Every finding on record at Brookmont Healthcare and Rehabilitation Center

Based on review of selected facility policies, clinical records, and staff interviews, the facility failed to show documented clinical justification for the administration of psychoactive medications for two residents out of five sampled residents for unnecessary medication prescribing practices (Residents 5 and 18).Findings included: A review of a facility policy entitled Psychotropic Medication Use last reviewed by the facility August 6, 2025, indicated that residents do not receive psychotropic medications that are not clinically indicated (a written explanation of why a medication is needed) and necessary to treat a specific condition documented in the medical record. The policy defined psychotropic medication as any medication that affects brain activity associated with mental processes and behavior. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless contraindicated, to determine whether the continued use of the medication in benefiting the resident, to find an optimal dose, or in an effort to discontinue the medication. When efforts to decrease one psychotropic medication are implemented, other psychotropic medications (for example, hypnotics) are not increased without documented clinical rationale. Further review of the policy indicated that residents on psychotropic medication receive gradual dose reductions (a step-by-step taper of a medication to see if a lower dose or stopping the medication is safe and effective) coupled with non-pharmacological interventions (non medication approaches use to address symptoms or behaviors) unless clinically contraindicated to determine whether the continued use of the medication is benefiting the resident, to find an optimal dose, or to discontinue the medication. Review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included unspecified dementia, severe with mood disturbance (decline in cognitive function that interferes with daily activities and experiences mood disturbances) and bipolar disorder (mental health disorder characterized by severe mood swings). Review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated September 11, 2025, indicated the resident had a BIMS (brief interview mental status that aids in detecting cognitive impairment) score of 3. A score of 3 indicates significant cognitive impairment suggesting Resident 5 required additional support and monitoring. Observation of Resident 5 on December 17, 2025, at 11:30 AM revealed Resident 5 was seated in a wheelchair at the nurse's station. Resident 5 did not verbalize any thoughts and did not respond to questions. Another observation of Resident 5 was conducted on December 18, 2025, at 1:05 PM in the common dining area. Resident 5 was observed seated in a wheelchair, at a table with her meal in front of her, her neck was flexed. Resident 5 was not alert, unable to feed herself or respond to any questions. Employee 1, a NA (nurse aide), was observed helping feed Resident 5 and attempted to awaken Resident 5 by rubbing her back and her arm. Employee 1 reported Resident 5 could not feed herself or propel her wheelchair in and out of the common dining area. A review of the clinical record revealed a medication order for Ziprasidone HCL (Geodon, a medication used to treat schizophrenia and manic symptoms of bipolar disorder and works by correcting chemical imbalances in the brain) 40 mg capsule by mouth twice a day. The medication order was initiated on December 17, 2021. A review of Resident 5's December 2025 Medication Administration Record (MAR) revealed the resident was administered Ziprasidone HCL 40 mg capsule at 8:30 AM and 4:30 PM every day in the month of December 2025. Review of the clinical record review titled, Documentation Survey Report, for August through December 2025 noted that Resident 5 was exhibiting no behaviors (such as restlessness, fearfulness, agitation, irritability, or mood disturbance) from August 2025 through December 2025 that would support the continued use of the medication. Further review of the clinical record review, Psychiatric Evaluation & Consultation, documented Resident 5 was confused but calm and cooperative and experienced a stable mood with no sleep or appetite changes, and no psychosis (loss of contact with reality) on evaluations dated December 14, 2025, November 23, 2025, September 28, 2025, September 2, 2025, and August 3, 2025. A review of the clinical document titled Note to Attending Physician/Prescriber, dated September 23, 2025, stated that a gradual dose reduction of Ziprasidone was considered contraindicated due to the potential for increased symptoms. The clinical record did not contain additional documentation explaining the clinical reasoning for continuing the current dose over the four-year period, in the absence of documented symptoms. The clinical record did not include an updated assessment of Resident 5's condition, identify current therapeutic goals, or show evidence of attempts at non-pharmacological interventions or other treatment approaches to evaluate whether a reduction or discontinuation of Ziprasidone 40 mg twice a day was appropriate. The above information was reviewed with the Director of Nursing and the Nursing Home Administrator on December 18, 2025, at 1:05 PM. At the time of review, no additional documentation was provided that explained the basis for continuing the current dose of Ziprasidone or the clinical rationale for not attempting a gradual dose reduction A review of Resident 18's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included unspecified psychosis (psychotic symptoms that do not match a specific condition),, recurrent depressive disorders (a mental health condition characterized by repeated episodes of deep sadness, hopelessness, and loss of interest in daily activities), anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome), and unspecified dementia with agitation (memory loss with restlessness or irritability). A review of Resident 18's physician orders revealed the resident was prescribed multiple psychoactive medications (medications that affect brain activity, mood, or behavior). An order dated January 22, 2022, at 8:30 AM directed Sertraline 50 mg (antidepressant used for mood-related conditions) by mouth one time daily for depression. An order dated March 8, 2022, at 9:30 AM directed Lorazepam 0.5 mg (a benzodiazepine used for anxiety that carries dependence and withdrawal risks) by mouth every 12 hours for anxiety. An order dated October 9, 2024, directed Seroquel 25 mg (Quetiapine an antipsychotic used for psychosis and bipolar disorder and is generally not recommended for behavioral symptoms in dementia) by mouth at bedtime for unspecified psychosis. An additional order dated January 10, 2025, directed Seroquel 12.5 mg by mouth one time daily for unspecified psychosis. A monthly pharmacy review completed by the consultant Pharmacist (PharmD) on September 23, 2025, documented that Resident 18 was receiving Quetiapine 25 mg in the morning and 50 mg at bedtime, Sertraline 50 mg daily, and Lorazepam 0.5 mg every 12 hours. The pharmacist noted that CMS (Center for Medicare/Medicaid Services) expects routine review of psychoactive medications and consideration of a gradual dose reduction (GDR), to determine if a lower dose or discontinuation is safe, unless there is documented medical reasoning that a reduction is not appropriate. The pharmacist requested clinical rationale if a GDR could not be attempted.A review of the attending physician/prescriber response dated October 6, 2025, disagreed with attempting a GDR and stated the resident continues with occasional symptoms, but no additional clinical rationale was documented to explain why the medication should continue at the current doses, what symptoms were being treated, or why a dose reduction would be unsafe. The record did not show current symptoms to support continued use, did not identify treatment goals, and did not document non-pharmacological interventions (non-medication approaches such as reassurance, calming activities, or environmental adjustments tried before or along with medications). No documentation was provided to show why a GDR was medically contraindicated. The above information was reviewed with the Director of Nursing on December 19, 2025, at 12:15 PM. No additional documentation was provided at that time to show a clinical basis for continuing the current psychoactive medication regimen. 28 Pa. Code 211.2 (d) (3) Medical Director 28 Pa. Code 211.5 (f) (ix)Medical records 28 Pa. Code 211.9 (k) Pharmacy Services 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(1)(3) Nursing Services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that necessary behavioral health care and services were provided to attain or maintain the highest practicable mental and psychosocial well-being for one of 24 residents reviewed for behavioral health needs (Resident 94). Findings include: A review of Resident 94's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including a personal history of suicidal behavior (defined as documentation of past suicidal actions or attempts, indicating increased risk for future suicidal thoughts or behaviors and the need for clinical monitoring). Further review of Resident 94's clinical record revealed a history and physical from the hospital prior to admission to facility dated [DATE], indicating he had been admitted to the hospital due to being found by a family member with self-inflicted lacerations to the left wrist and scissors present in the bed. The resident denied suicidal intent at that time; however, the documented history indicated the need for ongoing assessment and behavioral health monitoring. A review of the resident's care plan, initiated [DATE], revealed no individualized interventions or goals to address the resident's history of suicidal attempts or suicidal ideation (a term referring to thoughts or plans of self-harm or suicide). The care plan did not address documented behaviors, risks, or the need for behavioral health monitoring based on presented history. Further review of the clinical record revealed the resident's son died by suicide on [DATE]. The resident was evaluated by an outside psychiatric provider on [DATE]; however, review of the care plan through the survey exit date of [DATE], indicated there were no updates reflecting this significant psychosocial event or the resident's increased risk for mental health decline following the loss of a child. There was no evidence that the facility developed or implemented person-centered interventions or additional services to address the resident's ongoing behavioral health needs, psychosocial stressors, or potential for further suicidal ideation following the traumatic loss. During an interview with the Director of Nursing (DON) on [DATE], at 10:00 AM, the DON was unable to provide evidence that the care plan had been updated to address the resident's history of suicidal behavior, recent loss of a family member, or the need for behavioral health interventions to maintain the resident's highest practicable level of mental and psychosocial well-being. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure the availability of required emergency dialysis supplies and failed to provide person-centered care related to hemodialysis for one resident out of two residents reviewed who received hemodialysis (Resident 88).Findings include: According to the National Kidney Foundation, individuals receiving hemodialysis, (a life-sustaining treatment for individuals with kidney failure that removes waste and excess fluids from the blood) must have access to emergency supplies, such as clamps and pressure dressings, in the event of complications such as hemorrhage (bleeding) or catheter dislodgement. A review of the policy Care of Resident with End-stage Regal Disease last reviewed August 6,2025, indicated that staff caring for residents with ESRD ( End Stage Renal Disease) including residents receiving dialysis care outside of the facility shall be trained in the care and special needs of these residents, including the ability to recognize and intervene in medical emergencies such as hemorrhage or infection. The policy also indicated emergency supplies are to be maintained and accessible for residents with dialysis access sites. A review of the clinical record revealed that Resident 88 was admitted to the facility on [DATE], with diagnoses to include end-stage kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys cannot adequately filter the blood). The clinical record revealed the resident had a left upper arm arteriovenous (AV) fistula (a surgically created connection between an artery and a vein used for dialysis access). Current physician orders dated December 3, 2025, indicated the resident was to attend dialysis on Monday, Wednesday, and Friday at 6:30 AM; staff were to follow specific instructions related to the left upper extremity AV fistula including limb alert precautions, monitoring for signs and symptoms of infection and/or bleeding, maintaining an emergency fistula kit at the bedside, and documenting a progress note when the resident left the facility for dialysis and upon the resident's return. During an observation on December 17, 2025, at 1:35 PM, no emergency dialysis supply kit, clamps, pressure dressings, or other fistula-related emergency equipment were present at the bedside, mounted to the wall, or otherwise visible within Resident 88's room. An interview with Employee 2, Licensed Practical Nurse, on December 17, 2025, at 1:42 PM, confirmed that an emergency kit containing clamps and pressure dressings should have been present and immediately accessible in the resident's room based on the resident's dialysis access needs. A continued review of the resident's current care plan, initiated December 3, 2025, revealed the care plan did not include individualized interventions addressing the resident's hemodialysis treatment, AV fistula, required monitoring, or emergency measures for hemorrhage or dislodgement. There were no documented interventions regarding fistula care or emergency response planning. On December 18, 2025, at 12:15 PM, the above information was reviewed with the Nursing Home Administrator. 28Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and select facility policy, and staff interviews, it was determined the facility failed to monitor a resident's weight and timely identify significant weight loss and assure timely assessment of a resident's nutrition status to timely develop and implement nutritional approaches addressing significant weight and notify a resident's attending physician and responsible party of significant weight loss for one resident out of four residents sampled for nutrition (Resident 9). Findings included: A review of a facility policy entitled Weight Assessment and Intervention last reviewed August 6, 2025, indicated any weight change of five percent (5%) or more since the last weight assessment will be retaken for confirmation. The Dietitian will review the Weight Records and negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change had been met. The threshold for significant unplanned and undesirable weight loss will be based on the following criteria, one month 5% weight loss is significant and greater than five percent is severe, in three months 7.5% weight loss is significant and greater than 7.5% is severe, and in six months 10% weight loss is significant and greater than 10% is severe. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia (loss of appetite), weight loss, or increasing the risk of weight loss. A review of the clinical record revealed Resident 9 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (an ischemic stroke caused by interrupted blood flow to the brain), affecting the right dominant side; dysphagia (difficulty swallowing); and cognitive communication deficits (impairments in thinking and communication). A review of the comprehensive person-centered plan of care, initiated February 20, 2020, identified that Resident 9 was at risk for altered nutritional status due to a history of cerebrovascular accident (CVA, also referred to as stroke), underweight status with moderate protein-calorie malnutrition (a condition caused by inadequate intake of calories and protein), and a history of significant weight loss. Planned interventions included notifying the attending physician and responsible party of significant weight changes, providing a fortified diet (a diet enhanced with additional calories and protein to promote weight gain or maintenance), providing a regular texture diet, obtaining laboratory studies as ordered and notifying the physician of results, and obtaining weights as ordered.A review of Resident 9's weight records revealed the following documented weights documented in the electronic clinical record: September 1, 2025, at 11:19 AM, 119.2 pounds; and October 2, 2025, at 2:19 PM, 106.3 pounds. This reflected a weight loss of 12.9 pounds, representing a 10.8 percent decrease in one month, meeting the facility's policy definition of severe weight loss. Further review of the weight record revealed an additional weight was obtained on October 10, 2025, at 2:08 PM, nine days after the documented severe weight loss, with a recorded weight of 112.2 pounds. The record further showed the October 2, 2025, weight of 106.3 pounds was later stricken out on October 10, 2025, at 2:13 PM, by the facility's Registered Dietitian with a notation of reweight. A review of progress notes revealed a Weight Warning Nutrition Note dated October 10, 2025, at 2:21 PM, completed by the Registered Dietitian, which identified significant weight loss of 7.0 pounds or 5.9 percent in approximately 40 days, significant weight loss of 9.3 pounds or 7.7 percent in approximately 100 days, and non-significant weight loss of 6.4 pounds or 5.4 percent over 180 days. The note indicated the resident remained on a fortified regular texture diet with thin liquids, desserts twice daily, and health shakes (a high-calorie oral nutritional supplement) three times per day, with reported meal intake generally greater than 76 percent but variable. The Registered Dietitian documented the resident's body mass index (BMI, a calculation using height and weight to estimate body fat) as 19.3, indicating an underweight status for the resident's age, and noted weight loss was not desirable. Recommendations included discontinuing health shakes three times daily and adding a nutritional drink which provided essential vitamins, minerals and protein, twice daily to increase daily caloric intake by approximately 120 calories, with continued monitoring of intake, weights, and laboratory values. The plan of care was noted as updated. The facility was unable to provide documented evidence that Resident 9's weight loss occurring between September 1, 2025, and October 2, 2025, was timely addressed by the Registered Dietitian or that timely revisions to the resident's care plan and timely development and implementation of nutritional interventions were completed. Additionally, the facility was unable to provide documented evidence that Resident 9's attending physician and responsible party were notified of the weight loss. During an interview with the Nursing Home Administrator on December 18, 2025, at 10:45 AM, the above findings were reviewed. No additional documentation was provided to demonstrate that Resident 9's weight loss was timely addressed or that the attending physician and responsible party were notified. 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on observation, clinical record review, select policy review, and staff interviews, it was determined the facility failed to ensure the resident environment remained free from potential accident hazards for one resident (Resident 10) of 24 sampled residents when medications were left accessible at the bedside without documented clinical assessment for safety or authorization to self-administer.Findings included: A review of a facility policy titled Medication Policy, last reviewed August 6, 2025, revealed medications are to be administered by licensed nurses, or by other legally authorized staff to do so, as ordered by the physician and in accordance with professional standards of practice in a manner that prevents contamination or infection. The policy also stated the licensed nurse will observe resident consumption of medication. This was listed as number 16 in the policy explanation and compliance guidelines. A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that include cerebrovascular disease (conditions which affect blood flow to the brain. A review of Resident 10's quarterly Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 20, 2025, revealed a Brief Interview for Mental Status ( BIMS, an assessment tool that is used to assess the resident's attention, orientation, and ability to register and recall new information) score of 11 indicates moderate cognitive impairment, meaning the resident may require additional support, monitoring, and supervision to maintain safety. During an observation on December 17, 2025, at 11:25 AM, in Resident 10's room, two circular tablets (one yellow and one green) were observed sitting unattended on the bedside table in a clear plastic 30 milliliter cup. Resident 10 was seated on the side of the bed near the table where the medications were located. A review of Resident 10's clinical record review did not contain documented evidence that Resident 10 had been assessed or deemed safe to self-administer medications. Further review of the electronic medication record revealed a physician order for Tums Oral Tablet Chewable 500 milligrams (Calcium Carbonate Antacid) to be given by mouth, two tablets every two hours as needed for indigestion. The electronic medication administration record documented the medication was last administered on December 16, 2025, at 8:07 PM. During an interview on December 17, 2025, at 12:30 PM, the Director of Nursing and the Nursing Home Administrator were made aware of the observations and the clinical record findings. They acknowledged there was no documented assessment in the clinical record indicating that Resident 10 had been evaluated or determined safe to self-administer medication, and no additional documentation supporting self-administration was presented at that time. The facility failed to maintain an environment free from potential accident hazards by leaving medications accessible at the bedside without documented assessment or authorization for self-administration and the potential for accidental consumption by others. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on review of select facility policy and clinical records, and staff interview it was determined the facility failed to timely identify significant weight loss and monitor resident's weights consistently and accurately to timely identify changes in nutritional parameters and timely implement nutritional interventions for two of 24 residents sampled. (Residents 72 and 27) Findings include: Review of the facility Weight Monitoring Policy last reviewed March 2024 indicated the facility will ensure all residents maintain acceptable parameters of nutritional status. Information from the nutritional status and dietary standards are used to develop an individualized care plan. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; 3 months- 7.5% weight loss is significant; 6 months- 10% weight loss is significant. A review of Resident 72's clinical record revealed admission to the facility on [DATE], with diagnoses to include dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of the resident's weights noted the following: September 3, 2024, 164.1 Lbs. October 8, 2024, 173.5 Lbs. It was noted the resident refused a weight in November of 2024. December 5, 3024- 155.1 pounds indicating a 17.4-pound weight loss or 10% loss of body weight within sixty days. Review of a dietary note dated December 13, 2024 (eight days after the weight loss occurred), confirmed the weight loss and recommended discontinuing health shakes, adding Boost twice daily, and initiating weekly weight monitoring. Further review of the clinical record revealed no documented evidence that weekly weights were obtained as ordered. Resident 72's care plan was reviewed, and her nutritional care plan was not updated after the significant weight loss was noted on December 13, 2024, as directed in the facility's policy and as noted in the Registered Dietician's dietary note dated December 13, 2024. Interview with the Registered Dietitian (RD) on February 27, 2025, at approximately 11:30 AM confirmed the resident's weekly weights were not obtained following the weight loss on December 5, 2024, and failed to provide documented evidence the resident's care plan was updated to address the residents weight loss. A review of a facility policy entitled Weight Assessment and Intervention that was last reviewed by the facility March 2024, indicated that the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss. The nursing staff will measure resident's weights upon admission times two, then weekly for 4-weeks, then monthly thereafter if no further weight concerns. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. The dietitian will review the weight records. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change have been met. Further review of a facility policy Nutritional Assessment, last reviewed by the facility March 2024, indicated as a part of the comprehensive assessment, a nutritional assessment, included current nutritional status and risk factors for impaired nutrition shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutrition assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. A review of Resident 27's clinical record revealed the resident was initially admitted to the facility on [DATE], and most recently readmitted from the hospital to the facility on [DATE], with diagnoses that included congestive heart failure (CHF a progressive heart disease that affects pumping action of the heart muscles and causes fatigue, fluid accumulation, and shortness of breath), chronic kidney disease (involves a gradual loss of kidney function and impacts the kidneys ability to filter wastes and remove excess fluids from the blood, which are then removed in urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and wastes to build up in your body), hemodialysis (a treatment to filter wastes and water from blood and helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in blood), Clostridium difficile (C. diff a type of bacteria that can cause colitis, a serious inflammation of the colon and infections from C. diff often start after taking antibiotics and can sometimes be life-threatening), and moderate protein calorie malnutrition (an imbalance of nutrients from food and drinks that are needed to keep the body healthy and functioning properly). Additionally, Resident 27 had moderate cognitive impairment with a BIMS score of 9 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 08-12 equates to moderate impaired cognition). Further review of Resident 27's clinical record revealed that he was hospitalized on [DATE], and readmitted to the facility on [DATE], with diagnosis nontraumatic intracerebral hemorrhage (a type of stroke that causes blood to pool between the brain and skull and prevents oxygen from reaching the brain) and actively being treated for C. Diff. A review of Resident 27's weight record revealed the following recorded weights: January 17, 2025, at 5:08 PM, 205.5 - pounds post dialysis January 29, 2025, at 8:21 PM, 189.2 - pounds with use of a mechanical lift (post hospitalization but not confirmed as per the facility policy) January 31, 2025, at 7:57 PM, 194.7 - pounds post dialysis February 1, 2025, at 2:53 PM, 181.1 - pounds with use of a mechanical lift The RD completed a nutrition progress note for a 5-day MDS (Minimum Data Set assessment-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE] (5-days post readmission from the hospital) indicated a diet order for a CHO controlled (carbohydrate controlled diet is a diet that provides consistent amounts of carbohydrates to manage diabetes), NAS (no added salt diet involves restricting sodium intake to less than 4 grams, or 4,000 milligrams per day and is usually prescribed to decrease water retention for people who have high blood pressure), regular texture, thin consistency fluids, with an 1800 mL fluid restriction daily (the limitation of oral fluid intake to a prescribed amount for each 24-hour period. This therapeutic measure is indicated in patients who have edema associated with kidney disease). Additionally, the RD's progress note indicated that Resident 27 had a new Stage 2 pressure ulcer (partial thickness loss of skin without true ulceration) to sacrum as per wound care CRNP (certified registered nurse practitioner) note from January 30, 2025. This progress note documented a significant weight loss and a new Stage 2 sacral pressure ulcer but did not initiate immediate nutritional interventions. The dietitian recommended providing liquid protein (30 mL daily) for wound healing; however, the intervention was not implemented until February 4, 2025 (six days post-readmission and post-identification of the pressure ulcer) as per a review of the Medication Administration Record (MAR). The facility did not provide documented evidence of a timely comprehensive nutritional assessment related to the weight loss and pressure ulcer. During an interview with the Registered Dietitian (RD) on February 28, 2025, at 11:00 AM, it was reported a nutrition progress note was completed for Resident 27's 5-Day MDS and that it was within the set ARD (assessment reference date). Additionally, the RD confirmed that the nutrition progress note was not completed until 5-days after Resident 27 returned from the hospital with a significant weight loss of 24.4 lbs. or 11.9% in approximately 2 weeks and a significant loss of 29.2 lbs. or 13.9% in 30 days intervention was not put into place until 6-days post identification of a pressure ulcer. An interview with the Nursing Home Administrator on February 28, 2025, at 1:00 PM, confirmed the facility failed to timely assess and implement nutritional interventions for Resident 27. 28 Pa Code 211.5(f)(ii)(ix) Medical records 28 Pa Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a review of clinical records and staff interview, it was determined the facility failed to implement procedures to ensure accurate documentation of the disposition of controlled medications upon discharge for one (1) of three (3) discharged residents reviewed (Resident 109). Finding include: Review of Resident 109's clinical record revealed the resident was admitted to the facility on [DATE], and was discharged to the hospital on November 27, 2024. Review of controlled substance receipts indicated that 30 tablets of Tramadol 50 mg (dispensed as half tablets, totaling 60 tablets of 25 mg each) were delivered to the facility on [DATE], for Resident 109. Review of the Medication Administration Record (MAR) for November 2024 documented the resident was administered three (3) doses of Tramadol during the month. Further review of the resident's closed record revealed no documentation of the disposition of the remaining 57 tablets of Tramadol 25 mg at the time of the resident's discharge to the hospital on November 27, 2024. In an interview on February 27, 2025, at approximately 11:00 AM, the Nursing Home Administrator confirmed there was no documentation regarding the disposition of the remaining Tramadol upon the resident's discharge. The facility's failed to maintain accurate records of controlled substance disposition upon discharge of a resident. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. 28 Pa Code 211.5 (f)(x) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services.

Based on a review of select facility policies and clinical records and staff interview, it was determined the facility failed to administer pain medication as prescribed by the physician on an as needed basis for one of 24 residents reviewed. (Resident 10). Findings include: A review of the facility policy entitled Pain Assessment and Management last reviewed March 2024, indicated the purpose of the procedure is to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Review of Resident 10's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include post-surgical care for fracture of right tibia (leg bone), acute pain due to trauma, and hypertension. A review of current physician orders revealed that Resident 10 was prescribed pain medications based on a pain scale to guide appropriate administration. The pain scale categorizes pain levels as mild (1-3), moderate (4-7), and severe (8-10), with corresponding medications ordered to manage each level of pain effectively. Starting with the physician orders dated January 29, 2025, the resident was prescribed Acetaminophen 325 mg, two tablets every 4 hours as needed for mild pain (1-3). On January 30, 2025, additional pain medications were ordered to address increasing levels of pain: For moderate pain (4-7): Oxycodone HCL 5 mg - 0.5 (half) tablet every 4 hours as needed Tramadol HCL 50 mg - one tablet every 6 hours as needed For severe pain (8-10): Oxycodone HCL 5 mg - one tablet every 4 hours as needed (valid for 10 days, through February 9, 2025). Further review of the clinical record revealed that after February 9, 2025, there were no active physician orders for pain medication to treat severe pain (8-10). Despite this, Resident 10 continued to experience severe pain, and staff failed to notify the physician or obtain further pain management orders. An interview with the Director of Nursing (DON) on February 27, 2025, at approximately 1:30 PM confirmed that the facility failed to provide effective pain management and did not administer pain medication in accordance with physician orders. The DON acknowledged that the incorrect pain medication was given for severe pain, and no action was taken to update the physician or obtain additional orders after February 9, 2025. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10 (c) Resident care policies

Based on observations, clinical record review and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, respect, and quality of life of seven residents out of 17 sampled (Resident 3, 4, 7, 9, 11,12, 16). Findings include: A review of Resident 11's clinical record revealed the resident was admitted to the facility April 11, 2024, with diagnoses which included type 2 diabetes and muscle weakness. An interview with Resident 11 on May 23, 2024, at 9:10 AM revealed that the resident stated that staff do not answer call bells timely. The resident stated that on a good day the staff will answer the call bells in 30 minutes. The resident stated that it can take up to two hours for staff to answer his call bell. The resident further explained that he was in the bathroom recently and rang for staff because there was no toilet paper left in the bathroom. The resident stated it took 25 minutes for a staff member to come in and ask what he needed. The staff member stated she would be right back with toilet paper and then the resident waited another 26 minutes on the toilet until the staff member came back. Resident 11 stated he waited 51 minutes in total in the bathroom waiting for staff assistance. Further the resident stated that staff are very rude and talk down to him. He stated he does not feel respected and when he has brought his concerns to the director of nursing attention, she gaslights him and tells him what he is saying is not true. The resident stated that there are many staff that will yell and talk down to the residents on all shifts. A review of Resident 16's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included muscle wasting and cirrhosis of the liver. An interview with Resident 16 at 9:50 AM on May 23, 2024, revealed that the resident stated that staff take at least 30 minutes to answer his call bell when he rings for help. The resident stated this happens on all shifts. A review of Resident 7's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes and stage 3 kidney disease. An observation on May 23, 2024, at approximately 10:00 AM revealed Employee 3 NA (nurse aide) interacting with Resident 7 trying to get her dressed. The employee was heard yelling at Resident 7 telling her she needed to put these pants on. The employee was heard telling the resident resident your son called and said you need to do this. The resident replied to the employee, by stating Bullsh*t. The employee was heard yelling at Resident 7, Bullsh*t, Bullsh*t, call him you will see! The resident told Employee 3 to leave her alone, that she is not getting those pants on. The resident then yelled out ouch and stated, Don't fight with me. The employee got loud with the resident and stated, You don't fight with me! Resident 7 told the employee that she was not going to do what the employee was telling her to do. The resident stated she was not putting on those pants that the employee was trying to put on her. The employee said oh, why is this not your shirt or pants or walker here. The employee continued to try to force the resident to put the pants on. The resident continued to tell the employee that she doesn't feel good and to leave her alone. Employee 3 got loud and yelled, Whatever! at the resident and exited the resident's room. An interview with Resident 7 On May 23, 2024, at 10:07 AM, revealed that the resident was upset. The resident stated she was not doing well. The resident stated that Employee 3 tried to put a pair of pants on her she did not want on. The resident stated the employee was rude and fighting with her and went to go tellon her for not getting dressed. The resident stated she just wanted to be left alone but the employee kept fighting with her. The resident stated the employee just left her in a brief uncovered and pointed down. Observation at that time revealed the resident lying with no pants on just a brief in bed exposed. The resident stated staff are always rude and disrespectful to her. She stated that the call bell wait times are terrible. She stated that she has to wait an hour at times for staff to meet her needs. She stated she will be waiting for help while staff are yapping with each other in the halls. A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included muscle weakness, and osteoarthritis. An interview with Resident 9 on May 23, 2024, at approximately 10:15 AM revealed that the resident stated that staff do not answer call bells timely. The resident stated that he has waited up to two hours for staff to answer his bell and assist him. The resident stated normal wait time is over 30 minutes and it happens on all shifts. A clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that include neurogenic bladder and the need for assistance with personal care. Interview with Resident 3 on May 23, 2024, at approximately 10:16 AM, the resident stated that staff do not answer call bells timely and has experienced very long waits for staff to answer the call bells and this happens on a regular basis. It just happened this morning, waited over 30 minutes. Some waits are up to two hours. The resident states what if it was a true emergency, I would be dead. The resident mentioned complaining to staff and the administration is aware but the more they complain the more rude staff becomes when they finally come in to assist. The resident stated waits results in sitting in their own urine and feces while waiting for someone to come help them. A clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that include lack of coordination, muscle weakness, gait and mobility abnormalities and repeated falls. Interview with Resident 4 on May 23, 2024, at approximately 10:23 AM, revealed that she often waits up to an hour for staff to assist after ringing the call bell. The resident stated that she suffers from constipation and if she feel like having to hold a bowel movement ends up making this worse and becomes embarrassed when she becomes incontinent and requires total assistance to get cleaned up. An interview with Resident 12 (who wishes to remain anonymous in fear of retaliation) on May 23, 2024, at approximately 10:45 AM revealed the resident has to wait 30 minutes for the call bell to be answered. The resident stated it happens on all shifts. The resident further indicated that staff are rude and have bad attitudes. The resident stated some staff are disrespectful to the residents. The resident stated some employees speak very nasty to this resident and to other residents and tell them this is the way it is. The resident stated it is sometimes just the employee's demeanor and presence alone that make the resident uncomfortable. The resident stated employees are fighting with each other in that halls and residents can hear them. The resident reiterated please not to identify me for feat the staff will retaliate against the resident. During an interview on May 23, 2024, at approximately 1:15 PM with the Nursing Home Administrator (NHA) verified that it is the facility's expectation that all residents be treated with dignity and respect. The NHA was unable to explain why multiple residents are reporting untimely staff response times, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident rights 28 Pa Code 211.12 (d)(5) Nursing services

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on May 23, 2024, at approximately 9:00 AM revealed a strong urine smell when entering the facility. An observation on May 23, 2024, at 9:10 AM revealed a strong urine smell emanated from resident room [ROOM NUMBER]. There were gouges in the paint on the wall behind the residents' beds. Paper and debris was observed on the floor. A used glucose monitoring strip was observed lying on the baseboard heater. The light at the first bed did not turn off. The light switch was broken and does not turn the light off. The handle was broken off the nightstand. An observation on May 23, 2024, at 9:26 AM, in the Nourishment Room in the Center Hallway revealed the hinges broken off the cabinet door. An observation on May 23, 2024, at approximately 10:00 AM revealed resident room [ROOM NUMBER]'s door was cracked and chipped. Dirt, debris, and food crumbs were observed on the floor and fall mats. In Resident room [ROOM NUMBER] dirt and debris was observed on the floor. The room had a strong odor of feces. The bedroom door was cracked and chipping. [NAME] spots were observed splattered on the privacy curtains. An observation on May 23, 2024, at 10:03 AM, in resident room [ROOM NUMBER] revealed a dark brown water stain in the bowl of bathroom toilet. The surface of the wall to the right upon entering the room was cracked, crumbling and flaking. An observation on May 23, 2024, at 10:43 AM, in resident room [ROOM NUMBER] revealed a used wet washcloth in shared resident bathroom hanging on the top of the toilet seat. Upon entering the to right of the room, several black marks were observed on the wall. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 23, 2024, at approximately 1:00 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management

Based on clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs and prescribed medication therapy for one resident out of 17 sampled residents (Resident 13). Findings include: A review of the clinical record revealed Resident 13 was admitted to the facility April 29, 2024, with diagnoses of type two diabetes (a condition from insufficient production of insulin causing high blood sugar), sarcoidosis (a condition where there is an abnormal collection of inflammatory cells that form clumps in the skin or lymph nodes that result in dry cough and shortness of breath), and long-term use of anticoagulants (blood thinning medication) and insulin (injectable medication to treat diabetes). A review of a physician order initially dated April 29, 2024, revealed that the resident was receiving Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/milliliter (ml) inject 17 unit subcutaneously in the afternoon for diabetes and Apixaban (Eliquis) Oral Tablet 5 milligrams (mg) give every morning and at bedtime to prevent blood clots related to Atrial Fibrillation. A review of Resident 13's care plan, conducted during the survey ending May 23, 2024, revealed that the resident's comprehensive care plan did not include the resident's medical condition, type two diabetes and sarcoidosis, and the necessary care and services needed to manage those conditions and failed to identify the resident's daily insulin use for diabetes and interventions to monitor for signs and symptoms of hypo or hyperglycemia. The resident's plan of care failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding and related side effects. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 23, 2024, at approximately 1:15 PM confirmed the absence of Resident 13's medical conditions and failed to ensure that comprehensive care plans were developed in manner to meet the resident's medical and treatment needs. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on select facility policy, observation, and staff interview, it was determined that the facility failed to ensure adherence to medication expiration/use by dates for one of 15 residents (Resident 15) and failed to properly label medication in one of five medication carts (Center Cart). Findings include: A review of facility policy entitled Storage of Medications indicated that the pharmacy dispenses medications in containers that meet legal requirements including standards established, medications are maintained in the dispensed packaging. Medications outdated are disposed of according to disposal guidelines. A review of facility policy entitled Medication Administration indicated that the individual administering medications must verify the resident's identity before giving the medication verifying the name and date of birth, checking identification band, checking photograph and medical record. The manufacturer's expiration/beyond use date on the medication label must be checked prior to administering. An Observation on [DATE], at 9:41 AM, of the Center Hall medication cart in the presence of Employee 1 Licensed Practical Nurse (LPN), revealed an opened Hemorrhoid (Phenylephrine-Mineral Oil) 0XXX[DATE].9 % Ointment (hemorrhoid pain and discomfort relief ointment used rectally) and X-[NAME] Freeze (pain relieving cold therapy gel) 16-ounce bottle without a label identifying the resident or instructions of use. A clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses that include glaucoma (a condition where the eye's optic nerve is damaged with or without raised intraocular pressure and could cause gradual vision loss if untreated). A review of Medication Administration Record (MAR) for the month of May, revealed that Resident 15 was ordered Xalatan Solution (Latanoprost) with instructions to instill one drop in both eyes at bedtime for glaucoma with a start date of [DATE], and to be discontinued on [DATE]. An observation on [DATE], at 10:17 AM of the East Hall medication cart in the presence of Employee 2, LPN revealed an opened Latanoprost Ophthalmic (eye) drop medication with an open date of [DATE], and without an expiration date noted on the bottle. According to the product manufacturer storage instructions Latanoprost eye drops are to be thrown away and not used after six weeks of opening. The Latanoprost eye drops were opened on [DATE], and would have expired on [DATE] (six weeks after opening). During an interview with Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE], at 1:00 PM it was confirmed that the eye drops should be dated when opened and discarded six weeks after the initial date opened and medications in use should have a proper label present prior to administering. 28 Pa. Code 211.9 (a)(1)(k)(1) Pharmacy Services 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on review of clinical records, and staff interview, it was determined that the facility failed to implement individualized approaches to restore normal bladder function to the extent possible and provide maintenance incontinence care for two out of 23 sampled residents (Resident 36 and 64). Findings include: A review of Resident 36's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and epilepsy (seizure disorder). A review of the resident's plan of care for mixed bladder incontinence related to disease process revealed an intervention dated January 5, 2024, for the resident to have a scheduled toileting program for bowels only. The resident was to be toileted between 8:00 AM and 8:30 AM, 11:00 AM and 11:30 AM, 2:00 PM and 2:30 PM, 6:00 PM and 6:30 PM, 10:00 PM and 10:30 PM, and 11:30 PM and 12:00 AM. A review of the documented evidence of the implementation of the resident's scheduled toileting plan for January 2024 and February 2024, revealed that the facility failed to toilet the resident as scheduled on 34 occassions during the month of Janaury 2024 and on 36 occassions during the month of February 2024. A review of Resident 64's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of type 2 diabetes and heart failure. A review of the resident's plan of care for urinary incontinence related to impaired mobility revealed an intervention dated August 12, 2021, for the resident to have an incontinence care and comfort toileting program (check and change every two hours). A review of the documented evidence of the facility's provision of the resident's incontinence comfort and care during the months of January 2024, February 2024, and March 2024 revealed that the facility failed to provide the resident's every two hour check and change 90 times for the month of January 2024, 73 occassions during the month of February 2024, and . 52 times during the month of March 2024. Clinical record review revealed that Resident 301 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 22, 2024 revealed that Resident 301 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). MDS Section GG - Functional Abilities and Goals indicates that the resident usually requires caregivers to do more than half the effort when toileting. The resident's care plan, when reviewed at the time of the survey ending April 5, 2024, indicated that Resident 301 has a problem with urinary incontinence related to a cardiovascular accident {diagnosis not listed in resident medical diagnosis tab} initiated on May 25, 2021. Interventions in place were to establish toileting times, ask if toileting is needed and reminding resident that it is time to use the toilet, providing assistance with toileting or providing incontinent care as needed, and including the resident in the facility's incontinence comfort and care program {two-hour incontinence check and change if needed}. The resident's care plan also noted that Resident 301 has a self-care deficit related to immobility and deconditioning was initiated on March 10, 2021, with interventions in place include toileting the resident with the assistance of one staff member. During interview with Resident 301 on April 4, 2024, the resident stated that she waits long periods of time for staff assistance with toileting and often sits in her wet brief for long periods of time. Resident 301 explained that even yesterday she wanted to leave the facility because she did not get timely assistance with toileting from the nursing staff. The resident stated that she often waits over 20 minutes for staff to respond to her call-bell rings for assistance. The resident stated that she has brought this concern up with the facility in the past, but nothing has changed. A review of the facility Incontinence Comfort and Care Program logs revealed that the facility staff will check {the resident for incontinence} and change resident every two hours {if applicable}. A review of Resident 301's Incontinence Comfort and Care Program logs from March 6, 2024 through April 5, 2024 revealed that facility staff failed to indicate if the resident was checked every two hours for incontinence and changed if necessary as care planned and according to the facility's incontinence comfort and care program on the following date and times: March 6, 2024, from 8:30 PM through 12:00 AM March 9, 2024, from 2:30 PM through 10:00 PM March 10, 2024, from 6:30 AM through 4:00 PM March 11, 2024, from 6:30 AM through 4:00 PM March 16, 2024, from 2:30 PM through 12:00 AM March 17, 2024, from 2:30 PM through 12:00 AM March 18, 2024, from 2:30 PM through 10:00 PM March 19, 2024, from 4:30 PM through 12:00 AM March 20, 2024, from 2:30 PM through 10:00 PM March 23, 2024, from 2:30 PM through 12:00 AM March 25, 2024, from 8:30 PM through 12:00 AM March 27, 2024, from 2:30 PM through 12:00 AM March 28, 2024, from 8:30 PM through 12:00 AM March 29, 2024, from 8:30 PM through 12:00 AM March 30, 2024, from 8:30 PM through March 31, 2024 at 8:00 AM March 31, 2024, from 8:30 PM through April 1, 2024 at 8:00 AM April 3, 2024, from 10:30 PM through April 4, 2024 at 8:00 AM April 4, 2024, from 8:30 PM through 12:00 AM Interview with the Director of Nursing on April 5, 2024, at approximately 2:00 PM confirmed that the facility failed to demonstrate consistent implementation of scheduled toileting plans an the incontinence comfort and care programs 28 Pa. Code 211.12 (d)(5) Nursing services 28 Pa. Code 211.10 (a)(d) Resident care policies

Based on clinical record review and staff interviews, it was determined that the facility failed to develop person-centered care plans that addressed a resident's medical needs for one resident (Resident 82) and prescribed medication therapy for three residents out of 23 sampled residents (Resident 48, 80, and 53). Findings include: A review of the clinical record revealed Resident 82 was admitted to the facility January 24, 2024, with diagnoses of viral hepatitis C without hepatic coma, and cirrhosis of the liver. A review of Resident 82's care plan, conducted during the survey ending April 5, 2024, revealed that the resident's comprehensive care plan did not include the resident's medical condition, viral hepatitis or cirrhosis of the liver and the necessary care and services necessary to manage those conditions. Interview with the Director of Nursing (DON) on April 5, 2024, at approximately 9:10 AM, confirmed the absence of Resident 82's medical condition, viral hepatitis, and cirrhosis of the liver, on his care plan. A review of the clinical record revealed Resident 48 was admitted to the facility on [DATE], with diagnoses of congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of a physician order initially dated August 15, 2023, revealed that the resident was receiving Xarelto (anticoagulant medication to thin your blood) 20 mg (milligram) in the evening. A review of the current resident's plan of care, conducted during the survey ending April 5, 2024, revealed that the resident's anticoagulant therapy was not addressed on the resident's care plan to include necessary monitoring for potential side effects, including bleeding risks. A review of the clinical record revealed Resident 80 was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes. A review of a physician order initially dated January 11, 2024, revealed that the resident was receiving Insulin Glargine Subcutaneous Solution 100 UNIT/ML inject eight unit subcutaneously in the morning for diabetes. A review of the current resident's plan of care, in effect at the time of the survey ending April 5, 2024, revealed that the resident's care plan failed to identify the resident's insulin use for diabetes and interventions to monitor for signs and symptoms of hypo or hyperglycemia. A review of the clinical record revealed Resident 53 was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes and atrial fibrillation. A review of a physician order initially dated January 11, 2024 revealed that the resident was receiving Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML inject eight unit subcutaneously in the morning for diabetes and Apixaban Oral Tablet 2.5 MG give every morning and at bedtime dated January 23, 2024. A review of the current resident's plan of care, in effect at the time of the survey, revealed that the resident's care plan failed to identify the resident's daily insulin use for diabetes and interventions to monitor for signs and symptoms of hypo or hyperglycemia. The resident's plan of care failed to identify the resident's anticoagulant therapy and interventions to monitor for bleeding and related side effects. Interview with the Nursing Home Administrator and Director of Nursing on April 5, 2024, at approximately 1:30 PM confirmed the facility failed to ensure that comprehensive care plans were developed in manner to meet the resident's medical and treatment needs. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations of the resident pantry areas, review of select facility policy, and staff interview, it was determined that the facility failed to maintain a sanitary environment and acceptable practices for the storage and service of food to prevent the potential for microbial growth in foods and conditions, which increased the risk of food-borne illness in two of two resident pantry areas. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of the facility policy titled Foods Brought by Family/Visitors last reviewed by the facility March 25, 2024, indicated that non-perishable foods will be stored in re-sealable containers with tight-fitting lids. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. Nursing staff will discard perishable foods on or before the use by date. Observation of the resident food pantry located on Side 2 nursing unit on April 2, 2024, at 1:25 PM, revealed three Styrofoam Wawa bowls containing food without a name, leftover food wrapped in aluminum foil without a date or name, a clear plastic container of fruit without a date or name, a wheat germ container without a date or name, a 20 ounce strawberry lemonade beverage without a date or name, and a reusable bag containing an opened one-half gallon Silk almond milk, and a Tupperware container with leftover food without a date or name. Observation of the freezer revealed an opened blue Gatorade bottle without a date or name, a 16-ounce Styrofoam cup with an opened straw inserted in the lid without a date or name, ice bits scattered throughout the freezer and freezer door, and an aluminum soda can lid dislodged from the soda can on the freezer door shelf. Interview with Employee 5 (Concierge) on April 2, 2024, at 1:30 PM confirmed the observations of the Side 2 resident food pantry. Observation of the resident food pantry located on Side 1 nursing unit on April 2, 2024, at 1:45 PM, revealed two Styrofoam take-out containers without a date. Observation of the freezer revealed an opened one-half gallon of dark chocolate ice cream without a name and dated March 12, a Smart Ones frozen dinner without a name and dated March 5. Observation of the upper cabinet revealed an opened bag of honey barbecue Lays potatoe chips without a name. Interview with Employee 6 (RN) on April 2, 2024, at 1:50 PM confirmed the observations of the Side 1 resident food pantry. Further observation of the Side 2 resident food pantry on April 4, 2024, at 1:35 PM, in the presence of the Nursing Home Administrator (NHA) revealed the ice machine's condensation drain hose (hose which transports condensation from the ice machine to the floor drain) and the floor drain was visibly soiled with a black substance. Inside the cabinet supporting the ice machine, there was a black substance on the walls of the interior cabinet and on the floor tiles under the cabinet. Interview with the NHA on April 4, 2024, at 1:40 PM confirmed that the ice machine condensation drain hose, floor drain and cabinet were not maintained in a sanitary manner. He confirmed that the food in the resident pantry was to be labeled with a use by date and the name of the resident and that acceptable practices for food storage were to be followed. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on review of select facility policy and controlled drug shift count records, observations, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on three of five medication carts (Center, North, and West). Finding include: A review of the facility policy Controlled Substances last reviewed by the facility March 25, 2024, indicated that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty, and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. A review of the Inter Shift Drug Record sheet for April 2024, for the Center medication cart on April 3, 2024, at approximately 8:57 AM, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart April 1, and 2, 2024. Interview with Employee 1 (LPN), on April 3, 2024, at approximately 8:57 AM, confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift. A review of the Inter Shift Drug Record sheet for April 2024, for the [NAME] medication cart on April 3, 2024, at approximately 9:05 AM, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart April 1, 2024. Interview with Employee 2 (RN), on April 3, 2024, at approximately 9:05 AM, confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift. A review of the Inter Shift Drug Record sheet for April 2024, for the North medication cart on April 3, 2024, at approximately 9:10 AM, revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the task to count the controlled drugs in the respective medication cart April 1, 2024. Interview with Employee 3 (LPN), on April 3, 2024, at approximately 9:10 AM, confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift. Interview with the Director of Nursing (DON) on April 3, 2024, at approximately 12:10 PM, confirmed that it is her expectation that nursing staff signs the Control Substance logs, Inter Shift Drug Record, at change of shift to demonstrate that they completed the count of the controlled drugs to identify potential discrepancies. 28 Pa. Code 211.19(a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and select facility policy, and a staff interview, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for one out of the 23 residents sampled (Resident 23). Findings include: A review of facility policy titled Pain Assessment and Management, last reviewed by the facility on March 25, 2024, revealed that it is the facility's policy to identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. The policy indicates that non-pharmacological interventions for managing residents' pain may be appropriate alone or in conjunction with medications. Also, the policy indicates that pharmacological interventions (i.e., analgesics medications) may be prescribed to manage pain; however, they do not usually address the cause of the pain and can have adverse effects on the resident. A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included lumbar radiculopathy (a pinched nerve that may result in frequent pain, weakness, numbness, or tingling) and spondylosis (a weakness or stress fracture in one of the bony bridges that connect the upper and lower facet joints of the spine). The resident's care plan indicated that Resident 23 has acute right hip and shoulder pain after experiencing a fall initiated on February 21, 2024, with planned interventions to administer fentanyl patches as per physician orders, and the resident prefers to have pain controlled by fentanyl patches, lidocaine patches, and tylenol. The resident's care plan failed to identify any non-pharmacological interventions to be attempted to reduce or alleviate Resident 23's pain. A physician's order was initiated on February 26, 2024, for Resident 23 to receive a fentanyl transdermal patch 72 hours at 12 mcg/hr, which was discontinued on March 1, 2024. A physician's order was initiated on February 21, 2024, for Resident 23 to receive Hydrocodone-Acetaminophen Oral Tablet 10-325 mg (an opioid pain medication) with orders to give 2 tablets by mouth every 8 hours as needed for severe pain (7-10). A physician's order was initiated on February 21, 2024, for Resident 23 to receive Acetaminophen Oral Tablet 325 mg with orders to give 2 tablets by mouth every 4 hours as needed for mild pain (1-3). There was no physician order to treat moderate pain rated from (4-6). A review of the resident's Medication Administration Records (MARS) for March 2024 and April 2024 revealed that staff administered two tablets of Hydrocodone-Acetaminophen 10 -325 mg to the resident 55 times from March 1, 2024, through April 5, 2024. There was no documentation that any non-pharmacological interventions were attempted prior to any administration of the prn opioid pain medication. The resident MARs for March and April 2024 revealed that staff administered Hydrocodone-Acetaminophen 10 -325 mg outside the parameters of the physician's order (as needed for severe pain, level 7-10) on the following dates: March 15, 2024, at 2:47 AM for pain level 5 March 16, 2024, at 4:23 AM for pain level 6 March 25, 2024, at 3:21 AM for pain level 6 March 27, 2024, at 5:15 AM for pain level 6 March 30, 2024, at 9:25 PM for pain level 4 During an interview on February 5, 2024, at approximately 09:30 AM, the Director of Nursing (DON) was unable to provide evidence that the facility developed resident-centered non-pharmacological interventions for Resident 23's pain management. The DON was unable to provide evidence that the facility attempted non-pharmacological interventions prior to administering the prn opioid pain medication. The DON was unable to provide evidence that staff adminstered the opioid pain medication in accordance with physician's orders on the identified dates in March 2024. The DON confirmed that the facility failed to provide person-centered pain management consistent with professional standards of practice. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to demonstrate consistent monitoring and thorough assessment of one resident displaying constipation (Resident 116) and by failing to follow physician orders for bowel protocol prescribed for two residents out of 23 sampled (Residents 36 and 48) to promote normal bowel activity to the extent practicable. Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient ' s designated support person and other third parties. A review of the clinical record revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included heart failure, pneumonia, severe protein-calorie malnutrition, and atrial fibrillation (irregular heart rate). Review of Resident 116's report of bowel activity from the Documentation Survey Report v2 for January 2024, revealed that the resident did not have a bowel movement on January 2, 3, 4, 5, and 6, 2024 (5 days or 15 shifts of nursing duty). Review of Resident 116's Medication Administration Record (MAR) for January 2024, revealed no physician orders to follow to promote normal bowel activity for this resident or to treat constipation in effect at the time of the resident's period of constipation (January 2nd thru January 6th). Physician orders were subsequently noted on January 13, 2024, for Colace Oral Capsule 100 MG, (Docusate Sodium) give 1 capsule by mouth two times a day for constipation hold for loose stools, and Senna Oral Tablet 8.6 MG (Sennosides) give 1 tablet by mouth at bedtime for constipation hold for loose stools and orders noted for Milk of Magnesia (MOM) Suspension 400 MG/5ML (Magnesium Hydroxide) give 30 ml by mouth as needed for constipation administer if no BM by the third day/9 shifts document effectiveness. Dulcolax Suppository (Bisacodyl) insert 1 suppository rectally as needed for constipation for no Bowel movement within 24 hours after administration of Milk of Magnesia (MOM). Fleet Enema 7-19 GM/118 ML (Sodium Phosphates) insert 1 applicatorful rectally as needed for constipation for no bowel movement by the end of the following shift after administration of suppository. Notify MD if ineffective. There was no documented evidence that nursing staff consulted with the physician during the resident's five days of bowel inactivity or of a documented nursing assessment of the resident's physical status during the period of constipation, including any pain or discomfort the resident was experiencing and additional physical assessment of the resident's bowel function and status. A review of the clinical record revealed that Resident 48 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The resident had physician orders dated August 7, 2023, for the following bowel regimen: Milk of Magnesia 400 MG/5 ML. Give 30 ml by mouth as needed for constipation. Administer if no BM (bowel movement) by the third day/9 shifts. Document effectiveness. Dulcolax Suppository. Insert 1 suppository rectally as needed for constipation. For no bowel movement within 24 hours after administration of MOM. Fleet Enema 7-19 GM/118 ML. Insert 1 applicatorful rectally as needed for constipation. For no bowel movement by the end of the following shift after administration of suppository. Notify MD is ineffective. Review of Resident 48 's report of bowel activity from the Documentation Survey Report v2 for the month of March 2024, revealed that the resident did not have a bowel movement on March 23, 24, 25, 26, 27, 2024 (five days - 15 shifts). Review of Resident 48's Medication Administration Record (MAR) for March 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the period without a bowel movement to promote bowel activity. There was no documented evidence that the physician was notified of the five (5) consecutive days, March 23, 24, 25, 26, 27, 2024, without a bowel movement. A review of the clinical record revealed Resident 36 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain). A review of physician's orders initially dated December 21, 2023, revealed the following bowel regimen: Milk of Magnesia 400 MG/5 ML. Give 30 ml by mouth as needed for constipation. Administer if no BM (bowel movement) by the third day/9 shifts. Document effectiveness. Dulcolax Suppository. Insert 1 suppository rectally as needed for constipation. For no bowel movement within 24 hours after administration of MOM. Fleet Enema 7-19 GM/118 ML. Insert 1 applicatorful rectally as needed for constipation. For no bowel movement by the end of the following shift after administration of suppository. Notify MD is ineffective. Review of Resident 36 's report of bowel activity from the Documentation Survey Report v2 for the month of February 2024, revealed that the resident did not have a bowel movement on February 12, 13, 14, 15, 2024 (four days - 12 shifts). Review of Resident 36's Medication Administration Record for February 2024 revealed no documented evidence that nursing administered the prescribed bowel protocol during the period without a bowel movement to promote bowel activity. Review of Resident 36 's report of bowel activity from the Documentation Survey Report v2 for the month of March 2024, revealed that the resident did not have a bowel movement on March 11, 12, 13, 14, 15, 2024 (15 shifts) and again on March 22, 23, 24, 25, 26, 2024 (15 shifts). Review of Resident 36's Medication Administration Record for February 2024 revealed no documented evidence that nursing administered the prescribed bowel protocol during the period without a bowel movement to promote bowel activity. There was no documented evidence that the physician was notified of the five consecutive days the resident went without a bowel movement. During an interview with the Director of Nursing (DON) on April 5, 2024, at approximately 12:15 PM, the DON was unable to provide evidence that nursing staff assessed and consulted with the physician regarding potential treatment of Resident 116's constipation and that nursing staff had followed physician orders for the prescribed bowel protocol for Residents 48 and 36 during the period without bowel activity or had notified the physician of the extended days without a bowel movement. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5 (f) Medical records

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: An observation on April 2, 2024, at 11:10 AM , in resident room E-58 revealed multiple dark brown water stains in the bowl of bathroom toilet. Interview with Resident 33, a cognitively intact resident with a BIMS score of 13 (BIMS-brief interview to assess cognitive status. A score of 13-15 indicates intact cognitive responses), indicated that the previous housekeeper used a special cleaner to remove the stains, but the new housekeeper does not use the same cleaner and the toilet looks dirty all the time. Further observation of resident room E-58, bed A, revealed light brown stains on the Resident 33's fitted sheet and a yellow stain on the pillowcase. Resident 33 stated that he makes his bed every day. He also stated that his bed linens are the same sheets since I came back (from the Covid isolation room). I've been back over a month. Resident 33 further stated that he chooses to bathe at the sink and does not like to take showers. He stated that he performs his own bathing at the sink without assistance from staff. Continued observation on April 2, 2024, at 11:25 AM, in resident room E-58, bed B, revealed soiled bed linens on Resident 88's bed. Two pillowcases were stained yellow, and the fitted sheet was stained with multiple light brown stains in the middle of the mattress and a large brown stain at the foot of the bed. Interview during the observation with Resident 88, a cognitively intact resident with a BIMS score of 15, revealed that her bed linens are not changed regularly. Resident 88 stated that she chooses not to take a shower but prefers to bathe at the sink in the bathroom. Resident 88 state that she performs her own bathing at the sink, without assistance from staff. A second observation of the above areas in Room E-58 on April 3, 2024, at 10:35 AM, revealed the above findings remained as initially observed and in the same condition as previously observed during the initial observation conducted on April 2, 2024. Interview with Employee 7 (nurse's aide) on April 3, 2024, at 10:45 AM revealed that bed linens are changed on shower days or as needed. When asked about bed linen changes for residents who do not take showers, Employee 7 indicated that the bed linens are changed on their scheduled shower day even if the resident does not receive a shower. Review of Resident 33's April 2024 Documentation Survey Report v2 indicated that he was scheduled to receive a shower on Mondays and Thursdays during the day shift. The report also indicated that Resident 33 received a shower on April 1, 2024, the day before the surveyor's observation and interview. Review of Resident 88's April 2023 Documentation Survey Report v2 indicated that she was scheduled to receive a shower on Mondays and Thursdays during the evening shift. The report also indicated that Resident 88 refused a shower on April 1, 2024, the day before the surveyor's observation and interview. Interview with the Director of Nursing (DON) on April 4, 2024, at approximately 11:35 AM confirmed that it is the facility's expectation that bed lines are changed upon soilage and on the residents' bed bath and shower days. She also confirmed that Resident 33 and 88's bed linens should have been changed on their scheduled shower day, April 1, 2024. An observation on April 2, 2024, at 11:50 AM , in resident room E-56 revealed that the wall behind/above the heating and cooling unit was cracked, crumbling and flaking. Further observation in room E-56 revealed the front corner of bedside nightstand veneer to be peeling, leaving an exposed rough edge. Interview with the Nursing Home Administrator (NHA) on April 5, 2024, at approximately 11: 00 AM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management

Based on a review of clinical records, select facility policy CMS guidance and facility documentation, and resident, resident representative, and staff interviews, it was determined that the facility failed to ensure that resident Medicare beneficiaries were only disenrolled from Medicare health plans with the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding for four out of the 23 residents sampled (Residents 82, 95, 168, and 269). Findings include: A review of a CMS guidance titled Memo to Long Term Care (LTC) Facilities on Medicare Health Plan Enrollment dated October 2021 revealed CMS continues to hear reports of the unacceptable practice of nursing facilities or skilled nursing facilities (collectively, long-term care or LTC facilities) disenrolling beneficiaries from Medicare health plans (Medicare Advantage plans with and without Part D, Medicare-Medicaid plans, or Programs of All-Inclusive Care for the Elderly (PACE) without the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. Only a Medicare beneficiary, the beneficiary's authorized or designated representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan. Further it is indicated changes in a beneficiary's health care coverage generally must be initiated by the beneficiary or their representative. If a beneficiary or their legal representative requests assistance from the LTC facility in changing the beneficiary's health care coverage, the LTC facility should take the following steps to help ensure changes to a beneficiary's health care coverage comply with regulations regarding enrollment/disenrollment and resident rights: 1) Explain orally and in writing the impact to the beneficiary if they change coverage (e.g., to a stand-alone prescription drug plan (PDP) and Original Medicare, or to a different Medicare health plan). 2) Develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage. At a minimum, information should include the circumstances under which the facility can assist a beneficiary with a plan change. The need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that that the beneficiary and/or the representative understand the information. The need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change and that the beneficiary or representative (as applicable) received and understood the minimum required information listed above. In cases where beneficiaries request disenrollment from PACE, LTC facilities that are contracted with PACE organizations should work directly with the PACE organization and the participant's interdisciplinary team to ensure the PACE participant receives the information required under the PACE regulations and to coordinate the transition of care, including as specified in their contract requirements. According to the CMS memo if a LTC facility cannot provide documentation of a beneficiary's request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid. Lastly, If the facility has the beneficiary sign documentation regarding their understanding of an enrollment change, CMS will expect to find that the beneficiary's assessed cognitive function also supports an ability to understand this type of information. If CMS becomes aware of enrollment actions that the beneficiary alleges were taken without their request, consent, knowledge, and/or complete understanding, CMS will expect the facility to provide the above noted documentation to support that it appropriately assisted the beneficiary with their choice to change coverage, including that the beneficiary's cognitive function supports such decision-making. A review of facility policy titled Medicare Enrollment/Disenrollment, last reviewed by the facility on March 25, 2024, revealed that the facility is committed to complying with regulations regarding enrollment and disenrollment and resident rights. The policy indicates that the facility will explain orally, and in writing, the impact to the beneficiaries if they change to Original Medicare. At a minimum, the information provided to the beneficiary should include: 1. An explanation that medical services will be billed to original Medicare and/or Medicaid and what this means regarding deductibles and copays and loss or lack of supplemental coverage for the beneficiary. 2. The name of the drug plan that will cover the beneficiary's medication, including the deductible and co-pays/coinsurances, especially related to their current drug therapy. The policy titled Medicare Enrollment/Disenrollment indicated that policies and procedures regarding the process for assisting beneficiaries with changing their healthcare coverage should include at a minimum: 1. Under what circumstances can the facility assist a beneficiary with a plan change. 2. A document must be signed by the beneficiary or representative acknowledging that specific information regarding the impact of a change in coverage was provided to the beneficiary orally and in writing, and that they understand the information. 3. An attestation signed by the facility staff member that assisted with the change in enrollment must indicate that the beneficiary or representative requested the change, and that the beneficiary or representative (as applicable) understood the minimum required information. Also, the policy indicated two web resources at www.medicare.gov to provide the resident or resident representative with information on comparing Original Medicare and Medicare Advantage plans, locating a Medicare-approved agent, and education regarding Medicare disenrollment. A review of Resident 168's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included moderate protein - calorie malnutrition, hypertension, and osteoporosis. An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 27, 2024, revealed that Resident 168 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). Upon admission, Resident 168's primary insurance payer was Aetna Medicare Advantage Plan. On April 1, 2024, the resident's primary insurance payer was changed to traditional Medicare. A review of a facility form entitled Disenrollment Form dated March 28, 2024, revealed a request to disenroll Resident 168 from the resident's Aetna Medicare Advantage Plan so that the resident may be covered under original Medicare benefits. A clinical record review revealed that Resident 269 was admitted to the facility on [DATE], with diagnoses of muscle wasting and atrophy. A review of an admission MDS assessment dated [DATE] revealed that Resident 269 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact). Upon admission, Resident 269's primary insurance payer was noted to be Highmark Medicare Advantage Plan. On April 1, 2024, the resident's primary insurance payer was changed to traditional Medicare. A review of a facility form entitled Disenrollment Form, dated March 28, 2024, revealed a request to disenroll Resident 269 from the resident's Highmark Medicare Advantage Plan so that the resident may be covered under original Medicare benefits. During an interview on April 2, 2024, at 9:00 AM, Resident 269 stated that the facility approached her about disenrolling from her Medicare Advantage insurance plan and enrolling in original Medicare because it would allow her more days in the facility. The resident confirmed that it was her signature on the disenrollment form dated March 28, 2024. She explained that she was confused during the admission process and did not understand the insurance change the facility asked her make. The resident unaware and unable to state how the change impacted her copays, prescription plan, deductibles, or any supplemental insurance coverage, such as vision or dental. She stated that she did not recall anyone explaining that information to her when they asked her change. Resident 269 stated that she agreed to be disenrolled from her Medicare Advantage plan because the facility staff encouraged her to disenroll. A review of the clinical record revealed Resident 95 was admitted to the facility on [DATE], with diagnoses that included protein-calorie malnutrition, gastro-esophageal reflux disease (GERD), end-stage renal disease, and dependence on renal dialysis. An admission MDS assessment dated [DATE], revealed that Resident 95 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact). Upon admission, Resident 95's primary insurance payer was noted to be [NAME] Quality Options Medicare Plan. On March 1, 2024, the resident's primary insurance payer was changed to traditional Medicare. A review of a facility form entitled Disenrollment Form dated February 28, 2024, revealed a request to disenroll Resident 95 from her [NAME] Medicare Plan so that the resident may be covered under original Medicare benefits. During an interview on April 4, 2024, at approximately 10:05 AM, Resident 95 stated that she was aware of the change in her insurance, but stated that she did not ask or initiate the request and did not ask the facility for assistance in changing her insurance. The resident stated that the facility approached her to initiate the change. Resident 95 stated she did not sign anything authorizing the change. The state surveyor shared the facility form entitled Disenrollment Form dated February 28, 2024, and the resident, who was alert and oriented resident stated, That's not my signature. In further interview, Resident 95 stated that her son, her identified emergency contact #1, had called her and informed her that the facility staff had reached out to him regarding her insurance. She said that her son had stated, This is what they do, meaning change insurance. A telephone interview with Resident 95's son, emergency contact #1, on April 5, 2024, at approximately 1:05 PM, revealed that the facility's Director of Marketing called him regarding changing his mother's Medicare insurance. He further stated that he believes the call was on February 28, 2024, and was late in the day. He explained that the facility informed him that his mother's Medicare insurance plan would be cutting her from therapy services, but if they changed her insurance, she will receive additional paid days in therapy. Resident 95's son stated the facility did not fully inform him of the pros and cons of switching, including specific pharmacy changes, co-pays, physician choices, re-enrollment in her prior plan, deadlines, and potential penalties or loss of any additional coverage or benefits. Resident 95's son further stated he felt pressured by the facility to decide because the facility stated it was the end of the month and they needed to make the change now so his mother would receive more services. Resident 95's son further stated he called back the next day to further the conversation with the facility about potentially making a change in Medicare plans and the facility told him, It's done; your mother already signed it. He further stated that he never gave his permission nor signed anything to allow this change, and that his mother would most certainly know her signature when she saw it. A review of Resident 95's clinical record revealed no documented evidence of the date or time the resident, or her son, initiated their wish or desire to change, nor the circumstances surrounding the request to disenroll from her [NAME] Medicare Plan. During an interview on April 4, 2024, at approximately 12:15 PM, the facility's Director of Marketing explained that she assists residents with the Medicare disenrollment process. The Director of Marketing explained that the facility does not have a specific policy or procedure that details under what circumstances the facility can assist a beneficiary with an insurance plan change. The Director of Marketing stated that she approaches residents when they are eligible for additional days of Medicare Part A stay, if they disenroll from a Medicare Advantage Plan and switch to Original Medicare. She confirmed during interview that she was not aware of the need to assess and document the residents' cognitive abilities prior to asking the residents to sign disenrollment forms to ensure the residents were fully capable of making an informed decision and possessed the functional abilities to understand the potential implications of disenrolling from their Medicare plans. The Director of Marketing provided the surveyors, an information packet that is provided to residents, when the facility approaches them to disenroll from a Medicare insurance plan. The packet failed to include the information indicated in the facility's Medicare Enrollment/Disenrollment policy to ensure that residents and residents' representatives are able to make fully informed decisions on disenrollment. Specifically, the packet failed to include an explanation regarding deductible costs, copays, and loss or lack of supplemental coverage specific to the beneficiary. Also, the packet did not include the specific name of the drug plan that will cover the beneficiary's medication, including the deductible and co-pays or coinsurance. The Director of Marketing confirmed that the facility does not provide residents information from www.medicare.gov for information on locating a Medicare-approved agent or education regarding Medicare disenrollment, as indicated in the facility policy. Residents are directed and provided with a third-party health insurance agent that represents many major health insurance carriers. During an interview on April 5, 2024, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed that the facility's policy does not explain under what circumstances the facility can assist a beneficiary with a Medicare insurance plan change. The NHA was unable to provide documentation that the Director of Marketing was aware of the resident's cognitive assessment prior to disenrolling residents' Medicare plans. The NHA was was also unable to state why some residents stated that they did not understand or authorize the facility to make changes to their healthcare insurance coverage. During the interview, the NHA confirmed that it is the facility's responsibility to ensure that resident Medicare beneficiaries are only disenrolled from Medicare health plans with the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. During an interview with the Nursing Home Administrator (NHA) on April 5, 2024, at approximately 1:28 PM, a request was made for documented evidence of resident 95's [NAME] insurance indicating that the resident was being released-cut from therapy services. In response, the NHA stated that he was not aware of the notification letter and that the information communicated to the resident and her resident representative may have been presented hypothetically not factually. 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.29 (a) Resident rights

Based on a review of clinical records and staff interview it was determined that the facility failed to provide necessary staff supervision to prevent falls and serious injury, a fractured neck, for one resident with a known history of falls and unsafe behaviors out of three residents reviewed for falls (Resident 1). Findings Include: Review of Resident 1's clinical record revealed that the resident had a [DIAGNOSES REDACTED]. A review of the resident's Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 10, 2019, revealed that the required extensive assistance of one person for bed mobility, transfers between surfaces and use of the toilet. The resident was not steady with her balance during transfers and walking; she was not steady and only able to stabilize with staff assistance according to the assessment. The resident had a BIMS score of 3 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 0-7 equates to severe cognitive impairment). A review of the resident's comprehensive plan of care dated (MONTH) 25, 2019, indicated that the resident was at risk for falls and was non-compliant with transfer and ambulation status. It was noted that the resident observed to remove her clip alarms (devices clipped to her clothing while in her wheelchair or in her bed which sounds to alert staff when the resident attempts to transfer independently). Her bed was to be maintained in the low position and she was to be provided with staff assistance for transfers and ambulation. A review of this resident's clinical record revealed that the resident sustained [REDACTED]. May 24, 2019, at 2:15 a.m. the resident's bed alarm sounded and she was found on the floor in her bathroom. The resident did not sustain any injury. The facility planned to observe the resident every 15 minutes until the end of the shift at 7:00 a.m. On (MONTH) 4, 2019, at 1:45 AM the resident's alarm sounded and she was found sitting on the floor in her room, stating she had to go to the bathroom. The resident stated that she hit her head. The resident sustained [REDACTED]. The facility administered Tylenol and ice was applied to the area. A concave mattress (flat bottom surface configured to rest on a mattress and a concave portion formed in a support base opposite the flat bottom surface. The concave portion includes a recessed area between a head rest area and a leg rest area) was applied after this fall to assist with positioning and to prevent the resident from rising independently. On (MONTH) 4, 2019, at 8:10 PM the resident's alarm sounded and she was found on the floor in her room next to her bed. The resident was attempting to get up from her wheelchair to get herself ready for bed. The facility investigation indicated that the resident's wheelchair brakes were not locked and she was not wearing non-skid socks, both were noted as planned fall prevention measures for the resident. The resident did not sustain an injury. The facility reminded the resident to call for assistance. The resident agreed, but it was noted that the resident often forgets. On (MONTH) 6, 2019, at 8:35 p.m. staff observed the resident stand up from her wheelchair, take a few steps and fall, striking the back of her head sustaining a hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) to the back of her head measuring 4 cm by 4 cm. The physician ordered orthostatic blood pressure measurements (obtaining blood pressures from a lying, sitting and standing position to determine if the blood pressure decreases in these positions potentially causing dizziness, lightheadedness or [MEDICAL CONDITION]) since the resident had indicated that she was dizzy. The results were noted as lying - 150/72 mmHg; sitting - 160/82, standing - 136/70 and did not reflect [MEDICAL CONDITION] (low blood pressure). The facility also conducted neurological assessments (Neurological assessments include {at a minimum} pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength following a head injury) as per policy. The frequency of these checks were to be every 15 minutes for one hour, every 30 minutes for four hours, every one hour for two hours and every shift for 72 hours. There was no evidence that the facility had increased staff supervision of the resident after this fall. On (MONTH) 7, 2019 at 1:10 a.m., approximately 4 and ½ hours after the previous fall, the resident's alarm sounded. Staff found the resident sitting on the bathroom floor of her room in front of the toilet. There was a laceration (cut) to her left eyebrow and a skin tear to the inside of her lower lip and a bruised left thumb. At 2:30 a.m. the resident was transferred to the emergency room via ambulance. A review of the neurological check flowsheet revealed the resident's last neurological check was conducted at 11:20 p.m. on (MONTH) 6, 2019. The flow sheet indicated that the resident was to be assessed on (MONTH) 6, 2019 at 11:50 PM, on (MONTH) 7, 2019 at 12:20 a.m., and 12:50 a.m., as scheduled/identified on this facility tracking tool. There was no evidence that the neurological checks were conducted at those dates and times as identified on the flow sheet. There was no indication that the resident had been assessed from 11:20 PM on (MONTH) 6, 2019 until her fall at 1:10 a.m in the early morning of (MONTH) 7, 2019. The resident was not transferred to the hospital until 2:30 a.m. and neurological assements were not completed as of 11:20 PM on (MONTH) 6, 2019. Nursing documentation at 6:53 a.m. on (MONTH) 7, 2019, indicated that the report from emergency department indicated that the resident had sustained a cervical spine fracture and as a result was transferred to another hospital. The resident returned to the facility on (MONTH) 9, 2019, at approximately 5:00 p.m. wearing a cervical collar (neck brace used to support the broken neck), sutures to left eyebrow with bruising and also had bruising to her thumb. On (MONTH) 10, 2019, the facility initiated additional fall prevention interventions, which included placing the resident on every 15 minute watches, anti roll back device (prevents a wheelchair from rolling backwards) to her wheelchair. The facility was also to ensure the resident was wearing proper footwear and ensure that assistance was provided by staff for transfers and ambulation. The resident remained on every 15 minute watches, but sustained two additional falls, which occurred on (MONTH) 31, 2019, and (MONTH) 14, 2019, with no injury. On (MONTH) 18, 2019, the resident was observed in the dining room with her cervical collar in place. During interview attempts, the resident was able to answer to her name, but no further conversation could be conducted due to the resident's poor cognition. The facility was aware of the resident's fall risk and unsafe behaviors. The resident sustained [REDACTED]. The facility's fall prevention plan failed to prevent the resident's falls, but the facility failed to revise the plan to include the provision of staff supervision and assistance, at the level and frequency required, to prevent repeated falls and serious injury to the resident. An interview with the Director of Nursing (DON) on (MONTH) 20, 2019, at approximately 1:00 p.m. confirmed that the facility did not increase staff supervision of the resident beyond every 15 minute watches although the resident had fallen twice with this level of staff supervision. The DON stated that she had instructed staff to keep the resident in line of view, but this approach was not reflected on the resident's current comprehensive plan of care. The facility failed to provide adequate supervision to the resident to prevent falls which resulted in a fall with a fractured neck. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 11/02/18 28 Pa. Code 211.11(d) Resident care plan Previously cited 11/02/18, 8/31/18 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 11/02/18, 8/31/18

Based on a review of clinical records, observations and staff and resident interviews it was determined that the facility failed to consistently provide planned care and services, consistent with professional standards of practice, to prevent pressure sore development and promote healing for two of five residents sampled with pressure sores (Resident 84 and 83). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 84 was admitted to the facility on (MONTH) 18, 2019, with [DIAGNOSES REDACTED]. A review of 30-day Minimum Data Set assessment dated (MONTH) 30, 2019 (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was cognitively intact, required extensive assistance with activities of daily living and was at risk for developing pressure areas. A review of the resident's care plan dated (MONTH) 12, 2019, revealed that the resident was at risk for alteration in skin integrity. Interventions planned were noted as encourage and assist to reposition and use assistive devices as needed and a pressure reduction device to chair. A review of nursing documentation dated (MONTH) 12, 2019, at 5:20 PM revealed at 3:30 PM nursing staff notified the nurse that the resident had a skin impairment to his coccyx and that the resident was non-compliant at times with turning and repositioning. However, a review of nursing documentation and the resident's plan of care revealed no documentation that the resident had been non-compliant with turning and repositioning prior to identification of the pressure sore on (MONTH) 12, 2019. A review of a facility ulcer and pressure sore investigation dated (MONTH) 12, 2019, revealed that an open area was noted to the resident's coccyx (an area on the body located at the base of the spine) measuring 7.6 cm length x 3.8 cm width x 0.2 cm depth. The wound contained 100% slough (A layer dead tissue separated from surrounding living tissue, as in a wound or sore). The resident's pressure sore was staged as unstageable (wound severity cannot be determined with a visual exam due to slough covering the wound). New interventions put into place at the time of the discovery of the pressure area on (MONTH) 12, 2019, were to reposition the resident side to side while in bed and to cleanse the pressure sore with normal saline solution, apply Santyl and cover with an ABD pad daily and as needed. There was no documented evidence that prior to the resident's development of the pressure sore that the facility had consistently implemented the intervention of turning and repositioning the resident as planned. Facility nursing staff solely documented on a weekly basis that the pressure reducing device was on the resident's wheelchair. At the time of the survey ending (MONTH) 20, 2019, the facility was unable to provide documented evidence that the pressure reducing device planned had consistently been in place and being utilized daily by the resident as per the resident's care plan. An observation of the resident on (MONTH) 20, 2019, revealed that the resident was lying on his back in bed and was not positioned on his side as planned. Employee 1, RN (registered nurse) and Employee 2, RN turned the resident onto his left side and removed the resident's dressing. The resident was observed to have a wound on his coccyx measuring 4.6 cm x 3.6 cm with 100% slough covering the wound. An interview with Employee 1 and Employee 2 on (MONTH) 20, 2019, at 9:50 AM confirmed that there was no documentation to verify that the resident's care planned interventions of turning and repositioning and daily use of the pressure relieving device had consistently been implemented. Employee 1 stated that the care planned pressure sore prevention interventions are noted on the Kardex to alert the caregivers that the resident requires these services. An observation on (MONTH) 20, 2019, at 1:28 PM revealed staff had just assisted the resident back into bed. The resident was observed lying on his back and staff had not positioned him on his side as planned. An interview was conducted with Resident 84 on (MONTH) 20, 2019, at 1:30 PM. The resident stated that his bottom was sore. The resident was asked if the staff reposition him from side to side and the resident replied no. He further stated, once they put you here (in bed) you are here. The resident was asked if he preferred not be positioned onto his sides and if he repositions himself onto his back. The resident replied no, it doesn't matter how I lay. The facility failed to demonstrate the consistent implementation of planned preventative measures to prevent pressure sore development. The facility further failed to consistently implement planned measures (side to side repositioning) to promote healing and prevent worsening of the resident's pressure sore. A review of the clinical record revealed that Resident 83 was admitted to the facility on (MONTH) 21, 2012, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set assessment dated (MONTH) 10, 2019 revealed that the resident was severely cognitively impaired, required extensive assistance with activities of daily living and was at risk for developing pressure areas. A review of the resident's care plan initiated (MONTH) 27, (YEAR), revealed that the resident was at risk for alteration in skin integrity. Interventions planned were to turn and reposition resident every 2 hours and the use of pressure reduction device to wheelchair. A review of nursing documentation dated (MONTH) 18, 2019, at 10:22 p.m. revealed that nursing staff notified the nurse that the resident had an open area to her sacrum. A review of a facility ulcer and pressure sore investigation dated (MONTH) 18, 2019, revealed an open area was noted to the resident's coccyx (an area on the body located at the base of the spine) measuring 1.5 cm length x 1.0 cm width x 0.1 cm depth. The resident's pressure sore was staged as unstageable. New interventions put into place at the time of the discovery of the pressure area were assist to bed after lunch and dinner, and cleanse with normal saline solution, apply Santyl and cover with an ABD pad daily and as needed. No documentation was found prior to the development of the pressure sore that the facility had consistently implemented the intervention of repositioning the resident. The facility staff documented only weekly that the pressure reducing device was on the resident's wheelchair. The facility was unable to provide documentation that the pressure reducing device was in place and being utilized daily by the resident as per the resident's care plan. An observation on (MONTH) 20, 2019, revealed that the resident was lying on her back in bed on the site of the pressure sore. Employee 1 and Employee 2 turned the resident onto her left side and removed the resident's dressing. The resident was observed to have a wound on his coccyx measuring .3 cm x .4 cm. An interview with Employee 1 and Employee 2 on (MONTH) 20, 2019, at 9:50 AM confirmed that the facility did not have documented evidence of the daily implementation of the resident's care plan for pressure sore prevention. Employees 1 and 2 stated that the care plan interventions are noted on the Kardex to alert the staff of the interventions planned for the resident. An interview with the DON on (MONTH) 20, 2019 at approximately 2:15 PM confirmed that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for residents at risk for skin breakdown and to promote healing of existing pressure sores. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited 8/31/18, 11/2/18 28 Pa. Code 211.5(f) Clinical records. Previously cited 8/31/18

Based on a review of clinical records, select incident and accident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to utilize safe techniques and/or provide sufficient staff assistance during care to prevent an accident resulting in a [MEDICAL CONDITION] for one resident out of nine residents reviewed (Resident 10). Findings include: A review of the clinical record revealed that Resident 10 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 2, (YEAR), revealed that the resident was moderately cognitively impaired with a BIMS of 9 (Brief Interview for Mental Status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 8-12 equates to being moderately cognitively impaired) and required extensive assistance with two persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). A review of documentation dated (MONTH) 13, (YEAR), provided by the facility indicated that Resident 10 rolled out of bed onto the floor during incontinence care at approximately 6:15 a.m. on (MONTH) 12, (YEAR). The resident complained of a headache and a lump was found on the left side of her forehead. The physician was notified and no new orders were given. At 10:30 a.m. on (MONTH) 13, (YEAR), the resident's daughter requested that the resident be transferred to the hospital for evaluation. The resident was admitted to the hospital with [REDACTED]. A review of the resident's care plan in place at the time of the resident's fall from bed on (MONTH) 12, (YEAR), which was initially dated (MONTH) 9, (YEAR), revealed that at the time of the incident the resident required two person assistance for bed mobility. A review of a report submitted to the State Survey Agency on (MONTH) 15, (YEAR), by the local county Area Agency on Aging (state affiliated advocacy agency for the elderly) indicated that the facility had reported to their agency that Resident 10 was rolled over (in bed by facility staff) and pushed over a cushion and landed on the floor. The report indicated that the resident's daughter had to demand a transfer to the hospital for evaluation. A review of the incident/accident report dated (MONTH) 12, (YEAR), at 8:51 a.m. and review of an attached witness statement (a description of the event/incident by staff) signed by Employee 1, a nurse aide indicated, When I was changing (Resident 10) I had the bed to the ground. I went to roll her and let her go for a minute as she was on her side, to get a blanket to roll under her and that is when she went off the side of the bed. The report indicated that the resident bumped her head and had a bruise and was medicated for pain. Further review of the nursing documentation indicated that when the resident's daughter arrived at the facility at approximately 10:00 a.m. on (MONTH) 12, (YEAR), she, strongly requested that the facility send the resident to the hospital for an evaluation. A review of hospital records revealed that Resident 10 complained of right hip pain and was evaluated by CT scan (a computerized tomography (CT) scan combines a series of X-ray images taken from different angles providing more detailed information than plain X-rays), which revealed an impacted subcapital [MEDICAL CONDITION], the largest bone in the leg (fracture line extends through the junction of the head and neck of the femur) of the right hip and an MRI (a test that uses powerful magnets, radio waves, and a computer to make detailed pictures inside the body) revealed an impacted (a break in the bone in multiple pieces which are driven into each other) subcapital [MEDICAL CONDITION] hip. The resident was admitted to the hospital to determine if surgical repair was required. The resident did not require surgical intervention due to her immobility and returned to the facility on (MONTH) 15, (YEAR). An interview with Employee 1 at 11:00 a.m. on (MONTH) 2, (YEAR), revealed that she had rolled the resident away from her (to the right), the resident's top leg was bent in order to provide incontinence care. Employee 1 stated that she usually keeps her hand on the resident's hip, but said that, for some reason she took her hand off her (the resident) and, she let the resident go, which caused the resident to roll away from her (to the right) flattening out the bolster (thick cushion placed on either side of the bed to position residents to define where the side of the bed ends), which was on the side of the bed and landing on the floor on her left side. Employee 1 further stated that no other staff was with her and she was providing the resident's incontinence care herself. She stated that she thought the resident only required one person for care and bed mobility. Employee 1 stated that if she needed someone she, would have asked for help. She stated that she had to roll the resident away from her in order to clean her. Interview with the Director of Nursing (DON) on (MONTH) 2, (YEAR), at 1:30 p.m. failed to provide evidence that the resident had been provided with sufficient staff assistance and safe nursing technique to prevent the resident's fall from bed resulting in a fracture. The DON was also unable to provide evidence of any education provided to nurse aides regarding rolling a resident from side to side by one aide. The DON was unable to indicate the proper technique that is required by a nurse aide when rolling a resident from side to side without the help of another staff member. An interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 2, (YEAR), at 1:45 p.m. revealed that the facility does not have an established procedure for staff to follow when determining the amount of assistance that is required for a resident's bed mobility. These staff members stated that they, do not rely on the MDS because it is just a snapshot in time. A review of the resident's bed mobility daily care worksheet, which is documented by the nurse aides, indicated on (MONTH) 11, (YEAR), on all three shifts of nursing duty, that the resident required two persons for bed mobility. According to the Nursing Assistant - A Nursing Process Approach Handbook, 10th edition, when turning a resident away from the care giver, the side rail on the opposite side of the bed should be up and secure. Employee 1 failed to utilize a safe technique during this resident's care resulting in an avoidable accident with serious injury. The facility failed to ensure that the resident consistently received sufficient staff assistance to prevent this accident and injury. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/17/17, 9/15/17 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c) Nursing services Previously cited 6/18/18, 4/19/18, 10/17/17, 9/15/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 4/9/18, 10/17/17, 9/15/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/18/18, 5/31/18, 4/19/18, 10/17/17, 9/15/17

Based on a review of clinical records, select incident and accident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to utilize safe techniques and/or provide sufficient staff assistance during care to prevent an accident resulting in a [MEDICAL CONDITION] for one resident out of nine residents reviewed (Resident 10). Findings include: A review of the clinical record revealed that Resident 10 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 2, (YEAR), revealed that the resident was moderately cognitively impaired with a BIMS of 9 (Brief Interview for Mental Status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 8-12 equates to being moderately cognitively impaired) and required extensive assistance with two persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). A review of documentation dated (MONTH) 13, (YEAR), provided by the facility indicated that Resident 10 rolled out of bed onto the floor during incontinence care at approximately 6:15 a.m. on (MONTH) 12, (YEAR). The resident complained of a headache and a lump was found on the left side of her forehead. The physician was notified and no new orders were given. At 10:30 a.m. on (MONTH) 13, (YEAR), the resident's daughter requested that the resident be transferred to the hospital for evaluation. The resident was admitted to the hospital with [REDACTED]. A review of the resident's care plan in place at the time of the resident's fall from bed on (MONTH) 12, (YEAR), which was initially dated (MONTH) 9, (YEAR), revealed that at the time of the incident the resident required two person assistance for bed mobility. A review of a report submitted to the State Survey Agency on (MONTH) 15, (YEAR), by the local county Area Agency on Aging (state affiliated advocacy agency for the elderly) indicated that the facility had reported to their agency that Resident 10 was rolled over (in bed by facility staff) and pushed over a cushion and landed on the floor. The report indicated that the resident's daughter had to demand a transfer to the hospital for evaluation. A review of the incident/accident report dated (MONTH) 12, (YEAR), at 8:51 a.m. and review of an attached witness statement (a description of the event/incident by staff) signed by Employee 1, a nurse aide indicated, When I was changing (Resident 10) I had the bed to the ground. I went to roll her and let her go for a minute as she was on her side, to get a blanket to roll under her and that is when she went off the side of the bed. The report indicated that the resident bumped her head and had a bruise and was medicated for pain. Further review of the nursing documentation indicated that when the resident's daughter arrived at the facility at approximately 10:00 a.m. on (MONTH) 12, (YEAR), she, strongly requested that the facility send the resident to the hospital for an evaluation. A review of hospital records revealed that Resident 10 complained of right hip pain and was evaluated by CT scan (a computerized tomography (CT) scan combines a series of X-ray images taken from different angles providing more detailed information than plain X-rays), which revealed an impacted subcapital [MEDICAL CONDITION], the largest bone in the leg (fracture line extends through the junction of the head and neck of the femur) of the right hip and an MRI (a test that uses powerful magnets, radio waves, and a computer to make detailed pictures inside the body) revealed an impacted (a break in the bone in multiple pieces which are driven into each other) subcapital [MEDICAL CONDITION] hip. The resident was admitted to the hospital to determine if surgical repair was required. The resident did not require surgical intervention due to her immobility and returned to the facility on (MONTH) 15, (YEAR). An interview with Employee 1 at 11:00 a.m. on (MONTH) 2, (YEAR), revealed that she had rolled the resident away from her (to the right), the resident's top leg was bent in order to provide incontinence care. Employee 1 stated that she usually keeps her hand on the resident's hip, but said that, for some reason she took her hand off her (the resident) and, she let the resident go, which caused the resident to roll away from her (to the right) flattening out the bolster (thick cushion placed on either side of the bed to position residents to define where the side of the bed ends), which was on the side of the bed and landing on the floor on her left side. Employee 1 further stated that no other staff was with her and she was providing the resident's incontinence care herself. She stated that she thought the resident only required one person for care and bed mobility. Employee 1 stated that if she needed someone she, would have asked for help. She stated that she had to roll the resident away from her in order to clean her. Interview with the Director of Nursing (DON) on (MONTH) 2, (YEAR), at 1:30 p.m. failed to provide evidence that the resident had been provided with sufficient staff assistance and safe nursing technique to prevent the resident's fall from bed resulting in a fracture. The DON was also unable to provide evidence of any education provided to nurse aides regarding rolling a resident from side to side by one aide. The DON was unable to indicate the proper technique that is required by a nurse aide when rolling a resident from side to side without the help of another staff member. An interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 2, (YEAR), at 1:45 p.m. revealed that the facility does not have an established procedure for staff to follow when determining the amount of assistance that is required for a resident's bed mobility. These staff members stated that they, do not rely on the MDS because it is just a snapshot in time. A review of the resident's bed mobility daily care worksheet, which is documented by the nurse aides, indicated on (MONTH) 11, (YEAR), on all three shifts of nursing duty, that the resident required two persons for bed mobility. According to the Nursing Assistant - A Nursing Process Approach Handbook, 10th edition, when turning a resident away from the care giver, the side rail on the opposite side of the bed should be up and secure. Employee 1 failed to utilize a safe technique during this resident's care resulting in an avoidable accident with serious injury. The facility failed to ensure that the resident consistently received sufficient staff assistance to prevent this accident and injury. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 10/17/17, 9/15/17 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c) Nursing services Previously cited 6/18/18, 4/19/18, 10/17/17, 9/15/17 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 4/9/18, 10/17/17, 9/15/17 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/18/18, 5/31/18, 4/19/18, 10/17/17, 9/15/17

Based on a review of clinical records, resident incident reports, and Event Reports submitted to the State Survey Agency and staff interview, it was determined that the facility failed to implement planned interventions to prevent recurrence/occurrence of an accident and injury for two residents sampled (Resident 40 and Resident 69) and failed to provide sufficient supervision to prevent elopements for one resident (Resident CR1) out of 20 sampled. Findings include: A review of the clinical record revealed that Resident 40 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of an Incident Report dated January 31, 2013, at 9:15 a.m. and reviewed by the director of nursing February 16, 2013, indicated that Resident 40 turned around in her merry walker and fell to the floor. The merry walker closure and strap were noted to be intact. The investigation report indicated that the resident turned around in the merry walker so the seat was facing the front of her body and she started to sit down not realizing her positioning. No injuries were noted. Corrective measures that were being taken by the facility to prevent reoccurrence of similar falls was that the strap to the merry walker would be tightened and a referral was being sent to therapy. A referral dated January 31, 2013, was sent for Physical therapy and Occupational therapy indicating that the resident fell while participating in a task, due to poor positioning, or falling more often, and the resident was having trouble positioning self. A review of an Incident Report dated February 1, 2013, at 7:35 a.m. and reviewed by the director of nursing on March 3, 2013, indicated that the resident was being ambulated out of the shower by two staff members when she crossed her feet and fell . The resident sustained [REDACTED]. A message dated February 1, 2013, was sent from nursing to therapy indicating that the resident fell after her shower and that when staff was walking the resident she crossed her feet on the first step and fell . Documentation was noted at the conclusion of the facility investigation into this fall, indicating that the resident was currently being evaluated by therapy due to a fall the resident had on January 31, 2013. There was no documented evidence that the resident was evaluated by therapy following this fall on January 31, 2013. A review of an Incident Report dated February 2, 2013, at 10:30 a.m. and reviewed by the director of nursing March 4, 2013, noted that the resident was found lying on the floor of the resident's room, while still in the merry walker with the merry walker tipped over. The resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation at that time. The facility's investigation report indicated that for the merry walker to tip forward the back of the resident's legs would have to be against the front of the seat while the resident was standing up and that some type of forward force would have to be applied. Corrective measures to be taken by the facility after this fall, were to hold the resident's use of the merry walker until the resident was evaluated by therapy. A PT/OT evaluation and treatment and every 15 minute checks on the resident were planned as corrective measures following this fall. A review of an Event Report dated February 2, 2013, submitted to the State Survey Agency indicated that at 10:30 a.m. Resident 40 was found in room 24 (the resident's room) on the floor in a prone position. The report further indicated that the resident ambulates in a merry walker, which was found with the front side down under her, the strap was correctly placed with correct tightness, and the wheels unlocked. The resident sustained [REDACTED]. The resident was transported to the hospital and was admitted with a "small left parietal epidural hematoma" ( bleeding into the left side of the brain) and scalp laceration. On February 3, 2013, Resident 40 returned from the hospital and without physician orders [REDACTED]. Therapy evaluated the resident on February 4, 2013, and a recommendation was made for the resident to be in high visible areas when out of bed in wheelchair with a wedge cushion. Bilateral leg rests were to be utilized for transportation only. An interview with the nursing home administrator on September 26, 2013 at 11:30 a.m. revealed that the resident should have been seen by therapy at the latest within 24 hours of the initial fall that occurred on January 31, 2013. The administrator confirmed the fact that the resident was not seen until February 4, 2013, after the third fall during which the resident sustained [REDACTED]. A review of the clinical record revealed that Resident CR-1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Nursing documentation dated April 20, 2013 at 11:00 AM indicated that the resident was making statements that he had to leave (the facility) and wanted to go home. The resident was assessed to be at risk for wandering and a wanderguard bracelet was placed on his wrist. (This bracelet would set off a loud alarm at the front door if he was to exit through it). A review of an incident report dated April 26, 2013 at 08:00 AM revealed that the resident was sitting in the hallway near the living room. A statement written by Employee 1, a Registered Nurse (RN), noted that she was being picked up by her husband and saw the resident in the woods, headed down the road in front of the facility. He was leaning up against a tree. According to a statement from Employee 2, an RN, was leaving the building and saw a man walking outside the facility and she asked him his name; she then went into the facility and asked if they had a resident by this name. Employee 2 did not recognize him and he gave Employee 2 a false name. The facility then determined that it was Resident CR1. A code white was called and facility staff began to look for resident. Employee 1's husband picked him up in the car and drove him back to the facility. The resident was interviewed by Employee 3, an RN, when he returned and stated a family member came entered the facility and he walked out the door at that time. "Someone asked who I was and I gave them a different name." He stated he should have just hid in the bushes. He said he would stay here for now but he wanted to go home because he could take care of himself. A review of the incident report regarding this elopement failed to provide evidence that the resident was wearing a wander guard bracelet or if the alarm sounded. Interviews with the nursing home administrator (NHA) and director of nursing (DON) on September 27, 2013, at approximately 10:00 AM failed to verify if the wander guard bracelet was in place or if the alarm sounded when the resident exited the building without staff knowledge. According to documentation by the nursing staff on April 26, 2013, on the 11 PM to 7 AM and 7 AM to 3 PM shift the wander guard was present on the resident's right wrist and the battery was checked and functional on the day of resident's elopement. There was no documentation indicating that the wander guard alarm system at the front door was functioning properly at the time of the resident's elopement. After the resident's elopement, he was placed on every 15 minute checks along with the wander guard bracelet to prevent another elopement. The resident's picture was also placed at the reception desk. This incident report was not reviewed by the DON until May 8, 2013, which was twelve days after the incident. A review of an incident report dated May 5, 2013, revealed that the resident had removed his wander guard bracelet and put it on his dinner tray at approximately 6:15 PM. Employee 5, a nurse aide, who was picking up his tray noticed the wanderguard and reported it to the supervisor. Employee 1, an RN, located the resident in the lobby after receiving the report from Employee 5. She sat with the resident in the lobby and asked Employee 6 an LPN (who was passing medications) to watch him while she went to get another wander guard bracelet. Employee 1, wrote in her statement regarding this incident, that while en route for the bracelet she had to assist another resident to the bathroom. When she returned to the lobby the resident was missing. A review of the statement written by Employee 7, an off duty housekeeper , indicated that she was visiting with her family member at the facility when she noticed an elderly man walking slowly toward the road, which intersects with the road in front of the facility. This employee followed him and he refused to go back to the facility. Employee 1 then came out of the building and walked with this resident until Employee 6 got her car and they picked up the resident. They drove a ? mile down the road to the intersection where the resident tried to open the car door (the car was stopped) and the resident got out and continued to walk up the road into the woods with Employee 1 following him. After approximately an hour, an ambulance was called and the resident agreed to get into the ambulance and return to the facility. After his incident the resident placed on a one to one close observation watch. Interview with the DON on September 27, 2013, failed to provide evidence that sufficient supervisory and monitoring measures were in place to prevent the resident's elopement. She stated that Employee 6 was also assisting someone and was unable to observe Resident CR1 while he was sitting in the lobby without a wander guard bracelet. A review of the clinical record revealed that Resident 69 had multiple [DIAGNOSES REDACTED]. The resident's comprehensive plan of care dated January 14, 2013, indicated that the resident had the potential for falls or injury related to poor safety awareness and Parkinson's Disease. The resident had current physician's orders [REDACTED]. According to nursing documentation on March 26, 2013, the resident had a fall at 9:00 AM, witnessed by a staff member who was walking by the resident's room. The staff member saw the resident fall to the floor on the side of bed 37A. The nurse aide went to call the nurse, who had also heard the resident fall. The resident's neck was stabilized and was log rolled. A laceration to the left outer occipital area was noted. 911 was called and the resident was transported to the hospital. According to nursing documentation dated March 27, 2013 at 2:00 AM, the resident had to be transferred to another hospital for further evaluation and at 6:50 AM he was admitted to this hospital with a [DIAGNOSES REDACTED]. Review of a corresponding "INCIDENT REPORT" dated March 28, 2013 at 9:00 PM, indicated that the resident was heard falling. The resident was found unresponsive face down on the floor. A three cm long laceration was noted to his left eye. When the resident became arousable he stated he had pain to the head. The incident report noted that the alarms were not turned on and the Nurse Aide (Employee 8) who had just toileted the resident prior to the fall went to get supplies for this resident. The facility's investigation concluded that the safety alarm was not turned on as planned for this resident and an inservice for this Nurse Aide was done. Review of a corresponding Event Report submitted to the State Survey Agency dated March 26, 2013, also indicated that the resident was found face down on the floor near the foot of the bed. He sustained a 3 cm laceration to the left side of the head, was initially unresponsive and complained of pain in the head. He was transferred to the Trauma ER and was admitted to the hospital for an Epidural Hemorrhage. The Event Report noted that the resident had been in the bathroom with his nurse aide prior to the fall and was preparing to go to bed. The nurse aide left the room to obtain supplies while the resident was sitting at the bedside. The ordered mobility alarm was attached to his chair at the time of the fall, however, the clip alarm was not attached to his clothing. The nurse aide assigned to the resident was suspended an investigation was completed. According to an interview with the Director of Nursing on September 26, 2013, Nurse Aide (Employee 8 ) failed to put the clip alarm on the resident's clothing while he was seated at the bedside in his wheelchair and then the Nurse Aide left the resident's room to get supplies for the resident. The facility failed to consistently implement planned safety measures to prevent an accident for this resident who was identified at risk for falls. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services Previously cited 8/6/13, 8/31/12