Every finding on record at Carbondale Rehabilitation and Healthcare Center

Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one out of 25 residents reviewed (Resident 28). Findings include: A review of the facility policy titled Medication Administration, last reviewed by the facility on January 7, 2026, revealed that medications are to be administered by licensed nurses or other staff authorized to do so by the state, as ordered by the physician, and in accordance with professional standards of practice to prevent contamination, infection, and medication errors. The policy further requires that the licensed nurse administering a medication immediately document the resident's name, date and time of administration, dose, route of administration (how the medication enters the body, such as by mouth), and the signature of the nurse on the medication administration record. The policy requires the individual to sign the Medication Administration Record (MAR, the clinical record used to document each dose of medication administered, including date, time, medication, dose, and the administering staff member) after the medication is administered, and if the medication is a controlled substance (medications regulated under federal law due to their potential for misuse, dependence, or diversion, which require strict storage, tracking, and documentation requirements), sign the narcotic book. A review of the facility policy Controlled Substances last reviewed by the facility on January 7, 2026, revealed that controlled substance drug record serves as a dual purpose of recording both narcotic disposition (the handling and tracking of the medication from receipt through use, waste, return, or destruction) and administration of narcotic medications. The policy indicated the system for reconciling the receipt, dispensing, and disposition of controlled substances included documentation of personnel access and use, medication administration records, declining inventory records, and documentation of destruction, waste, or return to the pharmacy A review of the clinical record revealed Resident 28 was admitted to the facility on [DATE], with dementia (a general term for a decline in mental ability, such as memory loss, impaired reasoning, and behavioral changes that are severe enough to interfere with daily life) and anxiety (a common, treatable mental health condition characterized by excessive, uncontrollable worry, nervousness, or fear that interferes with daily life functioning).A physician's order dated September 9, 2025, directed Alprazolam 0.25 milligrams (mg), give one-half tablet every six hours as needed for anxiety. Alprazolam is a Schedule IV controlled substance (a medication regulated under federal law due to its potential for misuse, dependence, or diversion, meaning use by someone other than the intended resident). Review of facility records revealed the facility utilized a Controlled Drug Receipt/Record/Disposition Form (a narcotic log used to track the receipt, use, wasting, return, or destruction of controlled medications) and the MAR. A comparison of Resident 28's Controlled Drug Receipt/Record/Disposition Form with the MAR for September 2025, October 2025, November 2025, December 2025, January 2026, February 2026, and March 2026, revealed repeated discrepancies between medications signed out on the controlled substance record and medications documented as administered on the MAR. Specifically, staff signed out Alprazolam 0.25mg from the narcotic log without documenting administration on the MAR, or documented administration on the MAR without a corresponding entry on the narcotic log. The discrepancies included Alprazolam doses, signed out on the narcotic log but not documented as administered on the MAR on the following dates and times: December 3, 2025, at 11:45PMDecember 9, 2025, at 12:40 AMDecember 22, 2025, at 11:45 AMDecember 24, 2025, at 5:46 AMDecember 30, 2025, at 1:25 AMMarch 5, 2026, at 1:00 AM These inconsistencies demonstrated the facility failed to ensure accurate documentation and reconciliation of controlled substances. During an interview on March 19, 2026, at 12:00 PM, the Director of Nursing reviewed the above findings regarding the facility's failure to ensure accurate reconciliation of Resident 28's controlled substances. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interviews, the facility failed to ensure a resident was free from chemical restraint by failing to ensure a physician-ordered as-needed (PRN, meaning medication administered only when symptoms occur rather than on a routine schedule) psychotropic antianxiety medication was time-limited to 14 days or supported by documented physician rationale for continued use, including periodic reassessment of ongoing need, for one of 25 residents reviewed (Resident 28).Findings include: A review of the facility policy entitled Use of Psychotropic medications dated as reviewed January 7, 2026, included but was not limited to Psychotropic medications used on a PRN (as needed) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: PRN medication orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. According to Federal guidelines psychotropic medications are drugs that affect brain activity related to mood, behavior, or mental processes. Benzodiazepines such as lorazepam (Ativan) and alprazolam are antianxiety medications that slow activity in the brain and may cause sedation (sleepiness), confusion, impaired coordination, increased fall risk, and physical dependence in older adults. Federal regulation requires psychotropic medications to be used only when necessary to treat a resident's medical symptoms and only after non-pharmacological interventions (approaches that do not involve medication, such as environmental modification, reassurance, or behavioral techniques) have been attempted or determined clinically contraindicated. Continued use must include periodic reassessment and consideration of gradual dose reduction (stepwise reduction of medication dosage to determine if symptoms can be managed with less medication). A review of Resident 28's clinical record revealed the resident was admitted [DATE], with diagnoses including dementia and anxiety (a condition characterized by persistent worry or fear interfering with daily functioning). A review of physician orders revealed an order dated September 9, 2025, for alprazolam 0.25 milligrams (anti-anxiety medication used to produce calming effects), administer one-half tablet every six hours as needed for anxiety. The order did not include a stop date, documented duration of use, behavioral parameters supporting use, or documented physician rationale supporting continued PRN use beyond 14 days. A review of the Medication Administration Records revealed the PRN psychotropic medication remained active and available for administration from September 9, 2025, through the survey date of March 19, 2026, a period exceeding six months without documented physician rationale supporting continuation beyond 14 days. Review of the September 2025 Medication Administration Record revealed alprazolam was administered on the evening shift on September 1, 6, 9, 10, 11, 12, 15, 16, 17, 22, 23, 24, and 30, 2025 (13 administrations), and on the night shift on September 2, 4, 7, 14, and 22, 2025 (5 administrations), for a total of 18 administrations. Review of the October 2025 Medication Administration Record revealed alprazolam was administered on the evening shift on October 1, 2, 14, 15, 16, 20, 23, and 31, 2025, for a total of 8 administrations. Review of the November 2025 Medication Administration Record revealed alprazolam was not administered during the month, however, the PRN order remained active without documented physician evaluation of continued need. Review of the December 2025 Medication Administration Record revealed alprazolam was administered on the evening shift on December 6, 10, 11, 12, 15, 16, 17, 18, 19, 21, 22, 24, 29, and 30, 2025 (14 administrations), and on the night shift on December 3, 9, and 23, 2025 (3 administrations), for a total of 17 administrations. Review of the January 2026 Medication Administration Record revealed alprazolam was administered on January 26, 2026, on the evening shift and January 30, 2026, on the night shift, for a total of 2 administrations. Review of the February 2026 Medication Administration Record revealed alprazolam was administered on the evening shift on February 9, 10, 16, 22, and 25, 2026 (5 administrations), and on the night shift on February 5, 10, and 11, 2026 (3 administrations), for a total of 8 administrations. A review of physician progress notes and practitioner visit documentation from September 2025 through March 20, 2026, did not include documentation the physician reassessed the continued need for the PRN psychotropic medication after the initial 14-day period, documented clinical rationale supporting continuation, specified duration of use, or evaluated whether symptoms could be managed with reduced medication dosage. During an interview on March 20, 2026, at 11:15 AM, the above information was reviewed with the Director of Nursing. The facility could not provide documentation demonstrating the physician evaluated the continued need for the PRN psychotropic medication beyond 14 days or documented clinical justification supporting extended duration of use. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.10 (c)(d) Resident care polices. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in three of four medication storage locations observed (200 Hall Cart, Medication Storage Fridge, and 100 Hall cart).Findings include: A review of the facility policy titled Insulin Pen, last reviewed by the facility on January 7, 2026, revealed that insulin pens contain multiple doses of insulin (a medication used to lower blood sugar levels) but are intended for use by a single resident only. The policy indicated insulin pens must be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, dosage amount, frequency of administration, and expiration date. The policy further indicated that once a multi-dose insulin pen is opened, it must be discarded after 28 days or according to the manufacturer's recommendation. The policy specified that if a required label is missing, the pen is not to be used, and a replacement must be obtained from the pharmacy. An observation of the medication cart located on Unit 1 Hall Cart on March 19, 2026, at 8:22 AM, in the presence of Employee 1, Licensed Practical Nurse, (LPN), revealed two (2) multi-dose insulin pens of Insulin Glargine (a long-acting insulin medication used to control blood sugar levels over an extended period) that had been opened and were available for resident use; however, the pens were not labeled with the date opened or expiration date, despite the manufacturer label containing a designated area to document this information. Observation on March 19, 2026, at 8:30AM in the presence of Employee 2, LPN revealed one (1) multi-dose insulin pen of Insulin Lispro (a rapid-acting insulin used to lower blood sugar) that had been opened and was available for resident use, however, the pen was not labeled with the date opened or expiration date, despite the manufacturer label containing a designated area to document this information. An observation conducted on March 19, 2026, at 9:00 AM of the insulin storage area located in the medication refrigerator in the medication storage room behind the nurses' station on the Unit 100 Hall revealed one (1) additional multi-dose insulin pen of Insulin Glargine that had been opened and was available for use without documentation of an opened date or expiration date. During an interview on March 19, 2026, at 8:24 AM, Employee 1 confirmed the two (2) Insulin Glargine multi-dose pens observed on the Unit 1 medication cart had been opened, were currently in use for medication administration, and were not labeled with opened dates or expiration dates. Employee 1 confirmed that multi-dose insulin pens should be discarded 28 days after opening, however, the pens did not contain open dates, indicating staff would be unable to determine when the medication should be discarded in accordance with manufacturer recommendations and facility policy. During an interview on March 19, 2026, at 11:00 AM, the Director of Nursing (DON) reviewed the above findings and confirmed the facility failed to ensure staff adhered to facility policy requiring dating and labeling of multi-dose insulin pens to ensure medications are used within the safe and recommended time frame. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 23 residents sampled (Resident 40). Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on January 10, 2025, revealed it is the facility's policy to provide maintenance and restorative services designed to maintain or improve residents' ability to the highest practicable level. The restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Residents will receive services from restorative when they are assessed to have a need for restorative nursing services. A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the lung (an abnormal growth of cells characterized by uncontrolled and rapid growth, invasion of surrounding tissues, and the potential to spread to other areas of the body). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 5, 2025, revealed that Resident 40 is cognitively intact with a BIMS score of 15 (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). A care plan indicates Resident 40 exhibits a deficit in ambulation related to decreased mobility and fatigue initiated on February 16, 2025. Interventions implemented to assist Resident 40 in attaining his restorative nursing goal of ambulating with a rollator walker (a mobility device) for 50 ft include ensuring the resident is wearing appropriate footwear, instructing the resident on appropriate positioning with an assistive device, and following with a wheelchair during ambulation as recommended by skilled physical therapy. A Physical Therapy Discharge Summary dated March 10, 2025, revealed Resident 40 was discharged from physical therapy services with recommendations to implement a restorative nursing program for ambulation that includes walking 50 ft with a rollator walker and the assistance of one caregiver. During an interview on April 29, 2025, at 10:20 AM, Resident 40 indicated that physical therapy exercised with him regularly, but when his therapy services ended, no one was providing restorative ambulation services. He explained no one has walked with him in months. During an interview on April 30, 2025, at 1:00 PM, Resident 40 confirmed that no one provided restorative ambulation services today or since his physical therapy services ended over a month ago. A clinical record review revealed staff indicated Resident 40 received his restorative ambulation intervention (walking with the rollator walker for 50 ft with assistance) on 48 occasions from April 30, 2025, through April 30, 2025. The clinical record review revealed documentation indicating Employee 3, Nurse Aide, implemented Resident 40's ambulation program on April 30, 2025, at 12:35 PM. However, during an interview on April 30, 2025, at 1:05 PM, Employee 3, Nurse Aide, confirmed she did not implement Resident 40's restorative nursing ambulation program, despite documenting on the clinical record that he received the intervention on April 30, 2025, at 12:35 PM. During an interview on April 30, 2025, at approximately 1:30 PM, the Director of Nursing (DON) confirmed it is the facility's responsibility to provide and implement restorative nursing services for residents as planned to maintain residents' mobility to the highest practicable extent possible. The DON confirmed Employee 3, Nurse Aide, inaccurately documented that she provided Resident 40 restorative nursing interventions when none were implemented. 28 Pa. Code: 211.5(f)(viii) Medical records. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services.

Based on a review of clinical records and select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening, and the development of pressure sores for one resident out of 23 residents sampled (Resident 57). 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 the areas of risk. The American College of Physicians (ACP) 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 pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.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. Review of the facility policy entitled Pressure Injury Prevention and Management, last reviewed January 10, 2025, indicated the facility will provide interventions for prevention and to promote healing in accordance with evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to, redistributing pressure (such as repositioning, protecting, and/or offloading heels, etc.) and providing appropriate, pressure-redistributing support surfaces. Further review of the policy revealed the facility will provide interventions for prevention to promote healing in accordance with current standards of practice and will be provided for all residents who have a pressure injury present. The goals and preferences of the resident and/or authorized representative will be included in the plan of care, interventions will be documented in the care plan and communicated to all relevant staff, and compliance with interventions will be documented in the weekly summary charting. A review of the clinical record revealed that Resident 57 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet). A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 57 dated April 10, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (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 indicates severe cognitive impairment) and revealed the resident was dependent on staff for activities of daily living of putting on/taking off footwear and was at risk for pressure sore development. A review of the resident's care plan, initiated July 18, 2024, and last revised April 28, 2025, revealed a problem focus of risk for skin breakdown and actual impairment to the right heel related to fragile skin and decreased mobility. Planned interventions included use of heel-lift boots at all times (removable only during care), a pro-mat plus air mattress to bed, and a pressure redistribution cushion for the chair. Physician orders dated November 12, 2024, directed the use of heel-lift boots at all times, allowing removal only for care. A skin integrity wound assessment dated [DATE], revealed the presence of a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on the resident's right heel, measuring 0.3 cm (length) x 0.6 cm (width) x 0.2 cm (depth), with 50% slough (yellow/white necrotic tissue) and 50% granulation tissue (new connective tissue) and moderate serous drainage (clear or pale-yellow fluid similar to blood plasma). An observation of Resident 57 on April 29, 2025, at approximately 10:35 AM revealed the resident was in the activity hall wearing purple slippers and was identified by Employee 1 (Licensed Practical Nurse). An observation of her room revealed heel-lift boots lying on top of the Pro-mat mattress, not on the resident. A review of the resident's task report (a record of staff-documented care tasks) from April 29, 2025, indicated the heel-lift boots were documented as being on the resident, with no documentation of refusals noted. A second observation on April 30, 2025, at 10:50 AM revealed the resident sitting in her wheelchair in her room again without heel-lift boots and wearing purple slippers. At the time of the surveyor's observation, a nurse aide applied the heel-lift boots to the resident. An interview with Employee 1 (LPN) at that time confirmed the resident often removes the boots, stating: She kicks them off, and when she does, we just put the purple slippers on her. Further clinical review on April 30, 2025, revealed no documentation in the care plan regarding refusal of heel-lift boots, nor documentation of staff interventions to address such refusals. Additionally, the task report for April 30, 2025, indicated the heel-lift boots were on the resident at 9:05 AM, despite observations proving otherwise. During an interview with the Director of Nursing (DON) on April 30, at 1:10 PM, it was confirmed the facility did not consistently implement the planned interventions to promote healing or prevent the progression of the right heel pressure ulcer for Resident 57. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, resident financial documentation, and staff interview, it was determined the facility failed to safeguard, manage, and accurately account for the personal funds of one resident (Resident 40) out of 23 residents reviewed Findings include: A clinical record review revealed Resident 40 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the lung (an abnormal growth of cells characterized by uncontrolled and rapid growth, invasion of surrounding tissues, and the potential to spread to other areas of the body). A clinical record review revealed Resident 40's payor source is Medicaid (a joint federal and state program that helps cover medical costs for some people with limited income and resources. Individuals on Medicaid receive a Personal Needs Allowance- a monthly stipend to cover personal expenses. As of January 1, 2025, the PNA for Pennsylvania is $60 for residents residing in long-term care facilities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 5, 2025, revealed that Resident 40 is cognitively intact with a BIMS score of 15 (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). During an interview conducted on April 29, 2025, at 12:30 PM, Resident 40 stated he was upset about a charge of $6,092 that appeared on his March 2025 financial statement. He explained that the facility managed his personal funds and presented a copy of the resident fund ledger showing a care cost deduction of $6,092 on March 14, 2025. Review of Resident 40's resident fund ledger from December 1, 2024, through April 28, 2025, revealed the following charges for care costs totaling $10,025: December 2024: $324 January 2025: $0 February 2025: $0 March 2025: $7,712 April 2025: $1,989 Resident 40's income from Social Security and pension benefits totaled $10,210 during the same period: December 2024: $2,014 January 2025: $2,049 February 2025: $2,049 March 2025: $2,049 April 2025: $2,049 According to Pennsylvania Medicaid requirements, the facility was responsible for deducting only the monthly care cost balance after applying the PNA (personal needs allowance-$45.00 before January 2025 and $60.00 after January 2025). Based on the resident's monthly income, the proper care cost charges from January 1, 2025, through April 28, 2025, should have been: December 2024: $2,014 - $45 = $1,969 January 2025: $2,049 - $60 = $1,989 February 2025: $2,049 - $60 = $1,989 March 2025: $2,049 - $60 = $1,989 April 2025: $2,049 - $60 = $1,989 Resident 40 should have been charged $1,989 each month from January 2025 through April 2025 and charged $1,969 in December 2024, totaling $9,925. A review of credits Resident 40 received from Social Security and his pension ($10,210) and calculating for the personal needs allowance for Pennsylvania ($285) it was determined the facility over charged the resident by $100.00. During an interview on May 1, 2025, at approximately 9:00 AM, the Nursing Home Administrator (NHA) confirmed Resident 40 was overcharged due to billing errors. The NHA confirmed it is the facility's responsibility to safeguard, manage, and accurately account for residents' personal funds deposited with the facility. The NHA indicated Resident 40 would be reimbursed for the overcharge. 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on observation, review of select facility policy, and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and in two of two resident pantries. 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 a facility policy titled Use and Storage of Food Brought in by Family or Visitors, last reviewed on February 10, 2025, indicated food must be handled in a way to ensure the safety of the resident. The facility may refrigerate, label, and date prepared items in nourishment refrigerator and that food must be consumed by the resident within 3-days. Observation during the initial tour of the kitchen with the facility's registered dietitian on April 29, 2025, at 9:40 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: There was a heavy build-up of a black substance along the wall located under the soiled side (area where dirty dishes are slid into the dishwasher) counter space of the dishwasher. There was a build-up of debris under the ceiling light shield located in the janitor's closet. Interview with the registered dietitian at this time confirmed the kitchen was to be maintained in a clean and sanitary manner. An observation on April 29, 2025, at 11:13 AM, in the Nursing B Hall Pantry, revealed a resident food refrigerator/freezer with 5 plastic undated and unmarked containers with resident food. The refrigerator also contained the following items that were also not dated: a stick of butter wrapped in plastic, a piece of white bread in a plastic bag, a vanilla ice cream sundae with caramel, and an ice cream tub. During an interview on April 29, 2025, at 11:15 AM, Employee 2, Registered Nurse (RN), confirmed the food items identified during the observation were not dated. Employee 2, RN, explained that facility staff should date all food items when opened or received by residents or residents' families. Observation of the A Hall Nursing Unit resident pantry on April 30, 2025, at 1:30 PM revealed there was a build-up of a black substance on the end of the condensation hose (removes excess water from the ice machine) of the ice machine. Observation of the B Hall Nursing Unit resident pantry on May 1, 2025, at 9:20 AM revealed a build-up of a wet black substance on the end of the condensation hose of the ice machine. Interview with the maintenance director on May 1, 2025, at 9:25 AM confirmed that the ice machines, including the condensation hoses of the ice machines, were not cleaned and sanitized frequently enough to prevent the build-up of the black substance. 28 Pa. Code 201.18 (e) (2.1) Management

Based on review of clinical records and staff and family interview, it was determined the facility failed to consistently monitor resident weights to timely identify and act upon a resident's weight loss, and implement necessary nutritional support to promote acceptable nutritional parameters for one resident out of 6 sampled (Resident 1). Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include, lumbar radiculopathy (severe pain that radiates from the back into the hip and outer side of the leg caused by compression of a nerve), dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and a history of falling. A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident had a Brief Interview for Mental Status score of 7 (BIMS score is a structured evaluation aimed at evaluating aspects of cognition in elderly patients a score of 0 to 7 indicates severe cognitive impairment), and required assistance of staff for activities of daily living including set up assistance for meals. The resident was able to independently feed herself. A review of an admission physician order dated July 19, 2024 revealed the resident was to receive a regular diet with regular consistency and thin liquids. A review of her meal intakes dated July 19,2024 through August 8, 2024 indicated the resident consumed between 70% to 100% of her meals on most days. A review of Resident 1's weights revealed: July 19, 2024-185.8 pounds July 21, 2024-184.6 pounds August 1, 2024-184.6 pounds August 8, 2024-176.5 pounds From August 1 through August 8, 2024 Resident 1 lost 8.1 pounds which is a 4.39 % weight loss in one week. There was no evidence of reweights on or after August 8, 2024 to confirm the validity of the initial weight. A review of nursing documentation revealed there was no communication/notification at the time the weight was obtained on August 8, 2024, between nursing or the physician regarding the residents weight loss. A review of a dietary/nutrition note dated August 14, 2024 at 1:49 PM revealed, the Registered Dietitian (RD) reviewed the resident's weights. The current weight was 176.5 pounds on August 8, 2024, the previous weight from August 1, 2024 was 184.6 pounds, indicative of a significant weight loss of 8.1 pounds or 4.4% over one week. The RD indicates the resident meal consumption are between 75% and 100%. The resident is encouraged to consume all meals and offer alternatives when meal intake is poor. This RD evaluation note was written six days after the significant weight loss was identified. There was no documented evidence at the time of the survey the physcian was notified of the significant weight loss. There were no additional interventions such as reweights after the weight loss was identified. Interview with the Director of Nursing on September 24, 2024, at 12 PM confirmed the facility was unable to demonstrate timely response to the resident's weight loss. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility reports and staff interview it was determined the facility failed to investigate the origin and promote the healing of a pressure sore for one of six residents sampled (Resident 1). 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 pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.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 1 was admitted to the facility on [DATE], with diagnoses to include weakness, history of falling at home, lumbar radiculopathy (pinched nerve) and dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident had a Brief Interview for Mental Status score of 7 (BIMS is a structured evaluation aimed at evaluating aspects of cognition in elderly pateints score of 0 to 7 indicates severe cognitive impairment), and required assistance of staff for activities of daily living. Initial nursing notes as well as an admission nursing assessment dated [DATE] indicated the resident did not have skin impairment on her lower extremities. Nursing documentation dated August 4, 2024 at 7:57 PM indicated Resident 1 was noted to have a blister (painful skin condition where fluid fills a space between layers of skin caused by rubbing surfaces together) to the left medial (inner side) of her heel. The blister was noted to be flat and intact with redness. There was no complaint of pain or discomfort. The area was cleansed with soap and water and optifoam (an absorbent, adhesive, foam dressing that absorbs force and friction) was applied. A physician order to cleanse the left medial heel with soap and water, apply Optifoam dressing every other day and consult for wound therapy, was implemented. A review of a care plan initiated July 19, 2024 and updated August 16, 2024 revealed the resident was at risk for potential/actual impairment of skin integrity due to previous intact blister on the medial left heel. The planned interventions were for nursing staff to elevate the resident's heels when in she is in bed. Nursing staff were to identify and document the potential causative factors and eliminate or resolve the area when possible. Nursing staff were to complete weekly treatment documentation to include a measurement of each area of skin breakdown to include width, length, depth, type of tissue, exudate and any other notable changes or observations. Complete wound treatment as ordered. A review of a facility skin integrity report dated August 4, 2024. completed by Employee 1 (LPN). indicated Resident 1 had an intact blister on her left heel measuring 4 cm x 4 cm. The form did not include the measurement or stage (progression of a pressure area) of the area, the area on the form for this information was blacked out with no documented entry. Nursing documentation dated August 6, 2024 at 1:11 P.M. indicated Resident 1 had a change of condition regarding the blister on her left heel. Current clinical findings revealed the resident is alert with confusion noted and denies pain or discomfort in her left heel area. A flat blister measuring 4 cm x 4 cm x 0 cm was present to her left heel. Nursing staff encouraged the resident to leave her shoe off to prevent pressure to that area. The resident's feet are to be elevated on pillow when she is in her bed. A review of a physician wound evaluation and management summery dated August 8, 2024 revealed, the resident had a venous wound (open, non-healing wounds that occur on the legs or ankles due to poor blood circulation. They are caused by blood pooling in the veins, which increases pressure and fluid in the affected area. Venous ulcers are often painful, red, and covered with yellow, fibrous tissue). An examination of the left medial heel revealed a fluid filled blister measuring 4 cm x 5 cm. The treatment plan included apply skin prep once daily for 30 days and to off load her heels when in bed. Factors complicating wound healing to include, polyneuropathy (a condition where multiple peripheral nerves become damaged. It can cause symptoms such as pain, decreased sensation, and weakness), muscle weakness and dementia. There was no evidence at the time of the survey, regarding peripheral venous issues with this resident. There was no evidence at the time of the survey that an investigation was completed into the development of Resident 1's left medial heel fluid filled blister on August 4, 2024. During a telephone interview September 24, 2024 at approximately 3:00 PM, the resident's daughter stated her family visited Resident 1 on a daily basis. She stated on August 4, 2024 she visited the resident and saw a sign posted on the residents closet door stating, Do not put shoes on Resident 1, until OK given by Employee 2, RN. She stated she filed a grievance with the facility regarding her mother's blister. She stated when she saw the sign, the family looked at her heel and discovered the blister. She stated the sign on the closet door had a date of July 31, 2024 and indicated she was not informed as to why the sign was posted, or how long the resident had the skin issue on her heel. The facility never provided any information to the family as to how the blister developed or if it was caused by wearing her shoes. A review of the grievance report dated August 5, 2024 indicated the family was concerned with the blister on the resident's heel. There was no resolution to this grievance. Employee 2 the RN indicated she discussed the resident's condition with the family however, there was no documented evidence the blister was discussed. Interview with the director of nursing (DON) on September 24, 2024, at approximately 12:00 PM indicated Employee 1, LPN and Employee 2, RN did not investigate the blister on Resident 1's heel because they determined the area was a venous wound. She could not provide supporting evidence or any collaboration with the physician to support the diagnosis of venous insufficiency. 28 Pa. Code 211.12 (d) (5) Nursing services.

Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined that the facility failed to fully develop and implement established abuse prohibition procedures for screening five of five employees for employment (Employee 1, 2, 3,4 and 5) Findings include: According to regulatory requirements under SS483.12(a)(3) and 483.12(b)(1)] the facility must have written procedures for screening for prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's Resident Abuse policy last reviewed by the facility January 3, 2023, revealed no procedures for screening potential employees that included obtaining references from current/previous employers. Review of employee personnel files revealed that Employee 1 (Registered Nurse) was hired March 14, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility had contacted any of the employee's previous employers. Review of employee personnel files revealed that Employee 2 (unit aide) was hired April 16, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained information from former employers. Review of employee personnel files revealed that Employee 3 (LPN) was hired April 15, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained information from former employers. Review of employee personnel files revealed that Employee 4 (NA) was hired June 4, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained information from any former employers. Review of employee personnel files revealed that Employee 5 (unit aide) was hired May 2, 2024. The employee's application indicated that she had previous employers. There was no indication that the facility obtained information from the former employers Interview with the Administrator on July 12, 2024, at 12:15 p.m. the NHA verified that there was no evidence that previous employers were contacted for information regarding the employees past employment. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c)Resident Rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.19 (1) Personnel records

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure the presence of current documented clinical necessity of a resident's continued use of an psychotropic medication prescribed on an as needed basis for one resident out of five sampled (Resident 65). Findings included: A review of the clinical record revealed that Resident 65 had diagnoses of Parkinsons disease (a progressive neurological disease), dementia, and a history of falling. The resident was placed on Hospice services November 24, 2023, for end stage Parkinson's disease. The resident had a physician order dated January 9, 2024, for Haldol, an antipsychotic medication, 2 mg/ml, SL (sublingual, under the tongue), 1 ml, SL every 6 hours for anxiety/terminal agitation (a common symptom of dying, characterized by sudden agitation, anxiety, anger or confusion). There was no corresponding physicians documentation or any documentation from hospice staff of related to the resident's need for this newly added antipsychotic medication, and the resident's anxiety/terminal agitation. Prior to the addition of the Haldol to this resident's drug regimen, the had eight falls from his wheelchair, from October 17, 2023, through January 8, 2024, on one occasion sustaining injuries to his head. Following initiation of the Haldol, the resident incurred an additional fall from his wheelchair on January 18, 2024, and in response the resident's Haldol dosage was increased. A physician order dated January 24, 2024, was noted for Haldol 2 mg/1 ml, give 1.5 ml SL every 6 hours for terminal agitation due to end stage Parkinsons disease/anxiety. The resident again fell from his wheelchair on June 11, 2024, and fell from bed on June 12, 2024 from bed. A physician order dated June 12, 2024, was noted to again increase the Haldol 2 mg/1 ml, give 2 mg (1 ml) SL every 4 hours (around the clock). The pharmacist requested that the physician, attempt a gradual dose reduction (GDR) dated June 23, 2024, noting the resident's Haldol order was increased to 2 mg every 4 hours without physicians documentation of rationale. The physician responded to the pharmacy request dated June 24, 2024 stating, patient has increased episodes of agitation, increased behaviors and agitation regarding dementia and Parkinsons disease. The physician progress notes did not address the resident's behaviors and corresponding Haldol usage. There was no hospice physician documentation regarding the increase in the resident's dosage of Haldol. Interview with the interim Director of Nursing on June 12, 2024, at 10 AM, confirmed that there was no physician documentation regarding the initiation of the antipsychotic medication Haldol 2 mg/1mg, 1 mg every 6 hours around the clock, a doseage increase to 1.5 ml every 6 hours around the clock and the increase in the dose to 2 ml every 4 hours around the clock to reflect its clinical necessity. 28 Pa. Code 211.2 (d)(3) Medical director 28 Pa. Code 211.9 (a)(1) Pharmacy services 28 Pa. Code 211.5 (f) Clinical records

Based on review of select facility policy, clinical records, and incident reports and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events, as evidenced by multiple falls incurred by one resident out of 18 sampled (Resident 65). Findings include: Review of the facility policy entitled Quality assessment and improvement plan last reviewed by the facility January 9, 2024 revealed that the facility is committed to incorporating the principles of Quality Assurance and performance Improvement (QAPI) into all aspects of the center work processes, services lines and departments. All staff and stakeholders are involved in QAPI to improve the quality of life and quality of care that out patients and residents experience. The process included: - The administrator directs the development and documentation of the center QAPI plan, including an annual QAPI calendar, and is responsible for development, maintenance and ongoing evaluation of an active and effective Quality Assurance Performance Improvement Committee. -The committee meets at least 10 times annually, preferably monthly, to monitor quality within the center, identify issues and develop and implement appropriate plans of action to correct identified quality issues. The responsibilities to include: -Assess, evaluate and identify potential improvement opportunities based on: -Current reviews of core systems -all current regulatory on-site assessments -Adverse events since the past meeting, including prevention opportunities, investigations and corrective actions. A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], with diagnoses to include Parkinsons disease ( a progressive neurological disease), dementia, and a history of falling. The resident was placed on Hospice services November 24, 2023, for end stage Parkinsons disease. The resident's baseline care plan, initiated February 27, 2023, revealed that Resident 65 had a history of falling prior to admission to the facility and impaired cognitive function related to Parkinson's disease and dementia with moderate, cognitive function. According to the resident's care plan the resident was at risk for falls related to his diagnosis of Dementia and Parkinson's disease. The resident's care plan indicated that the resident used a wheelchair for mobility and self-propelled throughout the facility as desired. A quarterly minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 22, 2023, revealed the resident was moderately cognitively impaired, required staff assistance for activities of daily living and had a history of falling. A review of incident reports revealed that Resident 65 fell while leaning forward in his wheelchair, on the following occassions: -October 17, 2023, at 8:45 PM leaned foreward in his wheelchair and fell , sustaining a right forehead laceration -November 1, 2023, at 1:45 AM leaned foreward in his wheelchair and fell , sustaining an abrasion on his left forehead -November 17, 2023, at 7:45 AM leaned foreward in his wheelchair and fell , sustaining an abrasion on his left lateral forehead -November 17, 2023, at 5:49 AM leaned foreward in his wheelchair and fell , hitting his forehead on the floor. Staff placed him back into his wheelchair and he hit his head a second time on the door, sustaining an abrasion to his mid forehead, and a left frontal scalp abrasion. He was taken to the hospital and admitted with a left frontal scalp hematoma and a lumbar 1 fracture. -November 22, 2023, at 8:10 PM leaned foreward in his wheelchair and fell , sustaining an abrasion to his mid forehead with swelling -December 7, 2023, at 3:30 P.M., leaned foreward in the wheelchair, falling onto his forehead, receiving an abrasion to his mid forehead and bridge of his nose -December 10, 2023 at 4 PM leaned foreward in the wheelchair and fell , sustaining an abrasion to the left temple area with bleeding noted. -January 8, 2024, at 9:15 AM he leaned foreward in his wheelchair and fell , sustaining an abrasion to his forehead. -January 18, 2024 at 6 PM he leaned foreward in his wheelchair and fell , foreward, sustaining a bloody nose and a laceration above his left eye -June 11, 2024 at 5:54 PM stood up from the wheelchair, he leaned towards his left side and fell . A review of occupational therapy (OT) notes indicated that the resident was referred to OT with services rendered from September 16, 2023, through October 20, 2023 related to repeated falls from his wheelchair. An OT encounter note dated October 2, 2023, indicated that OT continued to trial the resident in a standard wheelchair with foam cushion and right lateral support. During observation, patient participated in therapy tasks, however, when pieces dropped onto the floor, patient attempting to reach down to pick up but this position does place patient at risk for falling. Patient required cues to adjust posture when he sat back up due to leaning over to the right side. At this time, patient may need direct supervision when he is positioning in standard wheelchair. OT discharge documentation dated October 20, 2023, indicated that the resident was noted to propel in the standard wheelchair with the use of his bilateral lower extremities. With propulsion, the resident continues to lean forward in attempt to gain momentum to move the chair. The resident had multiple falls after this therapy period as noted above. The resident fell from his wheelchair, leaning out of the chair November 17, 2023, twice with resulting injuries of a scalp hematoma and lumbar one fracture. The planned intervention following this fall with injury was to refer him to therapy to reassess his wheelchair seating. A review of occupational therapy notes revealed that Resident 65 received OT services from November 21, 2023, through December 8, 2023. OT documentation dated November 21, 2023 revealed Resident provided with training for wheelchair propulsion. He was able to follow verbal cues to maintain upright trunk position throughout and will correct same when told to do so. Resident present for a two hour period. While not directly working with the therapist, the resident was given a variety of activities intermittently including, exercises, games, and newspaper and displayed no behavioral issues and no attempts to self transfer. The Director of Rehab consulted with the facility Director of Nursing discussing therapy and the need for an interdisciplinary team approach to addressing and managing his falls. Incident reports revealed that the the resident continued to fall through December 2023 and January 2024. Occupational therapy for wheelchair seating was again ordered as an intervention, January 10, 2024 through January 20, 2024. The resident had an additional fall January 18, 2024. and again June 11, 2024, while leaning foreward from the wheelchair. The facility to demonstrate that their QAPI system had attempted to identify and effectively address the underlying cause or contributing factors to these repeated falls to timely initiate effective interventions in an effort to prevent recurrent falls of a similar nature. During an interview July 11, 2024 at approximately 2 P.M., the Nursing Home Administrator stated that the facility could not provide additional supervision of the resident as an fall prevention intervention to prevent multiple falls, and resultant head injuries and fractured lumbar one bone. At the time of the survey ending June 12, 2024, the facility had not yet effectively addressed the resident's behavior of leaning forward in his wheelchair, which had resulted in multiple falls and facial injuries. There was no evidence at the time of the survey that the facility demonstrated an effective QAPI program to include evaluating outcomes, quality of care and quality of life by investigating adverse incidents and evidence of maintenance of thorough documentation to support their analysis of the data collected and any corrective actions developed and implemented. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(4) Management 28 Pa. Code 211.12 (c) Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 21 residents reviewed (Resident 90). Findings include: According to the RAI User's Manual dated October 2023 a Significant Change in Status MDS assessment is required within 14 days of the determination of the significant change when: A resident enrolls in a hospice program; or A resident changes hospice providers and remains in the facility; or A resident receiving hospice services discontinues those services; or A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS). A review of the clinical record of Resident 90 revealed that the resident had experienced a significant decline in condition and was placed on Hospice Care (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, attending to their emotional and spiritual needs) on May 6, 2024. There was no documented evidence that a significant change MDS was completed to reflect that Resident 90's hospice services were initiated. Interview with the Nursing Home Administrator on July 12, 2024, at approximately 1:45 PM confirmed that a comprehensive significant change MDS assessment was not completed as required.

Based on observations, clinical record review and staff and resident interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis for one of 21 residents sampled. (Resident 52) Findings include: According to the National Kidney Foundation patients receiving hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) should keep emergency care supplies on hand. A review of Resident 52's clinical record revealed that the resident was admitted to the facility was on May 11, 2017, with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of the resident's current plan of care, dated October 8, 2021, revealed that the resident required dialysis related to renal failure along with a care planned approach to have 4 x 4 gauze pads and cloth tape were to be at the bedside. Observations conducted on July 11, 2024, at 10:17 AM revealed no emergency supplies were available in the resident's room. Observations of the resident on July 11, 2024, at 10:20 AM revealed no emergency supplies were present on her wheelchair. An interview with Resident 52 on July 11, 2024, at 10:20 AM revealed that the resident stated that no emergency supplies for her dialysis access site are kept in her room. The resident stated that she has never seen those supplies in her room. Interview with Employee 6, LPN (licensed practical nurse), on July 11, 2024, at approximately 10:25 confirmed there were no emergency supplies at the resident's bedside or on her wheelchair. Interview with the Nursing Home Administrator on July 12, 2024, at approximately 1:45 PM confirmed the facility failed to ensure the ready availability of necessary emergency supplies at the resident's bedside. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on observation, review of select facility policy and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two resident pantries. 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 a facility policy titled Use and Storage of Food Brought in by Family or Visitors that was last reviewed on January 27, 2023, indicated food must be handled in a way to ensure the safety of the resident. The facility may refrigerate, label, and date prepared items in nourishment refrigerator and that food must be consumed by the resident within 3-days. The initial tour of the kitchen was conducted with the facility's Certified Dietary Manager (CDM) on July 11, 2023, at 9:30 AM, and revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness. The wire spice rack, mounted to the wall near the cook's area, had debris and dust adhered to the surface. Below the spice rack, there was a mounted knife rack that had debris and dust accumulated on the rack. In the dish room, several ceiling tiles were observed coated with food splatter and were ill-fitting in select areas. The mounted wall fans inside of the dish room and in the kitchen area had an accumulation of dust. The juice station dispenser gun felt sticky and had an accumulation of product on the inside of the dispenser. In of the 100 hallway nourishment room there were two opened gallons of milk and two poured beverages from resident meal trays that did not have a discard date noted. In the 400 hallway nourishment room there were two opened gallons of milk and a takeout container of meatballs dated July 9, 2023. Interview with the facility's Registered Dietitian (RD) confirmed that the container of meatballs should have been discarded and that the manufacturer's date on the gallons of milk was the date that the staff should reference for discarding. Interview with the Director of Nursing (DON) on July 13, 2023, at 11:55 AM, confirmed that all opened items should have an open date and that any opened containers should be discarded within 3-days. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to afford a resident the ability to participate in his treatment, be fully informed of treatment decisions and proposed and to chose preferred treatment options for one resident out of 18 sampled (Resident 14). The findings include: Review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses to include Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), dementia (a group of thinking and social symptoms that interfere with daily functioning), and chronic hip pain. An annual comprehensive MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment, dated June 5, 2023, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. A physician progress note dated April 18, 2022, indicated that Resident 14's chief complaint was a right hip abnormality. The physician note indicated that No orthopedic follow up services at this time. Patient is able to stand and move. At this time, surgical intervention without any current pain or omitted range of motion would place the patient at an unnecessary risk. {Resident 14} remains in wheelchair most of the day. {Resident 14} is comfortable, chronic pain is managed and patient agrees with this plan. A quarterly MDS assessment, dated May 4, 2022, revealed the resident's self performance and staff assistance with activities of daily living was assessed as follows: independently roll from lying on back to left and right side, and return to lying on back on the bed with supervision or touching assistance move from sitting on side of bed to lying flat on the bed with supervision or touching assistance move from lying on the back to sitting on the side of the bed with feet flat on the floor with partial/moderate assistance come to a standing position from sitting in a chair, wheelchair, or on the side of the bed with partial/moderate assistance transfer to and from a bed to a chair or wheelchair walk 10-150 feet with partial/moderate assistance independently wheel 50 ft with two turns in a wheelchair The resident had an unwitnessed fall on May 15, 2022. A nursing progress note dated May 24, 2022, at 10:17 a.m. indicated that following the fall, Resident 14 had a change in mobility status. The resident was admitted to the hospital on May 25, 2022, and returned to the facility on [DATE]. A physical therapy evaluation dated June 7, 2022, indicated that Resident 14 had an order to be non-weight-bearing on the right lower extremity and to follow-up with an arthroplasty (joint repair) specialist to address the right hip once medically stable. The therapy evaluation noted that the resident complains of significant pain with right hip palpation (feeling with fingers or hands during the exam) and right lower extremity movement, such as with bed mobility tasks. The resident requires the use of a total lift for treatment. No physical therapy is indicated at this time. This evaluation indicated that the resident verbalized a pain level of 8/10 and experiences pain with all functional mobility tasks, including rolling. A nursing progress note dated June 8, 2022, at 2:02 p.m., indicated that Resident 14 was referred to a community arthroplasty specialist. A physician progress note dated June 13, 2022, that indicated that the orthopedic surgeon and nurse practitioner who originally were upset that {Resident 14's} subacute chronic fracture was not dealt with in a timely manner have now deferred the case to more capable orthopedic surgeons who deal with this area. Not sure if it will be dealt surgically. Since a timeline cannot be put on whether it is subacute or chronic. Nonetheless, {Resident 14} is in no discomfort, which the resident has never been, which is well documented, as well as, the process that lead up to his hospitalization and subsequent follow up. A significant change MDS assessment, dated June 14, 2022, revealed that the resident declined in all areas of mobility. As of this date, Resident 14 was able to: with substantial/maximal assistance roll from lying on back to left and right side, and return to lying on back on the bed (prior to fall in the facility level -independent) not applicable to move from sitting on side of bed to lying flat on the bed (prior level -able to complete task with supervision or touching assistance) not applicable to move from lying on the back to sitting on the side of the bed with feet flat on the floor (prior level -able to move with supervision or touching assistance) not applicable to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed (prior level -with partial or moderate assistance) dependent on staff to transfer to and from a bed to a chair or wheelchair (prior level -with partial or moderate assistance walking 10-150 ft was not attempted due to medical condition (prior level -with partial or moderate assistance) Not indicated to utilize a wheelchair or scooter (prior level -independently able to utilize wheelchair) An orthopedic surgeon consult dated July 7, 2022, at 9:30 a.m., indicated that Resident 14 needs a total hip replacement. Will discuss with the resident's physician and call with follow-up. A physician progress note dated July 14, 2022, indicated that I have a call with community arthroplasty (joint repair) surgeon today regarding patient's chronic hip pain current recommendation is to proceed with surgery. I will discuss with surgeon the resident's multiple comorbidities and medical clearance. An orthopedic consult dated August 16, 2022, indicated that Resident 14 presents for a follow-up of right hip pain. Patient fell . Diagnoses with a displaced femoral neck fracture. Since the fall patient has not been able to ambulate. Presents in a stretcher with emergency medical services. According to the consult the resident has been advised of X-Ray findings and treatment options; resident has failed conservative measures; Orthopedic Surgeons are recommending a right hip hemiarthroplasty (half joint replacement); The risks and benefits of surgery were discussed at length; Resident's questions addressed and answered; Resident to schedule appointment with community nurse practitioner one month prior to surgery; Resident advised will need preadmission testing - Labs, EKG, chest X-ray and follow-up with primary care physician for medical clearance prior to surgery. A physician progress note dated August 17, 2022, revealed that I did discuss Resident 14's case with community surgeon and they are planning on surgical repair of his hip. Community surgeon did agree that his hip fracture from his original X-ray was subacute/chronic in nature and this is a chronic pathologic is unknown duration since the patient is having discomfort and inability to ambulate, we will pursue surgery the patient agrees with same. A physician progress note dated September 7, 2022, indicated that I discussed this case with orthopedic surgeon. Since, {Resident 14} is not ambulatory and never really was and really only transferred with the help of the staff, we recommend he undergo full weight bearing with a lift on the right. He is in no pain and not complaining of pain in his hip. Community orthopedic surgeon agrees this is a chronic fracture and did not occur back with the initial workup began at our facility. No need for repairs at this time due to overall ambulatory status. At the time of the survey ending July 14, 2023, there was documented evidence that the physician had discussed the resident's treatment preferences, documented the preferences or discussion, or honored Resident 14's treatment or care decisions. According to the September 7, 2022 physician note, prior to the resident's fall on May 15, 2022, the resident was assessed to independently ambulate with a wheelchair. From June 7, 2022, through September 6, 2022, the resident had physician orders for non-weight bearing on the right leg extremity. A quarterly MDS assessment, dated September 20, 2022, Section GG0170 Mobility, revealed that as of this date, Resident 14 was able to: with substantial/maximal assistance roll from lying on back to left and right side, and return to lying on back on the bed (prior to fall in the facility level -independent) not applicable to move from sitting on side of bed to lying flat on the bed (prior level -able to complete task with supervision or touching assistance) not applicable to move from lying on the back to sitting on the side of the bed with feet flat on the floor (prior level -able to move with supervision or touching assistance) not applicable to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed (prior level -with partial or moderate assistance) dependent on staff to transfer to and from a bed to a chair or wheelchair (prior level -with partial or moderate assistance) walking 10-150 ft was not attempted due to medical condition (prior level -with partial or moderate assistance) Not indicated to utilize a wheelchair or scooter (prior level -independently able to utilize wheelchair) A physical therapy evaluation signed on October 7, 2022, at 8:38 a.m., indicated that Resident 14 continues to complain of significant right hip pain. Patient may be having surgery in the future, but unsure of when that will be scheduled. Resident has not been walking over the last few days secondary to right lower extremity causing pain. The assessment indicated that the resident's pain level was 6/10 from September 6, 2022, through discharge of therapy services on October 6, 2022. A physician progress note dated October 17, 2022, indicated that Resident 14 is expecting he is not going to have surgery because he is not ambulating this is a chronic finding no new changes. However, there was no documented evidence that the facility had discussed the resident's treatment preferences, documented the preferences or discussion, or honored Resident 14's treatment or care decisions. Clinical record documentation dated October 18, 2022, at 2:13 p.m. indicated that the orthopedic surgeon's office, was asking if surgery was going to be scheduled for Resident 14. A follow-up note dated October 19, 2022, at 2:04 p.m. indicated that the orthopedic surgeon had a discussion with Resident 14's primary physician and his other colleagues. The entry indicated that the patient was not a surgical candidate. Will not be proceeding with right hip hemiarthroplasty (a surgical procedure that involves replacing half the hip joint). The patient can transfer from bed to chair. Weight bear as tolerated. A nursing progress note dated October 19, 2022, at 2:28 p.m., indicated that per community orthopedic surgeon, after consulting with {Resident 14's} primary physician, it was decided that the resident is not a surgical candidate with his mental issues and other medical problems. During an interview on July 11, 2023, at 9:40 a.m., Resident 14 stated, My hip hurts. I am going to have my hip operated on to help with the pain. The resident did not state when the surgery was scheduled or planned. At the time of the survey ending July 14, 2023, there was no documented evidence that the facility had discussed the resident's treatment options for right hip pain with the resident and allowed the resident to participate in the decision making for his treatment plan. During an interview on July 14, 2023, at approximately 12:00 p.m., the Nursing Home Administrator (NHA) was unable to provide evidence that Resident 14's was afforded the right to participate in his treatment, including discussions regarding potential surgery or alternate treatment options for the resident's hip pain and to address the resident's decline in functional abilities. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of the minutes from Resident Council meetings and resident and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by six of the six residents (Residents 10, 31, 42, 45, 53, 77). Findings include: A review of the minutes from the Resident Council meetings held from August 2022 through June 2023 revealed that the residents in attendance at these meetings voiced their concerns regarding the facility's failure to consistently offer snacks in the evenings. During the January 20, 2023, Resident Council meeting, the residents relayed concerns that residents are only sometimes offered an evening snack. During the February 17, 2023, Resident Council meeting, the residents relayed concerns regarding not being offered evening snacks. During the March 27, 2023, Resident Council meeting, the residents relayed concerns regarding evening snacks. During the April 21, 2023, Resident Council meeting, the residents relayed concerns that evening snacks are still not consistently being offered. During the May 22, 2023, Resident Council meeting, the residents relayed concerns that residents are offered an evening snack only when select staff are working. During the June 20, 2023, Resident Council meeting, the residents relayed concerns about not consistently being offered an evening snack. During a group meeting held on July 12, 2023, at 10:00 a.m. with seven alert and oriented residents, all six residents reported that evening snacks are not consistently offered despite their complaints raised at Resident Council meetings over the last few months. The residents stated this issue has continued without resolution by the facility to date. The facility was unable to provide documented evidence that the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding not consistently being offered snacks in the evening. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on July 12, 2023, at 12:30 p.m., the NHA and DON were unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding consistently being offered evening snacks. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (e)(4) Management

Based on observation, a review of clinical records and resident and staff interviews it was determined that the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living received the necessary assistance to maintain good personal grooming and hygiene for one resident out of 18 sampled (Resident 1). Findings include: A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], 2021, with diagnoses of cerebral infarction (an event that causes a decrease in blood flow to the brain, commonly known as a stroke) and aphasia (a disorder that results from damage to portions of the brain that are responsible for language). A quarterly MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that the resident was moderately cognitively impaired and required one person assistance with personal hygiene. An observation and interview with Resident 1 on July 11, 2023, at 10:55 a.m. revealed that the resident had a partially outgrown beard that was inconsistent in length. The resident's beard was approximately 1.0 cm in length in the longest section. The resident stated that he wanted a shave and gestured to his beard. Resident 1 stated that he was not shaved with his morning care. An observation of Resident 1 on July 12, 2023, at 8:45 a.m. revealed the resident had not yet been shaved. An observation and interview with Resident 1 on July 13, 2023, at 10:10 a.m. revealed the resident had still not been shaved and stated that he wanted a have shave. During an interview on July 13, 2023, at 10:15 a.m., Employee 1, a nurse aide, stated that Every morning we provide personal hygiene care for residents. Employee 1 also stated that I provided personal hygiene care for {Resident 1} this morning. I wash residents' faces, assist with brushing hair, brush the resident's teeth, and offer shaving. During the interview, Employee 1, confirmed that I did not shave {Resident 1} this morning, but I do plan on going back later today to assist with shaving. A clinical record review revealed that staff noted the completion of the the resident's personal hygiene nursing task (how the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands, and excluding baths and showers) on July 10, 11, 12, and 13 of 2023. On each of these occasions, staff noted that the resident required extensive assistance with personal hygiene nursing task During an interview on July 13, 2023, at approximately 11:00 a.m., the Nursing Home Administrator (NHA) reported that residents are only offered shaving on shower days (twice weekly) and that Resident 1 often refuses his shower. The NHA was not able to provide evidence that Resident 1 was provided the necessary services to maintain good grooming and personal hygiene and at the frequency preferred by the resident. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records it was determined that the facility failed to consistently implement a resident's person centered plan of care for necessary assistance with activities of daily living for one resident out of 18 sampled (Resident 244). Findings included: Clinical record review revealed that Resident 244 was admitted to the facility on [DATE] with diagnoses to include end stage heart failure, and diabetes. A review of the resident's care plan ADL self performance deficit related to weakness initiated July 27, 2021 revealed that Resident 244 required the assistance of one person for bed mobility. A review of an interdisciplinary therapy screen dated January 9, 2023 revealed that Resident 244 had a change in status for transfers, wheelchair usage, pain and bed/chair positioning. Resident 244 was placed on hospice services on January 10, 2023 related to end stage cardiac disease. A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 18, 2023 revealed, Resident 244 was cognitively intact and required maximum assistance of two staff for bed mobility and transfers. The resident's ADL care plan was revised on January 26, 2023, and the resident's bed mobility status changed to assist of two persons with bed mobility, one person required to immobilize the resident's right lower extremity as a result of a recent fracture on January 7, 2023, and application of leg brace for treatment. A review of ADL records dated January 7, 2023 through February 6, 2023 revealed that only one person assisted the resident with bed mobility on most shifts. A review of nursing documentation dated February 6, 2023, at 3:23 P.M. revealed that the resident had a recent fracture, right femur with right lower leg brace. New open area noted of right lateral knee noted with moderate bloody drainage. A subsequent nurses note dated February 6, 2023 at 6:47 PM revealed that a change in the resident's condition was noted. A bone was protruding from Resident 244's right femur fracture site. There was no evidence at the time of the survey ending July 14, 2023, that the resident's bed mobility was consistently performed with the assistance of two staff members following the resident's leg fracture, application of the leg brace and as care planned on January 26, 2023, to maintain the resident's comfort and prevent further injury to the resident. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and select facility policy and staff and resident interview, it was determined that the facility failed to provide individualized effective pain management for one resident out of 18 sampled (Resident 14). The findings include: A review of the facility's current Pain Management policy, last reviewed by the facility on January 29, 2023, revealed that the facility will help residents attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being, and to prevent or manage pain, the facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. The facility's policy also stated that interventions for pain management will be incorporated in the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. A clinical records review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses to include Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), Dementia (a group of thinking and social symptoms that interfere with daily functioning), and chronic hip pain. An annual comprehensive MDS (Minimum Data Set-a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status). The resident had physician orders for Acetaminophen Tablet 325 mg 2 tablets by mouth every 4 hours as needed for mild pain since admission March 10, 2021, and an a physician order for non-pharmacological interventions to be utilized prior to administering as needed pain medications. During an interview on July 11, 2023, at 9:40 a.m., Resident 14 stated, My hip hurts. I am going to have my hip operated on to help with the pain. The resident did not state when the surgery was scheduled or planned. Resident 14 had a fall on May 15, 2022, while in the facility. After the fall, the resident was no longer able to independently ambulate and was on non-weight bearing orders for the right lower leg extremity from June 2022 until September 2022. Resident 14's attending physician and community orthopedic surgeon initially recommended hip replacement for the injury, but after consultation, it was determined that Resident 14 was not a surgical candidate. Resident 14's Medication Administration Record (MAR) for August 2022, indicated that staff administered two Acetaminophen 325 mg tablets on ten occasions for mild pain and once for moderate pain during the month. The August 2022 MAR also revealed no evidence that non-pharmacological interventions were attempted as ordered by the physician prior to administering prn Acetaminophen 325 mg on August 25, 26, 29, and 30, 2022. On September 7, 2022, a physician order was noted for the resident to be full weight bearing with a 1-inch heel lift. The resident's September 2022 MAR revealed an increase in the resident's use of the prn Acetaminophen, revealing that staff administered two Acetaminophen 325 mg tablets on 14 occasions for mild pain and twice for moderate pain. There was also no evidence that non-pharmacological interventions were attempted, as ordered by the physician, prior to administering Acetaminophen 325 mg on September 3 or 11, 2022. A physical therapy evaluation dated October 7, 2022, at 8:38 a.m., indicated that the resident continues to complain of significant right hip pain. Patient may be having surgery in the future, but unsure of when that will be scheduled. Resident has not been walking over the last few days secondary to right lower extremity causing pain. The assessment indicated that the resident's pain level was 6/10 (a scale of 0 being no pain and 10 being the most severe) from September 6, 2022, through discharge of therapy services on October 6, 2022. There was no documented evidence that the facility had fully assessed, and addressed, the resident's increased pain during physical therapy services from September 6, 2022, through September 16, 2022. On September 16, 2022, the physician ordered Acetaminophen 500 mg two tablets to be taken by mouth two times a day for pain management. However, the resident's pain remained 6/10 through the end of therapy services on October 6, 2022, despite the increase in pain medication. There was no documented evidence of additional pain relieving modalities developed and implemented to address Resident 14's increased pain and the development of alternate measures to manage the resident's hip pain when it was determined that he was not a candidate for surgery. During an interview on July 14, 2023, at approximately 12:00 p.m., the Nursing Home Administrator (NHA) was unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to administering prn pain medications or evidence of a reassessment of the resident's pain management needs. for Refer F552 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services

Based on a review of clinical records and select incident and accident reports 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 with injury for one resident (Resident CR1) and failed to provide sufficient staff supervision and effective safety measures to prevent a fall with injury for one resident (Resident CR2) out of 22 sampled residents. Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Can cause the inability to think or remember). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that the resident was severely cognitively impaired and had a BIMS (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 ,[DATE] equates to being cognitively intact) of 5 indicating a severe cognitive impaired. The resident required extensive assistance with two plus persons physical assistance for bed mobility and was totally dependent on staff for transfers between surfaces. A physician's orders [REDACTED]. The foam shell also includes contoured foam bolsters at the sides and ends of the mattress to provide added stability and positioning). A review of an incident/accident report dated [DATE], revealed that at 10:40 AM, Employee 7, a nurse aide, was providing morning care to the resident. Employee 7 pulled the resident toward her by means of an incontinence pad and then rolled the resident away from her towards the opposite side of the bed to apply the resident's adult brief. There was no siderail up on the opposite side of the bed at this time nor was there another staff member present. The resident rolled off the bed along with the mattress and landed on her left side, striking her head and face off the floor. The resident sustained [REDACTED]. The incident and accident report noted the facility's conclusion was that the root cause of the accident was that the resident rolled off the side of the bed and sustained an injury. The resident was sent to the emergency room for evaluation on [DATE], at approximately 11:50 AM. A CT Scan (computed tomography scan is a special type of x-ray that creates very detailed cross-sectional pictures of the body) completed on [DATE], at 2:15 PM, indicated that the resident had an acute (sudden onset) mildly displaced fracture (break in a bone in which the two pieces of bone become incorrectly aligned) along the anterior and inferior (in front and below) aspect of the C2 (second vertebrae in the spinal column immediately located below the skull) vertebral body (bones of the spinal column), suspicious for a tear drop fracture (fracture caused by forced extension {act of straightening}or flexion {act of bending} of the neck). The resident returned from the hospital on [DATE], and was required to wear a cervical collar at all times (a supportive device to be worn on her neck to maintain stability of her spinal cord). The nurses' notes dated [DATE], indicate the resident became cool and diaphoretic (sweaty) with shallow breathing (pulling minimal air into the lungs). The resident was sent to the hospital. Nursing documentation dated [DATE], at 4:51 PM indicated that a call was received by the physician who informed the facility the resident expired at the hospital on this date. A review of a statement dated [DATE], written by Employee 7 regarding the incident revealed that "while I was providing AM care I pulled (resident's name) hips towards me to the (L) side of the bed. I then repositioned her L leg to place a brief under her buttocks. When I tucked the brief under her buttocks she started to roll off of the bed to the floor, taking the mattress with her. I yelled out to the other staff that I needed assistance..." On [DATE], at 10:30 AM, Employee 7 was interviewed regarding the resident's fall from the bed during care. Employee 7 was unable to remember what type of mattress was on the bed at the time, but she confirmed that she was changing the resident's brief alone. She stated she did the resident's morning care alone at times, but if she needed assistance she would ask. She stated she was aware that the resident required a mechanical lift for transfers in and out of the bed, but stated that there was no clear direction for the staff to follow regarding the amount of assistance the resident required for bed mobility. A review of the resident's care plan in effect at the time of the incident initially dated [DATE], revealed that the resident required a mechanical lift for all transfers. However, the resident's care plan did not indicate the amount of assistance the resident required for bed mobility. An interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at 2:15 PM, revealed that the facility does not have an established procedure for staff to follow when determining the amount of assistance 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" and do not care plan for a specific amount of staff assistance for bed mobility. The NHA and DON stated that, "it is up to the nurse aide to determine the amount of assistance required for (a resident's) bed mobility on any given day." A report of the daily care provided to the resident dated [DATE], until [DATE], indicated that the resident required extensive assistance or was totally dependent on staff for bed mobility. The report indicated that only on [DATE], at 9:43 AM and 4:11 PM, the resident required only one person for bed mobility. During interview with Employee 7 on [DATE], at 10:40 AM, the employee stated that she rolled the resident away from her when applying the resident's brief. She stated that the side rail was not up nor was there anyone there to assist her in the event the resident rolled away from her. Employee 7 also stated that when she felt the resident was, "going to roll off the bed" she tried to reach over and grab her and when she did the employee's body made contact with the mattress, which caused the mattress to slide off the bed with the resident falling first making contact with the floor. 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 7 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. A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with a history of falls. An admission MDS assessment dated [DATE], revealed that the resident was cognitively intact, required assistance for transfers and ambulation and utilized a wheelchair for mobility. The physician's orders [REDACTED]. The staff were to check the function of the sensor pad every shift. The resident also had physician's orders [REDACTED]. A review of a resident incident\accident report dated [DATE], at 10:45 AM, revealed that staff heard Resident CR2 yelling for help. The resident was found lying on the floor next to his wheelchair with his oxygen tubing wrapped around his lower legs. Resident CR2 stated that he was trying to transfer from his wheelchair to his bed and fell forward out of the chair. He sustained multiple skin tears to his upper extremities and his right upper extremity was swollen. The physician was called on [DATE], and ordered an X-ray of the resident's right shoulder and upper extremity. Nursing applied ice and a sling to the resident's right arm. The X-ray results dated [DATE], revealed a fracture of the right shoulder, right upper extremity humeral neck (upper arm) and the distal radius (wrist). The resident continued to be medicated for pain daily on [DATE] and 3, 2014. The nursing documentation dated [DATE], at 6:30 PM, revealed that the resident had an appointment for a CT Scan for complaints of right hip pain. The CT scan of the right hip was completed [DATE], revealing a nondisplaced comminuted (a fracture in which the bone is splintered, crushed, or broken into pieces) of the subcapital region of the right femoral neck (the top of the bone). The resident was admitted to the hospital on [DATE], for surgical repair of the right hip and did not return to the facility. A review of an employee witness statement dated [DATE], at 11:40 AM, revealed that Employee 10 (third shift Nurse Aide) stated that he saw the resident at 6:00 AM, while completing rounds with the oncoming dayshift Nurse Aide, Employee 7. Employee 10 stated that the resident was in his bed with the sensor alarm intact when observed at 6 AM. A witness statement from Employee 7, dated [DATE], at 11:30 AM, noted that at 6:05 AM, while on rounds with Employee 10, Resident CR2 was observed seated in his wheelchair in his room. Resident CR2's witness statement dated [DATE], at 12:00 PM, revealed, "I put myself into the wheelchair. I was in bed and got out without any help. I did not ring the call bell for getting any help." The incident report noted that the sensor pad to the resident's bed was a preventative measure in place at the time of the resident's fall on [DATE]. However, there was no documented evidence that the resident's sensor alarm pad sounded to alert staff to resident's unassisted transfer from bed on the morning of [DATE]. The facility's corrective actions, as identified on the incident report, were noted as "sensor alarm pad applied to wheelchair. Alarm boxes placed out of reach." There was no evidence at the time of the survey that Resident CR2's bed sensor pad was connected and functioning at the time of the fall. Additionally, witness statements from Employees 7 and 10 differed as to the resident's location when he was last seen within five minutes before the fall on [DATE]. There was no indication of the resident's location between 6:00 AM to the time of the fall 10:45 AM, to include breakfast and toileting. During an interview [DATE], at 1:00 PM, the Director of Nursing confirmed that the facility's investigation into the fall was not complete. 42 CFR 483.25 Free of Accident Hazards and Supervision. Previously cited [DATE] 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited [DATE]

Based on a review of clinical records and select facility policy, observation and staff and resident interview, it was determined that the facility failed to timely identify declines in skin integrity to prevent pressure sore development for one resident (Resident 62) out of 22 resident's sampled. Findings include: A review of the facility policy for Skin Integrity Management reviewed by the facility January 2, 2014, revealed that the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Practice standards included review pre-admission information to plan for patients needs prior to admission. Determine the need for support surface for bed and chair, determine the need for heel protectors and heel lift devices. A review of the facility policy for Accidents\Incidents ( including injuries of unknown origin) reviewed by the facility May 15, 2014, indicated that if the incident is an injury of unknown origin, interview all staff assigned to the customer (resident) for the preceding 48 hours. A review of the clinical record revealed that Resident 62, a cognitively intact resident, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission Minimum Data Set assessment ( MDS process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.) dated June 6, 2014, revealed that the resident required assistance with her ADLs (Activities of Daily Living) and was at risk for developing pressure areas. A review of admission Physicians orders and a nursing plan of care dated May 30, 2014 revealed an order for [REDACTED]. Review of a Nursing Department Skin integrity report form dated June 8, 2014, revealed a DTI, pressure area on her right heel measuring 3 cm x 3 cm (deep tissue injury, a pressure-related injury to subcutaneous tissues under intact skin ), with intact skin, deep purple in color. A 1 cm x 1 cm DTI, with intact skin, deep purple in color was noted on her left heel. A review of an incident report dated June 8, 2014 at 8:30 pm revealed that while giving PM care to Resident 62, Employee 1 (nurse aide) noted the areas on the resident's heels. New interventions put into place to prevent further decline in skin integrity included an air mattress with a DPM overlay ( a specialty mattress used to prevent pressure sores and heel lift boots ( fully suspends heels off surfaces using adjustable elevation pad, dispersing pressure over calf). A review of Employee 1's witness statement indicted that a possible cause for the injury was Resident 62 digging her heels into the mattress. An observation on June 10, 2014, at 10 AM and again at 12 PM revealed that Resident 62 was seated in a wheelchair wearing socks and sneakers. Resident 62 stated that her heels hurt at that time. An observation on June 11, 2014, at 11:30 AM revealed that Resident 62's right heel DTI pressure area measured 3.5 cm x 3 cm, a 2.5 cm x 2 cm and had a dark purple center with red blanchable area surrounding. There was slough observed around the purple center. The left heel pressure area measured 1 cm x 1.1 cm purple area with pink, blanchable skin surrounding. A review of computer generated nurse aide documentation dated May 30, 2014 through June 8, 2014 indicated that the specialty air mattress with the DPM overlay and the heel lift boots were in place since the resident's admission to the facility. However, during an interview on June 12, 2014 at 11 AM, the facility's corporate registered nurse confirmed that the documentation from May 30, 2014 through June 8, 2014 did not reflect the actual interventions in place. There was no evidence at the time of the survey to support the consistent application of adequate preventative measures to prevent pressure sore development or of the actual preventative interventions that were implemented prior to the discovery of the heel pressure areas. During an interview June 12, 2014 at 1 PM, Employee 3(LPN) stated that staff use bed pillows to elevate resident's heels off the bed. During an interview on June 13, 2014 at 11:30 AM Resident 62 stated that prior to the discovery of the pressure area on her heels, her heels were placed directly on the mattress. She stated that pillows were not routinely placed under her heels to keep them off the bed. She further stated that she has continued pain in her heels and takes Tylenol (a non narcotic pain medication) to alleviate the pain. During an interview June 11, 2014 at 1:30PM, the Director of Nursing was unable to explain the lack of documented evidence of the consistent application of preventative measures to deter pressure development. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 5/23/13 28 Pa. Code 211.10 (a)(c)(d) Resident care policies previously cited 5/23/13

Based on a review of clinical records, select facility policy, incident/accident reports and an alleged abuse/neglect investigation (PB#22) it was determined that the facility failed to provide adequate staff supervision to prevent an accident with injury for one of 22 residents (Resident 61 ). Findings include: Review of the facility policy for Fall Prevention Management, reviewed by the facility May 15, 2014, revealed that patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of the clinical record of Resident 61 revealed [DIAGNOSES REDACTED]. A Quarterly minimum data set assessment (MDS- process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated March 20, 2014 revealed that the resident was cognitively intact and required assistance for transfers, ambulation and toileting and was at risk for falling. A physician's order and a nursing care plan, dated April 13, 2013, indicated that the resident was to have a sensor pad ( an alarming pad placed on the wheelchair seat, sounds an alarm when a person rises off the seat ) on her wheelchair. A review of an incident/accident report nurses note and an abuse investigative report (PB#22), dated April 9, 2014 at 2:30 PM revealed that a nurse aide (Employee 4) placed Resident 61 on the toilet. The nurse aide left the resident unattended in the bathroom while on the toilet to get a brief. Employee 4 (nurse aide) then heard the resident yelling for help. Resident 61 was found on the floor of the bathroom, with a 2. 5 cm x 2.0 cm bruise to the left elbow. At approximately 8:30 PM, the resident complained of hip pain. The physician was contacted and an X-Ray of the left knee and hip was ordered. The X-ray dated April 9, 2014 revealed a mildly displaced acute fracture involving the left superior pubic rami (pelvis). An orthopedic consult was ordered. A review of an initial pain assessment dated [DATE] revealed that Resident 61 had no complaints of pain. A pain evaluation Dated April 10, 2014 indicated that she developed pelvic pain, worse on movement. The physician was contacted and Norco 5/325 mg ( an opiod narcotic pain medication combined with Tylenol), 1 by mouth every 6 hours as needed for moderate/severe pain (6-10 on a 1 to 10 scale) was started. A review of daily pain assessment for April 2014 indicated that from April 9, 2014 through April 30, 2014 Resident 61 experienced pain daily. A review of medication administration records (MAR) and narcotic sign out sheets dated April 10, 2014 and April 21, 2014 revealed that the Norco was administered to Resident 61 several times daily on most days for complaints of pelvic pain. Corresponding nurses notes indicated that Norco was given for severe pain. Physicians orders dated April 21, 2014 were noted for Oxycodone ( a stronger, opiod narcotic pain medication) 5 mg, one by mouth every 6 hours as needed for pain. On May 2, 2014 the Oxycodone 5 mg by mouth was increased to every 4 hours as needed for severe pain. Corresponding MARs and narcotic sign out sheets dated from April 22, 2014 through May 13, 2014 indicated that the Oxycodone was given to the resident several times daily for severe pelvic pain. Physicians orders dated May 14, 2014, were noted to discontinue the Oxycodone and start Tramadol (a narcotic-like pain reliever used to treat moderate to severe pain ) 50 mg one by mouth every 6 hours as needed or moderate pain. A review of MARs for May 2014 and June 2014 indicated that Resident 61 continued to take that pain medication several times a week. The facility's investigation into the resident's fall revealed that Employee 4 (the nurse aide) was terminated for leaving a resident with an alarm on the chair unattended in the bathroom. During an interview June 12, 2014 at 1 PM, Resident 61 confirmed that Employee 4 left her alone in the bathroom, on the toilet and she fell to the floor. The resident stated that she has experienced a lot of pain due to the fall and still currently has pelvic pain. During an interview June 11, 2014 at 2 PM, the Nursing Home Administrator confirmed that a resident with an alarm on their wheelchair should not be left unattended on the toilet. 483.25(h) Accidents and Supervision Previously cited 5/23/13 28 Pa Code 211.10 (a)(c)(d) Resident care policies. Previously cited 5/23/13 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 5/23/13