Every finding on record at Chambersburg Skilled Nursing and Rehabilitation Ce

Based on facility policy review, clinical record review, facility documentation review, and staff interviews, it was determined that the facility failed to ensure residents were free from resident to resident abuse by a resident with a history of abuse (Resident 1). This resulted in actual physical harm by Resident 1, as evidenced by multiple skin tears and bruising of a resident (Resident 2). Effective interventions were not put into place to protect residents from physical and psychosocial abuse. This failure resulted in an Immediate Jeopardy situation.Findings include: Facility policy, titled Abuse Prohibition, revised November 15, 2025, read in part, 5. Actions to prevent abuse.will include: 5.2 identifying, correcting, and interviewing in situations in which abuse.is more likely to occur. 6. Staff will identify events - such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse. 6.3.1 The Center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], and had diagnoses that included Alzheimer's disease (progressive brain disease that destroys memory and thinking skills) and intermittent explosive disorder (repeated sudden bouts of impulsive, aggressive violent behavior). Review of Resident 1's progress notes revealed that on March 28, 2026, staff documented that Resident 1 punched another resident on the head. Review of the facility's provided incident report dated March 28, 2026, at 2:15 PM, revealed that Resident 1 punched Resident 3 on top of the head with his fist. Resident 1 was placed on 1:1 supervision and Resident 3 was transferred to the emergency department for further evaluation. In a written statement dated March 28, 2026, Employee 1, Nurse Aide (Nurse Aide [NA]) stated Resident 3 was sitting in the hallway and shouted something to Resident 1. Resident 1 responded by punching Resident 3 in the head. Clinical record review revealed that Resident 3 had diagnoses that included Alzheimer's disease, osteoporosis (brittle bones), and generalized anxiety disorder (persistent, excessive, and uncontrollable worry about everyday events). Review of Resident 3's care plan revealed that Resident 3 had a history of trauma with an intervention for no male staff in her room. On March 31, 2026, Resident 1 was evaluated by psychological service and removed from 1:1 supervision due to not displaying behavioral concerns. Further review of Resident 1's care plan revealed no behavior care plan was developed and no interventions were added. On April 27, 2026, at 11:15 AM, staff documented Resident 1 in the hallway sitting on a bench and became agitated and yelling out using several profanities. Resident 1 then walked over to the nurses' station and kicked the door threatening to hit the staff member. Resident 1 was walked down the hall by staff to attempt to redirect. Resident 1 then stated that I just need to kill everyone at this point. Resident 1 was seen recently by psychological services and Seroquel (antipsychotic medication) was recently increased to twice a day due to agitation. An order was obtained to send Resident 1 to hospital for further evaluation. On April 29, 2026, at 8:59 AM, staff documented that Resident 1 was pacing the hallways, pulling at the doors, cursing and threatening staff. A staff member approached Resident 1 to attempt to redirect the Resident and Resident 1 tried hitting her. When staff asked Resident 1 what he was upset about the Resident stated, you f***ing people won't let me out. Several attempts were made to redirect Resident 1 but were unsuccessful. The provider was notified of Resident 1's behaviors and an order was obtained for Hydroxyzine (medication used to treat anxiety and tension caused by nervous or emotional conditions) 25 milligrams (mg) every 12 hours as needed (PRN). Review of Resident 1's medication administration record for April 2026 and May 2026 revealed that Hydroxyzine 25 mg every 12 hours PRN was ordered for 14 days. Resident 1 received the medication on April 29 and May 5 and 11, and documented as effective. The Hydroxyzine was discontinued on May 14, 2026 and not reordered. On May 21, 2026, at 6:54 PM, staff documented that Resident 1 was verbally aggressive when asked to leave another resident's room, and that Resident 1 kicked the door and attempted to put his hands around another staff member's neck. Review of Resident 1's care plan revealed that a behavior care plan had still not been developed. On May 22, 2026, at 7:17 PM, a transfer note indicated that Resident 1 was transferred to the hospital for behavioral symptoms. Further review of Resident 1's progress notes revealed no additional notes indicating what symptoms Resident 1 was experiencing. Review of a facility provided incident report dated May 22, 2026, revealed that at 5:30 PM, staff in the dining room heard Resident 1 say G*d d**n b***h, and heard a female resident yell. Staff observed Resident 1 with his arms straight out in front of him and Resident 5 sitting on the floor in front of Resident 1. Due to a wall obstructing staff's view, they were not able to see if Resident 1 had made contact with Resident 5. Resident 5 was not able to communicate what had happened. No injuries were noted for either resident. Resident 1 was placed on 15 minute checks. An additional incident report dated May 22, 2026, revealed that at 7:00 PM, staff observed Resident 1 hit Resident 3 on the head with an open hand, and that Resident 1 was transferred to the hospital for evaluation. Review of Resident 1's progress notes revealed that Resident 1 returned from the hospital at 11:00 PM with no new orders and that 15 minute checks would be continued. Review of Resident 1's care plan revealed it was updated to include a care area that Resident 1 exhibits or has the potential to exhibit physical and sexual behaviors related to cognitive loss/dementia, initiated on May 22, 2026, with an intervention to encourage away from female residents when agitated and 15 minute checks. On May 26, 2026, at 1:25 PM, staff noted that Resident 1 was verbally aggressive with staff when redirected out of another resident's room. On May 26, 2026, at 3:04 PM, Resident 1 was seen by the medical doctor and 15 minute checks were discontinued. On May 27, 2026, at 2:54 PM, staff noted that they heard a woman scream from the parlor (Resident 4) and observed Resident 1 coming out of the parlor cursing. Upon entering the parlor, the Resident 4 reported that Resident 1 hit her on the arm and she asked him to stop coming into her room. Review of a facility provided incident report dated May 27, 2026, at 2:30 PM, revealed Resident 4 reported that Resident 1 hit her on the arm. The incident was not witnessed and no injuries were noted for either resident. Resident 1 was placed on 1:1 supervision. Review of Resident 1's care plan revealed that Resident 1's care plan was updated to include that Resident 1 was at risk or experiencing emotional distress related to past trauma, as evidenced by changes in mood, anxiety, agitation, aggression, sleep disturbance, and difficulty coping with daily stressors, initiated May 29, 2026; and interventions were added for 1:1 related to agitation, aggression as need, initiated on May 28, 2026 and resolved on June 4, 2026. On June 1, 2026, at 6:59 PM, staff noted that Resident 1 was walking in the hallway while being monitored 1:1 by a NA. Resident 1 passed by another female resident (Resident 3) that was sitting by the door to her room. The female resident told Resident 1 not to come close to her room. Resident 1 became verbally aggressive towards the female resident and hit her on the arm. Review of a facility provided incident report dated June 1, 2026, at 4:35 PM, revealed that Resident 1 hit Resident 3 on the arm after Resident 3 told him to stay away from her room. 1:1 supervision was in place at the time of the incident. No injuries were noted for either resident. Review of Resident 1's care plan revealed no updated interventions. On June 4, 2026, at 1:06 PM, Resident 1 was evaluated by psychological services and removed from 1:1 supervision due to not displaying behavior concerns. On June 4, 2026, at 6:17 PM, staff noted that Resident 1 was verbally aggressive to another resident he passed in the hallway and to staff when they intervened. On June 8, 2026, at 12:41 AM, staff noted that they entered Resident 1's room and observed Resident 1 standing over his roommate (Resident 2), kicking and screaming at the roommate. The staff removed Resident 1 from the room and returned to help the roommate. Staff then heard a scream down the hall and found that Resident 1 had slapped another resident (Resident 7) in the face. Review of Resident 2's clinical record revealed diagnoses that included aphasia (communication disorder affecting the ability to speak) following cerebral infarction (blood supply to part of the brain is blocked or reduced causing damage) and mild cognitive impairment (slight decline in memory or thinking). Review of a facility provided incident report dated June 8, 2026, at 12:40 AM, revealed that staff entered the room and observed Resident 2 on the floor and Resident 1 kicking him. Resident 2 responded yes when asked if Resident 1 had pulled him out of bed. Resident 2 had skin tears to his left arm, right cheek, and right arm, abrasions to his scalp, bruising and abrasion to his left knee, and multiple bruises to the left leg. Resident 2 was transferred to the hospital for further treatment. Review of a facility provided incident report dated June 8, 2026, at 12:46 AM, revealed that staff heard a resident scream and found Resident 7 sitting at the nurse's station holding the left side of her face. Resident 7 pointed at Resident 1 and stated that Resident 1 hit her. No injuries were noted for either resident. Resident 1 was transferred to the hospital for evaluation. Review of Resident 1's care plan revealed no updated interventions. An interview with the Director of Nursing (DON) on June 17, 2026, at approximately 11:31 AM, revealed that Resident 1 was being followed by psychiatric services and that multiple medication changes had been made since admission to the facility in attempts to regulate his mood. They had attempted numerous nonpharmacological interventions as well including buying him a guitar, moving him to a private room, and keeping him separated from residents he had altercations with. Social services had also attempted to contact other facilities but they either had no beds available or didn't call back. Review of Resident 1's clinical record revealed that PRN medication for behaviors was discontinued on May 14, 2026, and nothing new was ordered. The clinical record failed to include evidence that nonpharmacological interventions were put into place or that music therapy was used when the Resident was exhibiting behaviors. Observations made on June 17, 2026, at 12:20 PM, revealed Resident 1 sitting in the dining room at a table with Resident 2 and Resident 3, both were Residents that Resident 1 had previously assaulted. Resident 1's 1:1 staff was sitting to his left but not between him and the other residents. Upon exiting the dining room, Resident 1's 1:1 staff exited the room ahead of Resident 1. On June 17, 2026, at 2:42 PM, the DON was notified that the facility failed to put effective interventions in place for Resident 1 to ensure the safety of other residents and prevent physical and psychological abuse, which constituted an Immediate Jeopardy situation. The Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. On June 17, 2026 at 7:10 PM the facility's immediate action plan was accepted, which included the following:A full abuse investigation will occur within the facility with staff, residents and families of those who are unable to speak for themselves; to ensure no other residents have witnessed abuse or been abused.If any further potential abuse is brought forward, the facility will immediately remove the resident from the situation, ensure they are safe and comfortable, and potential interventions will be reviewed with a provider and put into place as indicated.A quiz will be given to all staff members after education to ensure the abuse process is retained. The quiz will include who the staff notifies upon alleged abuse identification (the abuse coordinator or DON), and when they notify (immediately).A full center behavior audit will occur to ensure all resident with current behaviors have been identified with interventions in place. If an intervention is not in place or not effective, psych and provider will be notified, change in condition will be documented and interventions will be reviewed and adjusted as indicated.An audit of current residents' skin will occur to ensure that there are no unidentified signs of injury or abuse. If any concerns are noted, the change in condition process will be followed and notifications to the provider, family and abuse coordinator will occur to ensure monitoring occurs. A report to the state agency will occur as necessary.Audits will be completed for the 1:1 documentation for completeness.Care plan will be updated to include Resident 1 will not be seated near resident that were assaulted and he will be kept within a safe distance from the residents that were assaulted.Findings will be taken to QAPI. On June 18, 2026, at 11:48 AM, the Immediate Jeopardy was lifted during the onsite survey after ensuring that the immediate action plan had been implemented. The facility failed to prevent resident to resident abuse. Resident 1 assaulted Resident 3 on March 28, 2026; May 22, 2026; and June 1, 2026. Resident 1 also assaulted Resident 4 on May 27, 2026, and Resident 5 on May 22, 2026. On June 8, 2026, Resident 1 pulled Resident 2 out of bed and was kicking and hitting him, resulting in multiple skin tears and bruising. Resident 1 was separated from Resident 2 and then walked down the hall and hit Resident 7. The facility did not have effective interventions in place to protect residents from physical and psychosocial abuse from Resident 1. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3)(e)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice for three of 38 residents reviewed (Residents 2, 23, and 163).Findings include: Review of the facility policy, titled Medication Administration - General Guidelines last reviewed March 2026, stated, The client (resident) is always observed after administration to ensure that the dose was completely ingested. Review of facility policy, titled Procedure: Wound Dressings: Aseptic, last reviewed March 2026, read, in part, Document: Treatment on Treatment Administration Record (TAR). Review of Resident 2's clinical record revealed diagnoses that included dementia (a condition characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and need for assistance with personal care. Review of Resident 2's physician orders revealed the following: Order 1: Vashe Wound External Solution 0.033 % (Wound Cleansers), apply to right lateral thigh topically every day shift every Tue, Thu, Sat for wound, with a start date of October 12, 2024. Order 2: Treatment: Right lateral thigh, right lower shin: cleanse with Vashe, apply skin prep to periwound, apply Lidocaine Gel to wound bed and cover with dry dressing, every day shift and as needed, with a start date of December 8, 2025. Order 3: Treatment: right lower extremity: cleanse with soap and water, pat dry, apply Xeroform to open areas, apply single layer UNNA boot, wrap with Kerlex and secure with coban, as needed and every day shift every Tue, Fri, with a start date of January 19, 2026. Review of Resident 2's TAR failed to reveal documentation for:Order 1 on May 2, 2026; Order 2 on December 31, 2025; March 29, 2026; April 13, 27, 29, and 30, 2026; and May 1 and 2, 2026; and Order 3 on May 1, 2026. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 7, 2026 at 10:38 AM, revealed that the nurse assigned to Resident 2 on the aforementioned dates failed to document Resident 2's wound treatments. The nurse was a new licensed practical nurse (LPN) and needed additional education. The facility has a performance improvement plan in place for the LPN. Review of Resident 23's clinical record revealed diagnoses that included dementia (a condition characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) and need for assistance with personal care. Review of Resident 23's physician orders revealed an order for Treatment: Bilateral heels: float heels utilizing a heelz up device while in bed as resident accepts, every shift with a start date of October 28, 2025. Review of Resident 23's care plan revealed a focus area At risk for alteration in skin integrity last revised July 20, 2023, with an intervention for float heels while in bed utilizing heelz up device as resident accepts, created on October 28, 2025. Observations of Resident 23 throughout the day on May 4, 2026, between 11:01 AM and 1:47 PM, revealed she was in bed and her heelz up device was across the room next to her television. Observations of Resident 23 throughout the day on May 5, 2026, between 9:33 AM and 1:30 PM, revealed she was in bed and her heelz up device was across the room next to her television. Observations of Resident 23 throughout the day on May 6, 2026, between 10:32 AM and 1:39 PM, revealed she was in bed and her heelz up device was across the room next to her television. Review of Resident 23's TAR revealed the heelz up device was signed as being in place during day shift on May 4, 5, and 6, 2026. Review of Resident 23's clinical record failed to reveal any documentation to indicate Resident 23 refused the heelz up device. Further review of Resident 23's clinical record revealed Employee 2 (LPN) had signed that the heelz up device was in place on May 6, 2026. During an interview with Employee 3 (LPN) on May 6, 2026, the surveyor questioned the TAR that was signed that the heelz up device was in place as it was not. Employee 3 revealed Employee 2 just left the building for the day but she should not have signed that the heelz up device was in place as it was not. Employee 3 then placed the heelz up device underneath Resident 23's heels. During an interview with the NHA and the DON on May 7, 2026, at 10:36 AM, the surveyor revealed the concern that Resident 23's heelz up device was not in place on May 4, 5, and 6, 2026, despite documentation on her TAR that it was in place. The DON revealed her expectation that devices to prevent pressure ulcer development should be implemented as ordered. Further Review of Resident 23's TAR revealed no documentation for the heelz up device on April 27, 29, and 30, 2026, on day shift; May 1 and 2, 2026, on day shift; and May 5, 2026, on evening shift. An interview with the NHA and DON on May 7, 2026 at 10:38 AM, revealed that the nurse assigned to Resident 23 on the aforementioned dates failed to document Resident 23's wound treatments. The nurse was a new LPN and needed additional education. The facility has a performance improvement plan in place for the LPN. Observation during screening of Resident 163 on May 5, 2026, at 8:55 AM, revealed a medication cup with 3 tablets on the bedside table. During an interview with Resident 163, she was unable to recall why the medications were there. Employee 1 (Registered Nurse), who was passing medications, was called into the room to observe the medications in the cup. Employee 1's response was, I thought she took them all. Employee 1 informed Resident 163 that she missed some of her medications and should take them now then gave the Resident the cup of water and medications. During an interview with the NHA on May 6, 2026, the NHA agreed that medications should never be left at the bedside and staff should observe that medications are ingested before leaving the room. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility assessment, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a member of the Food and Nutrition Services staff participates on the interdisciplinary team as required for two of 38 residents reviewed (Residents 7 and 105). Findings include: Review of the Facility Assessment (a comprehensive evaluation that determines the resources and capabilities needed to provide quality care to residents, ensuring compliance with regulatory standards), read, in part, Nutrition/Hydration: Dining: Discuss dining to ensure systems are in place to provide an enjoyable, dignified, and sanitary dining experience.Review of Resident 7's clinical record revealed diagnoses that included osteoarthritis (a condition where the protective cartilage that cushions the ends of the bones wears down over time) and need for assistance with personal care. During an interview with Resident 7 on May 6, 2026, at 2:14 PM, she revealed she didn't care for what she was served for breakfast that morning, and that she had concerns with the food. Review of Resident 7's comprehensive care plan revealed a focus area [Resident 7] is at nutritional risk, with an intervention for honor food preferences within meal plan, created on December 22, 2025. Review of Resident 7's Care Plan Meeting notes from July 2025 to present, failed to reveal a member of the Food and Nutrition Services staff had attended any of the meetings. Review of Resident 7's Nutritional Assessment notes and Nutrition progress notes from July 2025 to present, failed to reveal notation that her food preferences were updated. Review of Resident 105's clinical record revealed diagnoses that included depression (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) and muscle wasting and atrophy (wasting or thinning of your muscle mass). During an interview with Resident 105 on May 4, 2026, at 10:57 AM, she revealed her food preferences were not being honored and needed to be updated, and that she had concerns with the food and dietary services and would like to meet with a member of the foodservice staff. Review of Resident 105's comprehensive care plan revealed a focus area [Resident 105] is at nutritional risk, with an intervention for honor food preferences within meal plan, created on February 11, 2026. Review of Resident 105's Care Plan Meeting notes from September 2025 to present, failed to reveal a member of the Food and Nutrition Services staff had attended any of the meetings. Review of Resident 105's Nutritional Assessment notes and Nutrition progress notes from August 2025 to present, failed to reveal notation that her food preferences were updated. During an interview with Employee 4 (Dietary Manager) on May 6, 2026, at 9:33 AM, she revealed she was unable to attend quarterly care plan meetings due to being short staffed in the dietary department, and the dietitian does not attend because she typically only comes onsite to the facility on weekends. During an interview with Employee 5 (Social Worker) on May 6, 2026, at 1:42 PM, she revealed care plan meetings are typically held on Tuesdays and Wednesdays starting at 1:00 PM, and it is her understanding Employee 4 was unable to attend the care plan meetings because she was too busy to attend. Follow-up interview with Employee 4 on May 7, 2026, at 11:26 AM, she revealed she would need an extra dietary aide or food preparation designee to be able to attend care plan meetings as she was busy filling those roles at the time. During an email correspondence with the Nursing Home Administrator on May 7, 2026, at 1:13 PM, the surveyor revealed the concern that a member of the food and nutrition services staff is not attending care plan meetings or routinely updating resident preferences/addressing dietary concerns. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to monitor freezer temperatures in four of four (Station 1, Station 2, Station 3, and Arcadia) nourishment pantries; failed to maintain clean refrigerators in four nourishment pantries (Station 1, Station 2, Station 3, and Arcadia); and failed to discard food items brought in for residents in one of four nourishment areas (Station 3).Findings include: Review of facility policy, titled FNS402 Refrigeration/Freezer Temperature Standards, last reviewed March 2026, revealed, The Director of Dining Services/Director of Culinary Services or designee observes and records the temperatures of refrigerators and freezers on a daily basis using the Refrigerator/Freezer Temperature Log. Temperatures are not taken during the defrost cycle. Review of Station 1, Station 2, Station 3, and Arcadia Refrigerator/Freezer logs on May 4, 2026, from 10:27 AM to 10:45 AM, with Employee 4 (Dietary Manager), failed to reveal that any freezer temperatures had been checked or recorded for the month of May. Further review of Refrigerator/Freezer logs from February 2026 to April 2026 failed to reveal that any freezer temperatures had been checked or recorded in those months. Interview with Employee 4 on May 4, 2026, at 10:45 AM, revealed that the facility had no temperatures documented for the freezers during the February 2026 through May 2026 timeframe. Interview with the Nursing Home Administrator (NHA) on May 7, 2026, at 10:58 AM, revealed that she would expect that the facility policy would be followed and that freezer temperatures would be taken and recorded. Observation of Station 1, Station 2, Station 3, and Arcadia pantries on May 4, 2026, with Employee 4, from 10:27 AM to 10:45 AM, revealed debris and dried substances in all pantry refrigerators and three of four (Station 1, Station 2, and Arcadia) pantry microwaves. Interview with Employee 4 (Dietary Manager), at that time, revealed that Housekeeping cleans these areas. Review of the Routine Refrigerator Cleaning Log revealed the refrigerators were last cleaned on April 2, 2026. Review of the refrigerator cleaning log, dated 2026, revealed that refrigerators are cleaned monthly and failed to reveal any provision of PRN (as needed) cleaning between monthly cleanings. Interview with NHA and Director of Nursing (DON) on May 7, 2026, at 10:58 AM, revealed that they would expect that the refrigerators and microwaves would be cleaned monthly, as scheduled, and more often if needed. Review of facility policy, titled FNS413 Food Brought in for Patients/Residents, last reviewed March 2026, revealed 1.5 Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to the resident. Observation of Station 3 pantry refrigerator on May 4, 2026, at 10:35 AM, revealed a food container with a resident's name on it, dated April 29, 2026. Interview with the NHA on May 7, 2026, at 10:58 AM, revealed that she would expect that the facility policy would be followed and that the food would have been discarded after 3 days. 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 ensure the resident assessment accurately reflected the resident status for three of 38 residents reviewed (Residents 7, 15, and 18). Findings include: Review of Resident 7's clinical record revealed diagnoses that included osteoarthritis (a condition where the protective cartilage that cushions the ends of the bones wears down over time) and need for assistance with personal care. During an interview with Resident 7 on May 5, 2026, at 10:15 AM, she revealed her right foot was impaired and she was unable to walk on it. Review of Resident 7's Physical Therapy Evaluation from March 26, 2026, noted that her right lower extremity was impaired at her ankle. Review of Resident 7's Quarterly MDS assessment (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of March 31, 2026, revealed that Section GG- Functional Abilities, Subsection GG0115 Functional Limitation in Range of Motion, box B was coded no impairment, and should have been coded impairment on one side. Review of Resident 7's Quarterly MDS assessment with ARD of April 12, 2026, revealed that Section GG- Functional Abilities, Subsection GG0115 Functional Limitation in Range of Motion, box B was coded no impairment, and should have been coded impairment on one side. During an interview with the Nursing Home Administrator (NHA) on May 7, 2026, at 11:38 AM, she revealed Resident 7's aforementioned MDS assessments were marked in error and they were being modified. Review of the clinical record for Resident 15 revealed diagnoses that included right leg above the knee amputation, left leg below the knee amputation, and type 2 diabetes mellitus with hyperglycemia (chronic condition where blood glucose levels are consistently elevated due to insulin resistance or inadequate insulin production). Review of Resident 15's clinical record revealed that he was admitted to the facility on [DATE], with bilateral amputation of lower extremities. Review of Resident 15's Quarterly MDS's dated August 5, 2025, and September 9, 2025, revealed that Section GG- Functional Abilities, Subsection GG0115 Functional Limitation in Range of Motion, box B was coded a 1, indicating only one lower extremity was impaired and should have been coded a 2, indicating bilateral impairment. Review of Resident 15's Quarterly MDS dated [DATE], revealed that Section GG- Functional Abilities, Subsection GG0115 Functional Limitation in Range of Motion, box B was coded a 0 indicating no lower extremity impairment and should have been coded a 2, indicating bilateral impairment. Review of Resident 15's Annual MDS dated [DATE], revealed that Section GG- Functional Abilities, Subsection GG0115 Functional Limitation in Range of Motion, box B was coded a 1, indicating only one lower extremity was impaired and should have been coded a 2, indicating bilateral impairment. During an interview with the NHA on May 7, 2026, at approximately 11:30 AM, the NHA confirmed that Resident 15's Quarterly and Annual MDS's since last August 2025 were marked in error. Review of Resident 18's clinical record revealed diagnoses that included major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems) and dementia (a condition characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Resident 18's clinical record revealed a psychiatry note with an effective date of January 28, 2026, that read, in part, No psychotropic medications are deemed necessary at this time, as the patients behavior patterns are within normal limits. The patient has a diagnosis of schizophrenia listed. Will not make this diagnosis active as of today. It is unlikely, but not impossible for patient to be diagnosed with schizophrenia in her late 60's or early 70's. The patient is also not on any medications for schizophrenia. Review of Resident 18's Quarterly MDS assessment with ARD of February 16, 2026, revealed under Section I Active Diagnoses, it was marked yes to indicate that Resident 18 had an active diagnosis of schizophrenia. During an interview with the NHA on May 7, 2026, at 11:38 AM, she confirmed that Resident 18's Quarterly MDS with ARD of February 16, 2026, was marked in error. 28 Pa. Code 211.5 (f) Medical Records28 Pa. Code 211.11(d)(3)(5) Nursing services

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and to promote healing and prevent infection of a pressure ulcer for two of five residents reviewed for pressure ulcers (Residents 17 and 23).Findings Include: Review of facility policy, titled Procedure: Wound Dressings: Aseptic, last reviewed March 2026, read, in part, Document: Treatment on Treatment Administration Record (TAR). Review of Resident 17's clinical record revealed diagnoses that included chronic kidney disease stage 3B (moderate to severe loss of kidney function) and protein-calorie malnutrition (inadequate intake of protein and calories, leading to reduced body weight, muscle atrophy, and impaired function). Review of Resident 17's physician orders revealed the following orders, bilateral buttocks: cleanse with soap and water, pat dry, apply hydraguard every day and evening shift; left heel: skin prep and leave open to air every day and evening shift; heelz up device while resident is in bed as he accepts every shift. Review of Resident 17's TAR for April 2026 revealed no documentation for the aforementioned orders on evening shift April 13, 2026, and day shift April 29 and 30, 2026. Review of Resident 17's TAR for May 2026 revealed no documentation for the aforementioned orders on day shift May 1 and 2, 2026. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 7, 2026, at 10:38 AM, revealed that the nurse assigned to Resident 17 on the aforementioned dates failed to document Resident 17's wound treatments. The nurse was a new licensed practical nurse (LPN) and needed additional education. The facility has a performance improvement plan in place for the LPN. Review of Resident 23's clinical record revealed diagnoses that included dementia and need for assistance with personal care. Review of Resident 23's physician orders revealed an order for Treatment: Bilateral heels: float heels utilizing a heelz up device while in bed as resident accepts, every shift with a start date of October 28, 2025. Review of Resident 23's care plan revealed a focus area At risk for alteration in skin integrity last revised July 20, 2023, with an intervention for float heels while in bed utilizing heelz up device as resident accepts, created on October 28, 2025. Review of Resident 23's TAR revealed no documentation for the heelz up device on April 27, 29, and 30, 2026, on day shift; May 1 and 2, 2026, on day shift; and May 5 on evening shift. An interview with the NHA and DON, on May 7, 2026 at 10:38 AM, revealed that the nurse assigned to Resident 23 on the aforementioned dates failed to document Resident 23's wound treatments. The nurse is a new LPN and needs additional education. The facility has a performance improvement plan in place for the LPN. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on observation, policy review, and staff interview, it was determined the facility failed to maintain a safe and sanitary environment that supports infection prevention and control during the medication administration for one of five residents observed (Resident 186).Findings include: Review of the facility policy, titled Hand Hygiene last reviewed March 2026, it stated, Perform hand hygiene: Before patient/resident (hereinafter 'patient') care and after contact with the patient's environment. Review of the facility policy, titled Medication Administration - General Guidelines last reviewed March 2026, stated, Hands are washed with soap and water and gloves applied before administration of topical (skin), ophthalmic (eye), otic (ear), parenteral (intravenous, intramuscular, subcutaneous, intradermal), enteral (by mouth, nasogastric or gastric tube), rectal, and vaginal medications. Hands are washed with soap and water again after administration with any client (resident) contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and center policy. Observation on May 5, 2026, at 8:47 AM, revealed Employee 1 (Registered Nurse) preparing medications for Resident 186 without using hand sanitizer or hand washing after disposing of the previous resident's medication cup. Observation on May 5, 2026, at 8:55 AM. revealed Employee 1 preparing medications for Resident 186 by pouring Tylenol tablet (pain medication) from the stock bottle onto her bare hand, then placed Tylenol tablet in the medication cup. Employee 1 was observed removing six additional pills onto her bare hand for Resident 186. No hand hygiene was performed during the preparation of medications. After administration of medications to Resident 186, Employee 1 failed to perform hand hygiene. During an interview with the Nursing Home Administrator and the Director of Nursing on May 7, 2026, at 11:00 AM, both confirmed they would expect for nursing staff to perform hand hygiene appropriately and not place pills onto bare hands prior to placing in medication cup. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy and procedure review, clinical record reviews, facility provided documentation reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of two residents reviewed (Resident 4).Findings include: Review of facility policy, titled NSG 204 Neurological Evaluation, with a last revised date of January 15, 2026, revealed, in part, The evaluation shall include: Vital signs; General condition and appearance; Neurological evaluation for changes in: Physical functioning, Behavior, Cognition, Level of consciousness, Dizziness, Nausea, Irritability, Slurred speech or slow to answer questions, Changes in vision, hearing, or smelling. Review of facility procedure, titled Neurological Evaluation, with a last revised date of April 22, 2026, revealed, in part, 11. Document: 11.1 LOC, orientation, ability to follow commands, response to sensation and/or pain, pupil reaction, motor function, temperature, pulse, respiration, and blood pressure on Neurological Assessment Flow Sheet. Review of Resident 4's clinical record revealed diagnoses that included vascular dementia with mood disturbances (brain damage caused by multiple strokes, which causes memory loss in older adults), difficulty walking, and muscle weakness. Review of Resident 4's facility provided incident report dated January 11, 2026, revealed that Resident 4 had a fall at 1:05 PM, and was complaining of left leg pain and was noted to have a hematoma to the left side of forehead. Review of Resident 4's clinical record revealed that she had a fall on January 11, 2026, and was transferred to the hospital at 1:22 PM, and was admitted to the hospital for surgical repair of a hip fracture. She remained hospitalized until January 17, 2026. Review of Resident 4's neurological evaluation flow sheet revealed that her initial neurological status was documented as being evaluated post fall on January 11, 2026, at 1:15 PM. Further review of Resident 4's neurological evaluation flow sheet revealed that her neurological status was also documented as being evaluated on January 11, 2026, at 1:30 PM; 1:45 PM; 2:00 PM; 2:15 PM; 2:30 PM; 2:45 PM; 3:00 PM; 3:15 PM; 3:45 PM; 4:15 PM; 4:45 PM; 5:15 PM; 6:15 PM; 7:15 PM; 8:15 PM; 9:15 PM, and once on the 11-7 shift. Her neurological status was also documented as being evaluated on January 12 and 13, 2026, on the 7-3 shift, 3-11 shift, and 11-7 shift; and on January 14, 2026, on the 7-3 shift. Resident 4 was not present at the facility for any of these documented dates and times. Review of Resident 4's clinical record revealed that she had a fall on March 25, 2026, and was transferred to the hospital on March 26, 2026, at 9:59 AM, after changes were noted in her status. She remained hospitalized until March 28, 2026. Review of Resident 4's neurological evaluation flow sheet revealed that her neurological status was documented as being evaluated on March 26, 2026, on the 3-11 shift, although Resident 4 was not present at the facility. During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 27, 2026, at 2:10 PM, the DON indicated that the neurological flow sheets get placed on a clipboard for the nursing supervisors to complete during their shift. The NHA and DON confirmed that Resident 4 had neurological evaluations documented as being completed even though she was not present in the facility. They both also confirmed that they would expect documentation to be completed accurately. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on staff interviews, clinical record review, and select guidelines, it was determined that the facility failed to discontinue/alter medication dosage and/or to ensure the risks were known with refusal of monitoring to prevent hyperkalemia (elevated potassium level) for one of three residents reviewed (Resident 1). Findings include: A review of Food and Drug Administration guideline, last approved October 27, 2025, for use of Potassium Chloride ER (extended release) tablets stated, the use of potassium salts in patients with chronic renal disease, or any other condition which impairs potassium excretion, requires particularly careful monitoring of the serum potassium concentration and appropriate dosage adjustment. Based on National Institutes of Health guidelines, dated October 5, 2024, severe hypokalemia (<3mEq/L): For oral administration initiate at 40 mEq (milliequivalents- a unit of measure for concentration of electrolytes in body) 3 to 4 times daily or 20 mEq every 2 to 3 hours. The dose should be adjusted based on serum potassium levels, which should be rechecked every 2 to 4 hours. For patients with renal impairment: Starting at the lower end of the dosing range is recommended for patients with reduced renal function. Review of Resident 1's clinical record revealed diagnoses that include chronic kidney disease (progressive loss of kidney function), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and hypertension (the force of blood against the artery walls is too high). Further review revealed Resident 1 was admitted to the facility on [DATE], post-surgery for a right hip fracture. Review of Resident 1's admission MDS (Minimum Data Set, periodic assessment of care needs) dated December 21, 2025, Section C0500 a Brief Interview for Mental Status test (BIMS -brief interview of mental status) indicated a score of 13, indicating the Resident was cognitively intact. On December 17, 2025, laboratory results revealed Resident 1 had hypokalemia (low potassium level) of 2.8 (normal 3.5-5.3). Other lab results included:BUN (blood urea nitrogen [Normal level 7-20. High levels often indicate kidney dysfunction, dehydration, or heart failure]) -28 Creatinine (waste product from muscle metabolism and protein digestion, filtered from the blood by the kidneys [Normal level for women is 0.59 to 1.04]) -1.29. eGFR (estimated Glomerular Filtration Rate - a blood test calculating how well kidneys filter waste, primarily used to diagnose and monitor chronic kidney disease [Normal level is 90 or higher, with levels below 60 for 3 months indicating chronic kidney disease]) -40.9 On December 18, 2025, Potassium Chloride ER (extended release) orders were written for 20 mEq tablets and to administer 40 mEq (2 tablets) three times a day without an end date. On December 19, 2025, a repeat laboratory result revealed a normal potassium level of 4.5 (normal level).Other Lab results included:BUN -36 (high)Creatinine -1.33 (high)eGFR -39.5 (low) There were no laboratory tests ordered for December 20 or 21, 2025. A laboratory test was ordered for December 22, 2025, and the Resident refused two attempts to obtain a specimen for the potassium level. There was no documentation that the facility ensured Resident 1 was made aware of the risk of declining the laboratory test. When the physician was notified that Resident 1 refused the laboratory test, the physician reordered the test to be completed on December 24, 2025. The facility continued to administer Potassium Chloride ER 40 mEq three times a day on December 20, 21, 22, and 23, 2025, without laboratory testing of the potassium level. On December 23, 2025, at 6:30 PM, Resident 1 was sent to the hospital emergency department (ED) due to altered mental status (confusion). admission labs in the emergency room revealed hyperkalemia (elevated potassium level) of 7.1. Other labs in the ED revealed creatinine 2.29, eGFR 20.6, and BUN 65. The hyperkalemia was resolved with treatment in the ED. The Resident was admitted to the hospital for continued monitoring for cause of altered mental status and an elevated white blood cell count indicating possible infection. A written statement was received via email from the Medical Director on February 23, 2026, at 4:51 PM, which stated, After the chart review patient potassium was replaced and corrected but due to ongoing GI losses (with h/o [history of] Crohn's disease and ongoing diarrhea receiving IV fluid also for the same ) continued on Potassium supplement with the plan to recheck but unfortunately patient refused . Patient had K checked on 12/17 Wednesday, 12/19 Friday and was ordered to be checked on Monday 12/22 (which she refused). If patient had blood work done as scheduled on 12/22, we would be able to have plan of action in place but unfortunately, she refused and due to her ongoing diarrhea rationale seems like to continue meds as this point and attempt recheck next day. During an interview with the Nursing Home Administrator (NHA) on February 24, 2026, the NHA said staff followed the physician's orders. 28 Pa, Code 211.2(d)(3)(9) Medical Director28 Pa. Code 211.10(c) Resident Care Policies28 Pa. Code 211.12(c) Nursing Services

Based on facility policy review, observations, product label, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Findings include: Review of facility policy, titled Food Brought in for Patients/Residents last revised [DATE], read, in part, Food brought to residents by family or visitors will be handled and stored in a safe and sanitary manner. Food items that require refrigeration must be labeled with the resident's name and date the food was brought in. Food will be held in refrigerator for three days following the date on the label and will be discarded by staff upon notification to resident. Observation in Reach-in Refrigerator 1 on [DATE], at 9:52 AM, revealed one container of thickened lemon water open and not dated with an open date; and one container of thickened lemon water open with an open date of [DATE]. Further observation of the thickened beverage containers read After opening, may be kept up to 7 days under refrigeration. Observation in the Station II Pantry Area on [DATE], at 10:28 AM, revealed one thickened apple juice open with an open date of [DATE]. Interview with Employee 3 (Food Service Director) on [DATE], at 10:28 AM, revealed that container should have been discarded after seven days. Observation in the Medbridge Pantry Area on [DATE], at 10:30 AM, revealed one thickened lemon water open and not dated with an open date; and one container of food from an outside source not dated. Observation in the Arcadia Pantry Area on [DATE], at 10:32 AM, revealed a box of food from an outside source dated [DATE]; one container of thickened apple juice open and not dated with an open date; one thickened lemon water open and not dated with an open date; one thickened lemon water open with an open date of [DATE]; one pudding prepared for medication pass with a use by date of [DATE]; and one bag of food from an outside source not dated. Interview with Employee 3 on [DATE], at 10:33 AM, revealed the beverages should have been labeled properly and discarded after seven days of being open; and refrigerated food from outside sources should be labeled properly and discarded after three days. Interview with the Nursing Home Administrator on [DATE], at 1:32 PM, revealed it was the facility's expectation that expired items are discarded, foods items and beverages are labeled and dated per facility policy, and food items and beverages are stored in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services 28 Pa. Code 211.12(d)(3) Nursing services

Based on facility policy review, observations, review of select facility documentation, and resident and staff interviews, it was determined that the facility failed to maintain a clean, comfortable and home-like environment in one of 35 resident rooms reviewed. Findings include: Review of facility policy, titled Resident Rights Under Federal Law last revised February 1, 2023, read, in part, The resident has a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Interview with Resident 368 on April 27, 2025, at 12:29 PM, revealed he was disappointed about the condition of the wallpaper in his bathroom, and it had been that was since he was admitted to the room on April 21, 2025. Observation in Resident 368's bathroom on April 27, 2025, at 12:32 PM, revealed the wallpaper was coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. Interview with the Nursing Home Administrator (NHA) on April 29, 2025, at 2:11 PM, revealed it is the responsibility of staff to identify environmental concerns in resident rooms on a daily basis to be communicated to maintenance staff to be fixed. Review of facility maintenance work order report from April 22-29, 2025, failed to reveal an active work order in place for Resident 368's bathroom. Follow-up observation in Resident 368's bathroom on April 30, 2025, at 10:20 AM, revealed the wallpaper remained in the same condition as it was on April 27, 2025; coming away from the wall in several areas, rippling under the sink, and torn behind the toilet. During an interview with the NHA on April 30, 2025, at 11:44 AM, she revealed she would speak with Employee 4 (Maintenance Director) to address the issues in Resident 368's bathroom. She further revealed they have hired a third maintenance employee whose sole responsibility will be identifying and fixing physical issues such as the wallpaper around the facility. Follow-up interview with the NHA on April 30, 2025, at 1:32 PM, revealed Employee 4 is currently addressing the concerns in Resident 368's bathroom, and she would expect residents to be provided with a clean, comfortable and home-like environment 28 Pa. Code 201.18(b)(3) Management

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 35 residents reviewed (Residents 48 and 82). Findings include: Review of Resident 48's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations), end stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), and difficulty walking. Review of Resident 48's clinical record revealed that he had experienced a fall with no injuries on January 24, 2025. Review of Resident 48's Medicare Quarterly/5 Day MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of January 30, 2025, indicated in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on January 17, 2025. During a staff interview with Employee 2 (Registered Nurse Assessment Coordinator) on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 48's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 48. Review of Resident 82's clinical record revealed diagnoses that included muscle weakness, difficulty walking, and history of a traumatic brain injury (an injury to the brain caused by an external force). Review of Resident 82's clinical record revealed that he had experienced a fall with an injury on February 8, 2025, and was sent to the emergency room for evaluation of the injury. Review of Resident 82's Discharge Return Anticipated MDS with the assessment reference date of February 9, 2025, revealed in Section J. Health Conditions at question J.1800 that he had not experienced any falls since his prior assessment that was completed on February 2, 2025. During a staff interview with Employee 2 on April 30, 2025, at 9:31 AM, Employee 2 confirmed that Resident 82's MDS was coded inaccurately and that a modification would be completed. During a staff interview with the NHA and the DON on April 30, 2025, at 10:01 AM, both confirmed they would expect a resident's MDS to be coded accurately, and the DON indicated that the modification had been completed for Resident 82. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of 38 residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed diagnoses that included congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues) and atrial fibrillation (irregular heart beat). Review of Resident 84's physician order summary revealed an order for daily weights and to notify the doctor of a gain of 2 pounds or greater in a day or 5 pounds in a week for congestive heart failure, starting February 17, 2025. Review of Resident 84's daily weight documentation revealed that no weights, or refusals to be weighed, were documented for eight days in February 2025; for 15 days in March 2025; and for three days in April 2025. Further review of Resident 84's weight documentation revealed that a weight of 176.1 pounds was recorded on April 24, 2025, and that a weight of 187.8 pounds was recorded on April 25, 2025. This represented a weight gain of 11.7 pounds in one day. Review of Resident 84's clinical record failed to reveal that the practitioner was notified of this change in weight or that a reweigh was obtained. During an interview with the Director of Nursing on April 30, 2025, at 2:28 PM, she revealed the expectation that Resident 84's daily weights should have been recorded, and that follow-up should have occurred when a weight gain was recorded on April 25, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on facility policy review, record review, and staff and resident interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for two of 4 residents reviewed for nutritional status (Residents 60 and 72). Findings include: Review of facility policy titled Procedure: Weights and Heights last revised February 1, 2023, read, in part, A licensed nurse or designee will weigh the patient. If the body weight is not as expected, re-weigh the patient. Review of Resident 60's clinical record revealed diagnoses that included: muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in things). During an interview with Resident 60 on May 5, 2024, at 9:58 AM, he revealed he had lost a lot of weight at the facility. Further review of Resident 60's physician orders revealed an order for a weight every month with a start date of November 30, 2023, that was discontinued on November 30, 2023, noting the reason to be Resident on [nurse aide] task to weigh each month the 1st-7th. Review of Resident 60's weight measures revealed he had an unplanned weight loss of 8.6 pounds (4.9%) from March 4, 2024, to his next weight measure on April 11, 2024. Further review of Resident 60's weight measures failed to reveal monthly weight measures for November 2023, and January 2024; and failed to reveal a re-weigh was obtained for the weight change on April 11, 2024. Review of Resident 60's clinical record failed to reveal a nutrition assessment between the dates of March 22, 2024, and April 26, 2024. During an interview with the Director of Nursing on May 8, 2024, at 1:02 PM, she revealed she has identified problems with weight orders and weight monitoring at the facility; she revealed Resident 60 should have had a monthly weight obtained in November, and should have had an order in place and a monthly weight obtained in January; furthermore, she revealed she would expect him to have a re-weigh for his weight measure on April 11, 2024, and a nutrition assessment in response to his weight loss prior to two weeks later. Review of Resident 72's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of Resident 72's recorded weights revealed he experienced an unplanned significant weight loss of 16 pounds (approximately a 10% loss) between March 9, 2024, and April 2, 2024. Review of a dietician progress note dated April 3, 2024, revealed that this weight loss was noted and reviewed. Further review revealed instructions to monitor weekly weights due to the significant weight change. Review of Resident 72's clinical record failed to reveal that weekly weights were obtained or recorded between April 2, 2024, and May 1, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM she revealed the expectation that weekly weights should have been obtained as recommended by the dietician following Resident 72's significant weight loss. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review as well as resident and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 36 residents reviewed (Residents 12, 52 and 80). Findings include: Review of Resident 12's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking and behavior) and type II diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel resulting in too much sugar circulating in the bloodstream). During an interview with Resident 12 on May 5, 2024, at 11:04 AM she revealed that she has tooth pain due to poor dentition and needs to have several teeth removed. Review of the dental consult dated August 16, 2023, revealed that Resident 12's teeth, #22-#26, are broken and unrestorable. Review of Resident 12's dental consult dated January 15, 2024, revealed that the same teeth remain broken. Review of speech therapy evaluation dated December 5, 2023, revealed that Resident 12 had teeth that were observed to be black and rotted to the gumline. Review of Resident 12's January 13, 2024 comprehensive annual MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that the assessment was not coded to indicate that Resident 12 had obvious or likely cavity or broken natural teeth. During an interview with Employees 1 (Registered Nurse Assessment Coordinator) and 2 (Clinical Reimbursement Coordinator) on May 8, 2024, at 1:51 PM they revealed that Resident 12's January 13, 2024, MDS was completed by an off-site staff person who did not visualize Resident 12's dentition, but coded the assessment based on an admission/re-admission evaluation completed by nursing staff on January 10, 2024, which indicated that Resident 12 had dentures, but no other dental concerns. Review of Resident 52's clinical record revealed diagnoses including dementia (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and type 2 diabetes (decrease ability of the body to utilize insulin for the transport of glucose from the blood into the cells for nourishment). Review of Resident 52's clinical record revealed that Resident 52 was admitted to the facility on [DATE]. After admission, on February 28, 2024, facility staff identified a pressure injury to Resident 52's right heel that presented as a fluid filled blister measuring 5.0 centimeters (cm - metric unit of measure) by 5.0 cm. On March 6, 2024, a progress note stated that Resident 52's blister had opened with visible wound base. Review of wound tracking for Resident 52's pressure injury revealed the wound base developed slough (yellow/white accumulation of dead cells that usually presents as soft and wet but can be dry) on March 27, 2024 and necrotic skin (eschar - brown to black hard area of dead skin/tissue) was present upon an April 4, 2024 assessment. Review of the wound tracking revealed that Resident 52's pressure injury continued to have varying amounts of necrotic skin during assessments conducted on April 11, 19, 26, 2024, and May 3, 2024. Review of Resident 52's Discharge Return Anticipated Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs) with an assessment reference date of April 14, 2024, revealed that Section M Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, was coded to reflect that Resident 52 had an Unstageable - Slough and/or eschar pressure injury, and that the pressure injury was present upon admission or reentry to the facility. Review of Resident 52's Quarterly MDS with an assessment reference date of April 20, 2024, revealed that section K, subsection K0300 Weight Loss, Loss of 5% or more in the last month or loss of 10% or more in the last 6 month, was answered as Yes, not on prescribed weight-loss regimen. However, review of Resident 52's weight documentation during the look back of 30 days (or closest) and 180 days (or closest) revealed Resident 52 did not have a weight loss of 5% in 30 days nor 10% in 6 months. Further review of the Quarterly MDS revealed that section M - Skin conditions, subsection M0300 Current Number of Unhealed Pressure Ulcer/Injuries at Each Stage, subsection G1, was coded to reflect that Resident 52 had one unstageable deep tissue injury (purple or maroon area of discolored intact skin due to damage of the underlying soft tissue). Finally, the pressure ulcer coded under section M of the Quarterly MDS was identified as present upon admission or reentry, however; the pressure injury was sustained after Resident 52 had entered the facility. Review of aforementioned wound tracking revealed that, at the time of the Quarterly MDS with assessment reference date of April 20, 2024, Resident 52's pressure injury was acquired at the facility and presented with necrotic tissue/eschar and was not considered a deep tissue injury at that time. During a staff interview on May 8, 2024, at approximately 3:05 PM, the Director of Nursing confirmed that Resident 52's Discharge Return Anticipated MDS section M and Quarterly MDS section K and section M were coded incorrectly. During the staff interview the Director of Nursing revealed corrections were being made to the MDS errors identified. Review of Resident 80's clinical record on May 7, 2024, at 11:52 AM, revealed diagnoses that included epileptic seizures (a sudden alteration of behavior due to a temporary change in the electrical functioning in the brain) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 80's physician orders revealed Resident 80 was admitted to hospice services December 12, 2022. Review of Resident 80's minimum data set (MDS - assessment tool utilized to identify a residents' physical, mental, and psychosocial needs), section O0110 special treatments, procedures, and programs, subsection K1 hospice, revealed the facility failed to indicate that Resident 80 was receiving hospice services while a resident for two quarterly MDS assessments with dates of September 20, 2023 and March 18, 2024 and one annual MDS assessment dated [DATE]. During an interview on May 7, 2024, at 2:04 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor made the NHA and DON aware of the aforementioned MDS concerns. During an additional interview on May 8, 2024, at 1:15 PM, with the NHA and DON it was revealed that Resident 80's two quarterly and one annual MDS assessments where coded incorrectly and corrections had been completed. The DON stated that it was the facility's expectation that MDS assessments be completed accurately. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, clinical record review and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for three of 6 residents reviewed for pressure ulcers (Residents 11, 72 and 110). Findings Include: Review of policy, Wound Dressings: Aseptic, revised December 1, 2021, revealed that following application of a wound treatment, staff should document the treatment on the Treatment Administration Record (TAR- form used to document physician orders as well as when and how treatments are administered to a resident). Review of Resident 11's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. Review of nursing progress note dated March 14, 2024, revealed that staff discovered an open area at the top of Resident 11's sacrum on that date. Review of a skin integrity report revealed that Resident 11's open area was classified as a stage III pressure injury (involves the full thickness of the skin and may extend into the subcutaneous tissue layer). Review of Resident 11's March 2024 TAR revealed an order to cleanse the sacrum with saline solution, apply skin prep (liquid that forms a protective film or barrier) to the peri wound (skin around the wound), let dry, apply hydrogel to the wound bed (creates moist environment to promote healing) and cover with a dry dressing every evening shift. This order was effective March 16, 2024. Further review of Resident 11's March 2024 TAR revealed that it was not documented that this treatment was completed on March 18, 22, and 25, 2024. Review of Resident 11's May 2024 TAR revealed an order to cleanse the sacrum with wound cleanser and apply a wet to dry dressing each evening shift, effective April 29, 2024. Further review revealed that this treatment was not documented as being completed on May 3, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:41 PM, she acknowledged the missing documentation and revealed the expectation that treatments should be documented. Review of Resident 72's clinical record revealed diagnoses that included dementia and moderate intellectual disabilities (disability characterized by significant limitations in both intellectual functioning and in adaptive behavior). Review of nursing progress note dated April 30, 2024, revealed Resident 72 had stage III pressure injuries on his left heel, right heel, and right ankle. Review of Resident 72's April 2024 TAR revealed an order to cleanse the left heel with wound cleanser, apply skinprep to the periwound, apply hydrogel to the wound bed, and cover with an optifoam dressing (has a silicone border, waterproof backing and high absorbency) on day shift every Tuesday and Friday, effective April 12, 2024. Further review revealed that it was not documented that this treatment was completed on April 19, 2024. Resident 72's April 2024 also contained an order, effective April 5, 2024, to cleanse the right heel with wound cleanser, apply hydrogel to the wound bed, and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. Lastly, Resident 72's April 2024 TAR revealed an order, effective April 5, 2024, to cleanse the right lateral ankle with wound cleanser, apply therahoney (wound filler made of 100% medical grade Manuka honey that promotes healing and reduces odor) to the wound base and cover with a dry dressing on day shift every Tuesday and Friday. Further review revealed that it was not documented that this treatment was completed on April 9 and 19, 2024. During an interview with the Director of Nursing on May 8, 2024, at 2:42 PM, she revealed that she had no additional information, and stated she would expect that wound treatments would be documented. Review of Resident 110's clinical record revealed diagnoses that included: pressure ulcer of left heel (wound that occurs due to prolonged pressure), peripheral vascular disease (a disorder of the blood vessels outside the heart), and muscle weakness. Review of Resident 110's November 2023 TAR revealed a physician order for, Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's November 2023 TAR failed to reveal documentation that this treatment was completed on November 22 day shift and November 27 evening shift. Review of Resident 110's December 2023 TAR revealed a physician order for, Treatment: Buttocks: cleanse with soap and water, pat dry, apply Hydraguard (blue top tube) every shift and as needed, with a start date of December 20, 2023, and a discontinued date of January 3, 2024. Further review of Resident 110's December 2023 TAR failed to reveal documentation that this treatment was completed on December 23 night shift and December 29 day shift. Review of Resident 110's January 2024 TAR revealed a physician order for, Treatment: Buttocks: cleanse with normal saline solution, apply hydrogel to wound base and cover with Opti foam every evening shift, with a start date of January 4, 2023, and a discontinued date of January 26, 2024; and a physician order for Treatment: Left Heel: cleanse with normal saline solution, apply wet 4x4 gauze to wound base, cover with ABD, wrap with kerlex and secure every day and evening shift, with a start date of November 6, 2023, and a discontinued date of January 25, 2024. Further review of Resident 110's January 2024 TAR failed to reveal documentation that the aforementioned treatments were completed on January 5 and 8 evening shifts. Review of Resident 110's February 2024 TAR revealed a physician order for, Treatment: sacrum: cleanse with normal saline solution, Apply wet to dry dressing to wound bed, cover with ABD pad and secure with tape. Apply Hydraguard (blue top tube) to periwound every day and evening shift, with a start date of February 2, 2024, and a discontinued date of March 1, 2024. Further review of Resident 110's February 2024 TAR failed to reveal documentation that this treatment was completed on February 10 day and evening shifts. Review of Resident 110's May 2024 TAR revealed a physician order for, Treatment bilateral buttocks: Cleanse with soap and water, pat dry, Apply a thin layer of Zguard and cover with Nystatin Powder to every day and evening shift for wound care, with a start date of April 19, 2024. Further review of Resident 110's May 2024 TAR failed to reveal documentation that this treatment was completed on May 3 evening shift. Email correspondence with the DON on May 7, 2024, at 5:21 PM, revealed she was unable to provide additional information for Resident 110's missing TAR documentation. During a follow-up interview with the DON on May 8, 2024, at 12:54 PM, she revealed she would expect wound treatments to be documented as completed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on policy review, observation, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 32 residents reviewed (Resident 36). Findings include: Review of the facility policy titled Procedure: Nebulizer: Small Volume, last reviewed April 23, 2024, stated 21. Rinse SVN, mouthpiece, and T piece with sterile water and dry and 21.1 Place in treatment bag labeled with patient name and date. 21.2 Replace and date the setup daily, if used. Review of Resident 36's clinical record revealed diagnoses that included pulmonary embolism (blood clot in the lungs) with acute pulmonale (right-sided heart failure caused by an issue with the lungs) and chronic obstructive pulmonary disease (condition involving constriction of the airways causing difficulty breathing). Review of Resident 36's physician orders revealed an order for Ipratropium-Albuterol Solution (medication used to treat and prevent symptoms caused by ongoing lung disease) 0.5-2.5 (3) MG/3ML one application inhale orally four times a day for cough and one vial inhale orally every four hours as needed for cough. Review of Resident 36's April 2024 and May 2024 Medication Administration Record (MAR- documentation of medications administered) revealed Resident 36 received Ipratropium-Albuterol every four hours (9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM) daily. An observation on May 6, 2024 at 10:37 AM, revealed the nebulizer mask lying uncovered on Resident 36's nightstand. The medication reservoir was still attached to the mask and clear liquid droplets were visualized in the reservoir. The attached tubing was dated April 4. Resident 36 stated she receives the nebulizer treatment four times a day and that staff use to clean it and change the mask frequently, but they don't anymore. An additional observation was made May 7, 2024, at 10:39 AM, of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated April 4. During a staff interview with Employee 4 (Registered Nurse) on May 7, 2024, at 10:43 AM, it was revealed that nebulizer tubing is to be changed weekly by respiratory therapy. During a staff interview in Resident 36's room with Employee 5 (Respiratory Therapist) on May 7, 2024, at 10:56 AM, the surveyor informed Employee 5 of the aforementioned observations. Employee 5 revealed that she started here recently was waiting on a list of nebulizers in the building. Prior to her starting nursing was responsible for tubing changes. Employee 5 stated she changes oxygen tubing weekly and cleans filters and is planning to change nebulizer tubing weekly with the oxygen tubing changes. Employee 5 also revealed nebulizer masks are to be cleaned after each treatment and all should be bagged when not in use. Employee 5 stated was going to replace the nebulizer mask and tubing and get a bag to store it in when not in use. During an additional interview with Resident 36 on May 7, 2024, at 1:30 PM, she reported her nebulizer mask and tubing had been replaced. Resident 36 also revealed she received nebulizer treatment at 1:00 PM but staff never came back to remove it, so she had to do it herself and no one had cleaned the mask after the treatment. An observation was made of Resident 36's nebulizer mask lying uncovered on the nightstand with the medication reservoir still attached to the mask and clear liquid droplets visualized in the reservoir. The attached tubing was dated May 7. During a staff interview on May 7, 2024, at 1:56 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON) the surveyor made them aware of the multiple observations of Resident 36's nebulizer mask and tubing and of Resident 36's statement that staff do not clean the mask and reservoir after administering the treatment. 28 Pa code 211.12(d)(1)(2)(3) Nursing Services

Based on review of the review of clinical records, and staff interview, it was determined that the facility failed to maintain complete clinical records for one of 32 residents reviewed (Resident 107). Findings include: A review of the clinical record for Resident 107 on May 6, 2024, revealed diagnoses that include neurogenic bladder (lack of bladder control due to spinal cord problem and nerve problem) and spina bifida (a birth defect when the developing baby's spinal cord fails to develop properly). A review of Resident 107's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 20, 2024, revealed that the resident had a brief interview for mental status with a score of 15, indicating Resident 107 is cognitively intact. Further review of Resident R107's clinical records revealed, and he had moisture associated skin damage (MASD) on his buttock and scrotum and was ordered to have a thin layer of zinc paste applied every shift. Observation during wound care on May 7, 2024, revealed zinc paste was observed prior to the start of the observation and was applied post wound care. During an interview with Resident 107 on May 6, 2024, Resident 107 confirmed that he was receiving treatments every shift for both his chronic wounds and some white paste (referring to zinc paste was confirmed) to protect his buttock and scrotal area from damage. The resident also confirmed that he was receiving Ketoconazole cream 2% (treatment for skin condition, dermatitis) applied to his head, face, and neck to prevent dry, flaky skin every shift. A review of Resident 107's Treatment Administration Record (TAR) on May 7, 2024, revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the Ketoconazole cream 2% on April 8, 2024, on dayshift, April 11, 2024, on dayshift, and on April 14, 2024, on evening shift. Further review of Resident 107's TAR revealed that staff failed to initial and check the block on the TAR that confirms the administrations of the zinc past on April 5, 2024, on evening shift, April 7, 2024, on night shift, and April 14, 2024, on evening shift. During an interview with the Director of Nursing (DON) on May 8, 2024, at approximately 2:27 PM, the DON confirmed that all treatments should be signed off as completed on the TAR. 28 Pa Code 211.5(f) Medical records. 28 Pa Code 211.12(d)(1) Nursing services.

Based on observations and staff interview, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior for three of four nursing units observed (Stations 1, 2, and 3). Findings include: Observations made on February 20, 2024, at the noted times and locations revealed the following: - 9:03 AM in the dining room outside of the main kitchen (corner of Station 1 and 2) - the air vent was noted to be covered in a black, speckled substance. - 9:32 AM in Resident 1's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:37 AM in Resident 2's room (Station 2) - an accumulation of a black substance along the corner of the wall beside the heating vent/unit. - 9:41 AM in the Station 3 lounge - presence of a black substance on the grates of the wall heating/cooling unit. - 9:42 AM in Resident 3's room (Station 3) - the wall above the heating/cooling unit appeared to be crumbling with debris noted in and on the heating/cooling unit. - 9:44 AM in Resident 4's room (Station 3) - the plastic grate was missing from the heating/cooling unit. Food and other debris were noted in the unit. - 9:45 AM in Resident 5's room (Station 3) - dried spill/splash spots on the front grill panel of the heating/cooling unit. Food and other debris were observed inside of the unit. A black substance was present on the air vent grates. - 9:47 AM in Resident 6's room (Station 3) - an accumulation of debris was noted in the heating/cooling unit. Additionally, the air vent grates were noted to be soiled. - 9:57 AM in Resident 7's room (Station 2) - a black substance was present in the corner near the heating unit vent. - 9:59 AM in the Chapel Dining Room (located at the corner of Station 1 and 2) - black film on the wall around the vent/heating unit. - 10:01 AM in Resident 8's room (Station 1) - a black substance was present along the seam of the wallpaper in the corner near the heating unit. During a tour with the Nursing Home Administrator and Director of Nursing (DON) on February 20, 2024, at 10:30 AM, they acknowledged the aforementioned concerns. During a later interview with the DON on February 20, 2024, at 1:33 PM, she revealed that work orders had been submitted to have required repairs completed, and staff were in the process of going room to room to audit for cleanliness. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on facility policy and interview, it was determined the facility failed to ensure individuality and respect of resident personal property for one of three residents reviewed (Resident R2). Findings include: A review of the facility policy titled, Patient's Personal Property, last reviewed and revised [DATE], states, Personnel will identify and record the patient's/resident's (hereinafter patient) belongings upon admission to a Center. To protect the patient's right to retain their personal belongings and preserve the patient's individuality and dignity. In the event of the patient's discharge or death, valuables or other assets in the Center's possession will be secured until the appointed personal representative of the patient's estate presents a copy of the certified Letter of Administration to the Center. A review of the clinical record revealed that Resident 2 has resided at the facility since her most recent admission on [DATE]. Further review of the record revealed that Resident 2 passed away at the facility on [DATE]. Based on the written correspondence to the Department of Health on [DATE], from Resident 2's personal representative, when the family arrived to obtain the personal belongings of Resident 2 on [DATE], they were handed a closed box. Upon reviewing the items there were many items missing that included under ware, coloring books, colored pencils, pocketbook, wallet, and jewelry. During an interview with the Nursing Home Administrator (NHA) on [DATE], at approximately 1:00 PM, the NHA stated that housekeeping emptied the residents personal belongings from the resident's room into a box. The NHA also stated that housekeeping staff admitted to discarding the coloring books, pencils, and under ware. The NHA stated that she remains in contact with Resident 2's representative for any additional items that are reported missing. The facility was requested to provide the personal property inventory list for Resident 2 and the NHA admitted that no personal inventory list for Resident 2 could be located. The NHA also stated that she has changed the policy so that in the future personal items of the deceased are secured in the social workers office until they are picked up by family. 28 Pa. Code 201.18(b)(2)Management.

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that residents were free from neglect, in regards to following the plan of care, which resulted in actual harm as evidenced by a non-operable nondisplaced fracture of the atlas (first bone in neck) and closed odontoid fracture (second bone in neck), for one of three residents reviewed (Resident 1). Findings include: A review of the facility's policy, titled Patient Protection: Abuse, Neglect, Mistreatment and Misappropriation Prevention, last reviewed May 13, 2022, states the definition of neglect, the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident 1's closed clinical record revealed a history of diagnoses that included Type 2 Diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and Cerebral Palsy (A congenital disorder of movement, muscle tone, or posture). Review of Resident 1's care plan for ADL self-care deficit initiated July 8, 2019, revealed an intervention to assist with two persons when rolling in bed and use of a bedpan; assist with one person when bathing, grooming, and dressing. Review of facility's incident report dated December 6, 2022, revealed that Resident 1 experienced a fall on December 6, 2022, at 5:15 PM. Further review of the incident report revealed Employee 1 was administering medications and observed the Resident was incontinent. Employee 1 initiated providing incontinence care. During care, Employee 1 called for assistance to Resident 1's room for a witnessed fall that occurred while rolling Resident 1 away from her during incontinence care. Employee 1 stated she was on the left side of the bed washing Resident 1's backside while Resident 1 was on his right side and slid off the bed falling face first onto the floor. No other staff were present in the room at the time of the fall. The facility's abuse investigation of the fall revealed that Employee 1 was educated on abuse and neglect on July 4, 2022. Employee 1, during the fall investigation interview, agreed that she shouldn't have rolled Resident 1 away from her without a second person present on the opposite side of the bed to assist with rolling the Resident and provide safety. Review of facility documentation revealed staff education related to following the resident's interdisciplinary plan of care was completed with all active nursing staff on December 16, 2022, and education will be provided to any PRN (as needed staff) prior to providing resident care. An interview with the Nursing Home Administrator (NHA), on December 27, 2022, at 2:00 PM, revealed the facility's investigation found the incident to be a confirmed instance of staff neglect, resulting in harm to Resident 1. On December 27, 2022, at 2:00 PM, the NHA stated that a plan of correction was initiated, based on the outcome of the facility's investigation, which determined that Employee 1 failed to follow the care plan for a two person assist while providing Resident care in the bed. The facility's education and audits were reviewed during the survey. On December 8, 2022, Employee 1 was educated to review all care plans prior to providing care to all residents. On December 8, 2022, through December 16, 2022, Education of staff and Agency staff of ADL (activities of daily living) care best practices, with return demonstration provided by team members, as well as Kardex review. PRN staff will be educated prior to providing direct care. On December 8, 2022, through December 16, 2022, Review of all resident care plans was conducted to ensure consistency and accuracy. On December 16, 2022, the station care plans were reviewed and updated as needed. On December 26, 2022, Weekly audits will be completed weekly for four weeks. Review of facility documentation revealed that on December 16, 2022, the facility had completed education for staff, competencies, house wide audit for all residents, and will continue weekly audits, to ensure compliance. During an interview with Employee 2 on December 27, 2022, at approximately 1:00 PM, Employee 2 confirmed that she received education on reviewing the care plan prior to providing care to residents, providing care to resident when in bed per the care plan and having two persons to assist when required. Employee 2 was also aware that when 1 person assist is required the resident should be rolled toward the staff. During an interview with Employee 3 on December 27, 2022, at approximately 1:10 PM, Employee 3 confirmed that she received education on reviewing the care plan prior to providing care to residents, providing care to resident when in bed per the care plan and having two persons to assist when required. Employee 3 was also aware that when 1 person assist is required the resident should be rolled toward the staff. Prior to the abbreviated survey on December 27, 2022, the facility failed to provide two persons assist during rolling Resident 1 in bed, resulting in harm to the Resident. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions to prevent a future incident. Audits, staff education, incident reports, and resident care plans were reviewed. Resident record review and observations revealed no concerns with receiving the required assistance for the sampled residents. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a non-operable nondisplaced fracture of the atlas (first bone in neck) and closed odontoid fracture (second bone in neck), for one of three residents reviewed (Resident 1). Findings include: A review of the facility's policy, titled Bed Positioning, obtained from 2022 Lippincott nursing procedures manual, the policy states to verify transfer assist needed per Kardex. Obtain additional assistance as indicated. Review of Resident 1's closed clinical record revealed a history of diagnoses that included Type 2 Diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and Cerebral Palsy (A congenital disorder of movement, muscle tone, or posture). Review of Resident 1's care plan for ADL self-care deficit initiated July 8, 2019, revealed an intervention to assist with two persons when rolling in bed and use of a bedpan; assist with one person when bathing, grooming, and dressing. Review of facility's incident report dated December 6, 2022, revealed that Resident 1 experienced a fall on December 6, 2022, at 5:15 PM. Further review of the incident report revealed Employee 1 called for assistance to Resident 1's room for a witnessed fall that occurred while rolling Resident 1 away from her during incontinence care. Per Employee 1 who stated was on the left side of the bed washing Resident 1's backside while Resident 1 was on his right side and slid off the bed falling face first onto the floor. No other staff were present in the room at the time of the fall. The facility's investigation of the fall revealed that Employee 1 agreed that she shouldn't have rolled Resident 1 away from her without a second person present on the opposite side of the bed to assist with rolling the resident and provide safety. On December 27, 2022, at 2:00 PM, the NHA stated that a plan of correction was initiated, based on the outcome of the facility's investigation, which determined that Employee 1 failed to follow the care plan for a two person assist while providing Resident care in the bed. The facility's education and audits were reviewed during the survey. On December 8, 2022, Employee 1 was educated to review all care plans prior to providing care to all residents. On December 8, 2022, through December 16, 2022, Education of staff and Agency staff of ADL (activities of daily living) care best practices, with return demonstration provided by team members, as well as Kardex review. PRN staff will be educated prior to providing direct care. On December 8, 2022, through December 16, 2022, Review of all resident care plans was conducted to ensure consistency and accuracy. On December 16, 2022, the station care plans were reviewed and updated as needed. On December 26, 2022, Weekly audits will be completed weekly for four weeks. Review of facility documentation revealed that on December 16, 2022, the facility had completed education for staff, competencies, house wide audit for all residents, and will continue weekly audits, to ensure compliance. During an interview with Employee 2 on December 27, 2022, at approximately 1:00 PM, Employee 2 confirmed that she received education on reviewing the care plan prior to providing care to residents, providing care to resident when in bed per the care plan and having two persons to assist when required. Employee 2 was also aware that when 1 person assist is required the resident should be rolled toward the staff. During an interview with Employee 3 on December 27, 2022, at approximately 1:10 PM, Employee 3 confirmed that she received education on reviewing the care plan prior to providing care to residents, providing care to resident when in bed per the care plan and having two persons to assist when required. Employee 3 was also aware that when 1 person assist is required the resident should be rolled toward the staff. Prior to the abbreviated survey on December 27, 2022, the facility failed to provide two persons assist during rolling Resident 1 in bed, resulting in harm to the Resident. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions to prevent a future incident. Audits, staff education, incident reports, and resident care plans were reviewed. Resident record review and observations revealed no concerns with receiving the required assistance for the sampled residents. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on observations, review of clinical records, facility documentation, and interviews with staff and residents, it was determined that the facility failed to adequately maintain each residents' environment to ensure that the residents remained free of accident hazards created by an activity conducted with igniting alcohol for 12 of 12 residents reviewed (Residents 1 through 12). This failure placed all 180 residents in the facility at a high risk for injury and resulted in a Past Non-Compliance Immediate Jeopardy situation. Findings include: Review of the Material Safety Data Sheet (MSDS-documents that list information relating to occupational safety and health for the use of various substances and products) for [MEDICATION NAME] rubbing alcohol provided by the facility on (MONTH) 28, 2019, revealed Section 2. Hazards Identification. A subsection titled: Classification revealed 5 classifications for [MEDICATION NAME] rubbing alcohol, Acute Toxicity-Dermal, Acute Toxicity-Oral, Eye Damage/Irritation, Flammable Liquids, and Sensitization-Skin. An additional subsection titled: Hazard statements revealed [MEDICATION NAME] rubbing alcohol causes eye irritation, flammable liquid, and vapor, may be harmful if swallowed, may be harmful in contact with skin, and may cause an allergic skin reaction. Further review of the MSDS for [MEDICATION NAME] rubbing alcohol revealed Section 7. Handling and Storage; Handling Flammable: Keep away from heat. Keep away from sources of ignition. Review of the facility's Employee Health and Safety Commitment form revealed, We believe in full compliance with the safety and health standards contained in the Occupational Safety and Health Administration (OSHA) and all state and local health and safety regulations. This form was signed by Assistant Activity Director (AAD) 1 on (MONTH) 21, 2019. Review of the OSHA standards revealed that they prohibit using flammable or combustible liquids within 50 feet of an open flame or other ignition source. Review of a facility provided report revealed that on (MONTH) 22, 2019, at 4:00 p.m. AAD 1 was conducting an activity in the Rainbow Room with multiple residents in attendance. Part of this activity involved AAD 1 using rubbing alcohol and an ignition source, resulting in a fire which activated the sprinkler system. Review of a statement detailing an interview with AAD 1 conducted by the Nursing Home Administrator (NHA) on (MONTH) 22, 2019, no time given, revealed the NHA asked what experiment were you doing? To which AAD 1 replied, I don't know what it's called-you put rubbing alcohol on a table-and light it on fire. It's supposed to be very quick. I knew it makes a fire .but it never set anything off .I've done it before . the NHA asked, You never knew that you couldn't light candles or anything? AAD 1 replied, Well yes but I figured for a small activity it's not a permanent flame. On (MONTH) 28, 2019, interviews were conducted with 4 of the 12 resident's who were in the room at the time of the experiment. Resident 3 was asked if she was scared when the fire started? Not scared, but I could feel the heat. Resident 3 demonstrated to the surveyor she was between 5 and 6 feet from the fire. Resident 5 was asked if she was scared when the fire started? Scared, yes, I was scared. I took myself out of the room. I was two and a half feet from the fire and if I'd have had long sleeves on it probably would have caught. Resident 8 was asked if she was scared when the fire started? Boy, I sure was. Resident 9 was asked if she was scared when the fire started? Scared, are you kidding me? I was terrified. During interviews with the NHA and the Director of Nursing (DON) throughout the day on (MONTH) 28, 2019, it was revealed that on (MONTH) 22, 2019, AAD 1 had 12 residents in the Rainbow Room of the facility for an activity due to the heat outside. AAD 1 had attempted two experiments to entertain the residents, both failed to have the expected outcome. AAD 1 then put a CD of Burning Ring of Fire in the player. She then poured rubbing alcohol onto a Formica topped table in a large circle and lit it with a grill lighter. The flames rose higher than expected and then activated the sprinkler system as the residents attempted to evacuate the room. According to documentation from the sprinkler head manufacturer, this model of sprinkler head is designed to activate at a temperature of 165 degrees Fahrenheit. The NHA was notified of an Immediate Jeopardy situation related to the open flames and accident hazard on (MONTH) 28, 2019, at 2:50 p.m. and that an action plan was required. The NHA provided an action plan on (MONTH) 28, 2019, at 3:24 p.m. which included: 1) (MONTH) 22, 2019, immediately following the incident: the facility self-identified the area of noncompliance which included the facility sprinkler and fire alarm activation following the activity department activity. An activity was conducted with the residents entitled, Experiments with (AAD 1) where staff performed a science experiment with the residents observing. Residents were approximately 8-10 feet away for the science experiment. The science experiment involved rubbing alcohol and a heat source flame. The activity aide stated there was no smoke, however; the heat activated the sprinkler head. 2) (MONTH) 22, 2019, at 4:01 p.m.: the facility staff immediately evacuated 12 residents from the Rainbow Room. The 12 residents had been sprayed with sprinkler water from the sprinkler system. 3) (MONTH) 22, 2019, at 4:10 p.m.: the Fire Department arrived and assessed the sprinkler function and assisted in water clean-up. The Chief of the Fire Department notified the Code Inspector and asked for further inspection of the sprinkler system and fire system. 4) (MONTH) 22, 2019, at 4:30 p.m.: the facility began a fire watch. 5) (MONTH) 22, 2019, at 5:00 p.m.: the 12 residents involved in the activity were given a shower or a bath. 6) (MONTH) 22, 2019, at 5:30 p.m.: the Fire Department left the facility. 7) (MONTH) 22, 2019, at 5:30 p.m.: an Ad Hoc QAPI committee meeting was held to review the situation and the action plan. The Medical Director was notified and participated in the QAPI committee meeting. 8) (MONTH) 22, 2019, at 5:40 p.m.: the NHA suspended AAD 1, pending the results of the investigation. 9) (MONTH) 22, 2019, at 6:00 p.m.: the Regional Director of Plant Operations notified the remediation company to assist with the cleanup. The remediation company had an estimated arrival time of 9:00 pm. 10) (MONTH) 22, 2019, at 6:00 p.m.: the 12 residents involved in the activity received RN assessments and the MD and responsible parties were notified. Incident reports were completed for the 12 residents involved in the activity. The 12 residents involved in the activity were added to alert charting for continuous monitoring for 3 days. 11) (MONTH) 22, 2019, at 6:05 p.m.: the NHA suspended the Activity Director (AD 1) pending the results of the investigation. 12) (MONTH) 22, 2019, at 8:00 p.m.: the sprinkler company arrived at the facility, the company ensured the sprinkler system was fully operational, ensured all air was out of the system, tested the system for operation and completed a report. 13) (MONTH) 22, 2019, at 8:01 p.m.: the NHA notified the Department of Health of the incident resulting from the activity, the activation of the sprinkler system, the arrival of the Fire Department and the facility's response to the incident. 14) (MONTH) 22, 2019, at 8:31 p.m.: the sprinkler company report was emailed to the Fire Chief per his request. 15) (MONTH) 22, 2019, at 8:37 p.m.: the Fire Chief emailed the NHA informing her the fire watch was allowed to be discontinued. 16) Social Services support was provided to the 12 residents involved in the activity. 17) The responsible parties and the physicians for the residents not involved in the activity were notified of the incident on (MONTH) 22, 2019 and (MONTH) 23, 2019, by the nursing staff. 18) (MONTH) 22, 2019, at 7:30 pm.: an Ad Hoc Resident Council meeting was held, and the following was discussed with the council: the Rainbow Room was to be closed until repairs are made to the room, meal service was going to be disrupted because the dinning room had flooded, location of activities had to be changed and that a sanitation company was beginning cleanup. The facility continued with the Ad Hoc Resident Council meetings to keep the council up to date with the situation. Also discussed with the council was that a full investigation was being completed and that the sprinkler company would be out to complete a sprinkler inspection and discuss with the residents how the sprinkler system works. 19) Immediate education for licensed and non-licensed facility staff was initiated on (MONTH) 22, 2019, regarding fire safety and open flames - the education continued until all the staff were educated. A small number of staff were unable to attend the training, they were called and sent certified letters informing them that they needed to complete the training prior to working. An observation of the activity department was completed to ensure no additional safety concerns were identified. 20) The facility was swept to validate that no flammable hazards were present i.e. chemicals, Sterno, lighters, etc. 21) A contractor was contacted to assess any damage or repairs needed. The contractor was in the building on (MONTH) 23, 2019. 22) To monitor compliance, daily review of the activities calendar and supplies were reviewed by the NHA/or designee to ensure the safety of the residents. 23) The NHA/or designee will conduct activity audits daily x 5 days, weekly x 4 weeks and monthly x 2. The action plan was reviewed and accepted on (MONTH) 28, 2019, at 5:10 p.m. On (MONTH) 28, 2019, following the acceptance of the action plan after 5:10 p.m. observations and interviews at multiple times across two shifts, were conducted with the NHA, the DON, the Facilities Director, and multiple Nurse Aides to ensure implementation of the plan, including confirmation of education, and the policy on open flames in the facility. Documentation of audits conducted since (MONTH) 22, 2019, were received and reviewed. The Past Non-Compliance Immediate Jeopardy was lifted effective (MONTH) 28, 2019, at 6:10 p.m. The facility failed to adequately maintain each residents' environment to ensure that the residents remained free of accident hazards created by an activity conducted by igniting alcohol causing a fire which set off the sprinkler system for 12 of 12 residents reviewed (Residents 1 through 12). This failure placed all of the residents in the facility (Residents 1 through 180) at a high risk for injury and resulted in a Past Non-Compliance Immediate Jeopardy situation. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 4/30/19. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/30/19. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 4/30/19. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 4/30/19.

Based on clinical record review, review of select facility documentation, as well as staff interview, it was determined that the facility failed to implement interventions to prevent an accident during ambulation, resulting in harm from a fall with a facial laceration requiring the resident being sent to the hospital and receiving sutures (row of stitches holding together the edges of a wound) for one of three residents reviewed (Resident 1). Findings include: Review of facility's policy entitled, Ambulation updated (MONTH) 2019 revealed, Purpose: To provide physical support and appropriate safety precautions while walking .Equipment: Gait belt .Procedure: Verify medical practitioner's order for ambulation as well as instructions for specific techniques, if applicable .Place gait belt around patient's waist and hold with palm facing up, position low, and snug but not tight. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's (MONTH) 10, 2019, MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed Resident 1's cognition was severely impaired. Review of Resident 1's care plan for self-care deficit revealed an intervention to ambulate to and from the bathroom and the dining room, hand-held with an assist of one-person effective (MONTH) 28, (YEAR). Further review of Resident 1's care plan revealed to transfer with an assist of one using a gait belt and non-skid footwear effective (MONTH) 14, (YEAR). Review of Restorative Nursing Status assessment dated (MONTH) 5, 2019, revealed Resident 1 has fluctuating ADL's (activities of daily living), poor safety awareness, and a need for restorative care (program available in nursing homes that helps residents maintain any progress they've made during therapy treatments) for ambulation with a plan to ambulate to and from the dining room with gait belt, hand-held assistance, and shoes or non-skid socks. Review of facility's incident report dated (MONTH) 17, 2019, revealed that Resident 1 experienced a fall on this date. Further review of the incident report revealed Nursing Assistant (NA) 2 was walking resident from the dining room to her bedroom after dinner. NA 2 needed to quickly assist another resident and Resident 1 lost her balance, fell to the floor onto her buttocks, then fell back and hit the back of her head on the floor. Review of the witness statement attached to the incident report revealed that NA 2 let go of Resident 1 to redirect two other residents and Resident 1 fell to the floor. During an interview with NA 2 on (MONTH) 30, 2019, at 1:39 PM she revealed she could not remember much about the incident but recalled that she was attempting to swish another resident out of a third resident's room and let go of Resident 1 in doing so. During an interview with the Nursing Home Administrator on (MONTH) 30, 2019, at 1:15 PM, she revealed that NA 2 made the wrong choice to let of Resident 1 but should have instead ensured her safety before intervening with the other residents. Review of facility's incident report dated (MONTH) 27, 2019, revealed that Resident 1 experienced a fall on that date. Further review of the incident report revealed Resident 1 fell to the floor during a transfer and sustained a laceration to the forehead, which required a transfer to the hospital for treatment. Review of the witness statement attached to the incident report revealed that Nursing Assistant (NA) 1 transferred Resident 1 and was walking behind her holding onto her pants when Resident 1 stumbled, lost balance, and fell . Review of hospital treatment notes dated (MONTH) 27, 2019, revealed Resident 1 presented with a 5.5 cm (centimeter) contused (bruised) laceration over the left forehead, which required eight sutures to repair. During an interview with NA 1 on (MONTH) 30, 2019, at 12:04 PM she revealed that she had a gait belt with her when she was transferring and ambulating Resident 1 and was shown how to use one as part of her orientation but did not realize all residents required one. NA 1 also revealed that after Resident 1 fell , she figured she required a gait belt. During an interview with the Nursing Home Administrator on (MONTH) 30, 2019, at 1:09 PM she revealed the expectation that NA 1 should have referred to Resident 1's plan of care. The facility failed to implement interventions in place to assure resident's safety during ambulation, resulting in harm from a fall with a facial laceration (cut) requiring the resident being sent to the hospital and receiving sutures for one of three residents reviewed (Resident 1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 8/23/18, 2/9/18. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/3/19, 8/23/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/3/19.

Based on observations and staff interviews, as well as clinical record reviews, it was determined that the facility failed to ensure that a safe environment was provided during the use of a steam table located in one of four resident dining areas (Corner Cafe), which created a situation that placed the safety of five of 48 residents reviewed (Residents R25, R42, R43, R44, R45) in Immediate Jeopardy. The facility also failed to ensure that care plans for fall prevention were followed for two of 48 residents reviewed (Residents R5, R7) who had a history of [REDACTED]. Findings include: Observations in the Corner Café dining room on September 28, 2016, at 11:15 a.m. revealed that there were 14 residents sitting at the tables waiting for their lunch meal to be served, and there were no staff members present in the room. The steam table located in the room had two control gauges that were turned on high, and the lids on two of the water wells were hot to touch. Staff were in the process of bringing residents into the room and sitting them at the tables, and during this process there were no staff present in the dining room from 11:16 to 11:26 a.m. Dietary Aide 6 entered the dining room at 11:26 a.m. and when she removed two of the steam table lids, steam came from the units. The temperature of the water in wells was 155 degrees Fahrenheit at that time. Interviews with Registered Nurse 4 and Licensed Practical Nurse 5 on September 28, 2016, at 11:29 a.m. revealed that Resident 25 was confused and ambulatory (could walk independently), and that Residents R42, R43, R44 and R45 were able to self- propel in their wheelchairs, which they were sitting in during the above observations. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R25, dated August 12, 2016, revealed that the resident was confused and able to ambulate (walk) with the limited assistance of one. The resident's care plan, updated September 1, 2016, indicated that he was at risk for falls, was non-compliant with transfers and ambulation, had a history of [REDACTED]. An annual MDS assessment for Resident R44, dated August 27, 2016, and a quarterly MDS assessment for Resident R43, dated September 12, 2016, revealed that the residents were confused and were capable of independent locomotion. Quarterly MDS assessments, dated September 7, 2016, for Residents R42 and R45 revealed that the residents were confused and were capable of independent locomotion. Interview with the Nursing Home Administrator on September 28, 2016, at 3:00 p.m. revealed that the facility did not have a written policy regarding the use, safety and security of the steam tables in the Corner Café or the Rainbow dining areas. She also indicated that there was supposed to be a type of rope barrier in place in front of the steam tables when they were in use and there were no staff present. On September 28, 2016, at 3:55 p.m. the Nursing Home Administrator was informed that the health and safety of the above residents was in Immediate Jeopardy related to the ability to access an unattended and hot steam table. The facility submitted a plan on September 28, 2016, at 7:22 p.m. that included education of the dietary staff, a system of double checks to ensure that the steam tables were not accessible to residents when on, and constant supervision of the steam tables after they are turned on and until they return to room temperature after use. On September 29, 2016, at 1:15 p.m., after observations of the evening meals on September 28, 2016, and the breakfast and lunch meals on September 29, 2016, showed that the steam tables were supervised and not accessible to residents, the Immediate Jeopardy was lifted. An incident report for Resident R5, dated July 7, 2016, revealed that the resident was found on the floor in her room that day. The resident's care plan regarding her risk for falls, revised July 7, 2016, indicated that Resident R5 was to be kept in common areas, not in her room, when she was out of bed. Observations on September 26, 2016, at 6:00 p.m.; September 27, 2016, at 9:55 a.m.; September 28, 2016, at 8:15 a.m.; September 29, 2016, at 2:30 p.m.; and September 30, 2016, at 9:20 a.m. and 9:45 a.m. revealed that Resident R5 was in her room in a Broda chair (specialized wheelchair) and not in a common area. Interviews with Registered Nurse 4 and the Director of Nursing on September 30, 2016, at 9:46 a.m. and 10:19 a.m., respectively, confirmed that Resident R5's care plan should have been followed, and Resident R5 should not have been in her room when she was out of bed in her chair. A nursing note for Resident R7, dated November 25, 2015, indicated that the resident was admitted to the facility with [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE], indicated that the resident was confused and required the extensive assistance of two staff for transfers, and the extensive assistance of one staff for mobility. The resident's care plan regarding falls, initiated on November 26, 2015, revealed that upon admission she was identified as at risk for falls due to a previous history of falls, a traumatic head injury, and an inability to follow directions, to wait for assistance to get up, and to walk, due to cognitive impairment. Incident/accident reports for Resident R7 revealed that from December 15, 2015, through July 25, 2016, the resident fell eleven times. An incident/accident report dated July 25, 2016, revealed that a fall that day resulted in a hip fracture that required surgery, four left rib fractures, and a left shoulder fracture. Resident R7's care pla updated on July 29, 2016, indicated that the resident was at risk for falls due to dementia and impaired mobility. A nursing note dated August 6, 2016, at 3:20 p.m. indicated that Resident R7 was frequently non-compliant with placement of her legs when in her wheelchair, and a note dated August 9, 2016, at 3:56 p.m. indicated that the resident continued to be non-compliant while in her wheelchair, and would scoot herself to the edge of her wheelchair causing the chair to tip forward. There was no documented evidence that interventions regarding the resident's non-compliance when in the wheelchair were initiated in an attempt to prevent falls from the wheelchair. An accident/incident report for Resident R7, dated August 10, 2016, at 7:00 p.m. revealed that during the evening meal, staff reported hearing a loud thud and observed Resident R7 lying on her left side, on the floor, beside her wheelchair. Interview with the Director of Nursing on September 30, 2016, at 8:30 a.m. confirmed that Resident R7 had a history of [REDACTED]. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 8/27/15. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 7/27/16, 8/5/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/23/16, 7/27/16, 4/13/16, 12/16/15, 8/27/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/23/16, 7/27/16, 4/13/16, 12/16/15, 9/22/15, 8/27/15, 8/5/15, 7/14/15, 4/29/15, 3/10/15, 2/25/15, 9/25/14.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for one of six residents reviewed (Resident R5). Findings include: The facility's policy regarding pressure sore prevention, dated 2013, revealed that the facility was to evaluate residents who were at risk for skin breakdown and implement interventions to prevent the development of new areas and promote the healing of current areas. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated May 1, 2015, revealed that Resident R5 was alert and oriented, required extensive assistance with transfers and dressing, had a [DIAGNOSES REDACTED]. A physical therapy note, dated October 17, 2014, revealed the resident had a history of [REDACTED]. The physician's orders [REDACTED]. There was no documented evidence that the staff monitored the resident for changes in her skin condition following the application of the Unna boots. Resident R5's Treatment Administration Records (TAR's) for July 2015 revealed that an Unna boot wrap was applied to both of the resident's lower legs on July 17, 2015. There was no evidence in the resident's clinical record that the resident had any pressure sores on her legs as of July 17, 2015. Skin alteration records and nursing notes, dated July 20, 2015, revealed that Resident R5 developed an 18.0 x 3.0 centimeters (cm) open area below the right knee, a 17.9 x 2.5 cm open area below the left knee, a 6.0 x 3.0 cm open area to the right outer leg, a 5.0 x 8.0 cm open area to the back of the right knee, and a 3.0 x 1.0 cm open area on the left posterior leg. A wound clinic note, dated July 22, 2015, revealed that the resident had worsening bilateral (both) lower extremity [MEDICAL CONDITION] with [MEDICAL CONDITION] and had clear lines of wounds where it appeared that the Unna boots were placed. Interview with Licensed Practical Nurse 2 on August 5, 2015, at 10:32 a.m. revealed that when she completed Resident R5's Unna boot treatment on Friday, July 17, 2015, the resident had no open skin areas on her lower legs. When she completed the treatment on Monday, July 20, 2015, the resident had open skin areas around her legs where the tops of the Unna boots had rolled down. Interview with Registered Nurse 3 on August 5, 2015, at 8:50 a.m. revealed that Resident R5 had increased swelling above the Unna boots, and the skin wounds were where the Unna boots rolled down. Interview with Physical Therapist 1 on August 5, 2015, 9:20 a.m. revealed that an increase in the resident's [MEDICAL CONDITION] could cause the Unna boots to roll down, which could cause an increase in pressure to the areas. She confirmed that the location of the resident's skin breakdown was where the Unna boots rolled down. She indicated that nursing staff should have been monitoring the resident's skin condition after applying the Unna boots. There was no documented evidence that nusing staff were monitoring the condition of Resident R5's skin following the application of the Unna boots. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 4/29/15. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 7/14/15, 4/29/15, 3/10/15, 2/25/15, 9/25/14.