Every finding on record at Broomall Manor

Based on clinical records review and staff interview, it was determined that the facility failed to ensure medication was correctly administered to the resident and the physician's order regarding vital sign monitoring after a medication error incident was followed for one of two residents reviewed (Resident R1).Findings include: Clinical records review revealed Resident R1 was admitted to the facility on [DATE], with a diagnosis of small bowel obstruction and bladder cancer. A review of the progress notes dated December 19, 2025, at 5:46 a.m., revealed Medication error occurred this evening involving not prescribed medication Keppra (A medication used to treat seizures) PO (by mouth) and prescribed medication Lactulose (A medication used to treat constipation). Patient received 5 ml of Keppra PO instead of the ordered dose of 30 cc of Lactulose. Error identified during MAR (Medication Administration Record) review at 2130 (9:30 p.m.). A review of the facility's investigation, licensed nurse Employee E3's statement dated December 18, 2025, revealed Resident's evening medications were poured, including Lactulose. Lactulose was mistakenly poured into a medication cup in which Keppra had already been poured and emptied. Same cup with minimal Keppra mistakenly used by the nurse pouring Lactulose and was given to the resident. An interview was conducted with the Director of Nursing (DON) on December 16, 2025, at 1:00 p.m. The DON reported that Employee E3 accidentally poured Keppra instead of Lactulose into the medication cup. Employee E3 discarded the liquid Keppra, but with a minimal amount left, and decided to use the same medication cup and poured the ordered Lactulose and administered it to the resident. The DON confirmed that Resident R1's medication order was not correctly followed. A review of the progress notes dated December 19, 2025, at 5:46 a.m., revealed that after the medication error where Resident R1 was accidentally administered with 5 ml of Keppra, the physician was notified with orders received to monitor the resident's vital signs (Are measurements of the body's essential functions, which includes body temperature, pulse rate, respiratory rate, and blood pressure) every shift for two day. Clinical records revealed Resident R1's vitals were taken on the following days/times: December 19, 2025, at 5:55 a.m., blood pressure, respirations, pulse, temperature were taken; December 19, 2025, at 8:41 a.m., only blood pressure was taken; December 20, 2025, at 10:51 a.m., only blood pressure was taken; and December 21, 2025, at 8:50 a.m., only blood pressure was taken. Vital sign records revealed the following: Incomplete vital signs were taken on December 19, 2025, at the 7A-7P shift; Vital signs were not taken on December 19, 2025, on the 7P-7A shift. Incomplete vital signs on December 20, 2025, at the 7A-7P shift; No vital sign taken on December 20, 2025, on the 7P-7A shift. An interview with the Director of Nursing conducted on January 16, 2026, at 1:00 p.m., confirmed that the physician's order to monitor the resident's vital signs post medication error incident was not followed. The DON reported that the order to monitor the vital signs were put in the physician's order but was not properly transcribed into electronic medical records (EMR). The facility failed to ensure the physician's order to monitor Resident R1's vital signs was followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on review of clinical records, facility documentation, and staff interview, it was determined the facility failed to provide appropriate and consistent treatment for a skin tear for one of the 24 residents reviewed (Resident 54). Findings include: Review of Resident 54's nursing progress notes dated October 8, 2024, at 8:34 p.m., revealed while changing and repositioning Resident 54, a circular skin tear to the left elbow, approximately 2.5 cm. in size, was observed. The physician and the responsible party were notified. Review of the facility's documentation titled, Skin Integrity Events, dated October 8, 2024, at 8:31 p.m., revealed the resident had a 2.5 x 2.5 cm skin tear to the left elbow. The same report revealed the physician was notified, and under interventions, document revealed treatment ordered. Review of Resident 54's October 2024 Medication/Treatment Administration Record failed to reveal a treatment order for Resident 52's left elbow skin tear identified on October 8, 2024. Review of Resident 54's nursing progress notes dated October 9, 2024, at 6:43 p.m., revealed Skin tear to left elbow. No reported pain this shift. Treatment done. Review of Resident 54's clinical records failed to reveal type of treatment provided to Resident 54's left elbow skin tear on October 9, 2024, since there was no documented wound treatment order to the left elbow despite documents indicating a treatment was ordered. Review of Resident 54's clinical records failed to reveal Resident 54's left elbow skin tear identified on October 8, 2024, was provided with wound treatment on October 10, 11, 12, 13, and 14. The above information was conveyed to the Director of Nursing on October 31, 2024. The facility failed to ensure Resident 54's left elbow skin tear was appropriately and consistently provided with treatment. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interview it was determined the facility failed to develop comprehensive care plans for one of 24 residents reviewed. Findings Include: Review of Resident 43's Bladder Continence documentation from September 27, 2023 to October 26, 2023 revealed the resident had 10 episodes of bladder incontinence and 7 episodes of bowel incomitance. Review of Resident 43's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated September 22, 2023 revealed the resident was occasionally incontinent of bladder and frequently incontinent of bowel and was not on a toileting program. Review of Resident 43's care plan revealed there was no developed for Resident 43's incontinence of bowel and bladder. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2023 at 9:30 a.m. confirmed there was no care plan for bowel and bladder incontinence developed for Resident 43. 28 PA Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to provide care and service for residents to attain and maintain highest practicable bowel and bladder continence and provide care for a foley catheter for two of four residents reviewed. (Residents 43 and 76) Findings Include: Review of facility policy and procedure titled Continence Management Program, last revised on June 7, 2023, revealed the purpose of the Continence Management Program is to establish and maintain a pattern for control of bladder or bowel function. The following residents should be considered for a bladder or bowel incontinence program, those who: are usually continent but have episodes of incontinence, have recently had a Foley catheter removed, requires limited to extensive assistance in toilet use, could benefit from a prompted or scheduled toileting plan. Review of Resident 43's Bladder Continence documentation from September 27, 2023 to October 26, 2023 revealed the resident had 10 episodes of bladder incontinence and 7 episodes of bowel incomitance. Review of Resident 43's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated September 22, 2023 revealed the resident was occasionally incontinent of bladder and frequently incontinent of bowel and was not on a toileting program. Resident 43 was also coded as needing only supervision for transfers and the limited assistance of one person for toileting. Review of Resident 43's entire clinical record revealed the resident had not been assessed for continence or appropriateness of a training program since admission to the facility on [DATE] at which time Resident 43 as documented as having a Foley catheter (tube inserted into the bladder to allow drainage) and had orders for a foley catheter and care. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2023 at 9:30 a.m. confirmed there was no assessment to determine the cause of Resident 43's incontinence or the appropriateness of a training program. Review of Resident 76's physician orders revealed an order dated October 3, 2023 to document Foley output every shift. Review of Resident 76's Medication Administration Record revealed the nursing staff were signed off they were completing this order but there was no amount of output documented. Review of Resident 76's entire clinical record failed to reveal documentation of the Foley output as ordered. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2023 at 9:30 a.m. confirmed Resident 76's Foley output was not documented as ordered on October 3, 2023. 28 Pa. Code 211.5 (f) Clinical record 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services

Based on review of facility policy and clinical record review, it was determined that the facility failed to notify the physician of a change in condition in a timely manner resulting in a delay in hospitalization for one of 21 residents reviewed (Resident 39). Findings include: Review of facility policy, Seizure Management Policy, last revised July 19, 2023, revealed that if a resident has convulsions that last longer than five minutes or has subsequent seizures, the provider should be notified, or if not immediately available, emergency transfer should be initiated. Review of Resident 39's clinical record revealed a diagnosis of epilepsy (brain disorder that causes recurring, unprovoked seizures). Review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 6:36 a.m. which stated: Resident had a mild seizure x1 @ 0415 am and stopped at 0430 am. Per staff it was her normal baseline seizure activity. Further review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 6:43 p.m., which stated that the resident was noted to have a seizure this afternoon at 4:30. She was laying on her back on her bed, snoring very loudly. She was unresponsive until I sternal rubbed her. Her eyes opened and then looked at me then closed again. After about 20 minutes she was responding to her name and eating her dinner. [Her] only complaint was a headache to which she received tylenol which was effective. Nursing staff will continue to monitor the resident's status. Further review of Resident 39's progress notes revealed a nurse's note on September 17, 2023, at 10:08 p.m. which stated, Resident sent to [hospital] at [9:55 p.m. status post] epilepsy episode. Resident exhibited seizure activity which entailed uncontrollable jerk movement & decreased [level of consciousness] x 3 lasting more than 5 minutes. Review of Resident 39's history and physical from the emergency room revealed that the resident was noted by nursing home staff to have a total of 8 seizures today which prompted [emergency medical services] to be called. Clinical record review failed to reveal evidence that the physician was notified of Resident 39's seizures until the three seizures noted in the 10:08 p.m. progress note. The above findings were conveyed to the Nursing Home Administrator and Director of Nursing on October 27, 2023, at 11:05 a.m. 28 Pa. Code 201.18(b)(1) Management 28 Pa. 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interview it was determined the facility failed to accurately document a pressure ulcer for three of 8 residents reviewed. (Residents 42, 46, and 84) Findings Include: Review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident 42's weekly Skin evaluation, dated July 8, 2022 revealed the resident had a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on the sacrum (large, flat triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra bone) but there was no further documentation of the size, or description of the wound including staging. Further review of resident 42's clinical record revealed a Weekly Wound Assessment, dated July 12, 2022 indicating the resident had a stage 4 (the pressure injury is very deep, reaching into muscle and bone and causing extensive damage) community acquired pressure ulcer to the sacrum. Interview with the Director of Nursing and the Nursing Home Administrator on December 22, 2022 at 9:30 a.m. revealed wounds should be fully documented upon admission of a resident with a wound and confirmed there was no full documentation of Resident 42 sacral pressure ulcer until 4 days after admission. Review of Resident 46's clinical record dated March 16, 2022 revealed the resident had a stage 3 (full-thickness developed into the soft tissue underneath the skin) pressure ulcer on the sacrum measuring 2x2x0.3 cm. There are no measurements of the pressure ulcer after this date until December 6, 2022 when a sacral wound is noted as a stage 4 pressure ulcer measuring 1.5x 1x 0.9 cm. An interview with the Director of Nursing on December 22, 2022 at 11:30 a.m. revealed that the pressure ulcer never healed and this remains the same pressure ulcer as in March. Further confirmation that there is no further documentation in the clinical record of the wound healing process from March 16, 2022 until December 6, 2022. Review of resident 84's clinical record revealed a weekly wound assessment completed on December 5, 2022 indicating the resident had a stage 2 (partial-thickness skin loss into but no deeper than the tissue layer under the skin) pressure ulcer to the sacrum. Further review of the clinical record on December 21, 2022 revealed there were no further weekly wound assessments completed after December 5, 2022. Observation of resident 84's sacrum on December 22, 2022 at 10:00 a.m. confirmed the resident had a current stage 2 pressure ulcer to his sacrum. Interview with the Director of Nursing and the Nursing Home Administrator on December 22, 2022 at 9:30 a.m. revealed wound's should be fully documented weekly and confirmed there was no further documentation of resident 84's sacral pressure ulcer on the clinical record since December 5, 2022. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to accurately document the resident's status for three of 24 residents reviewed. (Residents 1, 49, 56, and Resident 66) Findings Include: Review of Resident 1's clinical record revealed the resident expired at the facility on [DATE]. Review of Resident 1's Minimum Data Set (MDS- periodic assessment of resident needs) revealed the last MDS completed for Resident 1 was a Quarterly assessment dated [DATE]. There was no assessment completed when Resident 1 expired. Interview with Licensed Nursing Employee E3 on [DATE] at 12:15 p.m. confirmed there was no MDS completed when Resident 1 expired. Review of Resident 49's clinical record revealed an order for hospice services dated [DATE]. Review of Resident 49's quarterly MDS assessments dated [DATE] and [DATE] revealed the resident was not coded as receiving hospice services. Interview with Licensed Nursing Employee E3 on [DATE] at 12:15 p.m. confirmed Resident 49 was under hospice services and the quarterly MDS assessment of [DATE] and [DATE] were coded incorrectly. Review of Resident 56's clinical record revealed an order for hospice services dated [DATE]. Review of Resident 56's comprehensive MDS assessment dated [DATE] revealed the resident was not coded as receiving hospice services. Review of Resident 66's clinical record revealed an order for hospice services dated [DATE]. Review of Resident 66's quarterly MDS assessment dated [DATE] revealed the resident was not coded as receiving hospice services. Interview with Director of Nursing on [DATE] at 9:15 a.m. confirmed that the MDS for Resident 56 and Resident 66 were coded incorrectly for the MDS's indicated. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based on the Centers for Disease Control (CDC) guidance, review of facility policy, and clinical record review, it was determined that the facility failed to follow the COVID-19 testing guidelines for symptomatic residents for one of 21 residents reviewed (Resident 58). Findings include: Review of the CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated September 23, 2022, revealed: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Review of facility policy, COVID Testing Guidance, last updated September 26, 2022, revealed: Residents, regardless of vaccination status, with signs or symptoms must be tested ASAP. If negative, test again 48 hours later, and, if negative, 48 hours after the second test. Review of Resident 58's physician's orders revealed a PRN (as needed) order dated May 31, 2022, for May test for Covid-19 per protocol. Review of Resident 58's progress notes revealed a nursing progress note dated October 19, 2022, which stated: Resident [complained of] cough that kept her up all night. Did note occasional cough, non productive. Temp 98.2 temporal [(forehead temperature)]. Lungs clear bilaterally. Order obtained for Tussin cough syrup, given as ordered at [10:00 a.m.] - effective. Daughter also updated via phone call. Will continue to monitor. Review of Resident 58's laboratory tests and October 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to reveal evidence that a COVID-19 test was administered to Resident 58 following the resident's complaints of a cough. Review of Resident 58's progress notes revealed a monthly nurse's note dated November 1, 2022, which stated: Cough present. Resident has a non productive cough. Further review of Resident 58's progress notes revealed a physician's progress note dated November 4, 2022, which stated that the resident says that she has been having a cough for two months. She says she got some cough medicine the other day, but that did not help. The physician ordered a chest x-ray. Review of Resident 58's chest x-ray results from November 7, 2022 revealed complete opacification (cloudiness) and atelectasis (lung collapse) of the right lung. Further review of Resident 58's progress notes revealed a nursing progress note dated November 8, 2022 at 9:42 a.m., which stated: Reside had [chest x-ray] due to chronic cough with results faxed to facility. Called & scanned results to [physician] who requested resident be sent out for further evaluation. A follow up nursing progress note at 2:51 p.m. stated that the resident was admitted with COVID [infection] & large right pleural effusion [(fluid in the lung.)] Review of Resident 58's laboratory tests and November 2022 MAR and TAR failed to reveal evidence that a COVID-19 test was administered to Resident 58 following the resident's continued complaints of a cough. Interview with the Director of Nursing on December 22, 2022, at 10:09 a.m. confirmed there was no documented evidence in Resident 58's clinical record that the resident was tested for COVID-19 even though the resident was symptomatic of COVID-19. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 211.12 (c) Nursing services.

Based on clinical record review and staff interviews it was determined that the facility did not ensure a resident's safety with supervision for one resident out of 32 reviewed (Resident 82) which resulted in harm (facial fractures) requiring a transfer to emergency room and two sutures (row of stitches holding together the edges of a wound). Findings include: Review of Resident 81's clinical record revealed an admitted [DATE] with the following diagnoses: general Anxiety Disorder, Alzheimer's disease, Dementia, encounter for other orthopedic aftercare and history of falls. Further review of the clinical record revealed a Quarterly Minimum Data Set (MDS- assessment of resident care needs) dated September 5, 2022, stating her cognition is 5 out of 15 (severly impaired). Review of the clinical record revealed a progress note dated October 19, 2022, indicating Resident 81 was found sitting on [resident] floor in front of [resident] walker in [resident] room facing the bed. Review of facility documentation dated October 19, 2022 indicates the patient with poor safety awareness due to dementia. Safety educating provded to utilize walker and call bell as need, but poor carryover to degree of cognition. Review of care plan provided no further interventions but stated that the resident is impulsive. Further review revealed, a nursing note dated October 24, 2022, Resident 81, fell trying to get into bed, hitting her head on ground causing large hematoma (bruising) with open laceration (cut). Moderate amount of bleeding, hematoma and laceration noted to right eyebrow. Bleeding controlled. Resident complained of head pain. Resident was picked up from floor by two staff members and placed in the bed in comfortable position. Resident was transferred to the ER dept (department) to be evaluated. On October 26, 2022, the resident was readmitted to the facility with the diagnosis of right maxillary sinus fracture (mid-face) and R inferior orbital wall fracture (eye socket) and two sutures placed above the left eye. A physician note dated November 2, 2022, revealed (Resident 81) with two recent falls, one resulting in facial fractures. Resident 81 continues with bruising to right side of face following fractures. Discussed recent falls with family, feel it is related to room set up. Interview with the Director of Nursing on December 21, 2022, confirmed that Resident 81, has dementia and short term memory is impaired and may be impulsive indicating education was not an appropriate intervention for the resident. 28 Pa Code 201.18(b)(1)(b)(3)(e)(1) Management 28 Pa Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa Code 211.5(f) clinical Records 28 Pa Code 211.12(c)(d)(1)(5) Nursing services

Based on review of the facility's policy, clinical records, staff and resident interviews, it was determined that the facility failed to ensure resident safety for two of seven residents (Residents 3 and 6). Findings include: Review of the facility's policy titled General Dose Preparation and Medication Administration, revised on January 1, 2022, revealed facility staff should not leave medications or chemicals unattended. Review of Resident 3's diagnosis list revealed [CONDITION(S)] (disorder that affects a person's ability to think, feel, and behave clearly), General Anxiety, and Post Traumatic Stress Disorder ([CONDITION(S)]-disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident 3's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated February 4, 2022, revealed the resident was cognitively intact. Review of Resident 3's nursing progress notes dated March 13, 2022, at 7:04 p.m., revealed medication was taken off the medication cart by the resident for attempts to distribute, and all medications were recovered and accounted for. The physician was notified, the resident was placed on every 15 minutes check, vital signs monitored, transfer the resident to the hospital for any change in condition. Interview attempted with Resident 3 on April 6, 2022, at 1:00 p.m., although resident was dismissive and refused to speak with the surveyor. Review of facility documentation dated March 13, 2022, revealed Resident 6 informed licensed nurse Employee 3 that Resident 3 was attempting to sell pills. The same documents revealed that all pills were recovered, MD was made aware and there were no adverse reactions to residents. Interview with Employee E3 conducted on April 6, 2022, at 2:00 p.m. revealed that on March 12, 2022, just before lunch, she/he was about to take her [MEDICATION(S)] (medication to treat high blood pressure) while attending a medication cart. Employee E3 stated that due attending to an emergency down the hallway, he/she left medication container on top of the cart. Employee E3 indicated, when she/he came back to the cart, the medication bottle was missing. Employee E3 asked nursing supervisor if there is anyone observed in the hallway, to which the nursing supervisor responded; only Resident 3 was in the hallway at the time. Employee E3 reported that she/he asked Resident 3 regarding the medication, but the resident denied seeing it. The nurse reported that she/he searched for it, thinking that it might have been placed somewhere else but was unable to find it. Further interview with Employee E3 revealed; the morning of March 13, 2022, the nursing supervisor handed him/her pills in a plastic baggie, characterized as small, white, circular tablets same appearance as [MEDICATION(S)]. The nursing supervisor informed Employee E3, the medication was given by Resident 6. Employee E3 narrated that during the morning shift, Nursing Assistant Employee E4, Dietary Aide Employee E5, and Nursing Assistant Employee E6 handed her/him a bag of pills and indicated they came from Resident 3. Employee E3 reported that a total of 52 pills of the same color, size, and shape were recovered and accounted for equaling the number of pills on the nurse's medication bottle before the medication went missing. Further interview of Employee E3 revealed she/he interviewed resident but Resident 3 denied knowledge of the incident. Employee E3 reported, Resident 3's attending physician was informed of the incident. The physician instructed to staff to monitor the resident every 15 minutes. Employees interviewed other residents to ensure no other medications were passed around. Education was provided to Employee E3 and other nursing staff. Interview conducted with Resident 6 on April 6, 2022, at 3:00 p.m, revealed an interaction on March 13, 2022 whereby Resident 3 attempted to sell Resident 6 white pills claiming it was a medication named [MEDICATION(S)] (medication to treat erectile dysfunction). According to the resident, he/she overheard Employee E3 was looking for her/his medication, so he/she handed the medication to a nurse after receiving it from Resident 3. Resident E6 denied any additional, similar interaction with Resident 3. Interview with the Nursing Home Administrator and Director of Nursing was conducted on April 6, 2022, at 6:00 p.m. The above information was discussed and confirmed that Employee E3 failed to ensure residents' safety by leaving medications unsupervised. 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 11/11/21 28 Pa. Code: 211.12(c)Nursing services Previously cited 11/11/21 28 Pa. Code: 211.12(d)(1) Nursing services Previously cited 11/11/21, 1/10/22

Based on observation, clinical records review, staff and resident interviews, it was determined that the facility failed to ensure accurate documentation related to medication administration for two of three residents reviewed (Resident R1 and R2). Findings include: Review of Resident R1's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated October 28, 2021, revealed the resident was cognitively intact. Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Resident R1 on January 10, 2022, at 11:00 a.m., revealed that he/she did not receive his [MEDICATION(S)] for the past two days, January 8, and January 9, 2022. The resident reported that he/she was informed by the nurses that the medication was a house stock but was not available in the facility. Review of Resident R1's January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview conducted on January 10, 2022 at 11:15 a.m. with a licensed nurse, Employee E3 confirmed the [MEDICATION(S)] ordered for Resident R1 was a house stock. Employee E3 confirmed that there was no available [MEDICATION(S)] in the facility. Employee E3 was unsure of when the [MEDICATION(S)] house supplies depleted. Review of Resident R2's MDS, dated [DATE], revealed that the resident was cognitively intact. Review of the resident physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Resident R2 on January 10, 2022, at 11:45 a.m., revealed that Resident R2 did not receive his/her [MEDICATION(S)] on January 8, and 9, 2022. Resident R2 reported that he/she was informed by the nurse that the [MEDICATION(S)] was not available. Resident R2 stated, There's nothing I can do if the medication was not available, I still did not get it today. Observation failed to reveal a [MEDICATION(S)] on the resident's neck. Review of Resident R2's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Employee E3 confirmed that there was no available [MEDICATION(S)] for Resident R2. Employee E3 stated, I already told both of them (Resident R1 and R2) that their [MEDICATION(S)] was not available. When asked regarding the signed [MEDICATION(S)] for January 10, 2022, Employee E3 stated, I automatically click all his medications in the computer (as administered). The above information was conveyed with the Nursing Home Administrator on January 10, 2022, at 2:00 p.m. 28 Pa. Code 211.5 (f) Clinical records Previously cited 11/11/21 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 11/11/21

Based on staff interviews and clinical record review, it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident R1's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident R1's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. For BG <60 or >400 contact MD. Subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. Review of Resident R1's clinical record including nursing progress notes revealed on August 3, 2021 at 6:28 a.m. revealed the resident had a blood sugar of 38, was unresponsive requiring emergent use of [MEDICATION(S)] (emergency medicine used to treat severe [CONDITION(S)] or low blood sugar). Continued review of Resident R1's clinical record revealed that on August 12, and August 27, 2021 Resident R1's blood sugar was documented as 54. Further review of Resident R1's clinical record revealed that on September 2, 2021, the blood sugar levle was documented as 50. Additional review of Resident R1's clinical record failed to reveal documentation of the attending physician being notified of the low blood sugar results. Review of Resident R1's clinical record, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] July 20, 2021 at 4:30 p.m. July 21, 2021 at 11:30 a.m., 4:30 p.m. and 9:00 p.m. July 28, 2021 at 4:30 p.m. August 11, 2021 at 4:30 p.m. August 20, 2021 at 6:00 a.m. August 22, 2021 at 9:00 p.m. August 30, 2021 at 6:00 a.m. September 5, 2021 at 6:00 a.m. September 7, 2021 at 9:00 p.m. September 14, 2021 at 4:30 p.m. September 19, 2021 at 9:00 p.m. September 21, 2021 at 6:00 a.m. September 22, 2021 at 6:00 a.m. Review of Resident R1's clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units For BG less than 60 or greater than 400, contact MD., intramuscularly after meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE Review of Resident R1's clinical record, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] October 12, 2021at 5:00 p.m. October 28, 2021 at 8:00 p.m. October 29, 2021 at 8:00 p.m. Interview with Nursing Home Administrator and Director of Nursing on August 11, 2021 at 12:50 p.m. confirmed that Resident R1's blood glucose was not monitored on those dates as ordered by the physician. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to monitor the resident's skin and failed to provide wound treatment to an identified unstageable necrotic right heel ulcer for one of six residents reviewed. This failure resulted in discovering a wound on an advanced stage (unstageable, necrotic) for one of six residents (Resident 36). Findings include: Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 36's admission Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated December 31, 2020, revealed that the resident required extensive two-person assistance with bed mobility. Review of the same MDS, under Section M (Skin Conditions) revealed that Resident 36 was at risk for developing a pressure ulcer. Additional review revealed that the resident does not have a pressure ulcer but had a venous/arterial ulcer. Review of Resident 36's admission notes dated December 24, 2020, revealed that the resident was admitted with a wound on the lateral leg identified as a vascular wound. Review of Resident 36's Braden Risk Assessment (tool used to determine risk factors for pressure sore development) dated January 14, 2021, revealed that the resident had a score of 17 which indicated a low risk for pressure ulcer development. An interview with the Director of Nursing (DON) on November 11, 2021, at 11:45 a.m., revealed skin checks completed bi-weekly on Fridays. Review of Resident 36's clinical records failed to reveal that skin check assessments completed for the first and third week of January 2021. The DON provided a copy of a bi-weekly skin check completed on January 31, 2021, that indicated that the resident had right lower leg skin issues with wound treatment in progress. The DON confirmed the only skin assessment completed for the month of January 2021 was on January 31, 2021. Review of the wound physician's consult dated January 12, 2021, revealed a thorough wound care assessment and evaluation was performed, the resident had a venous wound of the right lateral leg that measures 24.0 x 8.0 x 0.2 cm (centimeters). Review of the wound physician consults dated January 19, 2021, revealed that the resident had a venous wound of the right lateral leg that measures 23.5 x 5.5 x 0.2 cm. The same consult revealed an unstageable wound (due to necrosis) of the right heel. The wound on the right heel was identified as pressure with a measurement of 4.5 x 4.5 cm, surfaced area was 20.25 cm, no exudate, with 100% thick adherent black necrotic tissue. A wound treatment to apply skin prep daily was made by the wound physician. Review of Resident 36's January 2021, Treatment Administration Record (TAR) revealed that there was no wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical records failed to reveal that the wound treatment ordered by the wound physician on January 19, 2021's wound consult was not followed. Review of the wound physician consults dated January 26, 2021, revealed the right heel unstageable pressure ulcer had a measurement of 3.5 x 5.0 cm, no exudate, 100% thick adherent black necrotic tissue. The consult indicated that the wound was in an [CONDITION(S)] stage and was unable to progress to a healing phase because of the presence of a biofilm (composition of mixed strains of bacteria, fungi, [MEDICATION(S)], algae, microbes, and other cellular debris). The same consult revealed that a surgical excisional debridement procedure was performed to remove necrotic tissues and establish the margins of viable tissue. The resident agreed with the procedure. A wound treatment order to apply skin prep once daily was made by the wound physician. Review of the wound physician consult dated February 2, 2021, revealed the right heel unstageable pressure ulcer had a measurement of 4.0 x 5.0 cm, no exudate, and 100% thick adherent black necrotic tissue. The wound was on an [CONDITION(S)] stage and is unable to progress to the healing phase because of the presence of a biofilm. The wound progress was identified as deteriorated. A wound treatment order to apply skin prep once daily was made by the wound physician. Review of the wound physician consult dated February 16, 2021, revealed a vascular wound of the right lateral leg with a measurement of 19. 0 x 4.0 x 0.3 cm. The right heel unstageable pressure ulcer had a measurement of 4.0 x 5.0 cm, no exudate, and 100% thick adherent black necrotic tissue. A wound treatment order to apply skin prep once daily was made by the wound physician. Review of January 2021 TAR failed to reveal that the wound treatment order made by the wound physician on January 19, January 26, and February 2, 2021, the consult was followed. There was no documented treatment made for Resident 36's right heel unstageable ulcer from January 19, 2021, until February 16, 2021. Review of the wound physician consult dated February 23, 2021, revealed that the right heel unstageable pressure ulcer had a measurement of 4.8 x 5.0 x 0.2 cm, no exudate, and 100% thick adherent black necrotic tissue. The wound progress was identified as deteriorated. A wound treatment order to apply skin prep was changed from daily to three times a day. Further review of Resident 36's January 2021, TAR revealed a wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin prep treatment was applied to the left heel instead of the right heel where the unstageable pressure ulcer was located. Review of Resident 36's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical records review revealed that Resident 36's right heel unstageable pressure ulcer did not have a documented wound treatment from the time it was identified during the wound physician consult on January 19, 2021, until February 28, 2021. During that period, the right heel wound had increased in size (from 4.5 x 4.5 cm to 4.8 x 5.0 x 0.2 cm) and the wound progress was identified as deteriorated. An interview with the Director of Nursing on November 11, 2021, at 11:40 a.m., revealed that she was the wound nurse and was responsible for tracking the wounds. When questioned regarding Resident 36's right heel unstageable, necrotic pressure ulcer, identified by the wound physician on January 19, 2021's wound consult, the DON reported that the pressure ulcer was present on admission. The DON was unable to provide documented evidence during the survey that Resident 36 was admitted to the facility with an unstageable necrotic pressure ulcer to the right heel. The facility failed to perform scheduled skin checks to monitor skin condition of Resident 36, and failed to provide treatment to resident's identified right heel unstageable necrotic ulcer from the time it was identified on January 19, 2021, until February 28, 2021, resulting in wound deterioration as evidenced by increased in size. 28 Pa. Code 201.18(b)(1)(e)(1)Management Previously cited 2/13/20 28 Pa. Code 211.5(f) Clinical Records Previously cited 2/13/20, 6/25/20, 4/11/21 28 Pa. Code: 211.12(c)Nursing services Previously cited 6/25/20 28 Pa. Code: 211.12(d)(1) Nursing services Previously cited 2/13/20, 6/25/20, 4/11/21

Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate documentation related to treatment administration for one of 21 residents reviewed (Resident R8). Findings include: Review of Resident R8's clinical record revealed the resident has a history of, but not limited to, Essential Hypertention (high blood pressure that doesn't have a known secondary cause), [CONDITION(S)] (chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas) and [CONDITION(S)] (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of Resident R8's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R8's clinical record Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] July 9, 2021 at 8:00 p.m. with a BP (Blood Pressure) of 99/63 September 3, 2021 at 8:00 a.m. with a BP of 91/63 September 6, 2021 at 8:00 a.m.with a BP of 94/63 September 6, 2021 at 8:00 p.m. with a BP of 94/63 September 10, 2021 at 8:00 a.m. with a BP of 86/50 September 22, 2021 at 8:00 a.m. with a BP of 90/62 September 23, 2021 at 8:00 a.m. with a BP of 88/54 September 23, 2021 at 8:00 p.m. with a BP of 88/54 September 28, 2021 at 8:00 a.m. with a BP of 88/50 October 1, 2021 at 8:00 a.m. with a BP of 94/59 October 8, 2021 at 8:00 a.m. with a BP of 84/50 October 13, 2021 at 8:00 a.m. with a BP of 98/60 October 29, 2021 at 8:00 a.m. with a BP of 90/50 November 8, 2021 at 8:00 a.m. with a BP of 90/55 The facility's failure to maintain complete and accurate documentation on Resident R8's July, September, October, and November MAR ' s were discussed and confirmed with the Nursing Home Administrator and Director of Nursing on November 11, 2021, at approximately 11:30 a.m. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on review of facility policy, observation, resident and staff interview, it was determined that the facility failed to practice professional standards of nursing during medication administration for one of four residents observed (Resident 30). Findings include: Review of the facility's policy and procedure titled Self-Administration of Medication, with the a revision date of February 9, 2021, revealed the following procedure: Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication administration observation on November 9, 2021 at 8:55 a.m. was conducted with licensed nurse Employee E3. Employee E3 prepared Resident 30's medication (Nine pills/tablets) then proceeded to the resident's room. Employee E3 greeted the resident and informed her/him that a surveyor was present to observe, Resident 30 agreed to be observed but informed the nurse that she was not ready yet because she/he was still eating. Employee E3 politely asked the resident if she can take the medication, Resident 30 answered that she cannot take it all at once and would take it one at a time. Employee E3 informed the surveyor that she usually leaves the medication with the resident because it takes a while before she/he takes all the pills/tablets. The nurse left the room, prepared the roommate's medication then gave the medication to the roommate. The nurse asked Resident 30 if she/he was taking medication, Resident 30 answered I am taking it as fast as I could. Observation of five pills/tablets left in the medication cup, Employee E3 left the room and proceeded to administer medications to other residents in the unit. An interview with Employee E3 on November 9, 2021, at 9:10 a.m., revealed that Resident 30 was alert, oriented, and independent. The nurse also reported that the resident gets annoyed when someone watches while taking her/his medication. The nurse reported that she/he had been leaving the medication for Resident 30 to take while she prepares the roommate's medication then would check again on Resident 30 to ensure that the resident had taken all her/his medication. Employee E3 reported that Resident 30 was capable of self-medication administration but was unsure if the resident was assessed, and care planned for self administration of medications. The nurse was unsure if Resident 30 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 30's clinical records failed to reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview with the Director of Nursing on November 11, 2021, at 11:45 a.m., confirmed that Resident 30 was not assessed for self-medication administration, therefore was unable to determine if she/he was safe to self-administer medications. The facility failed to maintain a professional standard of practice by allowing Resident 30 to self-medication administer without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code: 211.12(c)Nursing services Previously cited 6/25/20 28 Pa. Code: 211.12(d)(1) Nursing services Previously cited 2/13/20, 6/25/20, 4/11/21

Based on observation, review of facility documentation, and staff interview, it was determined that the facility failed to consistently implement care plan interventions regarding suicidal ideation for one of 21 residents reviewed (Resident 58). Findings include: Review of Resident 58's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes dated August 17, 2021, revealed the resident was transferred to the hospital for suicidal ideation, verbalizing harm to themself. Review of Resident 58's clinical record revealed resident was readmitted to the facility on [DATE]. Review of Resident 58's psychiatrist consults dated September 22, 2021, revealed resident was not a danger to themself. Review of Resident 58's active care plan revealed: Resident has a history of suicidal ideation initiated on August 23, 2021, with a goal that the resident will remain free from self-inflicted injury through the next review. Additional review of the same care plan revealed interventions for plastic utensils, and to place a tab bell in place of a call light. An observation of Resident 58's lunch tray on November 11, 2021, at 12:20 p.m., revealed a plastic utensil on his/her meal tray. An observation on November 11, 2021, at 12:25 p.m., revealed resident was laying in bed sleeping. A call light was observed instead of a tap bell on the right side of the resident's bed. An interview with licensed nurse Employee E4 on November 11, 2021, at 12:30 p.m., revealed that the resident was from another unit. Employee E4 reported that the resident suicidal ideation care plan had been discontinued. Review of Resident 58's clinical records revealed that although the resident had no current suicidal ideation, there was no documented evidence that the care plan to prevent the resident from potential self-inflicted injury had been discontinued. The above information was discussed with the Director of Nursing on November 11, 2021, at 2:00 p.m. The facility failed to consistently implement interventions to prevent Resident 58 from potential self-inflicted injury. 28 Pa. Code: 211.12(c)Nursing services Previously cited 6/25/20 28 Pa. Code: 211.12(d)(1) Nursing services Previously cited 2/13/20, 6/25/20, 4/11/21

Based on clinical records review and staff interview, it was determined that the facility failed to effectively monitor and assess a pressure ulcer of one of six Residents reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], at which time a sacral wound was identified. A review of Resident R1's [DIAGNOSES REDACTED]. (a disorder of the central nervous system that affects movement, often including tremors). A review of Resident R1's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated May 20, 2020, revealed that Resident R1 was always incontinent of bowel and bladder and required extensive assistance with two people in bed mobility. Section M of the MDS (skin) revealed that the resident was at risk of pressure ulcers. A review of Resident R1's clinical records, Admission/Readmission Evaluation, revealed that the resident was readmitted to the facility on [DATE]. Nurses note at 6:18 p.m., revealed that the Registered Nurse (RN) spoke with Nurse Practitioner regarding a stage two (partial thickness wound, may involve tissue loss) pressure ulcer on bottom. The documentation failed to reveal Resident R1's Stage two bottom initial wound assessment. A review of Resident R1's Physician order [REDACTED]. 1. Cleanse Wound on bottom with Normal Saline Solution (NSS), apply [MEDICATION NAME] (A wound medication that helps the body clear bacteria and unhealthy tissue from the wound), and cover with dry dressing daily. 2. House moisture barrier cream apply to peri-area and sacrum (A shield-shaped bony structure that is located at the base of the vertebrae and connected to pelvis) every shift with incontinent care. 3. Bi-weekly (two times a week) skin checks by a licensed nurse. Review of Resident R1's June 2020, Treatment Administration Record (TAR) revealed that the Resident's [MEDICATION NAME] and house barrier cream treatment was administered as ordered. A handwritten note FYI- see PCC (Point Click Care - Electronic Record System of the facility) was written for the order to do a Bi-weekly skin assessment by a licensed nurse. A review of Resident R1's PCC records, Bi-weekly skin assessment revealed that the assessment was completed on the following dates: May 18, May 21, and May 24, May 27, May 28, June 9, June 12, June 15. No documented evidence that the bi-weekly skin assessment on the week of May 31 to June 6 was completed. Review of Resident R1's Bi-weekly assessment dated [DATE], revealed that the Resident had a skin issue on the sacrum and the right thigh. A review of the same documentation revealed no additional information regarding the right thigh. An interview on June 25, 2020, with the Nursing Home Administrator and the Regional Nurse at 2:30 p.m., revealed that the nurse had reported that the right thigh area, during an assessment on May 28, 2020, was blanchable (skin blanches with pressure), does not require any treatment, therefore, does not need to be documented. A review of Resident R1's daily nurses note dated June 2, 2020, at 10:14 a.m., revealed that Resident R1's current skin status was intact. Further review of the same notes revealed under observation: Treatment to sacrum as per physician's orders [REDACTED]. A review of the Dietary progress notes dated June 2, 2020, at 2:58 p.m., revealed that Resident R1 had consulted with the physician, the Resident was reported with unstageable, (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by a dead tissue) sacral pressure ulcer. A review of the Resident R1's June 2020, TAR revealed a changed treatment order to the sacrum from a [MEDICATION NAME] to a Santyl (A wound medication that works by helping to break up and remove dead skin and tissue) on June 2, 2020. A review of resident R1's clinical records, Head to Toe Evaluation, dated June 8, 2020, at 9:13 p.m., revealed that the Resident had a right hip excoriation. A treatment order from the physician for Mupirocin (A topical cream used to treat secondarily infected traumatic [MEDICAL CONDITION] due to specific bacteria) was made on June 8, 2020. A review of Resident R1's clinical records revealed a Daily Nurses Note documented by the nurses that indicated the Resident's current skin condition. Nurses note dated May 28, 2020, at 12:33 a.m., revealed the following notes Resident current skin condition: Skin impairment observed (see complete wound assessment), Physician/ physician designee and the responsible party was notified of the skin condition. The exact same notes were documented on the daily nurses note on the following dates: May 30, 2020, at 9:43 a.m., May 30, 2020, at 3:45 a.m., June 3, 2020, at 12:08 p.m., June 3, 2020, at 4:04 p.m., and June 8, 2020, at 9:53 a.m. Review of the clinical records from the facility's ERS and documents provided by the NHA revealed no documented evidence of a complete wound assessment for Resident R1's from March 27, 2020, until June 14, 2020. Further review of the Daily Nurses Note dated May 29, 2020, at 2:45 p.m., June 4, 2020, at 12:08 p.m., June 5, 2020, at 1:21 a.m., June 6, 2020, at 12:28 a.m., and June 7, 2020, at 12:28 a.m., revealed that Resident R1's current skin condition was noted to be intact despite the identified sacral wound upon admission on May 27, 2020, and sacral wound worsening (unstageable) on June 2, 2020. Review of the Biweekly Skin assessment dated [DATE], revealed documenation that Resident R1 does not have any current skin issues despite the identified unstageable ulcer on the sacrum on June 2, 2020, and identified excoriation of the right hip on June 8, 2020. Review of Resident R1's Wound Evaluation and Management Summary from a wound doctor on June 11, 2020, revealed the following: 1. Stage four (A full-thickness skin loss with exposed bone, tendon or muscle) pressure wound to the sacrum, wound size: 3.0x3.3x0.2 cm, with light serous (pale yellow to transparent in color) drainage, and 100% thick adherent necrotic (dead cell) tissue. 2. Unstageable (due to necrosis) of the right hip, wound size: 4.0x1.7x0.1 cm, light serous drainage, 100% thick adherent necrotic tissue. Further review of the same documents revealed that the wound doctor performed a surgical excisional debridement procedure (a medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) to Resident R1's sacral and right hip wounds. Right hip wound treatment was changed from Mupirocin to Santyl, Sacral ulcer treatment was maintained on Santyl ointment A review of Resident R1 ' s clinical records revealed a Pressure Skin Assessment documented on June 15, 2020. The assessment revealed as follows: Sacrum Stage four, 3x3.3x0.2 cm in size, small drainage, faint odor, appearance is necrotic. Unstageable Necrosis right hip, 4x1.7x0.1 in size, serous scant drainage, wound bed is necrotic, moderate odor, the wound is deteriorating. An interview with the NHA and the Regional Nurse on June 25, 2020, confirmed that Resident R1's sacral and right hip wound assessments and monitoring were not consistently, accurately, and comprehensively completed. The facility failed to effectively assess and monitor Resident R1's sacral and right hip wound. 28 Pa. Code 211.5(f) Clinical Records Previously cited 2/13/20 28 Pa. Code 211.12(c)Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 2/13/20

Based on review of the Resident Assessment Instrument User's Manual, clinical records and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for 15 of 18 residents reviewed (Residents 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, 19, 20, 22, and 51). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2017, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date. Review of Resident 3's clinical record revealed that the last assessment was completed on August 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 4's clinical record revealed that the last assessment was completed on August 30, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 6's clinical record revealed that the last assessment was completed on September 6, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 7's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 8's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 10's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 11's clinical record revealed that the last assessment was completed on September 20, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 12's clinical record revealed that the last assessment was completed on September 20, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 15's clinical record revealed that the last assessment was completed on October 4, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 16's clinical record revealed that the last assessment was completed on October 4, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 17's clinical record revealed that the last assessment was completed on September 27, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 19's clinical record revealed that the last assessment was completed on September 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 20's clinical record revealed that the last assessment was completed on August 30, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 22's clinical record revealed that the last assessment was completed on October 11, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Review of Resident 51's clinical record revealed that the last assessment was completed on August 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment. Interview with Employee E5 on February 12, 2020, at 10:13 a.m., confirmed that quarterly MDS assessments should have been completed for Residents 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, 19, 20, 22, and 51. 28 Pa Code 211.5(f) Clinical records Previously cited 3/25/19 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 3/25/19

Based on review of facility policy, review of information submitted by the facility to the state agency, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 18 residents reviewed (Resident 31). Findings include: Review of facility policy tiltled Pennsylvania Resident Abuse, last revised July 2019, defined injuries of unknown origin as an injury where the source of the injury was not observed by any person, or the source of the injury could not by explained by the resident and the injury is suspicious because of the extent of the injury. Further review of the policy revealed that the investigation must be completed in five working days from the alleged occurrence and that the investigation should include interviewing witnesses. The policy stated Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident .and employees who worked closely with the accused employee(s) and/or the alleged victim the day of the incident. Further review of the policy revealed If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. For injuries of unknown source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and the prior shifts as well. The policy went on to say that written statements should be obtained from each witness. Review of Resident 31's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 31's last available quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated October 22, 2019, revealed the resident had moderate cognitive impairment and was totally dependent on two staff persons for transfers. Review of Resident 31's progress notes revealed a nurse's note dated January 24, 2020, at 6:21 p.m. which stated notified this nurse that resident c/o (complained of) R (right) leg pain when attempting to reposition to left side. Upon assessment, slight facial grimacing when turned. (+)ROM (positive range of motion) without c/o pain, no redness, warmth or [MEDICAL CONDITION] noted. Medicated with PRN (as needed) Tylenol, results pending. Further review of Resident 31's progress notes revealed a nurse's note dated January 25, 2020 at 8:38 a.m. which stated resident cont (continues) to c/o severe right hip pain, when care being provided she is crying out in pain, prn Tylenol having minimal effects. call placed to (physician) informing him of situation N.O. (new order) xray 2 view of right hip. doctor request to be called with the results ASAP (as soon as possible) staff to monitor. Further review of Resident 31's progress notes revealed the resident's x-ray showed a right femoral neck fracture (right [MEDICAL CONDITION]), and the resident was transferred to the hospital for further evaluation. Review of information submitted to the state agency revealed that Resident 31 had no recent falls. Review of witness statement from nursing assistant Employee E6 revealed On Friday, January 24, 2020, I gave care to (Resident 31) and there were no complaints of pain. She was transferred by hoyer with assist of another (unidentified nursing assistant) and there were no complaints of pain during or after transfer. Review of all other witness statements obtained failed to reveal any employees stating that they helped Employee E6 transfer Resident 31 in the hoyer lift. The Director of Nursing was asked if the facility determined who the unidentified nursing assistant was. The Director of Nursing first stated that the second employee was another nursing assistant. The Director of Nursing then stated that the unidentified nursing assistant was actually a licensed nurse (Employee E7). Review of the information provided by the facility to the state agency failed to reveal a witness statement from Employee E7. The Director of Nursing provided a witness statement from Employee E7 that was obtained February 12, 2020, 13 working days from when Resident 31 first began complaining of right hip pain. The facility's failure to timely and thoroughly investigate Resident 31's injury of unknown origin was discussed with the Nursing Home Administrator on February 12, 2020 at 1:55 p.m. 28 Pa. Code 201.18(b)(1)(e)(1)ManagementPreviously cited 3/25/19 28 Pa. Code 201.29(a)(d) Resident Rights 28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 3/25/19 28 Pa. Code: 211.12(d)(1) Nursing servicesPreviously cited 3/25/19

Based upon review of clinical records, it was determined that the facility failed to ensure the physician was notified of the late administration of an antibiotic medication for one of two residents reviewed (Resident #77). Findings include: Review of Resident #77's [DIAGNOSES REDACTED]. Review of Resident #77's February, 2020, physician orders [REDACTED].>Review of Resident #77's nursing progress notes dated February 11, 2020, revealed Resident currently receiving IV (intravenous) [MEDICATION NAME] (antibiotic medication) via RUE (right upper extremity) D/L PICC (peripherally inserted central catheter) line; This nurse went to resident's room at 2:20 am to hang 2 am scheduled dose of IV [MEDICATION NAME] and administer resident's 2 am PO (by mouth) [MEDICATION NAME], and perform dressing change to resident's foot; resident was asleep, this nurse woke resident and informed her of time and scheduled meds and treatments that I attempted to administer; Resident watched this nurse prime IV tubing and just as I was about to connect her to her IV ABT (antibiotic), resident stated, 'can I give you money so that you can get me drinks out of the employee break room vending machine' , I explained to resident that staff is not permitted to receive any monies from residents and that she must arrange all money transfers involving purchases through facility social worker, resident then asked who was her assigned CNA and said, I'll just ask her to get her drinks from vending area; this nurse asked resident if she could administered IV resident then stated, 'You don't know what you are doing any damn way oh wait a minute, I have to pee; This nurse left room and returned 5 minutes later, resident was still in bathroom. This nurse made 3 more attempts to perform dressing change to wound and administer IV abt (antibiotic) and resident was still in (resident's) bathroom. Resident remained in bathroom for over 1 hour. While resident was in bathroom I informed (resident) that I needed to perform her dressing change to her foot and she said, you're and idiot, you could have been done it while I was asleep. At 4:30 am this nurse went to resident's room to remove IV antibiotic that was primed in pump and resident connected IV med on her own without this nurse present and approx. 60cc had infused, this nurse visualized IV ABT to ensure that it was safely connected. Review of Resident #77's clinical record failed to reveal evidence that the physician was notified that Resident #77 did not receive the antibiotic at the scheduled time of 2:00 a.m. Interview with the Director of Nursing on February 13, 2020, at approximately 8:30 a.m., confirmed that the physician was not notified of the late antibiotic administration. 28 Pa. Code 211.5(f) Clinical Records Previously cited 3/25/19 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/25/19

Based on a review of clinical records and staff interviews, it was determined that the facility failed to accurately assess a resident with a [DIAGNOSES REDACTED].(Resident F14). Findings include: Review of Resident F14's physician orders [REDACTED]. Further review of April 2011 physician orders [REDACTED]. Review of the Residents current plan of care for potential for [DIAGNOSES REDACTED] indicated that staff would assess the resident for signs and symptoms of [MEDICAL CONDITION] including changes in mental status, and administer the residents diet as ordered. Meal Consumption records for Resident F14's on April 12, 2011 indicated that the resident was noted to only eat 25 % of his breakfast, lunch, and dinner meal on this day. April 2011 Medication Administration Records indicated that the resident receive his daily dose of 14 units of his [MEDICATION NAME] N 100, and that there was no documented evidence that the nurse reviewed the resident's meal intake that day, and questioned whether the resident who had a [DIAGNOSES REDACTED]. Furthermore there was no evidence that the physician was notified to determine if the resident's low meal intake warranted the administration of the same nightly dose of insulin. Review of nurses notes dated April 12, 2011 at 10:45 p.m. revealed the resident was found lying on his back in bed. The notes on that date further documented that the resident became agitated, combative, was resistant to care, and was trying to get out of bed. The resident was also documented to be pulling at his hair and flailing his body all over the room. Further documentation indicated that the resident was calm enough for staff to place him in bed for a short period, but was still flailing body in bed before calming. According to nursing documentation within 10 minutes, the resident was back on floor flailing around the room and becoming more agitated when he was touched. Smeared blood was noted on the floor of the resident's room, and the resident was noted to have hit his head, feet, and legs on different furniture in the room. Further review of nursing documentation produced no evidence that during any time, including the short period that the resident was calm, were the resident's vital signs assessed or was the resident's blood sugar checked. Nursing documentation indicated that 911 was called and upon arrival the paramedic did an accucheck which was 19 (blood sugar levels below 70 are considered to be hypoglycemic). Nursing notes documented that the resident was transferred and admitted to the hospital with [REDACTED]. A review of hospital documentation dated April 12, 2011 indicated that the paramedics reported that the resident was found at the nursing facility unresponsive and that upon arrival, an accucheck indicated that the resident had a blood sugar of 19. The paramedics further indicated that they administered a shot of [MEDICATION NAME] ( sugar based injectable medication that is administered intramuscularly to quickly raise the blood sugar levels of someone who is found to be hypoglycemic), and that the resident became more alert and responsive during the transport to the hospital. Telephone interview with the administrator and director of nursing on April 15, 2011 in the afternoon related that the nurse should have assessed the resident for [DIAGNOSES REDACTED] but was thinking the resident had a behavior issue. The facility failed to assess a diabetic resident with a [DIAGNOSES REDACTED]. F 309 483.25 QUALITY OF CARE Previously cited 6/15/2010, 8/17/2010, 12/13/10, 02/24/11. 28 Pa. Code 211.5(f) Clinical Records Previously cited 6/15/2010, 5/20/2010, 4/1/2010, 1/8/2010 28 Pa. Code 211.10(d) Resident care policies Previously cited 1/8/2010 28 Pa. Code 211.11(d) Resident care plan Previously cited 6/15/2010 and 1/8/2010 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 6/15/2010, 5/20/2010, 4/1/2010 and 1/8/2010