Every finding on record at Casselman Healthcare and Rehabilitation Center

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for two of 34 residents reviewed (Residents 4 and 37).Findings include: A facility policy regarding medication orders, dated January 8, 2026, indicated that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 21, 2026, revealed that the resident was cognitively intact, required maximum assistance from staff for daily care needs, had diagnoses that included diabetes, and received insulin (a diabetic medication to regulate glucose levels). Physician's orders for Resident 4 dated July 9, 2026, included an order for the resident to receive 6 units insulin aspart 100 units/milliliter (a fast-acting medication to regulate blood sugar levels) at 8:00 a.m. and to hold the medication if the blood sugar level was less than 110 milligram/deciliter (mg/dL). Review of Resident 4's Medication Administration Record (MAR) for July and August 2026 revealed that the resident received 6 units of insulin aspart at 8:00 a.m. on July 13, 2026 when the resident's blood sugar was 92 m/dL; on July 19, 2026 when the resident's blood sugar was 106 mg/dL; on July 21, 2026 when the resident's blood sugar was 105 mg/dL; on July 24, 2026 when the resident's blood sugar was 104 mg/dL; on August 4, 2026 when the resident's blood sugar was 94 mg/dL; and on August 5, 2026 when the resident's blood sugar was 75 mg/dL. Interview with Director of Nursing on August 5, 2026, at 2:30 p.m. confirmed that 6 units of insulin aspart was administered to Resident 4 on the above dates and times and should have been held per physician's orders. A quarterly MDS assessment for Resident 37, dated June 9, 2026, revealed that the resident was cognitively impaired, was dependent on staff for his daily care needs, and had diagnoses that included insulin dependent diabetes. Physician's orders for Resident 37, dated June 3, 2026, included an order for the resident to receive 6 units/mL of Insulin Aspart two times a day with lunch and supper and to hold if the resident's blood sugar was less than 150 mg/dL or the resident ate less than 50 percent of his meal. Review of Resident 37's MAR dated June 2026 revealed no documented evidence of a meal intake for lunch or dinner on June 3 and 6, 2026; for lunch on June 5 and 7, 2026; or dinner on June 8, 2026, but Resident 37 was administered the 6 units of insulin aspart. Interview with the Director of Nursing on June 6, 2026 at 1:18 p.m. confirmed that staff should have obtained Resident 37's meal intake prior to administering the insulin on the dates and times noted above. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of 34 residents reviewed (Resident 39). Findings include: Review of the facility policy for Restorative Nursing Programs dated May 31, 2026, revealed that it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The interdisciplinary team, with the support of and guidance from the physician, will ensure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment goals and preferences. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated April 24, 2026, indicated that the resident was cognitively intact, was independent with transfers and ambulation, used a walker and a wheelchair, and had diagnoses that included Parkinson's Disease (a brain disorder that can affect movement). A quarterly MDS assessment dated [DATE], indicated that the resident was cognitively intact, used a walker and a wheelchair, and required substantial or maximum assistance from staff for transfers and ambulation. A care plan for restorative nursing dated February 17, 2026 revealed that staff are to report and document any declines in ability to restorative nurse, and to report abnormal assessment findings, decline in function, or complication associated with restorative activities to physician. A restorative nursing program for Resident 39 for February 2026 - August 2026 included for the resident to participate in a restorative nursing program walking 100 feet twice a day, 7 days a week for 15 minutes. A review of the restorative nursing program documentation revealed that in May 2026 the resident participated twice a day for 15 minutes and was able to walk an average of 75 feet each time. In June 2026, the resident participated twice a day from Juny 1, 2026 - June 10, 2026, and walked an average on 15-50 feet twice a day. From June 11, 2026, to June 30, 2026, there was documented evidence that restorative nursing was offered twice a day for 3 of the days and only once a day for 8 of the days and the resident walked 15 feet each occurrence. In July 2026, the resident was offered restorative nursing twice a day for 3 days and participated for 15 feet each occurrence, once a day for 9 days and walked 15 feet each occurrence. August 1, 2026, to present (August 5, 2026) the resident was not offered restorative nursing. There was no documented evidence of the resident's decline reported to the restorative nurse or physician.Interview with Resident 39 on August 6, 2026, at 9:45 a.m. revealed that he used to be able to walk longer distances two months prior, and nursing staff will sometimes take him for a walk. It depends on how much staff they have and if they have time. Interview with Nurse Aide 3 on August 6, 2026, at 9:52 a.m. revealed that they don't have enough time to ensure that the resident completes his restorative nursing program and they will document NA in his chart when they don't have the time. Interview with Physical Therapist 4 on August 6, 2026, at 10:01 a.m. revealed that the resident has been seen by therapy and was placed on a restorative nursing program to help prevent decline in mobility with his disease process with Parkinson's. Interview with Physical Therapist 5 on August 6, 2026, at 12:01 p.m. revealed that the resident was able to walk 150 feet with a walker in April, and has had a decline in mobility. Interview with the Nursing Home Administrator on August 6, 2026, at 12:05 p.m. revealed that the resident was in and out of therapy and restorative nursing and their Director of Therapy only works 3 days a week which could be the reason why his decline missed being re-evaluated. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures for one of 34 residents reviewed (Resident 51). Findings include: The facility's policy regarding food quality and palatability, dated March 31, 2026, indicated that food is prepared by methods that conserve nutritive value, flavor and appearance. Food is palatable, attractive and served at a safe and appetizing temperature. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 51, dated June 27, 2026, revealed that the resident was cognitively impaired, required substantial/maximum assistance with eating, required a mechanically altered diet, and had diagnoses that included cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain). A care plan for the resident, initiated April 6, 2026, indicated that she required cueing and prompting at mealtimes to feed herself as much as possible and staff were to assist as needed. A physician's order for Resident 51, dated March 30, 2026, revealed that the resident received a regular diet, mechanical soft, ground texture with nectar consistency liquids and required supervision and assistance with meals. Observations in the third-floor dining room on August 3, 2026, at 11:43 a.m. revealed that Resident 51 was sitting in her broda chair at a dining room table and staff delivered her lunch tray and uncovered her food. At 11:50 a.m., the resident was sitting in her broda chair in the dining room with her eyes closed and she was not attempting to feed herself. No staff attempted to assist her with her meal, or cue her to eat. At 12:17 p.m., the resident continued to sit at the dining room table with her lunch in front of her and she was not attempting to feed herself. No staff attempted to feed her, or cue her to eat. At 12:22 p.m., the resident continued to sit at the dining room table with her lunch in front of her. No staff attempted to feed her, or cue her to eat. At 12:28 p.m., Nurse Aide 1 sat down to feed the resident. Interview with Nurse Aide 1 on August 3, 2026, at 12:32 p.m. indicated that they are to try and have Resident 51 attempt to feed herself, but she usually needs assistance with feeding. The resident did not attempt to feed herself from the time the tray was served at 11:43 a.m. until Nurse Aide 1 sat down to feed her at 12:28 p.m. No staff attempted to assist her with her meal or cue her to eat. She was receptive to food when Nurse Aide 1 started to feed her. This surveyor requested the Dietary Manager take temperatures of the resident's lunch meal at the time Nurse Aide 1 began to feed the resident. The temperature of the spinach was 103 degrees Farenheit. The temperature of the chicken was 108.6 degrees Farenheit. The temperature of the sweet potatoes were 102 degrees Farenheit and the temperature of the milk was 61 degrees Farenheit. Neither the NA or the dietary manager attempted to reheat the residents food or get her another tray. Interview with Nursing Home Administrator on August 3, 2026, at 12:34 p.m. confirmed that staff should have assisted Resident 51 to eat, and should have heated her food or got the resident another tray. Interview with the Regional Dietary Manager on April 20, 2026, at 8:20 a.m. confirmed that the breakfast tray should have been covered and that the eggs were cold and not palatable and should not be served to the residents. 28 Pa. Code 201.18(b)(1)(2)(e) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.6(c) Dietary Services.

Based on review of facility policies as well as observations and interviews with staff it was determined that the facility failed to serve food in accordance with professional standards for food service safety. Findings include: The facility's policies regarding food handling, dated January 8, 2026, indicated that staff should avoid handling actual unwrapped food items with bare hands. Observations during lunch on August 4, 2026, at 11:54 a.m., of Hospice Registered Nurse 2 preparing resident 56 tray and touching the resident's dinner roll with her bare hands. Interview with Hospice Registered Nurse 2 on August 4, 2026, at 12:36 p.m. confirmed that she should have worn gloves when handling the resident's dinner roll. Interview with the Administration on August 4, 2026, at 3:45 p.m. confirmed that the hospice RN should have worn gloves. 28 Pa. Code 211.6(f) Dietary Services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that care and services were provided according to accepted standards of practice for two of 34 residents reviewed (Residents 1 and 55). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated June 3, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, received insulin (medication used to lower blood sugar levels), and had diagnoses including diabetes. Physician's orders for Resident 1, dated June 9, 2026, and July 1, 2026, included orders for the resident to receive 10 units of Novolog insulin (insulin aspart-a fast-acting insulin) subcutaneously with meals. A review of Resident 1's Medication Administration Record (MAR) for June and July 2026, revealed that 10 units of Novolog insulin was held on June 25 at 5:26 p.m. for a blood sugar of 98 milligrams per deciliter (mg/dl); on July 1 at 5:03 p.m. for a blood sugar of 86 mg/dl; on July 13 at 6:16 p.m. for a blood sugar of 84 mg/dl; and on July 23 at 6:06 p.m. for a blood sugar of 85 mg/dl. Physician's orders for Resident 1, dated June 17, 2026, included orders for the resident to receive 28 units of Lantus insulin (long-acting insulin) subcutaneously every 12 hours. A review of Resident 1's MAR for July 2026, revealed that 28 units of Lantus insulin was held on July 8 at 8:07 p.m. for a blood sugar of 71 mg/dl; and on July 17 at 8:20 p.m. for a blood sugar of 94 mg/dl. Interview with the Nursing Home Administrator on August 5, 2026, at 12:29 p.m. confirmed that Resident 1's Novolog and Lantus insulins were held and there were no physician's orders to hold the insulins, and there was no documented evidence that the physician gave orders to hold the insulins on the above-mentioned dates and times. A quarterly MDS assessment for Resident 55, dated May 6, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included hypertension (high blood pressure). Physician's orders for Resident 55, dated January 30, 2026, included an order for Metoprolol Tartrate (blood pressure medication) 25 mg every morning and bedtime. A physician's order dated July 16, 2026 included an order for staff to hold Resident 55's Metoprolol and obtain vital signs twice a day for seven days and for the provider to assess the appropriateness of the Metoprolol by reviewing the resident's vital signs.There was no documented evidence in Resident 55's clinical record to indicate that vital signs were obtained as ordered by the provider to assess the appropriateness of the Metoprolol. Review of Resident 55's Medication Administration Record for July 2026, revealed that the order for Metoprolol was resumed on July 26, 2026 without any communication with the physician.Interview with the Director of Nursing on August 6, 2026, at 8:40 a.m. confirmed that the facility failed to communicate with the provider prior to restarting the order for Metoprolol. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to provide dependent residents the necessary services to maintain nutritional status for one of 34 residents reviewed (Resident 51).Findings include: A facility policy regarding Activities of Daily Living, dated March 31, 2026, indicated that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 51, dated June 27, 2026, revealed that the resident was cognitively impaired, required substantial/maximum assistance with eating, required a mechanically altered diet, and had diagnoses that included cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain). A care plan for the resident, initiated April 6, 2026, indicated that she required cueing and prompting at mealtimes to feed herself as much as possible and staff were to assist as needed. A physician's order for Resident 51, dated March 30, 2026, revealed that the resident received a regular diet, mechanical soft, ground texture with nectar consistency liquids and required supervision and assistance with meals. Observations in the third-floor dining room on August 3, 2026, at 11:43 a.m. revealed that Resident 51 was sitting in her broda chair at a dining room table and staff delivered her lunch tray and uncovered her food. At 11:50 a.m., the resident was sitting in her broda chair in the dining room with her eyes closed and she was not attempting to feed herself. No staff attempted to assist her with her meal, or cue her to eat. At 12:17 p.m., the resident continued to sit at the dining room table with her lunch in front of her and she was not attempting to feed herself. No staff attempted to feed her, or cue her to eat. At 12:22 p.m., the resident continued to sit at the dining room table with her lunch in front of her. No staff attempted to feed her, or cue her to eat. At 12:28 p.m., Nurse Aide 1 sat down to feed the resident. Interview with Nurse Aide 1 on August 3, 2026, at 12:32 p.m. indicated that they are to try and have Resident 51 attempt to feed herself, but she usually needs assistance with feeding. The resident did not attempt to feed herself from the time the tray was served at 11:43 a.m. until Nurse Aide 1 sat down to feed her at 12:28 p.m. No staff attempted to assist her with her meal or cue her to eat. She was receptive to food when Nurse Aide 1 started to feed her. Review of Resident 51's ADL documentation for August 1 and 2, 2026, for the breakfast, lunch and supper meals and for August 3, 2026, for the breakfast meal revealed that the resident was dependent on staff for eating assistance. ADL documentation for August 3, 2026, for the 12:30 p.m. lunch meal indicated that the resident required set up assistance for eating when it was observed that the resident did not attempt to feed herself and required total assistance from staff for eating. Interview with Nursing Home Administrator on August 3, 2026, at 12:34 p.m. confirmed that staff should have assisted Resident 51 to eat. Interview with Nurse Aide 1 on August 4, 2026, at 12:28 p.m. confirmed that Resident 51 required total assistance with eating the lunch meal on August 3, 2026. She indicated that they are to set her up, but she needed total assistance with eating, otherwise she would not eat. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility documents, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident and staff environment was maintained in a safe and sanitary environment in one of two medication rooms (third floor). Findings include: Observations of the third-floor medication room on June 29, 2026, at 9:47 a.m. revealed that upon entering the medication room there was a strong musty odor. The ceiling had an area approximately two feet in diameter that was discolored, water damaged and had loose plaster and tape. There was a basin on the floor that contained water. The medication room contained the Pyxis machine (medication dispensing machine) and over the counter medications stored in cabinets. An e-mail communication, dated May 26, 2026, revealed that there were several roof leaks that were coming in on the third floor. The roof was in bad shape with shingles missing, waterways cracked and open, missing caps, nails popped up, and rotted plywood. A quote was received regarding the cost of the materials required to repair the roof. An e-mail communication, dated June 8, 2026, revealed that approval was received to purchase the materials to repair the roof with a debit card and the worker wanted to start that week. An email communication, dated June 29, 2026, included a quote for the cost of the roof, however there was no documented evidence that any materials had actually been purchased to repair the leaking roof and medication room ceiling. Interview with the Director of Nursing on June 29, 2026, at 9:47 a.m. revealed that the damage to the ceiling was caused by the roof leaking. Interview with Registered Nurse Supervisor 1 on June 29, 2026, at 9:51 a.m. revealed the roof has been leaking for the past few months. Interview with the Nursing Home Administrator on June 29, 2026, at 3:35 p.m. indicated that the condition of the third-floor medication room ceiling and leaking roof was not affecting the residents, and that coming up with the money to repair the roof was not easy. 28 Pa. Code 207.2(a) Administrator's Responsibility

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to change an indwelling urinary catheter as ordered by the physician and to change an indwelling urinary catheter as recommended by the urologist for two of four residents reviewed (Residents 1, 2).Findings include:The facility policy for urinary catheter care, dated January 8, 2026, indicated that changing indwelling catheters or drainage bags at routine, fixed intervals, was not recommended. Rather it was suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 11, 2026, revealed that the resident was cognitively intact, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition).Physician's orders for Resident 1, dated October 27, 2025, included an order for the resident to have her suprapubic urinary catheter (tube inserted through the lower abdomen into the bladder to drain urine) changed every six weeks. A care plan, dated January 3, 2024, revealed that the suprapubic catheter was to be changed as ordered.A review of Resident 1's Treatment Administration Records (TAR's) for January 2026 revealed that Resident 1's urinary catheter was not changed on January 27, 2026, as ordered.Interview with the Director of Nursing on May 5, 2026, at 1:25 p.m. confirmed that there was no documented evidence that Resident 1's suprapubic catheter was changed as ordered on January 27, 2026. A quarterly MDS assessment for Resident 3, dated March 31, 2026, revealed that the resident was moderately cognitively impaired and had an indwelling urinary catheter. Physician's orders, dated December 24, 2025, included orders for the resident to have a Foley catheter (a flexible tube inserted and held in the bladder to drain urine) for obstructive uropathy (blockage in the urinary system) and bladder prolapse (bladder is not supported and descends).A urology consult for Resident 2, dated March 13, 2026, indicated that they were not able to fit her with a pessary (device used to support pelvic structure) and it was recommended to change the resident's Foley catheter every four weeks.A review of Resident 2's TAR's for April 2026 revealed that her urinary catheter was not changed in April 2026, as recommended by the urologist (physician who specializes in the urinary system).Interview with the Director of Nursing on May 5, 2026, at 10:55 a.m. confirmed that there was no documented evidence that Resident 2's Foley catheter was changed as recommended by the Urologist. She indicated that the facility did not change catheters on regular intervals.28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 6 residents reviewed (Resident 2).Findings include: A facility policy related to controlled substances, dated April 7, 2025, indicated that waste and/or disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated January 15, 2026, indicated that the resident was cognitively impaired, was dependent for care needs, had signs indicating delirium, received controlled medications including antianxiety medications (used to treat anxiety), and had diagnoses that included dementia, anxiety, depression and psychotic disorder. Physician's orders for Resident 2, dated January 14, 2026, included orders for the resident to receive a 0.5 milligram (mg) tablet of Ativan (a controlled medication used to treat anxiety) twice daily with instructions to cut the pill in half to equal 0.25 mg. The Medication Administration Record (MAR) for Resident 2, dated January 2026, revealed that the resident was to receive 0.25 mg of Ativan twice daily. Review of a controlled drug count record (tracks each dose of a controlled medication) for Resident 2, revealed that the tablets of Ativan on hand at that time were 0.5 mg tablets and the staff were cutting the tablets in half to administer 0.25 mg of Ativan twice daily. The other 0.25 mg half tablet of Ativan was to be disposed of in the presence of the nurse and a witness who would also sign the disposition sheet. There was no documented evidence on the controlled drug count record that two staff members signed that the other 0.25 mg tablet of Ativan was disposed of on the following dates and times: January 17, 2026, at 7:55 p.m.; January 21, 2026, at 8:12 a.m.; January 23, 2026, at 8:16 p.m.; January 28, 2026, at 7:26 p.m.; and January 31, 2026, at 9:07 p.m. Interview with the Director of Nursing on February 18, 2026, at 3:11 p.m. confirmed that there was no documented evidence that two staff members witnessed and signed that the other 0.25 mg half tablets of Resident 2's 0.5 mg tablets of Ativan were disposed of on the above-mentioned dates and times. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.Findings include: The facility's policy regarding food safety requirements, dated April 7, 2025 indicated that foods and beverages shall be distributed and served in a manner that is palatable, and the temperatures will be at the recommended temperatures per the Federal Food Code temperature Requirements which states that hot food must be held at 135 degrees Fahrenheit or higher.Observations in the kitchen for the lunch meal service on September 17, 2025, at 11:31 a.m. revealed that a test tray left the kitchen and arrived on the west wing at 12:01 p.m. The lunch meal on September 17, 2025, consisted of baked fish, rice, and mixed vegetables. Trays were passed to the residents in their rooms, and the last resident was served and eating at 12:06 p.m. The test tray on September 17, 2025, at 12:06 p.m. revealed that the temperature of the baked fish was 122.8 degrees Fahrenheit, rice was 143.3 degrees Fahrenheit, the mixed vegetables were 119.0 degrees Fahrenheit, the mechanically altered fish was 144.3 degrees Fahrenheit, and the mechanically altered rice was 147.1 degrees Fahrenheit. The mixed vegetables were cold and unpalatable and the fish was not at the appropriate holding temperature.Interview with the Dietary Director on September 17, 2025, at 12:09 p.m. confirmed that food should be served at correct temperatures and be palatable.

Review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans after an incident for one of 5 residents reviewed (Resident 2). Findings include: The facility's policy regarding care plans, dated April 7, 2025, indicated that the care plan will be reviewed and revised to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 21, 2025, indicated that the resident was cognitively intact, could understand and was understood, required assistance from staff for her daily care needs and had diagnoses that included, morbid obesity, anxiety and chronic migraines. A care plan, revised July 14, 2025, indicated that Resident 1 had the potential to be verbally aggressive related to ineffective coping skills. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 3, 2025, indicated that the resident was severely cognitively impaired, makes himself understood and rarely understands, required assistance from staff for his daily care needs and had diagnoses that included, paranoid schizophrenia and intellectual inabilities. A care plan, revised February 7, 2025, indicated that Resident 2 had the potential to be physically aggressive (hitting others), a history of harm to others and poor impulse control. Nursing notes dated September 3, 2025, indicated that Resident 1 and Resident 2 had an altercation/incident in the 3 west hallway. Resident 1 was in her electric wheel chair attempting to pass Resident 2 who was in his wheelchair. The residents came in close proximity to each other and Resident 2 hit Resident 1 on the arm six times. A review of Resident 2's care plan revealed no documented evidence that new interventions were attempted or implemented after the incident on September 3, 2025, to prevent similar incidents of physical abuse in the future. Interview with the Nursing Home Administrator on September 17, 2025, at 3:05 p.m. indicated that in her viewpoint, the facility was following the care plan and was not sure what other intervention they could put in place to prevent him from further altercations with Resident 1 or other residents. 28 Pa. Code 211.11(d) Resident care plan.

Based on Review of Pennsylvania's Nursing Practice Act and information submitted from the facility, it was determined that the facility failed to ensure that a licensed practical nurse's license remained current for one of one licensed practical nurse's reviewed (Licensed Practical Nurse 2). This was cited as past non-compliance.Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, for the expiration and renewal of licensure revealed that notice of the renewal period of a license will be sent to each active licensee prior to the expiration date of the licensee's license. The applicant for license renewal may complete and submit an application online or may mail a completed application form to the Board's administrative office. When applying for licensure renewal, a registered nurse shall complete and submit the renewal application, including disclosing any license to practice nursing or any allied health profession in any other state, territory, possession or country, pay the biennial renewal fee, verify the completion of mandatory continuing education and child abuse recognition and reporting requirements, disclose any discipline imposed by a state licensing board on any nursing or allied health profession license or certificate in the previous biennial period, and any criminal charges pending or criminal conviction, plea of guilty or nolo contendere, admission into a probation without verdict, or accelerated rehabilitation during the previous biennial period.Information submitted by the facility staff on [DATE], revealed that Licensed Practical Nurse 2's license expired on [DATE], and that she continued to work from [DATE], until a whole house audit on [DATE] revealed that her license had expired. No care concerns were identified during this time.Licensed Practical Nurse 2 was immediately removed from the schedule and not permitted to return to work until she renewed her license on [DATE]. An interview with the Human Resources Director on [DATE] at 11:06 a.m. revealed that the facility suspended License Practical Nurse 2 when they learned that her license had expired and that she was not permitted to return to work until she renewed her licensed on [DATE]. The facility's corrective actions taken following the incident included:1. An immediate audit of all licensed staff was conducted and results were reviewed.2. The licensed practical nurse was suspended and disciplined for failing to renew her license timely.3. Staff education was completed regarding renewing their licenses prior to expiration. All of the staff was educated by [DATE].4. Monthly audits will be completed and reviewed at QAPI meetings.5. Human Resources will now offer reminders to the staff prior to expiration.6. Human Resources will offer support to staff who may struggle to use the computer to renew.7. On-going audits will be submitted to the facility's QAPI meetings as appropriate for review.Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F658 on [DATE].28 Pa. Code 201.14(a) Responsibility of license.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 28 residents reviewed (Resident 3).Findings include:The facility's policy regarding laboratory services and reporting, dated April 7, 2025, revealed that the facility would provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility would provide or obtain laboratory services to meet the needs of its residents.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 25, 2025, revealed that the resident was cognitively intact and had diagnoses that included hypothyroidism (when the thyroid gland doesn't make and release enough hormone into your bloodstream). A pharmacy review for Resident 3, dated May 3, 2025 revealed the resident was taking levothyroxine (medication used to treat hypothyroidism) and to consider monitoring TSH/thyroid panel (thyroid stimulating hormone-hormone produced by the pituitary gland). Physician's orders for Resident 3, dated May 14, 2025, included an order for staff to obtain a TSH level for hypothyroidism when the next labs were drawn. A care plan, dated July 14, 2022, revealed the resident had hypothyroidism and labs were to be obtained as ordered.Laboratory results, dated June 2, 2025, revealed that the TSH level was not included with the laboratory tests that were drawn that day.Interview with Director of Nursing on July 29, 2025, at 3:14 p.m. confirmed that there was no documented evidence that Resident 3's TSH level was drawn as ordered.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 28 residents reviewed (Residents 3, 38, 52). Findings include:The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day assessment period and Section N0415K1 was to be checked if the resident received an anticonvulsant medication during the seven-day assessment period.Physician's orders for Resident 3 dated May 1, 2025, included an order for the resident to receive 300 milligrams (mg) of Gabapentin two times a day for diabetic neuropathy (nerve damage that can cause pain, numbness, tingling, and weakness in the hands and feet, and sometimes other parts of the body). The resident's Medication Administration Record (MAR) for May 2025 revealed that the resident received Gabapentin twice a day from May 1 through 28, 2025.A quarterly MDS assessment for Resident 3, dated May 24, 2025, revealed that Section N0415K1 was not checked, indicating that the resident did not receive any anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 38 dated March 18, 2024, included an order for the resident to receive 100 mg of Pregabalin three times a day for neuropathy. The resident's Medication Administration Record (MAR) for May 2025 revealed that the resident received Pregabalin three times a day from May 1 through 31, 2025.A quarterly MDS assessment for Resident 38, dated May 9, 2025, revealed that Section N0415K1 was not checked, indicating that the resident did not receive any anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 53 dated May 1, 2025, included an order for the resident to have 1% Silvadene External Cream (antibiotic) applied to the sacrum gluteal fold (horizontal crease or fold located at the base of the buttocks) every day and evening shift for wounds. The resident's Treatment Administration Records (TAR's) for May 2025 revealed that the resident received Silvadene External Cream every day and evening from May 2 through 10, 2025.A quarterly MDS assessment for Resident 53, dated May 9, 2025, revealed that Section N0415F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period. An interview with the Director of Nursing on July 30, 2025, at 2:59 p.m. confirmed that assessments for Residents 3, 38, and 53 were coded incorrectly.28 Pa. Code 211.5(f) Medical records.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 28 residents reviewed (Residents 4 and 9). A facility policy for Care Plan Revisions Upon Status Change dated April 7, 2025, indicated that the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 4 dated May 2, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included Multiple Sclerosis (disease in which the immune system eats away at the protective covering of nerves). The Care plan for Resident 4 dated October 13, 2023, indicated that the resident was receiving diuretic therapy (water pills, to increase urine production and help the body eliminate excess fluid and sodium). Review of the Medication Administration Record (MAR) for Resident 4 dated July 2025, revealed no documented evidence that the resident was receiving a diuretic medication. An interview with Licensed Practical Nurse Assessment Coordinator on July 31, 2025, at 9:53 am confirmed that Resident 4 was not receiving diuretic medications and that Resident 4's care plan should have been revised to reflect that, however it was not. An admission MDS assessment for Resident 9 dated July 2, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses that included necrotizing fasciitis (a severe bacterial infection that rapidly destroys skin, fat, and muscle tissue).The Care plan for Resident 9 dated July 3, 2025, indicated that the resident was receiving anticoagulant therapy (medications that prevent blood clots from forming or existing clots from getting larger).Review of the MAR for Resident 9 revealed that the resident had not received any anticoagulant medications since July 8, 2025.An interview with the Nursing Home Administration on July 31, 2025, at 12:04 p.m. revealed that the Resident 9 was no longer receiving anticoagulant medication and that his care plan should have been revised to reflect that, however, it was not. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders related to bowel protocols for one of 28 residents reviewed (Resident 42).Findings include:A facility policy for Bowel Movements Monitoring dated April 7, 2025, indicated that all residents' bowel movements will be documented. If a resident has not had a bowel movement for three full days, the licensed nurse will follow bowel protocol as ordered by the physician. All shifts will then monitor for effectiveness. If initial laxative is ineffective, then a second laxative if ordered is given as per order. Resident will be monitored on all shifts for bowel movements to see if second laxative was effective. If the second laxative was ineffective, then an enema will be given per physician order. All three shifts will monitor resident for bowel movement to see if enema was effective. If enema is ineffective, notify the physician.A quarterly MDS assessment for Resident 42 dated July 3, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, was always incontinent of bowel, and had diagnoses that included paranoid schizophrenia (a chronic mental health condition characterized by persistent delusions and hallucinations). Physician's orders for Resident 42, dated May 10, 2022, included an order for the resident to receive 30 milliliters (ml) of Milk of Magnesia Suspension (laxative- used to produce a bowel movement) as needed for constipation if no bowel movement by the third day/nine shifts and document effectiveness. Resident 42's bowel movement records dated June 2025 and July 2025 indicated that the resident did not have a bowel movement on June 17, 2025, through June 23, 2025. There was no documented evidence that 30 ml of Milk of Magnesia Suspension was offered to or refused by the resident after the third day/ninth shift of no bowel movement. Review of the Medication Administration Record dated June 2025, revealed 30 ml of Milk of Magnesia Suspension was administered on June 21, 2025, five days after no bowel movement, however, it was ineffective, and no further interventions were provided. Bowel movement records revealed that Resident 42 did not have a bowel movement for five days from July 11, 2025, through July 15, 2025. There was no documented evidence that 30 ml of Milk of Magnesia Suspension was offered or declined after three days/nine shifts of no bowel movement. Bowel movement records revealed that the resident did not have a bowel movement on July 18, 2025, through July 25, 2025, however there was no documented evidence that the resident was offered or declined 30 milliliters (ml) of Milk of Magnesia Suspension after three days/nine shifts of no bowel movement.Interview with the Director of Nursing on July 30, 2025, confirmed that the staff did not follow the facility's bowel policy and physician's orders for Resident 42 on the above-mentioned dates. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that staff renewed their nurse aide registry to allow individuals to work as a nurse aide for one of three nurse aides reviewed (Nurse Aide 3). Findings include:The facility's job description, undated, revealed that a nurse aide certification was necessary to perform functions of the position. This was cited as past-noncompliance.The personnel file for agency Nurse Aide 3 revealed that her certification on the nurse aide registry expired on [DATE]. The facility was unaware that Nurse Aide 3's certification on the nurse aide registry had expired until they were notified on [DATE], by Nurse Aide 3. Nurse Aide 3 worked in the facility from [DATE] through [DATE] and was immediately removed from the schedule when it was discovered that her registry had expired. Interview with the Director of Human Resources on [DATE] at 11:06 a.m. confirmed that Nurse Aide 3's certification on the nurse aide registry expired on [DATE], and should have been renewed prior to expiring and that she continued to work from [DATE] until [DATE] when it was discovered.The facility's corrective actions taken following the incident included:1. An immediate audit of all nurse aides was conducted and results were reviewed.2. The nurse aide was suspended and disciplined for failing to renew her registry timely.3. Staff education was completed regarding renewing their registry prior to expiration. All of the staff was educated by [DATE].4. Monthly audits will be completed and reviewed at QAPI meetings.5. Human Resources will now offer reminders to the staff prior to expiration.6. Human Resources will offer support to staff who may struggle to use the computer to renew.7. On-going audits will be submitted to the facility's QAPI meetings as appropriate for review.Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F658 on [DATE].28 Pa. Code 201.29 Personnel policies and procedures.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 28 residents reviewed (Resident 37). Findings include:The facility's policy regarding labeling of medications, dated April 7, 2025, indicated that all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Labels for individual drug containers must include appropriate instructions and precautions. The pharmacy must be informed of any changes or changes in directions for use of the medication. Physician's orders for Resident 37, dated July 1, 2025, indicated that the resident was to receive two 300 milligram (mg) capsules of Gabapentin (a medication used to treat nerve pain) daily and one 300 mg capsule of Gabapentin at bedtime. Observations during the medication administration on July 31, 2025, at 8:24 a.m. revealed that Licensed Practical Nurse 1 obtained Resident 37's blister pack (commonly used as unit-dose packaging for pharmaceutical tablets, capsules or lozenges) containing the resident's Gabapentin. The label on the blister pack containing the Gabapentin revealed that the resident was to receive one 300 mg capsule of Gabapentin daily and two 300 mg capsules of Gabapentin at bedtime. Interview with Licensed Practical Nurse 1 at the time of observation confirmed that the label on the blister pack containing the resident's Gabapentin did not match the resident's current orders for Gabapentin and that there should have been a change in direction sticker (a label used to indicate that a change has been made to the instructions or directions for something, often medication or a process) on the blister pack containing the resident's Gabapentin. Interview with the Director of Nursing on July 31, 2025, at 1:48 p.m. confirmed that there should have been a change in direction sticker on Resident 37's blister pack of Gabapentin to alert staff of the change in orders. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(3) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of three residents reviewed (Resident 1).Findings include:The facility's policy regarding medication administration, dated April 7, 2025, indicated that the individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.The facility's policy regarding controlled substance administration, dated April 7, 2025, states that an individual controlled substance record is made for each resident who will be receiving a controlled substance.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 14, 2025, revealed that the resident is cognitively intact, required assistance for daily care needs, and had medical diagnosis that include lumbosacral disc displacement.Physician's orders for Resident 1, dated May 3, 2025, included an order for the resident to receive two milligrams (mg) tablet of Dilaudid (a controlled narcotic pain medication) every six hours as needed for severe pain.A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 1, for April and May 2025 indicated that a 2 mg tablet of Dilaudid was signed out for the resident on April 14, 2025 at 9:50 p.m., May 12, 2025 at 4:47 p. m., and June 7, 2025 at 10:40 a.m. However, there was no documented evidence in the resident's Medication Administration (MAR) that the signed-out tablets of Dilaudid were administered to the resident on these dates.Interview with the Director of Nursing on July 2, 2025, at 1:46 p.m. confirmed that there was no documented evidence to indicate that Resident 1 actually received the doses of Dilaudid on the dates listed above dates.28 Pa. Code 211.9(h) Pharmacy services.28 Pa. Code 211.12(d)(1) Nursing service28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation of medications for one of five residents reviewed (Resident 3).Findings include:The facility's policy regarding controlled narcotics dated April 7, 2025, indicated that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the comprehensive drug abuse prevention and control act of 1976). Misappropriation was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent example drug diversion (taking the residents medication).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 29, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had medical diagnoses that included peripheral vascular disease (affects blood circulation to lower legs).Physician's orders for Resident 3, dated March 27, 2025, included orders for the resident to receive 30 milligrams of Morphine (a controlled narcotic used for pain) every twelve hours for pain.The controlled drug record for Resident 3 for April 2025 indicated that three doses of Morphine were signed out on April 28, 2025 at 7:00 a.m.An investigation report, dated May 6, 2025, revealed that Resident 3's medication packet containing Morphine was missing three 30 mg doses and that Licensed Practical Nurse 1 misappropriated the Morphine tablets and had replaced them with other pills.Interview with the Director of Nursing on July 2, 2025, at 4:14 p.m. confirmed that Resident 3's Morphine was taken by Licensed Practical Nurse 1. She indicated that the police were notified and Licensed Practical Nurse 1 was referred to the Pennsylvania Department of State.28 Pa. Code 201.14(a) Responsibility of License.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that podiatry appointments were carried out, failed to follow podiatry recommendations, failed to provide weekly surgical wound assessments, and failed to provide treatments for an ingrown toenail resulting in an infection and pain for one of three residents reviewed (Resident 2). Findings include: An interview with the Resident 2 on September 27, 2023, revealed that she had concerns about cancelled podiatry appointments. One appointment was cancelled because she was late, but the other appointment was cancelled for an unknown reason, and she was not informed the reason. Resident 2 explained that she has been on treatments for an ingrown toenail for months now. She has been on multiple antibiotic medications, and it continues to be painful, red, and infected. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 30, 2023, revealed that the resident was understood, could understand, and required extensive assistance with all care with the exception of eating. Physician's orders, dated June 12, 2023, included an order for Resident 2 to receive 500 milligrams (mg) of Cefuroxime Axetil (antibiotic) twice a day for seven days for a right ingrown toenail. Nursing notes for Resident 2, dated June 18, 2023, revealed that the resident complained about the ingrown toenail on her great right toe. The toe was red, swollen, and painful upon palpation multiples times. The provider was notified and new orders were received to see podiatry and to be administered 500 mg of Keflex twice a day for ten days. Physician's orders, dated June 19, 2023, included an order for the resident to receive 500 milligrams (mg) of Keflex (antibiotic) three times a day for ten days for a right ingrown toenail. A nursing note for Resident 2, dated June 27, 2023, revealed that the Certified Registered Nurse Practitioner (CRNP) was in to see the resident for a problem visit and removed an ingrown toenail. A social services note for Resident 2, dated July 6, 2023, revealed that the resident was seen by consult podiatry and will be followed up in two to three months. A nursing note for Resident 2, dated July 10, 2023, revealed that the resident complained of pain with her ingrown toenail on the great right toe. The toe was red and inflamed. Physician's orders, dated July 12, 2023, included an order for Resident 2 to receive 500 milligrams (mg) of Keflex twice a day for seven days for a right ingrown toenail. A nursing note for Resident 2, dated July 12, 2023, revealed that the CRNP ordered ten-minute warm-water soaks and a follow up with podiatry. The physician ordered Keflex antibiotic for a possible infection. A nursing note for Resident 2, dated July 17, 2023, revealed that the warm soaks were discontinued as the area resolved. A nursing note for Resident 2, dated June 24, 2023, revealed that the resident was scheduled for an appointment with an outside podiatry consultant on August 24, 2023. Resident 2 did not attend the outside podiatry appointment on August 24, 2023, because the appointment was cancelled by the facility. There was no documented evidence of who cancelled the appointment or why. An in-house podiatry consultation for Resident 2, dated September 7, 2023, indicated that the resident had debridement of toenails to remedy pain and decrease thickness to prevent further pain and ingrown toenails. The boarder of the great right toe was cauterized to promote healing and healthy nail regrowth. Recommendations included daily warm Epsom salt soaks to the right great toes for 14 days and daily treatments of triple antibiotic ointment and a dry sterile dressing for 14 days or until resolved. There was no documented evidence in Resident 2's clinical record to indicate that the in-house podiatry recommendations of September 7, 2023, were followed or that weekly surgical wound assessments were being done. Interview with the Social Worker on September 27, 2023, at 4:26 p.m. revealed that she reviews all in-house consult paperwork, schedules follow-up appointments, and forwards the recommendations to the Director of Nursing. The recommendations for Resident 2 were missed on the September 7, 2023, exam because the podiatry consults were written differently than other consults A nursing note for Resident 2, dated September 9, 2023, revealed that she complained of great right toe pain. A nursing note for Resident 2, dated September 11, 2023, revealed that the great right toenail was ingrown and the skin was surrounded by bloody drainage, was red, warm, and painful. Physician's orders, dated September 11, 2023, included an order for Resident 2 to have the right great toe cleansed with wound cleanser, patted dry, apply triple antibiotic ointment, cover with a band aid twice a day until healed, and 500 mg of Ceftin twice a day for 1 week. A nursing note for Resident 2, dated September 14, 2023, revealed that the resident complained of pain and was administered pain medication. A nursing note for Resident 2, dated September 15, 2023, revealed that the resident was scheduled for an outside podiatry consult on September 21, 2023. Interview with the Director of Nursing on September 27, 2023, at 4:15 p.m. revealed that Resident 2 did not see the podiatrist on September 21, 2023, because the transportation service was late, so the resident arrived late and the appointment had to be rescheduled. The DON also confirmed that the podiatry appointment on August 24, 2023, was cancelled but did not know why, and podiatry recommendations from September 7, 2023, were not followed because she did not receive the consult podiatry paperwork from the social worker until September 26, 2023. Interview with the Director of Nursing on September 28, 2023, at 10:46 a.m. revealed that there were no weekly assessments completed on the surgical wound after it was debrided on September 7, 2023, and that the practitioner who did the procedure would follow the wound and order any treatments, not the facility. 28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to adequately monitor residents' bowel function, ensure that physician's orders [REDACTED]. Immediate Jeopardy (Residents R1, R24) due to their risk for bowel complications. The facility also failed to follow bowel protocols for three additional residents who were at risk for constipation (Residents R3, R8, R10), and ensure that physician's orders [REDACTED]. Findings include: The facility's policy regarding bowel protocols, undated, indicated that residents were to receive 30 cubic centimeters (cc's) of Milk of Magnesia (an oral laxative) by mouth at bedtime if there was no bowel movement for two days. If the Milk of Magnesia was ineffective, the resident was to receive a 10 milligrams (mg) [MEDICATION NAME] suppository (a laxative inserted directly into the rectum) given rectally the next morning. If the [MEDICATION NAME] suppository did not produce a bowel movement, the resident was to then to receive a sodium [MEDICATION NAME] enema (liquid instilled into the rectum in order to stimulate a bowel movement) in the evening, of the same day, that the suppository was given. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R1, dated June 30, 2016, indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. In addition, the physician's orders [REDACTED]. Milk of Magnesia to be given at bedtime if the bowels did not move for two days, a 10 mg [MEDICATION NAME] suppository to be given the following morning if the Milk of Magnesia was not effective, and a Fleets Enema (liquid instilled into the rectum in order to stimulate a bowel movement) to be given at bedtime if the suppository was ineffective. Review of Resident R1's bowel movement documentation for June and July 2016 revealed that the resident did not have a bowel movement on June 28, 29 and 30, and July 1, 2 and 3, 2016 (6 days). The resident's Medication Administration Records (MAR's) revealed that on July 4, 2016, the staff administered a 10 mg [MEDICATION NAME] suppository at 6:10 a.m. There was no documented evidence that the bowel protocol was initiated during the evening on June 29, 2016 (the second day) by administering the Milk of Magnesia, followed by the [MEDICATION NAME] suppository in the morning of June 30, 2016, and then a Fleets Enema in the evening of June 30, 2016, as ordered by the physician. An interview with the Director of Nursing on December 22, 2016, at 3:00 p.m. confirmed that that the bowel protocol should have been initiated for Resident R1 by administering Milk of Magnesia at bedtime on June 29, 2016, and then following the rest of the protocol if there were no bowel movements. Resident R1's bowel movement records showed that after having a single medium-sized bowel movement on July 4, 2016, the resident did not have a bowel movement on July 5 and 6, 2016, and there was no documented evidence that the bowel protocol was initiated on July 6, 2016, by administering Milk of Magnesia at bedtime. However, the resident's MAR's revealed that staff administered 30 cc's of Milk of Magnesia at 6:08 p.m. on July 7, 2016 (the third day without a bowel movement), and then a [MEDICATION NAME] suppository on July 8, 2016, at 5:54 a.m. which was effective for a large amount of stool. A nursing note for Resident R1, dated July 8, 2016, at 5:55 p.m. revealed that the resident vomited a moderate amount of brown liquid, and the physician gave an order for [REDACTED]. A nursing note for Resident R1, dated July 10, 2016, at 4:04 p.m. revealed that the resident returned from the hospital with a [DIAGNOSES REDACTED]. Bowel movement records revealed that the resident did not have a bowel movement after returning from the hospital on July 10, 2016, and did not have a bowel movement on July 11 and 12, 2016. There was no documented evidence that the bowel protocol was initiated on July 11, 2016, and no documented evidence that the nursing staff sought clarification from the physician as to whether or not to use the bowel protocol that was previously ordered. A nursing note for Resident R1, dated July 12, 2016, at 8:10 a.m. revealed that the resident vomited a bright green substance with dark flecks, that her abdomen was slightly firm and distended, and that the resident's physician was made aware and ordered an abdominal x-ray, which revealed a mild colonic ileus. Resident R1's MAR's revealed that staff administered Milk of Magnesia on July 13, 2016 at 5:08 p.m., a [MEDICATION NAME] suppository on July 14, 2016 at 6:04 a.m., followed by a Fleets enema on July 14, 2016 at 11:46 p.m., which was effective for two bowel movements on July 15, 2016. The resident's bowel records then revealed that she did not have a bowel movement on July 16 or 17, 2016, and the MAR's revealed that the bowel protocol was not initiated as ordered on the evening of July 17, 2016. The MAR's revealed that the bowel protocol was not initiated until the evening of July 18, 2016, at 8:23 p.m. the resident's third day without a bowel movement. A nursing note for Resident R1, dated July 21, 2016, at 4:17 p.m. revealed that the resident's physician was in the building and was informed that the resident had a decrease in her appetite to almost no intake and would not take any medications. The physician examined the resident and found that her abdomen was becoming firm, and an X-ray of the abdomen was ordered, revealed an ileus, and the resident was transferred to the hospital on July 22, 2016. While hospitalized , a CT scan of the abdomen, dated July 22, 2016, revealed a small amount of free intraperitoneal air (gas trapped within the peritoneal cavity but outside the bowel which could be due to perforation of the bowel) and pneumotosis intestinalis (gas within the bowel walls) in the right lower quadrant. The resident was transferred from that hospital to another hospital where the CT scan was repeated on July 24, 2016, and revealed a large fecal impaction that was about eight centimeters (cm) in length, with stool occupying most of the rest of the colon. Nursing notes revealed that Resident R1 returned to the facility on [DATE], and that her last bowel movement at the hospital was on July 24, 2016. Bowel movement documentation revealed that Resident R1 did not have a bowel movement on July 25, 26 and 27, 2016, and the bowel protocol, which was ordered to start on the evening of day two without a bowel movement (July 26), was not started until July 28, 2016, at 11:48 p.m. when staff attempted to administer Milk of Magnesia, but the resident would not open her mouth. The resident's MAR's indicated that staff attempted to administer a dose of Milk of Magnesia again at 4:55 a.m. on July 29, 2016, but the resident was sleeping and instead was given a 10 mg [MEDICATION NAME] suppository at 4:56 a.m. on July 29, 2016, which was effective for a medium-sized bowel movement; however, the bowel movement records indicated that the resident did not have a bowel movement until July 30, 2016. Even though the [MEDICATION NAME] suppository was documented as effective, Resident R1's MAR's indicated that a Fleets enema was administered at 10:31 p.m. on July 29, 2016. Resident R1's bowel records revealed that she did not have a bowel movement on August 10 through 16, 2016, and the resident's MAR's revealed that the bowel protocol was not initiated on the evening of August 11, 2016, as ordered. Milk of Magnesia was not administered until August 12, 2016, at 5:22 p.m., followed by a [MEDICATION NAME] suppository on August 13, 2016, at 6:44 a.m., and then a Fleets enema on the evening of August 13, 2016, at 10:45 p.m. The MAR's showed that Milk of Magnesia was administered again on August 14, 2016, at 8:21 p.m., followed by another [MEDICATION NAME] suppository on August 15, 2016, at 5:56 a.m., and then a Fleets enema on the evening of August 15, 2016, at 10:06 p.m. There was no documented evidence that the physician was notified that Resident R1 did not have a bowel movement after receiving all three steps of the bowel protocol on August 13, 2016. There was no evidence the physician was notified until August 16, 2016, at 12:25 a.m. when the registered nurse was notified that the resident vomited and was found to have a distended abdomen with no bowel sounds (the noise produced by movement of intestinal contents). The physician was informed that the resident had the above symptoms and had not moved her bowels in six days, and he ordered the resident to be transferred to the local emergency department. Nursing notes, dated August 16, 2016, revealed that Resident R1 was transferred from the local emergency room to a different hospital for a bowel obstruction. A nursing note for Resident R1, dated August 18, 2016, at 4:15 p.m. revealed that the resident would be returning to the facilty that day after an admission to the hospital for a perforated (ruptured) bowel, and a CT scan of the abdomen confirmed the perforation, but surgery was not indicated, and the resident was placed [MEDICATION NAME] (antibiotics frequently used to treat gastrointestinal infections). The radiologist's (a physician who specializes in using medical images to diagnose diseases and injuries) report for the CT scan of the abdomen, dated August 16, 2016, indicated the presence of free peritoneal air and [MEDICATION NAME] (an accumulation of fluid between the membranous tissues that secure the abdominal contents in the abdominal cavity) in the sigmoid mesocolon (a fold of the membranous lining of the abdominal cavity that attaches the intestines to the wall of the abdominal cavity), consider the [MEDICATION NAME] or sigmoid colon as potentially the site of the perforation. The hospitalist's (physicians who only practice medicine in the acute care hospital setting) discharge summary for the resident's hospital stay for August 16-18, 2016, indicated that the discharge [DIAGNOSES REDACTED]. Upon return from the hospital, bowel records revealed that Resident R1 did not have a bowel movement on August 20, 21 and 22, 2016, and there was no documented evidence that the bowel protocol was initiated as ordered at bedtime on August 21, 2016. The resident's MAR's revealed that a [MEDICATION NAME] suppository was given at 4:30 a.m. on August 23, 2016 (the fourth day without a bowel movement). Resident R1's bowel records revealed that the resident did not have a bowel movement on August 24, 25 and 26, 2016, and there was no evidence that the bowel protocol was initiated as ordered. The resident did not have a bowel movement on August 28, 29, 30 and 31, and September 1, 2 and 3, 2016, and the MAR's revealed that the bowel protocol that should have been initiated on day two without a bowel movement (August 29) was not initiated until August 30, 2016. The MAR indicated [REDACTED]. Resident R1's bowel records for September 2016 revealed that the resident did not have a bowel movement on September 14, 15 and 16, 2016, and the bowel protocol was not initiated. The resident also did not have a bowel movement on September 21, 22, 23, 24 and 25, 2016, and the MAR's showed that the bowel protocol that was ordered to be initiated on September 22, 2016 (day two), was not initiated until September 25, 2016 (day five). Resident R1's bowel records for October 2016 revealed that the resident did not have a bowel movement on October 22, 23, 24 and 25, 2016, and there was no documented evidence that the bowel protocol was initiated. Resident R1's bowel records for November 2016 revealed that the resident did not have a bowel movement on November 5, 6 and 7, 2016, and the MAR's showed that the bowel protocol was not initiated on day two as ordered (November 6), and there was no documented evidence that it was initiated until November 8, 2016 (day four), when a [MEDICATION NAME] suppository was given at 4:54 a.m. The initial step of the bowel protocol (Milk of Magnesia) was not given. Resident R1 also did not have a bowel movement on November 13, 14 or 15, 2016, and the MAR's showed that the bowel protocol that should have been initiated on November 14, 2016 (day two), was not initiated until November 16, 2016 (day four), when a [MEDICATION NAME] suppository was given at 6:18 a.m. The initial step of the bowel protocol (Milk of Magnesia) was not given. The resident did not have a bowel movement on November 23, 24 and 25, 2016, and the MAR's showed that the bowel protocol was not initiated until November 26, 2016 (day four), when a [MEDICATION NAME] suppository was administered instead of Milk of Magnesia. Resident R1's bowel records for December 2016 revealed that the resident did not have a bowel movement on December 6, 7, 8, 9 or 10, 2016, and the bowel protocol was not initiated until December 10, 2016 (day five), when Milk of Magnesia was administered at 6:36 p.m. Interview with the Director of Nursing on December 22, 2016, at 3:00 p.m. confirmed that Resident R1's bowel protocol was to be initiated with Milk of Magnesia in the evening of the second day that the resident did not move their bowels. She confirmed that the bowel protocol was not consistently followed during July, August, September, October, November and December 2016. A comprehensive MDS assessment for Resident R24, dated November 18, 2016, revealed that the resident was cognitively impaired, dependent on staff for care, was continent of bowel function (could control bowel movements), and had [DIAGNOSES REDACTED]. effectiveness. A nursing note, dated September 12, 2016, at 12:46 p.m. indicated that the resident's physician was notified that the resident was having hard stool (bowel movement), and the physician gave an order for [REDACTED]. A nursing note for Resident R24, dated September 18, 2016, at 4:33 p.m. indicated that the resident complained of being constipated. There was no documented evidence that the resident's attending physician was notified about the resident's complaint until September 20, 2016, at 5:20 p.m. two days later, when the physician changed the orders from [MEDICATION NAME] 30 ml daily, to [MEDICATION NAME] 100 mg daily, at bedtime. A nursing note for Resident R24, dated September 23, 2016, at 12:25 p.m. indicated that the resident had a large, dark black vomitus with a foul odor that was positive for blood, and she complained of abdominal pain. At that time, the resident's attending physician was notified and the resident was transferred to the hospital emergency room . Hospital admission records, dated September 23, 2016, indicated that the resident was admitted with a questionable small bowel obstruction (blockage). An x-ray dated September 23, 2016, indicated that the resident had dilated large bowel loops, questionable for ileus and obstruction. A nursing note, dated September 24, 2016, at 3:00 p.m. indicated that the resident was admitted to the hospital for an ileus and small bowel obstruction. A nursing note, dated September 24, 2016, at 6:55 p.m. revealed that Resident R24 returned to the facility. physician's orders [REDACTED]. The resident's bowel records for October and November 2016 indicated that the resident did not have a bowel movement from October 22-26, and November 13-22, 2016, and there was no documented evidence that the resident's physician-ordered bowel protocol was implemented. An interview with the Director of Nursing on December 26, 2016, at 4:45 p.m. confirmed that staff should not have waited for two days prior to notifying the physician when Resident R24 complained of constipation. She also confirmed that the resident's bowel protocol was not followed when the resident returned from the hospital. On December 22, 2016, at 3:30 p.m. the Nursing Home Administrator was informed that due to the failure of the facility to follow the physician-ordered bowel protocols and notify the physician when medications for constipation were ineffective, that the health and safety of Residents R1 and R24 was in Immediate Jeopardy, due to the residents' risk for serious bowel complications. The facility submitted and implemented a plan to ensure the residents' safety by monitoring all residents to ensure that each resident's physician's orders [REDACTED]. [REDACTED]. A quarterly MDS assessment for Resident R8, dated November 16, 2016, revealed that the resident was alert and oriented, was incontinent of bowel and bladder, and required extensive assistance from staff for toileting and hygiene needs. The resident's care plan related to bowel elimination, dated August 11, 2015, revealed that in order to achieve a bowel movement at least every three days, staff were to monitor and evaluate the resident's bowel patterns and consistency, and provide bowel medication as ordered by the physician. physician's orders [REDACTED]. enema to be given at bedtime if the suppository was ineffective. Resident R8's bowel records for October 2016 revealed that the resident did not have a bowel movement on October 27, 28 and 29, 2016, and the resident's MAR's revealed no documented evidence that the physician's orders [REDACTED]. A comprehensive significant change MDS assessment for Resident R10, dated November 22, 2016, revealed that the resident was confused at times, and was incontinent of bowel, and required extensive assistance from staff for toileting and hygiene needs. The resident's care plan related to bowel elimination, dated November 4, 2016, revealed that the resident had a history of [REDACTED]. physician's orders [REDACTED]. Resident R10's bowel records for November and December 2016 revealed that the resident did not have a bowel movement on November 5, 6, 7, 8, 9 and 10, 2016, and the resident's MAR's revealed no documented evidence that the physician's orders [REDACTED]. The MAR's showed that [MEDICATION NAME] was not administered until November 10, 2016, at 8:42 p.m. (day six). The resident also did not have a bowel movement on December 16, 17 and 18, 2016, and the MAR's contained no documented evidence that physician-ordered bowel medications were initiated until a [MEDICATION NAME] suppository was administered on December 19, 2016, at 4:06 a.m. (day four). There was no documented evidence that [MEDICATION NAME] solution was administered at bedtime on day two without a bowel movement (December 17), as ordered by the physician. A quarterly MDS assessment for Resident R3, dated November 21, 2016, revealed that the resident was cognitively impaired, dependent for activities of daily living, and was incontinent of bowel function. The resident's care plan regarding constipation, dated October 14, 2016, indicated that the resident had an alteration in bowel function related to constipation, and staff were to provide bowel medication as ordered by the physician and monitor their use and effectiveness. physician's orders [REDACTED]. was ineffective. Resident R3's bowel records for November and December 2016 revealed that the resident did not have a bowel movement from November 23-26, 2016, and December 10-13, 2016. There was no documented evidence that the resident's physician-ordered bowel protocol was implemented. An interview with the Nursing Home Administrator on December 23, 2016, at 8:50 a.m. confirmed that the bowel protocols were not followed for the above residents. A quarterly MDS assessment for Resident R3, dated November 21, 2016, indicated that the resident had impaired range of motion of the upper extremities on one side. An occupational therapy evaluation for the possible development of a contracture (shortening or stiffing of muscle, skin, or connective tissue resulting in decreased movement) of the right upper extremity, dated October 31, 2016, indicated that the right hand was flaccid (having defective or absent muscle tone) and was noted to have [MEDICAL CONDITION] (swelling). A recommendation was made to keep the right arm elevated at all times with the use of a pillow. physician's orders [REDACTED]. hand was to be elevated when the resident was in bed or out of bed in a chair. Observations on December 21, 2016, at 12:15 p.m. and 12:50 p.m. revealed that Resident R3 was out of bed in her chair without a pillow underneath her right arm. An interview with Nurse Aide 7 on December 21, 2016, at 12:50 p.m. confirmed that Resident R3 did not have a pillow placed under her right arm, and she was not aware that the resident was to have a pillow in place. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services For Highest Well Being. Previously cited 11/13/15, 7/15/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/15/16, 11/13/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/15/16, 5/12/16, 4/7/16, 2/19/16, 11/13/15, 7/15/15, 12/8/14.