being combative and trying to attack Resident 399 and staff. The note also indicated that Resident 90 would not get off Resident 399's bed and indicated that Resident 90 was going to slap Resident 399 and break her television. A progress note dated October 25, 2024, at 4:41 PM for Resident 90 revealed that she was becoming increasingly physically and verbally aggressive. She hit a staff member in the face and was refusing medications. She was stating that everyone is attempting to poison her. The physician was made aware, and Resident 90 was sent to the emergency room for a psych evaluation and treatment. Resident 90 returned from the emergency roiagnom on [DATE], around 5:00 AM, with no new orders. She remained in the same room with Resident 399, upon her return, with the same resident that she kicked two days earlier, and continued to threaten to kill her, slap her, and break her television Clinical record review for Resident 399 revealed a progress note date October 27, 2024, at 10:00 PM that indicated she was observed on the floor just inside her room. She complained of left hip pain and was reluctant to straighten her left leg. Her left leg was also noted to be shorter in length. The nurse practitioner was notified and ordered for Resident 399 to go to the emergency room for an evaluation. Further clinical record review for Resident 399 revealed a progress note dated October 28, 2024, at 12:39 AM that indicated she was admitted to the hospital with a comminuted intertrochanteric fracture of the left femoral neck (a bone broken in multiple pieces in the area of the femur that connects the ball joint to the shaft of the thigh bone). Review of the facility's investigation into Resident 399's fall revealed a witness statement that indicated the staff member was walking down the hallway and heard Resident 90 say, Bitch, so she went into the room. She noted that Resident 399 was on the floor complaining of pain and Resident 90 was lying in bed. When the witness asked Resident 399 what happened, Resident 90 interjected and stated she picked her up and threw her to the ground because she was attacking her. Resident 90 had no injuries when assessed. Review of the facility reported event dated October 27, 2024, at 9:27 pm revealed that Resident 399 indicated that she was coming out of the bathroom and Resident 90 pushed her and she fell . The event indicated that Resident 90 was unprovoked. Clinical record review for Resident 90 revealed an MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) quarterly assessment that revealed Resident 90 had a BIMS (Brief interview for mental status, an assessment to determine a resident's cognitive status) of 13, indicating she was cognitively intact. On October 27, 2024, Resident 399 had a fall in her room and Resident 90 admitted to throwing her to the ground. The actions by Resident 90, resulted in a fracture to Resident 399's left femoral head requiring hospital admission and intervention. The NHA was made aware of the concerns related to resident-to-resident abuse on November 22, 2024, at 2:39 PM and the failure of the facility to initiate further interventions (i.e., a room move, use of outside resources, etc.) to prevent resident-to-resident abuse resulting in a major injury to Resident 399. The facility failed to protect Resident 399's right to be free from physical abuse by another resident resulting in actual harm to Resident 399, of a left femoral neck fracture. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures 28 Pa. Code 201.20(b)(d) Staff development 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent a resident's accident with injury for one of 25 sampled residents (Resident CR1). Findings include: The facility policy entitled, Fall Prevention, last reviewed on January 14, 2016, revealed that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents. The facility reviews and revises the care plan on a quarterly basis, at the time of a significant change, and following each fall. After a fall, the licensed nurse ensures timely and adequate documentation of evaluation and management in the resident clinical record. The resident care plan is reviewed and updated. Physicians order appropriate multi-disciplinary measures in consultation with the interdisciplinary team to manage acute injuries and reduce the risk of future falls or injuries. The facility policy entitled, Investigation of Incidents and Unusual Occurances (sp Occurrences), last reviewed on January 14, 2016, revealed that the registered nurse supervisor investigates unusual occurrences, falls, and skin issues during the shift of occurrence. Nursing will implement interventions to prevent the unusual occurrences, falls, and skin issue from happening again. Closed clinical record review for Resident CR1 revealed documentation by the licensed practical nurse dated April 18, 2016, at 5:27 PM indicating that staff found Resident CR1 on the floor in front of his comfort (recliner) chair with the chair in the up position. Documentation by the registered nurse supervisor (RNS) dated April 18, 2016, at 5:28 PM revealed that staff assisted Resident CR1 in to a wheelchair, and brought him out to the nursing station. The physician ordered chair and bed alarms. RNS documentation dated April 18, 2016, at 6:35 PM revealed that Resident CR1 was on the floor. The documentation indicated that Resident CR1 got out of his wheelchair and landed on his face. Staff assessed (no measurements indicated) a laceration to both sides of Resident CR1's forehead and obtained physician orders [REDACTED]. Review of the facility's investigation into Resident CR1's fall on April 18, 2016, at 6:30 PM revealed that staff noted safety alarms were not applicable and that no alarm sounded at the time of the incident. An unsigned witness statement dated April 19, 2016, noted that on April 18, 2016, before 5:10 PM, the writer discussed with staff to implement chair and bed alarms. Interview with the Nursing Home Administrator and Director of Nursing on June 3, 2016, at 9:50 AM indicated that they obtained the unsigned statement from the RNS on duty at the time of Resident CR1's falls. The facility confirmed that staff did not implement the safety alarms for Resident CR1 until after his second fall that resulted in his head injuries. RNS documentation dated April 18, 2016, at 11:23 PM revealed that the report received from the hospital informed the facility that Resident CR1 was returning with his left forehead lacerations glued. Nursing documentation dated April 19, 2016, at 2:30 AM revealed a readmission assessment upon Resident CR1's return from the emergency room . Per the emergency room , treatment included skin adhesive glue to the forehead. The assessment indicated a right forehead abrasion 2 centimeters (cm) by 0.75 cm with a 1.2 cm by 0.1 cm laceration, and a left forehead abrasion measuring 3 cm by 1 cm. The facility failed to implement planned safety interventions (i.e. alarms) resulting in an injury that required medical evaluation and treatment beyond first aid was required. 483.25 (h) Free of Accident Hazards/supervision/devices. Previously cited deficiency 5/19/15. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 5/19/15 and 9/10/15.

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent a resident accident with injury for one of 15 sampled residents (Resident 57). Findings include: The facility policy entitled, "Fall Prevention," last reviewed January 8, 2013, revealed that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents. Clinical record review for Resident 57 revealed nursing documentation dated June 22, 2013, at 9:00 PM indicating that staff found Resident 57 on the floor in her bathroom with her left arm under her walker and the rest of her body on top of the walker. The resident stated that she had been on the toilet and was attempting to walk to the sink to brush her teeth. A skin tear was noted to her right arm and blood was noted on the left arm. Resident 57 complained of severe pain in her left shoulder, hip, arm, and ankle. Nursing documentation dated June 23, 2013, at 12:50 AM revealed that staff obtained a new physician's orders [REDACTED]. Nursing documentation dated June 23, 2013, at 4:17 AM revealed that Resident 57 was admitted to the hospital with [REDACTED]. Social services documentation dated June 24, 2013, at 12:41 PM noted that in a conversation with Resident 57's son, Resident 57's son stated that due to her broken arm, Resident 57 was in a lot of pain, had a large skin opening from where her arm was in contact with the walker, and was concerned that she would not be able to bear weight on her broken arm, thus no longer capable of utilizing her walker. The documentation also noted that Resident 57's son reported that his mother stated the nurse aide left the area when she fell . Review of the facility's investigation of the incident confirmed that staff left Resident 57 alone in the bathroom at the time of the fall. Resident 57's plan of care to address her history of a fall with a hip fracture before her admission to the facility instructed staff to remain with the resident while on the toilet. Current physician orders [REDACTED]. Interview with Employee 4, registered nurse/assistant director of nursing, on June 25, 2013, at 11:36 AM confirmed the above findings for Resident 57. 483.25 (h) Accidents. Previously cited deficiency 5/3/13. 28 Pa. Code 201.18 (e)(1) Management. Previously cited deficiency 5/3/13. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited deficiency 5/3/13. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited deficiency 5/3/13.

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent resident accidents for four of 24 sampled residents (Residents CR3, 83, 119, and 105). Findings include: The facility policy entitled, "Fall Prevention," last reviewed January 28, 2013, revealed that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents. The care plan is reviewed and revised following each fall. Physicians order appropriate multi-disciplinary measures in consultation with the inter-disciplinary team to manage acute injuries and reduce the risk of future falls or injuries. The facility policy entitled, "Investigation of Incidents and Unusual Occurrences," last reviewed January 28, 2013, revealed that nursing staff will implement interventions to prevent the unusual occurrences, falls, and skin issues from happening again. The facility policy entitled, "Alarms, Bed/Chair," last reviewed January 28, 2013, revealed that it is the policy of the facility that nursing staff monitors placement of bed/chair alarms with all shift changes and when providing care to residents. Clinical record review for Resident 83 revealed nursing documentation dated August 19, 2012, at 3:57 PM indicating that Resident 83 sustained a witnessed fall to the floor. Review of the facility's investigation of the incident revealed that the resident lost her balance and sat down too soon after getting off the toilet. The nurse aide transferred Resident 83 without obtaining additional assistance or a gait belt (fabric belt secured around a resident that staff utilizes to provide additional stability when needed). According to the incident investigation, Resident 83 was to be transferred with two people assisting while using a gait belt. Closed clinical record review for Resident CR3 revealed nursing documentation dated November 13, 2012, at 8:30 PM indicating that at 7:40 PM, staff transferred Resident CR3 to bed. Staff noted Resident CR3 sitting on the mat beside the bed at 7:50 PM. Review of the facility's investigation of the incident revealed that staff had recently changed Resident CR3's room assignment. Resident CR3's plan of care required her to have a low bed, with a bed alarm, and a scoop mattress (designed to reduce a resident's ability to roll out of bed). Resident CR3 fell out of the bed that had an air mattress and no alarm. Nursing documentation dated December 12, 2012, at 8:14 PM revealed that staff found Resident CR3 on the gray mat on the floor beside the bed. Review of Resident CR3's clinical record and the facility's investigation of the incident revealed no evidence that nursing staff implemented any new interventions to Resident CR3's plan of care, in response to the fall, to prevent future falls out of bed. Nursing documentation dated December 20, 2012, at 1:56 PM revealed that staff found Resident CR3 lying on the floor mat, next to the bed. Interview with the Director of Nursing on May 3, 2013, at 9:25 AM confirmed the above findings for Residents 83 and CR3. Review of Resident 119's clinical documentation revealed that the facility admitted her on November 2, 2013, with [DIAGNOSES REDACTED]. Nursing documentation dated February 10, 2013, at 6:51 PM revealed that one staff member transferred Resident 119 with her rolling walker from her bed to her chair. Resident 119 stated that her knees were going to buckle and the staff member lowered her to the floor. Review of the facility's Incident/Accident Report dated February 10, 2013, at 6:25 PM and a facility "Employee Statement Regarding Knowledge of Resident Incident" dated February 10, 2013, revealed that Employee 5, nurse aide, assisted Resident 119, but failed to utilize a gait belt during the transfer. The facility completed a coaching and supervision session with Employee 5, which revealed that gait belts are to be used during any transfer or ambulation of Residents requiring staff assistance to minimize risk of falling. At the same time, the facility implemented the use of two staff members to assist Resident 119 with transfers and ambulation. On February 11, 2013, nursing staff updated Resident 119's care plan for falls and indicated that she was an assist of two staff with her roller walker for transfers and ambulation. Nursing documentation dated March 18, 2013, at 12:32 AM revealed that Resident 119 remains an assist of two staff members for transfers and ambulation. Nursing documentation dated March 18, 2013, at 5:46 PM revealed that staff lowered Resident 119 to the floor. The nurse aide stated she was ambulating Resident 119 in her room when her (Resident 119's) knees gave out. Staff noted a 1.5 centimeter (cm) by 1.5 cm abrasion on Resident 119's left knee. Interview on May 1, 2013, at 10:00 AM with the Director of Nursing confirmed the above information. Review of the facility policy entitled, "Resident Care Policies/Nursing Department," last reviewed January 28, 2013, revealed that all residents of the facility would receive the highest standard of care. Nursing care should be rendered in a safe and sanitary environment to promote the psychological, social, spiritual, and rehabilitative development of the Resident. Nursing services coordinates the completion of an individual's plan of care for each Resident by assessing, planning, implementing, and evaluating the prescribed treatment based upon the Resident's individual physical, social, and spiritual needs. Review of physician orders dated April 19, 2013, revealed that Resident 105 is to have a low bed (a bed lowered close to the floor to help prevent injuries, should a Resident fall out of bed) and grey (fall) mats (mats placed on each side of the Resident's bed to cushion a fall). Observation on the following dates revealed that there were no grey (fall) mats located in Resident 105's room: April 30, 2013, at 10:30 AM May 2, 2013, at 12:00 PM, 1:15 PM, and 2:34 PM May 3, 2013, at 9:40 AM Interview on May 3, 2013, at 11:20 AM with the Director of Nursing confirmed that the facility failed to provide grey (fall) mats to Resident 105, as ordered. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. Previously cited 6/1/12. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. Previously cited 6/1/12.

Based on closed clinical record review, review of select facility policy and procedures, and staff interview, it was determined that the facility failed to implement physician ordered interventions to deter skin breakdown for one of 10 residents sampled (Resident CR1). Findings include: The policy entitled "Routine Skin Care and Prevention," reviewed January 2011, indicates that facility staff will inspect a residents skin every shift and when repositioning a resident. It does not clarify who will be inspecting the skin. The policy entitled "Skin Care Protocol," reviewed January 2011, indicates that nursing staff are to use creamy [MEDICATION NAME] to protect healthy skin and that it is standard protocol for the facility to use this cream as a protective barrier on all residents that are incontinent of urine and feces. The policy entitled "Pressure Ulcers, Assessment and Documentation Guidelines," reviewed January 2011, indicates that nursing staff will assess residents with pressure ulcers that will include location and staging and a description of the wound bed and edges. Review of Resident CR1's closed clinical record revealed that the facility admitted her on January 13, 2011. An admission skin assessment dated [DATE], indicates that nursing staff assessed Resident CR1 as having no pressure sores on her buttocks. Review of Resident CR1's Braden Scale (a scale used to predict pressure sore risk) dated January 13, 2011, indicated that nursing staff determined Resident CR1 to be at mild risk for developing a pressure area. A Minimum Data Set Assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated January 19, 2011, indicated that nursing staff assessed Resident CR1 as needing the extensive assist of two caregivers for toileting, and turning and repositioning in bed. A physician order [REDACTED]. There was no evidence in Resident CR1's closed clinical record to indicate that nursing staff provided these interventions in January 2011. Nursing documentation dated January 31, 2011, at 6:45 PM, revealed that Resident CR1's family members assisted Resident CR1 to stand to check her buttocks. Resident CR1's family members reported to nursing staff that Resident CR1 had an open area. Nursing staff indicated that the area was 8.5 cm (centimeters) by 8 cm, dark red, without a thin layer of skin. Nursing staff did not differentiate the width from the length or identify where the open area was located. There was no indication that facility staff were inspecting Resident CR1's skin every shift and during repositioning, as per facility policy. On February 3, 2011, the nursing assessment revealed that nursing staff described Resident CR1's open area as a pressure area to her right buttock measuring 4 cm with a 2.75 cm area of sloughing (dead tissue separating from living tissue). Nursing staff did not describe the wound bed, edges, or stage of the pressure area. Nursing documentation dated February 3, 2011, at 4:00 PM, revealed that nursing staff discussed treatment modalities with Resident CR1's physician and received a physician order [REDACTED]. These changes in interventions did not occur until three days after staff assessed Resident CR1 as having a pressure area. Documentation from February 3, 2011 until February 7, 2011, indicate that nursing staff were still turning Resident CR1 on an every two hour schedule, not every one hour as ordered by her physician on February 3, 2011. Nursing documentation dated February 5, 2011, at 3:15 PM, now indicated that Resident CR1 had another open area above her original pressure area that measured 1.5 cm in diameter. Interview with the Director of Nursing on March 4, 2011, at 1:35 PM, confirmed that there was no evidence to indicate that nursing staff were implementing physician ordered interventions for prevention and treatment of [REDACTED]. There was no evidence that facility staff followed the policies to ensure that Resident CR1 received the necessary treatment and services to promote healing and prevent new pressure sores from developing. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services. Previously cited 6/24/10