Every finding on record at Chestnut Hill Rehabilitation and Healthcare Center

Based on select facility policy, review of clinical records, and resident and staff interviews, it was determined that the facility failed to comprehensively evaluate, monitor, communicate, and implement appropriate pain management interventions for continued pain for one of 11 residents reviewed (Resident 1).Findings include: Review of the facility's Pain Assessment and Management policy, last reviewed June 26, 2026, revealed that the purpose of the policy was to help staff identify resident pain and to help develop interventions that are consistent with resident goals and needs and that address the underlying cause of pain. The policy indicated the facility will monitor the resident to ensure pain is effectively managed. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of vascular parkinsonism (happens when tiny strokes-or lack of blood flow-damage parts of the brain that help control movement) and chronic obstructive pulmonary disease (long-lasting lung condition that makes it harder to breathe over time). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 21, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; BIMS score 13-15 means no significant cognitive difficulties are apparent during the brief assessment. Further the MDS indicated that over the past 5 days, Resident 1 experienced occasional, moderate pain and described the pain at the level of 6 (a numerical pain scale ranging from 0 to 10 is commonly used to assess pain intensity, with 0 representing no pain, 1 through 3 representing mild pain, 4 through 6 representing moderate pain, and 7 through 10 representing severe pain). Review of physician orders dated July 15, 2026, revealed an order for acetaminophen (a non-opioid pain-relieving medication) to be administered for resident-reported pain levels of 1 through 3, consistent with mild pain. The physician orders also included an order for Tramadol HCL (used when milder pain medicines don't work well enough; it's part of the opioid family, but it also works in a different way from many other opioids) to be administered for resident-reported pain levels of 5-7. Review of the July 2026 electronic medication administration record (eMAR) revealed Resident 1 received Acetaminophen 650 milligrams on the following days:July 16, 2026, for a pain level of 3July 19, 2026, for a pain level of 6July 20, 2026, for a pain level of 0July 26, 2026, for a pain level of 0July 30, 2026, for a pain level of 6July 31, 2026, for a pain level of 3 In July 2026, Resident 1 was given Acetaminophen on July 19 and 26 for pain rated at 6, which exceeded the ordered parameters of 1-3. The record provided no explanation for why Tramadol HCL, ordered for pain levels 5-7, was not administered. Review of the July 2026 eMAR record revealed Resident 1 received Tramadol HCL 50 mg on the following days:July 16, 2026, for pain level of 7July 18, 2026, for pain level of 7July 22, 2026, for pain level of 7July 23, 2026, for pain level of 8July 25, 2026, for pain level of 7July 28, 2026, for pain level of 7July 29, 2026, for pain level of 7 On July 23, 2026, Resident 1 received Tramadol for a pain level of 8, which exceeded the ordered parameters of 5-7. There was no documentation the physician was made aware the resident was experiencing pain greater than what the medications were ordered for. A review of the August 2026 eMAR revealed Resident 1 received Acetaminophen 650 mg on the following days:August 1, 2026, for a pain level of 6August 5, 2026, for a pain level of 3August 7, 2026, for a pain level of 2August 8, 2026, for a pain level of 3August 11, 2026, for a pain level of 5August 12, 2026, for a pain level of 5August 13, 2026, for a pain level of 5 In August 2026, Resident 1 received Acetaminophen on August 1, 11, 12, and 13 for pain levels outside the physician ordered parameters. On August 18, 2026, at 10:40 AM, Resident 1 was observed lying in bed and reported he was in pain when asked by the surveyor. The interview with the resident confirmed his pain was not be managed effectively. There were no additional orders for pain medication to treat moderate or severe pain during the month of August 2026 despite Resident 1 reporting pain levels consistent with moderate pain. The medical record lacked documentation revealing the physician was notified of the resident-reported pain greater than mild pain, Resident 1's consistent use of as needed pain medication, nor consideration of additional pain management interventions. During an interview on August 18, 2026, at 1:30 PM, the Director of Nursing and Nursing Home Administrator were unable to provide evidence that the facility had re-evaluated the resident's pain experience in accordance with facility policy, notified the physician of pain levels exceeding the resident's current treatment parameters, or obtained timely physician intervention to address the resident's ongoing pain complaints. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of the facility's abuse policy, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of five residents reviewed (Resident 1) from non-consensual sexual contact by another resident (Resident 2) despite Resident 2's known history of documented inappropriate sexual behaviors. As a result, Resident 1 experienced actual harm when Resident 2 placed his hand underneath her clothing, touched her bare breast, and twisted her nipple, constituting non-consensual sexual contact.Findings included: A review of the facility policy titled Abuse Policy, last reviewed by the facility on January 21, 2026, revealed that its purpose is to establish policy and procedures to prevent, identify, investigate, and report abuse, neglect, exploitation of residents, and misappropriation of property, and to ensure residents are actively protected from such occurrences. The policy defined sexual abuse as non-consensual sexual conduct of any type with a resident. A review of Resident 2's clinical record revealed admission to the facility April 27, 2021, with diagnoses to include Type 2 diabetes (a chronic condition where the body either does not make enough insulin or it resists it) and restlessness and agitation. A review of Resident 2's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 5, 2026, revealed that Resident 2 was moderately cognitively impaired with a BIMS score of 8 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). A review of nursing documentation dated April 26, 2026, at 5:23 PM revealed Resident 2 exposed himself twice to another resident in the dining room. Documentation indicated Resident 2 was removed from the dining room and placed on one-to-one supervision (continuous observation by one staff member assigned to one resident). Review of facility investigative documentation dated April 26, 2026, at 4:00 PM revealed Employee 3, nurse aide, observed Resident 2 expose himself to another resident while Employee 3 was on break in the dining room. A witness statement completed by Employee 3 dated April 26, 2026, at 5:20 PM revealed Employee 3 observed Resident 2 sitting beside Resident 1 when he removed his penis from his brief. After Employee 3 redirected Resident 2, he replied, What, I'm itchy, and exposed himself a second time.A physician's order dated April 26, 2026, directed staff to provide one-to-one supervision for Resident 2. The order was discontinued on April 30, 2026. A review of Resident 2's care plan, initiated May 20, 2025, and revised March 17, 2026, identified behaviors including verbal aggression toward staff and residents and inappropriate interpersonal sexual behaviors. Planned interventions included administering medications as ordered, assisting the resident to develop appropriate coping and interaction skills, intervening as necessary to protect the rights and safety of others, removing the resident from situations when necessary, and monitoring behavioral episodes to identify contributing factors. A review of Resident 1's clinical record revealed admission to the facility on January 30, 2004, with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). An admission Minimum Data Set assessment dated [DATE], revealed that Resident 1 was severely cognitively impaired with a BIMS score of 2 (a score of 0 through 7 indicates severe cognitive impairment). Due to her severe cognitive deficits, Resident 1 lacked the capacity to consent to any sexual contact or to independently defend herself from unwanted physical advances. Nursing documentation dated May 6, 2026, at 10:34 AM indicated that on May 5, 2026, at 1:45 PM Resident 2 was observed sitting beside Resident 1 in the dining room with his hand inside the front of her shirt. Staff immediately separated the residents, completed skin assessments, placed Resident 2 on one-to-one supervision, relocated him to another room, and referred him for psychological services. Review of the facility-provided investigative documentation dated May 5, 2026, at 1:45 PM confirmed Resident 2 was observed with his hand inside the front of Resident 1's shirt. Documentation indicated no injuries were identified, responsible parties were notified, Resident 2 was moved to another room, and one-to-one supervision was initiated. A witness statement completed by Employee 4, nurse aide, dated May 5, 2026, revealed Employee 4 observed Resident 2 with one hand underneath Resident 1's shirt on her bare breast while twisting her other nipple with his opposite hand. Employee 4 immediately separated the residents and notified the nurse and nurse supervisor. Review of the facility's report of abuse and neglect dated May 5, 2026, revealed the facility investigated the allegation and substantiated that sexual abuse occurred. Due to Resident 1's severe cognitive impairment documented on the June 9, 2026, MDS she was unable to reliably communicate the emotional or psychological effects of the incident or demonstrate whether she experienced fear, humiliation, or emotional distress following the event. Therefore, the reasonable person standard was applied. A reasonable person with similar vulnerabilities would likely experience unwanted sexual touching beneath their clothing, contact with a bare breast, and twisting of a nipple as invasive, humiliating, frightening, and emotionally distressing. This non-consensual sexual contact violated Resident 1's bodily integrity and dignity and resulted in actual psychosocial harm. During an interview on June 24, 2026, at 11:45 AM the Director of Nursing confirmed the facility's investigation substantiated the allegation of sexual abuse. The Director of Nursing acknowledged the facility failed to protect Resident 1 from non-consensual sexual contact by Resident 2 despite Resident 2's documented history of inappropriate sexual behaviors. 28 Pa. Code 201.29 (a)(c) Resident rights, 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies.

Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses accurately administered prescribed medication for one resident out of 25 sampled residents (Resident 73).Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Administering Medications last reviewed by the facility on January 15, 2026, revealed that medications are administered as prescribed and in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. A clinical record review revealed Resident 73 was admitted to the facility on [DATE], with diagnoses to include COPD (chronic obstructive pulmonary disease, lung disease which causes restricted airflow and breathing problems) and hypotension (low blood pressure). Review of a physician's order dated February 12, 2026, revealed an order for Midodrine hydrochloride 10 mg, to be given by mouth twice daily for hypotension, with instructions to hold the medication for systolic blood pressure greater than 110 mmHg (systolic blood pressure is the top number in the blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood). Review of Resident 73's Medication Administration Record (MAR) for February 12, through February 26, 2026, revealed that Midodrine was administered four times outside of the physician ordered parameters, as evidenced by the following documented blood pressure readings at the time of administration:February 21, 2026, at 9:00 AM BP 133/68 mmHgFebruary 22, 2026, at 9:00 PM BP 120/62 mmHgFebruary 23, 2026, at 9:00 PM BP 112/74 mmHgFebruary 26, 2026, at 9:00 AM BP 125/67 mmHg These administrations occurred despite the physician's explicit hold parameters. During an interview on February 27, 2026, at 11:00 AM the Director of Nursing acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. 28 Pa. Code 211.5(f)(ii)(ix) Medical records. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, resident and staff interviews, and facility provided documentation, it was determined the facility failed to ensure that residents who were dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for one resident out of 25 sampled residents (Residents 119).Findings include: A review of Resident 119's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include respiratory failure (occurs when the lungs cannot properly move oxygen into the blood or remove carbon dioxide) and muscle wasting (the loss of muscle tissue causing reduced size, strength, and movement capability). Review of Resident 119's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 4, 2025, revealed that Resident 119 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 119's Kardex (a quick-reference summary for staff to guide delivery of care) documented that Resident 119 was scheduled to receive showers on Mondays and Fridays during the evening shift. A review of the Documentation Survey Report v2 for December 2025 and January 2026 revealed that on multiple scheduled shower dates (December 5, December 8, December 12, December 15, December 19, December 22, and January 9), showers were either not documented as provided or the resident was provided a bed bath with no documented reason for a bed bath and not a shower as preferred. There was no supporting documentation indicating a change in condition that would have precluded showering. During an interview with the Director of Nursing (DON) on February 26, 2026, at 11:00 AM, the DON acknowledged that Resident 119 was scheduled to receive showers on Mondays and Fridays and confirmed that showers should have been provided as scheduled. The DON could not explain why showers were not consistently provided or documented. The above findings were reviewed with the DON on February 27, 2026, at 11:00AM. The facility could not provide documented evidence that Resident 119's showers were provided as ordered and preferred by the resident. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on review of facility policies and clinical records, and staff interviews, it was determined the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the residents' needs for communication for one of 25 residents reviewed (Resident 15).Findings include: A review of the policy titled Care Plans, Comprehensive Person Centered last reviewed by the facility on January 21, 2026, revealed that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. Review of Resident 15's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of Disease of the Pharynx (a disease of the muscular tube connecting the mouth and nose to the esophagus and larynx /voice box) and dysphagia (difficulty swallowing). An attempt at an interview on February 24,2026 at 11:45 AM in Resident 15's room revealed the resident was unable to verbalize his needs. A review of Resident15's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 20, 2026, revealed Resident 15 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; (a score of 13 through 16 indicates intact cognition). The assessment indicated Resident 15 had unclear speech. An interview with the Nursing Home Administrator on February 25, 2026, at 9:15 AM revealed she communicated with Resident 15 by the resident writing things down so she can understand his needs. An interview with Employee 1(LPN) on February 26, 2026, at 8:39 AM revealed if the resident needs something he writes it down so staff can understand his needs. A review of the resident's care plan initiated on March 19, 2024 and updated January 28, 2026, revealed there was no communication care plan to address Resident 15's inability to verbally communicate with staff. An interview was conducted with the Director of Nursing (DON) on February27,2026, at 11:30 AM to review the above findings related to the facility's failure to develop a comprehensive person-centered care plan to meet the resident's physical, psychosocial, and functional needs. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, select facility policy, and staff interview it was determined the facility failed to accurately identify a resident's request for future health care and advance directives as evidenced by one resident (Resident 73) out of 25 residents sampled. Findings include: Review of the facility Advance Directives Policy last reviewed [DATE], indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, family members, and, or legal representative, about the existence of any written advance directives. The resident or resident representative is provided with written information concerning the right to refuse or accept medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or resident representative. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. A clinical record review revealed Resident 73 was admitted to the facility on [DATE], with diagnoses that included COPD (chronic obstructive pulmonary disease, lung disease which causes restricted airflow and breathing problems), congestive heart failure (heart cannot pump enough blood) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Review of Resident 73's clinical record revealed a completed and signed POLST (Physician Orders for Life Sustaining Treatment a medical order form used to communicate a resident's preferences for life sustaining measures across care settings) dated February 17, 2026. The POLST indicated that the resident elected DNR status (Do Not Resuscitate a medical order directing that CPR, cardiopulmonary resuscitation, a lifesaving procedure performed when the heart or breathing stops, should not be attempted, with a goal of allowing a natural death). Further review of the resident's current physician orders, initially entered on February 12, 2026, in the electronic health record, identified the resident's code status as Full Code, indicating CPR was to be performed in the event of cardiopulmonary arrest. There was no documentation to indicate that Resident 73 had revised an advance directive or changed the preference documented on the POLST. No clinical notes or care conference records reflected a discussion or update to the resident's wishes regarding life sustaining treatment. An interview with the Director of Nursing (DON) on February 27, 2026, at 9:00 AM confirmed that physician orders are required to align with the most current, signed POLST. The DON acknowledged that Resident 73 had elected DNR status on the POLST form and the current physician orders incorrectly reflected Full Code, which did not honor the resident's documented treatment preferences. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to ensure that physician ordered intravenous (giving fluids or medication directly into a vein using a needle or tube) antibiotics were administered as prescribed for one resident out of 25 sampled (Resident 73). Findings include: Review of the facility policy titled Administering Medications last reviewed by the facility on January 15, 2026, revealed that medications are administered as prescribed and in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meals). The individual administering the medication initials the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. A clinical record review revealed Resident 73 was admitted to the facility on [DATE], with diagnoses that included COPD (chronic obstructive pulmonary disease, lung disease which causes restricted airflow and breathing problems), congestive heart failure (heart cannot pump enough blood) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Review of a hospital procedure note dated January 30, 2026, revealed that Resident 73 had a tunneled central venous catheter (a thin, flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream) inserted into the right chest on January 30, 2026.A physician order dated February 13, 2026, noted an order for Cefazolin Sodium (an antibiotic medication) Intravenous (IV) Solution reconstituted 2 gram intravenously every 8 hours for bacteremia (bacteria in the blood) until March 6, 2026. Review of Resident 73's Medication Administration Record (MAR) for February 2026, indicated that he was scheduled to receive Cefazolin Sodium at 6:00 AM, 2:00 PM, and 10:00 PM. The MAR was not signed by licensed staff to confirm the medication was administered as scheduled on the following dates: February 16, 2026, the 6:00 AM dose was coded 9 (per the MAR means other, see progress note). However, review of progress notes revealed no documented explanation for the indicated code of 9. February 17, 2026, the10:00 PM dose was left blank.February 18, 2026, the 10:00 PM dose was left blank.February 23, 2026, the 2:00 PM dose was left blank.February 24, 2026, the 2:00 PM dose was left blank. Interview with the Director of Nursing (DON) on February 26, 2026, at 10:00 AM failed to provide documented evidence the facility timely administered 5 doses of the IV antibiotic therapy prescribed for Resident 73. The DON confirmed that licensed staff failed to document medication administration on the MAR for the 5 doses of IV antibiotic as required per facility policy to ensure that physician ordered IV antibiotics were administered as prescribed by the physician. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services.

Based on review of select facility policy and clinical records, and staff interview, it was determined the facility failed to develop and implement an individualized plan to meet the toileting needs of one of 25 sampled residents (Resident 119), including the timely provision of staff assistance with toileting and management of urinary and bowel incontinence. Findings include: A review of facility policy titled Urinary Continence and Incontinence Assessment and Management reviewed by the facility on January 21, 2026, revealed that, as appropriate, and based on assessment of the category and causes of incontinence (inability to control the release of urine or stool) staff will provide scheduled toileting (a planned program in which staff assist the resident to use the toilet at routine, predetermined time intervals to reduce episodes of incontinence), prompted voiding (a toileting program in which staff regularly remind or ask the resident if they need to urinate and provide assistance to the toilet based on the resident's response), or other interventions to try to improve the individual's continence status. The staff and physician will review the progress of individuals with impaired continence until continence is restored or improved as much as possible, or it is identified that further improvement is unlikely. A review of Resident 119's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include respiratory failure (occurs when the lungs cannot properly move oxygen into the blood or remove carbon dioxide) and muscle wasting (the loss of muscle tissue causing reduced size, strength, and movement capability). Review of Resident 119's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 4, 2025, revealed that Resident 119 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of the resident's person-centered plan of care, dated December 1, 2025, included a focus area related to bladder incontinence related to impaired mobility. Resident goals included remaining free from skin breakdown due to incontinence and brief use. Interventions included providing cleaning peri-area after each incontinence episode, monitor for signs and symptoms of a urinary tract infection, monitor, document, and report any possible causes of incontinence. However, the care plan failed to identify or implement a structured toileting schedule or individualized incontinence program (e.g., check-and-change protocols, scheduled toileting, or prompted voiding) to manage the resident's known incontinence and promote timely care to prevent the potential of skin breakdown. A review of the resident's Kardex (a nursing information system used to obtain specific care information for each resident) in effect at the time of the survey ending February 27, 2026, failed to include the incontinence management needs of the resident. There was no documented evidence on the Kardex that staff were instructed to provide the resident with timely toileting or incontinence care. A review of a 3 day voiding diary (a record kept over a continuous 72 hour period that documents the times a resident urinates, amount, episodes of incontinence and related toileting patterns to evaluate bladder function to plan care) dated November 29, 2025, through December 3, 2025, revealed Resident 119 was incontinent majority of the time. A review of a Functional Abilities Assessment and Goals assessment documented on December 1, 2025, at 3:22PM revealed Resident 119 was completely dependent on staff for toileting hygiene. A review of Documentation Survey Report v2 (general care nursing tasks completed for the resident) for December 2025 revealed Resident 119 was incontinent of urine, resident was incontinent of urine 82% of the time, of the documented shifts. 13% of the documentation was left blank on multiple different shifts. A review of the Documentation Survey Report v2 for January 2026 revealed Resident 119 was incontinent of urine 67% of the documented shifts. There was no evidence the facility had developed and implemented a plan to address the resident's toileting needs based on an evaluation of the resident's habits and voiding patterns and assure timely care was provided to meet the resident's toileting needs and manage the resident's urinary incontinence to prevent extended periods of time without toileting, checking for incontinence and changing the resident. An interview with the Director of Nursing on February 27, 2026, at 11:15 AM, revealed the facility was unable to provide documented evidence the facility developed and implemented planned incontinence management for Resident 119. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 30 residents sampled (Resident 3).Findings include: A facility policy titled Controlled Substances last reviewed by the facility on January 21, 2026, revealed that the facility will comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications (medications regulated by federal law due to the potential for abuse, dependence, or misuse requiring strict storage, prescribing and record keeping control). The policy indicated the facility's system for reconciling the receipt, dispensing, and disposition of controlled medications includes documentation of personal access and usage, medication administration records, declining inventory records, and records for destruction, waste, or return of medication to the pharmacy. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that include wedge compression fracture of the T11-T12 vertebrae (a spinal injury in which the front portion of a vertebra collapses, often related to trauma or osteoporosis, a disease that causes bones to become weak and fragile) and fibromyalgia (a chronic medical condition characterized by widespread musculoskeletal pain, fatigue, and sleep disturbance). Review of Resident 3's clinical record revealed a physician's order dated December 6, 2025, directing staff to administer OxyContin Oral Tablet HCL ER 12-hour abuse-deterrent formulation 15 milligrams every 12 hours for moderate to severe pain. OxyContin is an extended-release (ER) opioid pain medication designed to slowly release medication over a 12-hour period. The abuse-deterrent formulation contains properties intended to make the medication difficult to crush, dissolve, or inject in order to discourage misuse. OxyContin contains oxycodone, which is classified as a Schedule II narcotic medication, meaning it has a high potential for abuse and therefore requires strict control and documentation. Continued review revealed a physician's order dated December 4, 2025, directing staff to administer Oxycodone HCL oral tablet 15 milligrams by mouth every six hours as needed for moderate to severe pain rated 7 through 10 on the pain scale (standardized tool to measure intensity of pain where 0 means no pain and 10 represents the worst pain) for fourteen days. A review of facility records revealed the facility utilizes a Controlled Drug Receipt/Record/Disposition Form, which is a controlled medication inventory log used to track the receipt, dispensing, and remaining quantity of each controlled medication. The facility also utilizes a Medication Administration Record (MAR) to document each medication administered to a resident. The MAR records the medication administered, the date and time of administration, the staff member administering the medication, the resident's pain level before administration, and the clinical reason for administering the medication. A comparison of Resident 3's Controlled Drug Receipt/Record/Disposition Form with Resident 3's Medication Administration Record (MAR) for the period of December 1, 2025, through February 2026, revealed seven entries indicating Oxycodone HCL was removed or utilized according to the Controlled Drug Receipt/Record/Disposition Form; however, there was no corresponding documentation in Resident 3's MAR indicating the medication was administered. The discrepancies occurred on the following dates and times:December 6, 2025, at 9:00 PMDecember 9, 2025, at 8:10 PMDecember 11, 2025, at 8:08 PMDecember 14, 2025, at 5:34 PMDecember 20,2025, at 9:00 PMDecember 24,2025, at 11:30 AMJanuary 28, 2026, at 2:00 AM Continued comparison of Resident 3's Controlled Drug Receipt/Record/Disposition Form with Resident 3's Medication Administration Record for the same period revealed two additional entries in which Oxycodone HCL 15 milligrams was documented on the MAR as administered; however, there was no corresponding entry on the Controlled Drug Receipt/Record/Disposition Form documenting removal of the medication from the controlled medication inventory. These discrepancies occurred on the following dates and times: December 11, 2025, at 9:00 AMFebruary 2, 2026, at 6:32 PMOn February 27, 2026, at 11:35 AM, an interview was conducted with the Director of Nursing (DON) regarding the discrepancies identified between Resident 3's controlled medication inventory record and the Medication Administration Record. The DON reviewed the findings related to the facility's failure to consistently reconcile Resident 3's controlled substance medications, including OxyContin and Oxycodone. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings on a quarterly basis for two of four quarters reviewed. (Quarter 2 and Quarter 3 of 2025). Findings include: A review of the facility policy titled Quality Assurance Performance Improvement (QAPI, a facility wide program that uses ongoing review of data and care practices to identify problems, correct them, and improve the quality and safety of services provided to residents) last reviewed by the facility on January 21, 2026, revealed the facility would develop and maintain an effective, comprehensive, data-driven QAPI program. However, the policy did not clearly identify the required QAPI committee membership, did not specify the required participation of the Medical Director or a physician designated by the Medical Director, and did not outline attendance expectations or accountability for participation in quarterly QAPI meetings. A review of QAPI committee meeting sign-in sheets for the period of April 2025 through January 2026 revealed the facility conducted QAPI meetings on a quarterly basis. However, documentation showed that the Medical Director or a designated physician representative was not present at the QAPI meetings held on April 30, 2025, August 8, 2025, and December 31, 2025, representing three of the four quarterly meetings reviewed for 2025. Without participation of the Medical Director or the Medical Director's designated physician representative, the QAPI committee lacked required physician involvement in the facility's process for reviewing clinical care practices, identifying potential quality or safety concerns, and implementing improvements. During an interview on February 27, 2026, at 9:35 AM, the Director of Nursing and the Nursing Home Administrator reviewed the findings related to the absence of the Medical Director or designee from the identified QAPI committee meetings and acknowledged the physician representative had not attended those meetings. 28 Pa. Code 201.18 (e)(1)(3) Management. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 211.10(c)(d) Resident care policies.

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address dementia and dementia related behaviors displayed by one out of 25 residents reviewed. (Resident 47)Findings include: A review of Resident 47's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 47's Annual Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 19, 2025, revealed the resident was severely cognitively impaired. A review of Resident 47's nursing progress notes during February 2026, revealed the resident had an increase in exit seeking behaviors, culminating in the resident being transferred to the facility's locked dementia unit on February 23, 2026. A review of the Resident 47's current care plan initially dated May 28, 2025, last revised May 28, 2025, revealed there were no new interventions to address these concerns. Further review revealed no documented evidence the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage, modify or decrease the resident's dementia-related behavioral symptoms. Interview with Nursing Home Administrator on February 27, 2026, at 10:00 AM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address the resident's dementia care. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review, observation, and staff interviews, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for three residents out of 12 sampled (Residents 1, 2, and 3).Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include dysphagia (difficulty swallowing food or liquid), mild protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and lack of coordination. A review of the physician's orders, dated January 16, 2025, revealed the resident was to utilize a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with meals. Review of Resident 1's plan of care, dated June 7, 2024, indicated the resident had a nutritional problem or potential nutritional problem due to variable appetite, history of protein-calorie malnutrition and dysphagia. Interventions included the use of adaptive equipment. More specifically, the resident was to utilize a Kennedy cup with all hot beverages. Observation of Resident 1's lunch meal ticket (a menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) indicated the resident was to be provided with a Kennedy cup. However, an observation of the lunch meal tray on September 23, 2025, at 11:43 AM, revealed that the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnosis to include muscle wasting and atrophy (a condition that causes a progressive loss of muscle mass, strength, function, and power), and major depressive disorder. A review of the physician's orders dated April 27, 2023, revealed the resident was to utilize a Kennedy cup with all meals. Review of Resident 2's plan of care, dated January 21, 2025, indicated the resident had a nutritional problem or potential nutritional problem due to muscle wasting and atrophy, COPD (chronic obstructive pulmonary disease- type of obstructive lung disease which causes difficulty breathing), type 2 diabetes (a chronic disease where the body does not use insulin properly, leading to high blood sugar levels) , metabolic encephalopathy( temporary brain dysfunction caused by chemical imbalances in the body, such as infection, organ failure, or electrolyte problems), dysphagia, sepsis (a life-threatening condition where the body's response to an infection spreads through the bloodstream and can cause organ failure), hypokalemia (low levels of potassium, a mineral important for heart and muscle function, in the blood), iron deficiency anemia (a condition where a lack of iron leads to too few healthy red blood cells, causing fatigue and weakness), osteoarthritis (a common joint disease where the cartilage wears down, leading to pain, stiffness, and limited movement), hypertension (high blood pressure), GERD (Gastroesophageal Reflux Disease- a condition where stomach acid flows back into the esophagus, causing heartburn and irritation.), depression, altered skin integrity, and significant weight gain. Interventions included the use of adaptive equipment. More specifically, the resident was to utilize a Kennedy cup.Observation of Resident 2's lunch meal ticket indicated the resident was to be provided with a Kennedy cup. However, an observation of the lunch meal tray on September 23, 2025, at 11:45AM, revealed the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnosis to include dysphagia, severe protein-calorie malnutrition, legal blindness, and lack of coordination. A review of the physician's orders dated July 30, 2025, revealed the resident was to utilize a Kennedy cup for all liquids. Review of Resident 3's plan of care dated July 17, 2026, indicated the resident had a nutritional problem or potential nutrition problem due to malnutrition. Interventions failed to include the use of the physician ordered Kennedy cup for all meals. Observation of the lunch meal tray on September 23, 2025, at 11:47 AM, revealed the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.An interview with Employee 1 (nurse aide) on September 23, 2025, at 11:50 AM, stated the dietary staff frequently fail to provide Kennedy cups on the resident trays. She further stated that nursing staff must then stop meal service to contact the kitchen to obtain the adaptive equipment, causing interruptions in resident care and meal service.Interview with the Dietary Manager on September 23, 2025, at approximately 2:50 PM, confirmed the facility failed to consistently provide the required adaptive dining equipment as ordered by the physician. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to three residents out of 14 sampled (Resident 1, 2, and CR1). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records. A review of a facility policy titled Administering Medications, last reviewed on January 22, 2025, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and are administered within one hour of their prescribed time unless otherwise specified. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered. A clinical records review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 19, 2025, revealed Resident 1 had moderately impaired cognition with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of Resident 1's clinical record revealed a physician's order dated March 21, 2025, for Oxycodone 10 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet three times a day for back pain. A review of Resident 1's May 2025 Medication Administration Record (MAR) revealed the resident did not receive their scheduled oxycodone 10 mg administration on May 8, 2025, at 2:00 P.M. An interview with Resident 1 on June 18, 2025, at 1:00 P.M. revealed he did not receive his medication on May 8, 2025, at 2:00 P.M., and stated they did not give a reason why it wasn't administered. A clinical records review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include neuropathy (a nerve problem that can cause pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of a quarterly MDS dated [DATE], revealed Resident 2 had moderately impaired cognition with a BIMS score of 11 (a score of 8-12 indicates cognition is moderately impaired). A review of Resident 2's clinical record revealed a physician's order dated January 2, 2025, for Gabapentin 100 mg (a medication used to treat neuropathic pain), with instructions to give two capsules three times a day for neuropathy. A review of Resident 2's May 2025 MAR revealed the resident did not receive their scheduled gabapentin 100 mg administration on May 8, 2025, at 2:00 P.M. A clinical records review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and fracture (a bone break) of the acetabulum (part of the pelvis that forms the socket of the hip joint, where the head of the thigh bone fits in). A review of a quarterly MDS dated [DATE], revealed that Resident CR1 was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). A review of Resident CR1's clinical record revealed a physician's order dated April 9, 2025, for Gabapentin 600 mg, with instructions to give one capsule three times a day for neuropathy. A review of Resident CR1's May 2025 MAR revealed the resident did not receive the scheduled gabapentin 100 mg administration on May 8, 2025, at 2:00 P.M. A review of a medication error report, dated May 9, 2025, for Resident 1 revealed he did not receive his medication at 2:00 P.M. Further review revealed the nurse assigned to his unit left early, and she did not give Resident 1 his scheduled oxycodone for 2:00 P.M. A review of a facility investigative report/employee corrective action form, dated May 13, 2025, revealed Employee 1, LPN, had accepted the assignment from Employee 2, LPN, without ensuring that all care and medications ordered were provided before the end of the shift. Further review revealed that Employee 2 left the assigned unit for an extended period of time without ensuring alternative coverage of the assignment was available. An interview with Employee 1 on June 18, 2025, at approximately 1:30 P.M. revealed she did take over Employee 2's assignment on May 8, 2025, around 1:00 P.M., due to Employee 2 having to leave early. Employee 1 stated prior to her taking over the assignment, she had been an extra staff member in the facility throughout the day and was assisting other employees who needed help. Employee 1 stated after she received the report, she had left the unit she was then assigned to help assist employees on another floor. Employee 1 stated she was not sure how long exactly she left the floor but stated it was not a long time, around five minutes. Employee 1 did acknowledge she did not check to make sure resident medications and treatments were provided before she left her shift at 3:00 P.M. When asked if she knew what treatments or medications were not provided before the end of the shift, she stated that three residents had missed their 2:00 P.M. medication administration, which had consisted of an oxycodone and two gabapentin doses. An interview with Employee 2 on June 18, 2025, at approximately 1:00 P.M., revealed she was assigned to Resident 1 on May 8, 2025, for the 7:00 A.M. to 3:00 P.M. shift and left early due to a family emergency and gave report to Employee 1, who took over the assignment until the end of the shift. Employee 2 stated after she gave report, she saw Employee 1 go in the elevator and leave the unit. There were no medication error reports for Resident 2 and Resident CR1 available for review. An interview with the Nursing Home Administrator on June 18, 2025, at approximately 2:30 P.M., confirmed the nurse failed to administer medications as prescribed, The facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to Resident 1, Resident 2, and CR1. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services 28 Pa. Code 211.5 (f) (xi) Medical Records

Based on a review of clinical records, controlled drug records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate accounting and the administration of controlled medications for one of 14 residents sampled (Resident 1). Findings include: A review of a facility policy titled Administering Medications, last reviewed on January 22, 2025, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and are administered within one hour of their prescribed time unless otherwise specified. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered. A review of Resident 1's clinical record revealed a physician's order dated March 21, 2025, for Oxycodone 10 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet three times a day for back pain. A review of the controlled substance record for Resident 1's Oxycodone 10 mg tablet (schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) showed that nursing staff signed out doses of the medication on the following dates and times: May 3, 2025, at 6:00 AM May 24, 2025, at 6:00 AM. However, a review of Resident 1's May 2025 Medication Administration Record (MAR) revealed there was no documentation indicating that the medication was administered to the resident on these dates and times. During an interview on June 18, 2025, at 2:30 PM, the Nursing Home Administrator confirmed the discrepancies in the accounting and administration of opioid pain medications for Resident 1. 28 Pa Code 211.5 (f)(xi) Medical records 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on observations, a review of select facility policies, the facility's infection control log, and staff interviews, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program and failed to implement transmission-based precautions to mitigate the spread of infectious disease for one out of the 27 residents sampled (Resident 56). Findings included: A review of a facility policy titled Respiratory Syncytial Virus (RSV) Prevention, last reviewed by the facility on January 22, 2025, revealed it is the facility policy to ensure that residents diagnosed with RSV are placed on contact precautions for the duration of the illness. A review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, last reviewed by the facility on January 22, 2025, revealed that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to wear gloves (clean-nonsterile) and a disposable gown when entering the room and remove before leaving the room and to avoid touching potentially contaminated surfaces with clothing after gown is removed. A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 56 dated February 03, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment). A review of Resident 56's clinical record for the laboratory of a respiratory panel, which resulted on April 22, 2025, at 11:11 AM, revealed abnormal results of positive RSV. A review of Resident 56's clinical record revealed a laboratory result from a respiratory panel collected April 22, 2025, at 11:11 AM, indicated the resident tested positive for Respiratory Syncytial Virus (RSV), an infectious viral illness that requires implementation of transmission-based precautions. A physician's order dated April 22, 2025, at 12:17 PM, directed that contact precautions 9 prevent the spread of bacteria or viruses by the use of gowns, gloves and masks) be initiated for Resident 56 due to the positive RSV result, to remain in place through May 2, 2025. However, an observation conducted on April 22, 2025, at 1:30 PM revealed: No signage was posted outside Resident 56's room indicating that contact precautions were in effect. No personal protective equipment (PPE), such as gloves or gowns, were available outside the resident's room for staff use. An interview conducted at the time of observation with Employee 6, Licensed Practical Nurse (LPN), confirmed that Resident 56 required contact precautions due to the RSV diagnosis. A second observation conducted at 2:20 PM on April 22, 2025, again revealed the continued absence of contact precaution signage and PPE outside the resident's room. A third observation conducted on April 23, 2025, at 8:10 AM continued to show no signage or PPE readily available for use. An interview with Employee 7, LPN, conducted during the April 23, 2025, observation, revealed that the nurse was unaware that Resident 56 required contact precautions. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 23, 2025, at 9:40 AM confirmed the contact precautions ordered for Resident 56 were not implemented as directed by the physician. The NHA further confirmed that the contact precautions were not initiated until approximately 11:00 AM on April 23, 2025, one day after the observation after the order was issued, and only following surveyor inquiry. The NHA confirmed the facility is responsible for ensuring full implementation of infection control procedures, including contact precautions, in accordance with facility policy and nationally recognized infection control guidelines. A review of a select facility policy titled Infection Prevention and Control Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy to establish an infection prevention and control program (IPCP) to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. The policy indicates surveillance data and reporting information are used to inform the infection prevention and control committee of potential issues and trends. Data gathered during surveillance is used to oversee infections and spot trends. The policy indicates the infection Preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility- or community-acquired), and records the absolute numbers of infections. A review of the facility's infection control data revealed the facility's infection control program failed to implement an operational system to monitor and investigate causes of infection and manner of spread from November 2024 through April 2025. The facility's surveillance and data analysis system of infectious disease data failed to identify clusters of infection, track changes in prevalent organisms, or identify increases in infection rates in a timely manner. During an interview on April 25, 2025, at approximately 9:00 AM, the infection Preventionist indicated that she has not been able to keep up with infection control data analysis. She provided handwritten infection surveillance logs from November 1, 2024, through March 18, 2025, that indicated the resident's name, prescribed medication, date range of administered medications, and an incomplete listing of infectious disease category (e.g., urinary tract infection, rash, wound). The Infection Preventionist, explained that she was behind on her data analysis and surveillance of facility infectious disease. She indicated the last time she was able to fully analyze infectious disease was October 2024. Additionally, review of the logs from November 2024 through April 2025 indicated the facility failed to consistently document critical infection-related details such as: Resident room numbers or location in the facility Identification of organisms as applicable Indication of whether infections were facility- or community-acquired Symptoms experienced by residents Date of infection onset During an interview on April 25, 2025, at approximately 10:00 AM, the NHA confirmed the facility is responsible for implementing a comprehensive infection control program that includes effective surveillance and timely analysis of infectious disease trends. The NHA was unable to provide documentation demonstrating that the facility had a functional surveillance system capable of tracking infection clusters or analyzing changes in prevalent organisms from November 2024 through April 2025. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, clinical record review, and staff interview it was determined the facility failed to ensure respiratory care including tracheostomy (surgical procedure where a hole is created in the neck and a tube is inserted into the trachea or windpipe to help a person breathe) care was provided in accordance with physician orders for one of three sampled residents (Resident 2). Findings include: Review of the clinical record revealed Resident 2 had diagnoses which included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy and cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination). A physician order dated February 3, 2025, was noted for a Pulmonary Consult on February 17, 2025. Review of the Pulmonary Consult dated February 17, 2025, revealed that Resident 2 was weaned to room air (normal air without supplemental oxygen) during the appointment. The plan/medical decision making/recommendations included to use oxygen as needed to maintain O2 level (oxygen saturation- the amount of oxygen carried by red blood cells in blood) was greater than 89%. Maintain humidification (process of adding moisture to the air a person with a tracheostomy breathes, without humidification the air can dry out secretions, making them thick and difficult to clear) via trach even if on room air. Start vest (SmartVest- provides high frequency chest wall oscillation to simulate repetitive mini-coughs to shear mucus away from the walls of the lung's airways and reduce the viscosity [thickness] of secretions) twice daily as tolerated for airway clearance. Use Albuterol (bronchodilator which works by relaxing and opening the air passages to the lungs to make breathing easier) twice daily with vest. Follow-up with pulmonary medicine in three months for evaluation. A physician order following the Pulmonary Consult dated February 17, 2025, noted to use oxygen as need to keep O2 level greater than 89%. Use humidification for trach. Start vest therapy twice daily to assist with mucous clearance if the resident tolerates. Use Albuterol nebulizer twice daily with vest therapy. Observation of Resident 2 on April 24, 2025, at 1:25 PM revealed the resident was in bed. Further observation revealed the resident was not receiving oxygen or humidification via the resident's tracheostomy. There was no evidence of a SmartVest in the resident's room. Interview with Employee 8 (RN) on April 24, 2025, at approximately 1:40 PM confirmed that humidification was not being used for the resident when the resident is on room air. Employee 8 (RN) confirmed the resident had not yet received a SmartVest. Further review of the clinical record revealed no documented evidence that arrangements had been made to obtain a SmartVest for the resident based on the physician order dated February 17, 2025, for vest therapy twice daily. Upon surveyor inquiry on April 24, 2025, the facility clarified recommendations from the resident's pulmonary consult on February 17, 2025. A telephone encounter note dated April 25, 2025, confirmed the resident should be receiving humification when on room air to keep secretions moist and easier for the resident to cough the secretions out or be suctioned. A phone number to obtain a SmartVest was also provided. Interview with the director of nursing on April 25, 2025, at 12:23 PM failed to provide documented evidence that physician orders related to respiratory and tracheostomy care for Resident 2 were timely implemented. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure that four residents out of 27 sampled (Residents 18, 104, 108, and 224) were free from abuse perpetrated by another resident (Residents 37 and 49) and failed to ensure one resident out of 27 sampled was free from neglect (Resident 57). Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents. A clinical record review revealed Resident 49 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a five-day Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 31, 2025, Section C1000. Cognitive Skills for Daily Decision Making revealed that Resident 49 is severely impaired in her ability to make decisions regarding tasks of daily life. The assessment indicated the resident's BIMS score was 99 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this section). A care plan revealed Resident 49 is at risk for harm related to homicidal ideation, grabbing other residents, and resident-to-resident altercations initiated on April 15, 2024. Interventions in place to assist Resident 49 with her goal of other residents remaining without injury include a one-staff-to-one-resident level of observation, one-staff-to-one-resident re-education including maintaining distance from other residents, keeping the resident at least an arm's length away from other residents, encouraging the resident to verbalize the cause for aggression, placing staff between the resident and other residents to prevent altercation, maintaining a consistent schedule with a daily routine, and minimizing environmental stimuli. A care plan revealed Resident 49 has a problem with impaired thought processes related to dementia initiated on April 15, 2024. Interventions implemented to assist Resident 49 to communicate her basic needs include asking yes/no questions, cueing, reorienting, supervising as needed, and presenting one thought, idea, question, or command at a time. A review of clinical records and documentation provided by the facility revealed Resident 49 physically abused three residents from November 26, 2024, through February 24, 2025, including slapping Resident 224 in the face, punching Resident 108 in the back of the head, and pushing Resident 104. A clinical record review revealed Resident 224 was admitted to the facility on [DATE], with diagnoses that included dementia. A review of an annual MDS assessment dated [DATE], revealed that Resident 224 is severely cognitively impaired with a BIMS score of 03 (a score of 01-07 indicates severe cognitive impairment). A progress note dated November 26, 2025, at 5:50 PM indicated Resident 224 was slapped in the face by Resident 49 in the dining room. Resident 224 was upset, stating, She just came up to me. Emotional support provided and skin assessment completed; no bruising, bleeding, swelling, or reports of pain assessed. A progress note dated November 26, 2025, at 5:50 PM indicated Resident 49 was seen slapping Resident 224 in the dining room. No provocation witnessed. Resident 49 slapped Resident 224 behind the back of the one-to-one safety sitter who was between the residents. A statement form dated November 26, 2024, revealed Employee 8, Nurse Aide (NA), turned around as she heard Resident 49 get upset, standing by Resident 224 at the table in the dining room. Employee 8, NA, indicated Resident 49 backhand slapped Resident 224 in the face. A statement form dated November 27, 2024, revealed Employee 9, Activities Aide (AA), indicated she was in between Resident 49 and Resident 224 when Resident 49 reached around Employee 9, AA, and hit Resident 224. A clinical record review revealed Resident 108 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 224 is severely cognitively impaired with a BIMS score of 06 (a score of 01-07 indicates severe cognitive impairment). A progress note dated January 17, 2025, at 9:05 AM revealed Resident 49 spat, punched, and scratched a nurse aide during morning care. Supervision and administration were notified. The note indicated a physician order not to send the resident to the emergency department, and the administration was in agreement. A progress note dated January 17, 2025, at 1:30 PM revealed Resident 108 was walking in the hallway. Staff witnessed Resident 49, unprovoked, hit Resident 108 on the left side of her head with a closed fist. The residents were separated. Resident 108 was assessed with no open area, scratches, or bruising noted. Resident 108 denied pain. A progress note dated January 17, 2025, at 1:51 PM revealed that while on a one-to-one (level of observation of one staff member to one resident continuous observation), Resident 49 hit Resident 108 with the back of her hand, with a closed fist. Resident 49 was assessed without injury. A clinical record review revealed Resident 104 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 104 is severely cognitively impaired with a BIMS score of 04 (a score of 01-07 indicates severe cognitive impairment). A progress note dated February 24, 2025, at 5:34 AM revealed Resident 104's roommate was agitated and trying to spit and hit the nurse aide. Resident 104 asked Resident 49 to stop. Resident 49 shoved Resident 104 on to her bed. Resident 104 was assessed, and no injuries were noted. A progress note dated February 24, 2025, at 6:42 AM revealed Resident 49 is on a one-to-one. The note indicated Resident 49 slept without incident until 2:00 AM, when she began walking the hallways and became aggressive towards the nurse aide and the roommate, Resident 104. The roommate tried to intervene, Resident 49 pushed her back on the bed, and scratched, punched, and spat at the nurse aide. A statement form, dated February 24, 2025, revealed Employee 13, Licensed Practical Nurse (LPN), was with Resident 104, beginning on February 23, 2025, at 10:00 PM. Employee 13, LPN, indicated at 2:00 PM Resident 49 began walking the hall, punching, pushing, scratching, and spitting. Redirection was attempted. Employee 13, LPN, indicated Resident 49 pushed Resident 104 because Resident 104 told her to stop. A clinical record review revealed Resident 37 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 37 was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact). A review of the care plan for Resident 37, initiated May 1, 2024, revealed the resident had a very low tolerance for confused and behavioral residents. Documented behaviors included yelling at other residents, calling residents names, making obscene gestures, and swinging at other residents. Interventions to address these behaviors included intervening as necessary to protect the rights and safety of others, praising progress and improvement in behavior, and educating the resident on successful coping and interaction strategies. A clinical record review revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 18 was severely cognitively impaired with a BIMS score of 02 (a score of 01-07 indicates severe cognitive impairment). A progress note dated March 7, 2025, at 7:30 PM, documented that a nurse aide reported Resident 18 had been struck multiple times with the laundry room door by Resident 37. The physician was notified and ordered a STAT X-ray. A progress note dated March 7, 2025, at 8:45 PM revealed Resident 37 struck Resident 18's left arm multiple times with the laundry room door. Residents were separated, and both residents were assessed for injuries. No injuries were documented in the note. A witness statement, dated March 7, 2025, completed by Employee 11, Nurse Aide (NA), revealed the employee heard yelling while at the nurses' station. Upon investigation, Employee 11 witnessed Resident 37 slamming the laundry room door against Resident 18's left arm repeatedly. Employee 11 reported running toward the residents, verbally directing Resident 37 to stop. Resident 37 stated, She's going to lock me in the laundry room. Tell her to get out of the way. Employee 11 separated the residents and reported that Resident 37 continued yelling at staff. A witness statement dated March 7, 2025, completed by Employee 12, Nurse Aide (NA), revealed the employee observed Resident 37 taking the laundry room door and striking Resident 18's left forearm multiple times with the door handle. Employee 12 documented that Resident 37 continued hitting Resident 18 even after staff directed Resident 37 to stop. Staff intervened and separated the residents. A progress note dated March 10, 2025, at 3:22 PM, documented that Resident 18 sustained an injury to the left arm as a result of the altercation with Resident 37, with Resident 18 reporting pain but no bruising observed. The X-ray results were negative for fracture. During an interview conducted on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents are free from abuse, including abuse between residents. The NHA confirmed that it is the facility's responsibility to ensure that Resident 37 and other residents do not physically abuse other residents. The facility was aware of the physically aggressive behaviors of Resident 49 but failed to implement effective interventions to prevent the physical abuse of other residents. Also, the facility was aware of Resident 37's low tolerance for confused residents, but failed to implement effective interventions including supervision to prevent the physical abuse of another resident. A review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of his lower extremities. A review of a quarterly MDS dated [DATE], revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (a score of 8-12 indicates cognition is moderately impaired). Additionally, the MDS was coded that the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was identified as dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). The most current review of a quarterly MDS, dated [DATE], revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact). Resident 57's comprehensive person-centered plan of care was initiated on November 23, 2024, and indicated the resident required the assistance of two staff members with transfers and was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers. A review of Resident 57's clinical record revealed physician orders dated December 6, 2024, directed the use of a mechanical lift for all transfers and bed mobility, with the assistance of two staff members. A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) revealed that Resident 57 was an assist of two staff members via the mechanical lift for transferring initiated on December 8, 2024. A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer. A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used. A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm. After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident. A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor. The facility's investigation report lacked documentation of an interview with Resident 57 regarding the incident. The Nursing Home Administrator (NHA) was unable to provide a reason why no statement was obtained from the resident. A nurse's progress note dated December 14, 2024, at 10:37 AM, indicated that Resident 57 complained of right-sided rib pain following the fall on December 13, 2024. A physician's order was obtained for an x-ray of the right ribs. An x-ray report dated December 17, 2024, showed no acute or chronic fracture. A physician's progress note dated December 19, 2024, documented a clinical impression of a right rib contusion (bruise) based on the negative x-ray and the resident's continued pain. A review of Resident 57's Medication Administration Record from December 2024 revealed that he received Tylenol as needed for right rib pain on December 14, 2024, at 8:24 AM for a pain of 8; (pain scale rating of 1 equals no pain 10 equals the worst pain) on December 15, 2024, at 4:22 AM for a pain of 7; and on December 20, 2024, at 9:26 PM for a pain of 3. An interview with Resident 57 on April 24, 2025, at 8:40 AM, revealed that prior to the transfer, he mentioned to Employee 14 that he required the use of a mechanical lift for transfer with two staff members and that Employee 14 ignored his request. Resident 57 stated that he felt Employee 14 moved him without the lift because he was in a hurry to get it done faster. An attempt was made to contact Employee 14 via telephone on April 24, 2025, during the on-site survey. The employee could not be reached, and no additional clarification regarding the incident was obtained. Employee 14 was no longer employed by the facility. The NHA could not provide a reason for his departure. An interview on April 24, 2025, at 11:00 AM with Employee 15 revealed he was unsure why Employee 14 was transferring the resident alone. A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident. Despite this documented competency, the resident's clinical record confirmed that Employee 14 did not follow established care plan and physician-ordered protocols requiring the use of a mechanical lift and two-person assistance when transferring Resident 57 on December 13, 2024. Despite this documented training and acknowledgment of competency, review of Resident 57's clinical record confirmed that Employee 14 failed to adhere to established care plan and physician-ordered protocols requiring the use of a mechanical lift and two-person assistance when transferring the resident on December 13, 2024. An interview with the NHA on April 24, 2025, at 1:30 PM, confirmed that the facility failed to ensure staff followed the resident's care plan and physician orders for the use of a mechanical lift with two-person assistance for transfers. The NHA acknowledged that failure to follow these directives resulted in increased pain and discomfort to the resident. Refer to F610 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on observation, clinical record review, review of facility policy, investigative documentation, and staff and resident interviews, it was determined the facility failed to thoroughly investigate an incident involving a fall with minor injury to determine whether neglect occurred and failed to identify that planned fall interventions were not in place for one of 27 sampled residents (Resident 57). The findings include: A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents. Further review of the facility policy revealed the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and will investigate and report any allegations within time frames required by federal requirements. A review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of the lower extremities. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2024, revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). Additionally, the MDS indicated the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was indicated to be dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). The most current review of a quarterly MDS, dated [DATE], revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact). Resident 57's comprehensive person-centered plan of care initiated on November 23, 2024, indicated the resident required the assistance of two staff members with transfers. The care plan was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers. A review of Resident 57's clinical record revealed physician's orders dated December 6, 2024, to utilize a mechanical lift for all transfers and bed mobility with the assistance of two staff members. A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) initiated on December 8, 2024, revealed that Resident 57 was an assist of two staff members via the mechanical lift for transferring. A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide, was transferring Resident 57 and experienced a fall during the transfer. A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer. A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used. A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm. After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident. A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor. The facility investigation failed to obtain a resident statement from Resident 57 at the time of the incident. During the survey, the Nursing Home Administrator (NHA) was unable to explain the omission of the resident's statement. When interviewed on April 24, 2025, at 8:40 AM, Resident 57 stated that he had informed Employee 14 he required a mechanical lift with two-person assistance, but the aide proceeded to transfer him manually. The resident believed the aide in a hurry to get the transfer done faster. A nurse's progress note dated December 14, 2024, at 10:37 AM documented complaints of rib pain, and a subsequent x-ray was ordered. Although the December 17, 2024, radiology report showed no fracture, a physician's note dated December 19, 2024, noted that Resident 57 was likely to have a right rib contusion (bruise), as x-ray findings were negative, and the resident was experiencing pain. The resident required Tylenol for rib pain on multiple occasions between December 14-20, 2024, with reported pain scores ranging from 3 to 8 (pain scale of 1 to 10 1 being no pain and 10 being the worst pain). The facility investigation lacked evidence the facility evaluated whether the plan of care for Resident 57 was implemented as directed. There was no documentation identifying the resident was transferred by only one staff member or that the mechanical lift was not used. The facility failed to identify or document the deviation from the care plan. Furthermore, attempts to re-contact Employee 14 during the on-site survey were unsuccessful. The NHA was unable to provide documentation or rationale for the staff member's departure from the facility. Employee 15, interviewed on April 24, 2025, stated he did not know why the aide was transferring the resident alone. A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident. Despite this documented training and acknowledgment of competency, review of Resident 57's clinical record confirmed that Employee 14 failed to adhere to established protocols by not using the required mechanical lift to transfer Resident 57 along with another staff member on December 13, 2024. The facility failed to implement its established procedures in response to a fall with minor injury by failing to conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment of the resident as a potential cause of the fall with minor injury. There was no indication the facility identified at the time of the incident that there was only one nurse aide, Employee 14, and no use of a mechanical lift for transfers. During an interview conducted on April 24, 2025, at 1:30 PM, the NHA confirmed that the facility could not provide documented evidence the facility fully investigated to rule out potential neglect following Resident 10's fall with minor injury. The facility failed to identify that planned interventions were not in place and/or implemented in a manner to ensure the resident's safety to prevent the fall and prevent future reoccurrence to the extent possible and implement appropriate corrective actions to prevent recurrence. Refer F600 28 Pa. Code 201.14 (a)(c) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)Nursing Services

Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 27 sampled (Residents 2, 40, and 47). Findings included: A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). A current physician order initially dated January 28, 2025, noted an order for Warfarin Sodium (an anticoagulant medication also known as a blood thinner) 4 mg via PEG-tube (percutaneous endoscopic gastrostomy- feeding tube placed directly into the stomach through the abdominal wall to provide liquid nutrition, medications, and fluids into the stomach) at bedtime for diagnosis of atrial fibrillation. A review of Resident 2's February 2025 Medication Administration Record revealed Apixaban 5 mg (anticoagulant) was administered daily as ordered by the physician. A review of Resident 2's quarterly MDS assessment dated [DATE], indicated the resident did not receive an anticoagulant (blood thinner) medication during the 7-day look-back period. An interview with the RNAC (registered nurse assessment coordinator) on April 23, 2025, at approximately 1:30 PM confirmed Resident 2's MDS assessment was not accurate. A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A review of Resident 40's annual MDS assessment dated [DATE], Section I active diagnoses, infection in the past seven days, indicated infections of MDRO (multi-drug resistant organism is a germ that is resistant to many antibiotics) and pneumonia (infection that affects one or both lungs, which makes it difficult to breathe and can cause a fever and cough). However, review of the clinical record revealed no documented evidence the resident had an MDRO infection or pneumonia. An interview with the RNAC on April 23, 2025, at approximately 1:45 PM confirmed that Resident 40 did not have an MDRO infection or pneumonia during the seven-day look-back period of the MDS assessment. The RNAC confirmed that Resident 40's MDS assessment was not accurate. A clinical record review revealed Resident 47 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces). A review of a 5-day MDS assessment dated [DATE], Section N0350. Insulin: Resident 47 did not receive any insulin injections during the seven-day look-back period. However, a review of Resident 47's Medication Administration Record dated February 2025 revealed Resident 47 received a Lantus 100 unit/ml solution pen injector (insulin) on five occasions from February 7, 2025, through February 11, 2025. During an interview on April 24, 2025, at approximately 1:30 PM, the RNAC confirmed Resident 47's February 11, 2025, MDS, Section N0350. Insulin was not accurate. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to accurately identify a resident's request for future health care and advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident (Resident 173) out of 27 residents sampled. Findings include: A review of the clinical record of Resident 173, revealed the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (type of arthritis that causes joints to become painful and stiff) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow). Review of Resident 173's clinical record revealed a completed and signed POLST (Physician Orders for Life-Sustaining Treatment a medical order form used to communicate a resident's preferences for life-sustaining measures across care settings) dated [DATE]. The POLST indicated that the resident elected DNR status (Do Not Resuscitate a medical order directing that cardiopulmonary resuscitation [CPR], a life-saving procedure performed when the heart or breathing stops, should not be attempted), with a goal of allowing a natural death. Further review of the resident's current physician orders, initially entered on [DATE], in the electronic health record, identified the resident's code status as Full Code, indicating CPR was to be performed in the event of cardiopulmonary arrest. There was no documentation to indicate that Resident 173 had revised the advance directive or changed the preference documented on the POLST. No clinical notes or care conference records reflected a discussion or update to the resident's wishes regarding life-sustaining treatment. An interview with the Director of Nursing (DON) on [DATE], at 9:10 AM confirmed that physician orders are required to align with the most current, signed POLST. The DON acknowledged that Resident 173 had elected DNR status on the POLST form and the current physician orders incorrectly reflected Full Code, which did not honor the resident's documented treatment preferences. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

APPEAL FILED Based on a review of clinical records and facility documentation and staff interview it was determined that the facility failed to consistently provide sufficient staff assistance with activities of daily living to maintain resident safety and prevent falls and utilize safe technique during care to prevent an accident resulting in a serious head injury for one resident out of 24 sampled (Resident 45) Findings include: A review of the clinical record revealed that Resident 45 was admitted to the facility on [DATE], with diagnoses to include dementia and history of a stroke. The resident had multiple contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of her lower limbs according to the clinical record. A review of a quarterly Minimum Data Set (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) assessment dated [DATE], Resident 45 was severely cognitively impaired, required maximum staff assistance with activities of daily living, including bed mobility, personal hygiene and required total assistance with bathing. A review a care plan for ADL (activity of daily living), which the facility initiated February 12, 2020, revealed that the resident had a self care deficit related to bilateral upper and lower extremity contractures, severe cognition and communication deficits. The goal was that the resident's needs will be met through the next review date. The planned intervention was that the resident requires total assistance from staff for all activities of daily living. A review of the nurse aide care tracker documentation (the method of communication used at the facility to allow nurse aide staff to obtain resident care information prior to and during a current shift of duty) dated [DATE], revealed that staff were to assist Resident 45 with bed mobility. No futher instructions, to include the amount of staff necessary to safely move and reposition the resident in bed, was noted at that time. There was no noted further instructions available to nurse aide staff caring for this resident at the time of the survey ending [DATE]. The absence of this information was confirmed by the Director of Nursing (DON) during interview on [DATE], at 9 AM. The DON further stated that the nurse aide would decide on the need for additional staff assistance with the resident's care activities depending on the resident's needs during that shift. The DON stated that the resident's level of assistance with ADL care was not noted on the kardex or on the resident's care plan. A review of current physician orders initially ordered February 11, 2020, revealed that Resident 45 had an order for [MEDICATION(S)] (brand name [MEDICATION(S)], an anti platelet medication, which inhibits blood clotting, but increases bleeding risk. This drug can cause serious and sometimes fatal bleeding. [MEDICATION(S)] may make you bruise and bleed more easily, have nosebleeds, and it will take longer than usual for bleeding to stop ) 75 mg tablet, by mouth once a day. A corresponding [DATE] medication administration record revealed that Resident 45 received a daily dose of this blood thinning medication. The last dose received was on [DATE], at 6 PM. A review of information submitted by the facility and a facility incident investigation report dated [DATE], at 8:19 PM, revealed that Resident 45 fell out of bed during care. She is total assist with activities of daily living cares and she was in the process of being provided PM cares by a nursing assistance. The resident rolled out of bed while being turned over to have her back cared for. The nurse aide attempted to stop the fall and lost her grip on the resident. The resident fell to the floor. Her vital signs became acutely abnormal. 911 (emergency services) called to transfer resident. Resident 45 is on a blood thinner (medication). The resident was transferred to the hospital. The facility was notified that Resident 45 expired in the emergency department shortly after arrival. Possible traumatic brain injury, [CONDITION(S)]. The resident's MDS states that Resident 45 is an assist of 2 staff for bed mobility. The nurse aide that provided care to the resident was sent home pending the facility investigation. Further review of the facility investigation of a witnessed fall dated [DATE], indicated that on that date at 8:19 PM, Employee 3 (LPN) was called to Resident 45's room by Employee 4 (a nurse aide). Employee 4 stated that she was providing care to the resident when the resident slipped off the air mattress onto the floor. The nurse aide was on the opposite side of the bed from which the resident fell . The resident was lying on her left side between the beds in the room. The resident is nonverbal (her baseline), but crying. The resident was assessed for injuries, which showed no outward signs of trauma. The resident was moved to the bed and in position of comfort. Pillows were placed on either side of the resident. The immediate actions taken by nursing staff was to complete neuro checks (A neurological examination assesses motor and sensory skills, hearing and speech, vision, coordination, and balance), every 15 minute checks by nursing and providing the assistance of 2 nurse aides with all care until a wider bed is available. A review of a fall risk assessment dated [DATE], at 8:19 PM, revealed that Resident 45 was a moderate fall risk. A review of care tracker information for Resident 45 revealed that the bed mobility task on the 7 AM to 3 PM and 3 PM to 11 PM shift on most days, was completed with the assistance of one staff member and on the 11 PM to 7 AM shift was completed with two staff members. In response to surveyor inquiry regarding Resident 45's fall, the DON interviewed the following staff during the survey ending [DATE], regarding the level of assistance staff provided with Resident 45' care and bed mobility: Employee 5 (nurse aide) stated that Resident 45 requires two persons to assist all the time for repositioning and incontinence care; Employee 6 (nurse aide) stated that Resident 45 requires two persons to assist all the time for repositioning and incontinence care; Employee 7 (nurse aide) stated that Resident 45 requires the assistance of one or two people, the employee stated that I can reposition and change her by myself, unless another aide is available to help me; Employee 8 (nurse aide) revealed that Resident 45 requires two person assistance with repositioning and incontinence care. Employee 8 stated that the resident is contracted and difficult to move. An interview the facility Assistant Director of Nursing conducted with Employee 4 (nurse aide) on [DATE], regarding the incident involving Resident 45, revealed that Employee stated I was giving care to Resident 45. I moved her to the center of the bed. I was on her left side and rolled her to the right. She was fine when I rolled her-she seemed herself. I was washing her back and she reached for something with her left hand. The top of her body started to slide and I couldn't stop her from sliding off the bed. She fell on her left side. I didn't see any marks or any blood anywhere. The nurse came and looked at her and we got her back on the bed. Employee 4 stated that her hands were wet and soapy from providing care to the resident. The resident reached over the side of the bed and began to fall. Employee 4 could not keep a grip on her because her hands were wet. A review of a nurses note, by Employee 3 (LPN), dated [DATE], at 9:09 PM, revealed in to do neuro checks, Resident 45 unresponsive (nonverbal baseline), skin pale, cool and diaphoretic (sweating heavily), pupils, equal and round to light, 6 mm in size, respirations labored, oxygen saturation ,d+[DATE]% on room air, placed on 12 liters of oxygen, lungs clear. The physician and responsible party contacted and the resident was sent to the emergency room . A review of a hospital discharge summary dated [DATE], at 1:40 AM, revealed that Resident 45's Admission history and physical read [AGE] year old female presents as a level 1 trauma after being found down after a fall. The patient was unresponsive and brought to the trauma bay for evaluation. She was hypotensive (low blood pressure) and bradycardic (low heart rate) on arrival. After discussion was held with the patient's husband, it was found that the patient is a DNR/DNI ( do not resuscitate/intubate, a tube placed down the throat to assist in breathing) and patient was made comfort measures. She passes away shortly after arrival to the trauma bay. The resident's preliminary cause of death was listed as possible traumatic brain injury, [CONDITION(S)]. During an interview [DATE], at approximately 11 AM, the DON confirmed that the resident's current MDS assessment indicated that Resident 45 was an extensive assist of two staff for bed mobility. The DON confirmed that at the time of the fall, two staff members should have been providing care for Resident 45 to prevent the fall. 483.25 (d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited [DATE] 28 Pa. Code 211.12(a)(d)(1)(3)(5) Nursing services. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE]

Based on review of clinical records, select facility policy, and incident/accident reports and staff interview, it was determined that the facility failed to implement sufficient measures and timely identify and monitor skin integrity to prevent the development or worsening of pressure sores for three of 26 sampled residents (Residents 25, 86 and 89). Findings include: A review of the facility policy for pressure ulcer prevention and management program reviewed by the facility April 2015 revealed that this facility is committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the individual's clinical condition demonstrates they are unavoidable. Pressure ulcers are assessed weekly or more frequently as necessary by a licensed nurse. Individual skin site sheets are used for assessment and documentation. A comprehensive description of each pressure ulcer is documented by a licensed nurse weekly. A review of the clinical record revealed that Resident 25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission and quarterly Minimum Data Set assessment (MDS - a federally mandated assessment completed at periodic intervals by the facility to determine a resident's health care needs) dated April 23, 2015 and June 11, 2015, revealed that the resident was cognitively intact and required extensive assistance of one staff member for bed mobility. Upon admission to the facility, the resident was identified with an unstageable pressure area on the right buttock measuring 10 centimeters by 3.5 centimeters by 2 centimeters that received daily treatment. A nurse's note dated May 8, 2015, revealed that treatment orders to the right buttock were changed and now included the us of a KCI vac (a device that promotes wound healing through negative pressure). A nurse's note dated May 26, 2015, at 5:58 a.m., revealed that during routine rounds a nurse aide noted two six centimeter by .5 centimeter fluid filled blisters (Stage II pressure sores - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister) on the resident's left hip area. The entry noted that the wound vac tubing utilized to heal the right buttock pressure sore was positioned between the blisters. An Incident/Accident Report dated May 26, 2015, at 5:30 a.m., revealed that the probable cause of the two newly in-house acquired pressure sores was the result of the resident laying on the KCI vac tubing. Review of the clinical record and further review of the Incident/Accident report failed to indicate that this cognitively intact resident was interviewed to determine how the KCI vac tubing was positioned. There was also no documention in the resident's clinical record, care plan or facility protocol to indicate how staff was to position the KCI vac tubing to prevent pressure from the resident laying on the tubing. In addition, there was no documention in the clinical record describing the pressure sores condition up to the time the area was healed (June 1, 2015). Interview with the director of nursing on July 2, 2015, at 8:45 a.m., was unable to provide evidence that reasonable preventative measures were taken to prevent the development of these Stage II pressure sores and that documentation representing progression of healing was present. A clinical record review of Resident 86 revealed a nursing note dated December 27, 2014, indicating that a physician order was obtained for skin prep (brand name for a skin protectant) to be applied twice daily to the resident's left great toe. No additional documentation was noted in the resident's clinical record indicating why the skin prep was being used for this resident's toe. A review of an Incident/Accident Report dated for December 27, 2014, indicated that the nursing assistant noted a blister on the resident's left great toe and the charge nurse and nursing supervisor were made aware. The Incident/Accident Report failed to identify the size of the blister, what the surrounding tissue looked like, and the color of the blister (whether it was clear fluid filled or bloody). No additional documentation was noted regarding the appearance of the blister. An interview with the Director of Nursing, on July 2, 2015, at 8:45 a.m., confirmed that there was no documentation regarding what the blister initially looked like upon discovery. The Director of Nursing further confirmed that the area should have been monitored weekly to determine whether it was improving or declining and whether the treatment was effective. The DON was unable to explain why the facility failed to do so. A review of the clinical record revealed that Resident 89 had [DIAGNOSES REDACTED]. Resident 89 was noted to have an open abscess wound on her coccyx, measuring 3 cm x 11.5 cm x 0.2 cm; the wound bed was noted as 20% slough, 20% red and 60 % purple, the wound edges were macerated. The next assessment of the area was noted on April 14, 2015, 21 days later. A quarterly minimum data set assessment dated [DATE], revealed that Resident 89 was cognitively impaired, required assistance with activities of daily living, assist of 2 staff for bed mobility and was frequently incontinent of bowel and was at risk for skin breakdown. A care plan for impaired skin integrity initiated October 18, 2013, revealed interventions to prevent skin breakdown included all treatments as ordered and encourage turning and repositioning as needed. This care plan was revised May 5, 2015, to reposition and rotate the resident's body every 1 hour to promote wound healing. Physician's recapped orders dated April 1, 2015, revealed that staff were to encourage/assist the resident to turn and reposition at a minimum of every two hours and as needed. Staff were to notify the nurse if a decline in performance is observed. A review of an incident report and nursing documentation dated April 14, 2015, at 2:30 PM, revealed a that the resident had developed a facility acquired Stage II pressure area (a partial thickness skin loss) on the coccyx, measuring 3.4 cm x 1.5 cm x < 0.1, scant amount sero sanguineous drainage. The wound bed was noted to be 100% intact red tissue. The wound edges were noted to be reddened and intact. The next weekly wound progress note for the coccyx area was dated May 13, 2015, 29 days after the wound was first discovered, and when the wound was noted as healed. A second pressure area was noted to the resident's right buttock, identified as unstageable (an unstageable ulcer involves a breakdown into at least the subcutaneous tissue and is covered with necrotic tissue, such as slough or eschar, formed from remnants of the collagen matrix of subcutaneous tissue. It is a always a full-thickness ulcer-either stage III or stage IV) measuring 2.4 cm x 2.4 cm x <0.1 cm, a small amount of sero sanguineous drainage, 100% intact yellow slough ( dead skin separating from an ulcer). The surrounding wound edges were macerated (the softening and whitening of skin that is kept constantly wet). The physician was called and a treatment and a Bari alternating air mattress ( an air mattress providing alternating pressure ) were ordered. Dietary was notified and Juven ( a therapeutic nutritional supplement drink to support tissue healing) 1 pack in 8 ounces of fluid, twice a day for wound healing. The next weekly progress note for the right buttock pressure sore was dated May 15, 2015, 29 days after the wound was first discovered. The wound now measured 1. 1cm x 1.7 cm x < 0. 1cm, described as unstageable, with a small amount sero sanguineous drainage, the wound bed was 50 % yellow slough at the base of the wound bed and 50 % beefy red, the surrounding skin was reddened and intact. The area was noted as healed on June 3, 2015. A review of electronic nurse aide documentation for April 2015 revealed that the turning and repositioning documentation was completed once a shift. There was no documentation to support the timeliness and that the resident was repositioned every 2 hours and as needed according to the resident's plan of care. The daily nurse aide electronic documentation did not indicate that this resident displayed any skin issues prior to April 14, 2015. There was no evidence of licensed nurse documentation prior to discovery of the Stage II and unstageable pressure area noted on April 14, 2015. The electronic documentation also indicated that Resident 89 was incontinent of bowel, however there was no evidence at the time of the survey that her bowel incontinence was reassessed to determine if her toileting schedule was adequate. During an interview July 2, 2015, at approximately 11 AM, Employee 7 (LPN wound nurse) confirmed that an comprehensive skin assessment was to be completed weekly on Resident 89. She was unable to state why 29 days had passed without an assessment for Resident 89's pressure areas or why the right buttock pressure area was discovered at as unstageable. She confirmed that Resident 89 could not reposition herself in bed and required staff assistance for repositioning. She further confirmed that the resident refused to get out of bed. During an interview July 3, 2015, at approximately 12 PM, the Director of Nursing verified that it could not be determined if this resident was consistently turned and repositioned every 2 hours. The DON also verified that the pressure areas should have been monitored weekly to determine whether they were improving or declining and if the treatment was effective. There was no evidence of the development and implementation of additional interventions for this resident who had a history and risk of developing of pressure ulcers prior to the development of a Stage II and an unstageable pressure area. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services Previously cited 6/12/14, 11/18/14, 2/4/15 28 Pa. Code 211.5(f)(g) Clinical records Previously cited 6/12/14 28 Pa. Code 211.10(d) Resident care policies

Based on clinical record and select policy review and staff and resident interviews, it was determined that the facility failed to provide the necessary care and services, in a timely manner, to promote adequate bowel activity and prevent constipation with resulting pain and discomfort for one sampled residents (Resident 89), failed to co-ordinate medical services for for one resident (Resident 76) and develop an initial plan of care to meet specific needs of one resident (Resident 15) out of 26 residents sampled. Findings include: A review of the clinical record revealed that Resident 89 had [DIAGNOSES REDACTED]. Irritable bowel syndrome commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation) and refusal to get out of bed. A review of a quarterly minimum data set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 6, 2015, revealed that Resident 89 was severely, cognitively impaired, needed assistance with activities of daily living, including toileting and was frequently incontinent of bowel. The physician's monthly recapped orders dated April 1, 2015, included [MEDICATION NAME] 20 mg by mouth daily, [MEDICATION NAME] 300 mg by mouth daily, [MEDICATION NAME] SR 200 mg by mouth daily (all antidepressant medications with a potential side effect of constipation) Klonopin 0.5 mg by daily (an antianxiety medication with a possible side effect of constipation), Levothyroxin 250 mg by mouth daily and Accuchecks before meals and at bedtime (blood glucose monitoring) with [MEDICATION NAME]coverage on a sliding scale. A review of medication administration records and nursing documentation for April 2015 revealed that Resident 89 consistently took her Levothyroxin daily. There was no documented evidence at the time of the survey of any [MEDICAL CONDITION] laboratory blood tests performed to indicate this resident's blood [MEDICAL CONDITION] hormone levels. The resident was on a bowel protocol consisting of: if no bowel movement (BM) in 5-7 shifts, give 4 oz of prune juice on the 3 PM to 11 PM shift , if no BM in 8-10 shifts, give 30 ccs of milk of magnesia ( MOM, a laxative) and [MEDICATION NAME] suppository rectally on the 7 AM to 3 PM shift, if no BM in 11-13 shifts, give fleets enema, and if no BM after fleets enema, contact the physician and obtain further orders. A review of BM records for April 2015 revealed that from April 8, 2015, 7 AM to 3 PM shift through April 11, 2015, 11 PM to 7 AM Resident 89 did not have a BM. After the 7th shift with no BM, 30 ccs of MOM was given to the resident, but with no results. The resident went a total of 12 shifts with no bowel movement. There was no evidence at the time of the survey that the resident's bowel protocol was implemented as ordered. A review of bowel movement records revealed that from April 16, 2015, 11 PM to 7 AM shift through April 17, 2015, 3 PM to 11 PM shift Resident 89 did not have a BM for 9 consecutive shifts. There was no evidence that any of the physician ordered steps of the bowel protocol were provided to the resident to promote bowel activity. From April 18, 2015, 7 AM to 3 PM shift, 6 shifts, the resident had no bowel movement and there were no prescribed interventions provided. Resident 89 was noted to have three bowel movements on April 20, 2015, and one on April 22, 2015, according to bowel records. However, nursing documentation dated April 22, 2015, at 9:32 AM revealed that Resident 89 had two episodes of emesis (vomiting), was medicated for the same and the physician was notified. At 10 PM she again vomited twice according to nursing notes. A nursing note dated April 23, 2015 at 2:50 PM indicated that the Certified Registered Nurse Practioner (CRNP) saw the resident and sent her out to the hospital to be evaluated. The nursing note indicted that she was admitted to the hospital with [REDACTED]. A review of an emergency room history and physical report dated April 23, 2015, at 4:18 PM revealed that Resident 89 had been vomiting since last night (April 22, 2015) and staff indicated that it may be fecal material and her last bowel movement was several days prior. A review of a hospital discharge form dated May 3, 2015 revealed Resident 89 was admitted for evaluation of severe constipation and fecal impaction. Patient has severe [MEDICAL CONDITION] with [MEDICAL CONDITION] ( a condition marked by thickening and swelling of the skin caused by insufficient production of [MEDICAL CONDITION] hormones by the [MEDICAL CONDITION]. The function of [MEDICAL CONDITION] hormones is to regulate your metabolism. [MEDICAL CONDITION] is associated with other symptoms of underactive [MEDICAL CONDITION], also called [MEDICAL CONDITION], including lethargy, weight gain, fatigue, depression, and cold sensitivity, among others) due to non compliance (with taking medication). However, according to Medication Administration Records the resident was compliant with accepting [MEDICAL CONDITION] medication and had consistently received this medication prior development of the fecal impaction. There was no evidence that the facility had consistently and accurately implemented the resident's prescribed bowel protocol to promote bowel activity and prevent fecal impaction. A CT scan (CT scanner emits a series of narrow beams through the human body as it moves through an arc, unlike an X-ray machine which sends just one [MEDICAL CONDITION] beam. The final picture is far more detailed than an X-ray image) of the abdomen was ordered, the results included fecal impaction without bowel obstruction (a solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation). The fecal impaction was removed at the hospital. She returned to the facility May 5, 2015. A review of daily glucose monitoring records for May 2015 and June 2015 indicated that on May 7, 2015, at 6 AM Resident 89's accucheck was 147 and no insulin was given, but the physician ordered sliding scale indicated that 1 unit of insulin should have been given. On May 16, 2015, at 6 AM the resident's Accucheck was 189 and no insulin was given, but the sliding scale indicated that 2 units of insulin should have been given. On June 1, 2015, at 6 AM Resident 89's Accucheck was 147 with no insulin given, but the sliding scale indicated that 1 unit should have been given. A review of nursing documentation entitled open lesion weekly progress note dated March 24, 2015, at 4 PM revealed that Resident 89 had a facility acquired abscess on her left buttock measuring 3 cm x 11. 5cm x 0.2 cm in depth, currently being treated with [MEDICATION NAME] wet to dry dressing. The wound description was 20% intact yellow tissue, 20% bright red tissue, 60% intact purple tissue, surrounding skin is reddened, hardened with macerated wound edges. The physician was called and the treatment was changed. The next nursing documentation regarding this open area was dated April 14, 2015, 21 days later. The facility failed to provide evidence, at the time of the survey, that open lesion weekly progress notes had been completed. There was also no evidence at the time of the survey of any prior documentation of this area as an intact abscess. During an interview with Employee 7 (LPN, wound nurse) at the time of the survey Employee 7 stated that this area started as a small pimple like area on the resident's buttock. Employee 7 confirmed that there was no documentation of this area prior to the March 24, 2015, notation of the decline in the wound and verified that weekly wound assessment documentation was not completed. During an observation of the resident's left buttock wound July 3, 2015, at 10 AM revealed the area measured 2.9 cm x 5.5 cm, with a very small light area in the center. The remaining wound bed was beefy red. The wound edges were granulating tissue. There was a scant amount of sero-sanguineous drainage on the dressing. Interview with the Director of Nursing (DON) on July 3, 2015, at approximately 2 PM, confirmed that the facility was unable to provide evidence that the facility implemented its established bowel protocol for this resident. The facility failed to effectively monitor and respond to this resident's lack of bowel activity until the resident exhibited vomiting, was admitted to the hospital required removal of a fecal impaction. She further confirmed that the physician ordered insulin coverage was not followed. The DON also verified that there was no evidence that this resident's left buttock abscess area was assessed timely and monitored weekly to prevent further decline. During an interview with Resident 76 on July 2, 2015, at approximately 10:00 AM the resident stated that he missed an appointment with his neurologist on July 1, 2015, because arrived too late to be seen. The resident, who is cognitively intact, stated that the facility staff did not inform him of the appointment until transport came at 9:10 AM to take him to the appointment. Resident 76 further stated that Employee 8 (a nurse aide) was not aware that he had the appointment and did not have him cleaned and dressed at the time transportation arrived. Because Resident 76 arrived late for the medical appointment, the appointment was cancelled. The resident was not seen by the doctor and the appointment was rescheduled for September 10, 2015. During an interview with Employee 8, nurse aide, on July 2, 2015, at 10:50 AM she stated that she does not remember being told that Resident 76 had a doctor's appointment and did not have him ready to go at the time transportation came to pick him up; therefore he arrived late for his appointment, which was then cancelled. During an interview with the Director of Nursing on July 2, 2015, at approximately 10:45 AM she confirmed that the resident's medical care had not been coordinated. The resident was not aware of the neurologist appointment. A message was left with the resident's responsible party regarding the appointment. The DON further stated that Employee 1 (RN supervisor) did not inform Employee 8, the resident's assigned nurse aide, that Resident 76 had a doctor's appointment on July 1, 2015, and therefore the resident arrived too late for the appointment resulting in the cancellation of the appointment and rescheduling two months later. A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], and receives [MEDICAL TREATMENT] treatments three times a week. The resident had a current physician's orders [REDACTED]. The resident's fluid intake records from June 18, 2015, through July 1, 2015, revealed that the resident had exceeded his fluid restriction four days and was under less than 75% of the restriction on seven days. The resident's compliance with the fluid restriction and the potential for dehydration were not included in the resident's initial plan of care at the time of the survey ending July 2, 2015. 483.25 Quality of Care Previously cited 6/12/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 11/18/14, 2/4/15, 6/12/14

Based on review of clinical records, select facility policy, incident report, observation and staff interview it was determined that the facility failed to ensure that planned interventions were effectively implemented to prevent the development of an unstageable pressure ulcer for one resident (Resident 104) and failed to ensure that pressure relieving devices were implemented as prescribed for one resident (Resident 167) out of 27 sampled. Findings include: Review of the facility Pressure Ulcer Prevention and Management Program dated January 18, 2011, revealed that the facility was committed to providing a comprehensive pressure ulcer prevention and management program to ensure that residents admitted to the facility without pressure ulcers do not develop them unless the resident's clinical condition demonstrates they were unavoidable. Daily inspection of resident's skin condition is performed during provision of personal care by nursing staff. Weekly full body inspection of resident's skin condition is performed during the shower/bath by nursing staff. Individualized mobility and function plans of care including, but not limited to: ambulation programs, turning and repositioning schedules, and contracture prevention (range of motion exercises) and management (splinting) are implemented as needed. Routine skin barriers or protectants are utilized once each shift and following each incontinent episode in accordance with the resident's plan of care. Residents that are coded as extensive or totally dependent for bed mobility on the most recent Minimum Data Set are to be "turned and repositioned at a minimum of every two hours and as needed". Clinical record review revealed that Resident 104 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment (tool completed at specific intervals to identify resident care needs) dated, May 20, 2011, indicated that the resident was independent for decision making, required extensive staff assistance for activities of daily living, which included bed mobility, transfers, dressing, toilet use, and personal hygiene, was frequently incontinent of bowel and bladder, had limited range of motion to the lower extremity on one side ([MEDICAL CONDITION]), and was at risk for developing pressure ulcers. Review of a Braden scale for predicting pressure ulcer risk dated, May 10, 2011, indicated that the resident scored a 16 (a score of 15 to 18 represents at risk and a score of 12 or less represents high risk). A nurses note dated, May 23, 2011, at 11:30 a.m., revealed that a 1 cm x 5 cm x 0.1 cm area was noted to the sacral area. A physician order [REDACTED]. Review of the resident's Skin Site Report dated, May 23, 2011, indicated that the area on the resident's sacrum was an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed) 1 cm by 5 cm by 0.1 cm pressure ulcer with slough (necrotic/avascular tissue) on the edges, eschar (brown in the center), and [DIAGNOSES REDACTED] (redness) was present in the peri-wound area (surrounding skin area). Review of a facility Incident/Accident Report dated, May 23, 2011, at 11:15 a.m., revealed that Employee 2 ( a nurses aide) was providing morning care to the resident and found the area on the resident's sacrum and alerted the nurse. A review of the resident's activities of daily living records since the resident's admission revealed that the resident was usually continent of bowel and bladder. Review of the "summary of tentative conclusions" related to the probable cause of the pressure sore development included the resident's immobility, diabetes, and status [REDACTED]. was effectively monitored, if the resident was consistently repositioned as scheduled, and if routine skin barriers/protectants were applied to the resident as per facility policy and planned. Review of the resident's admission care plan dated, May 11, 2011, revealed that the resident had actual skin impairment (a back abrasion) secondary to impaired mobility, diabetes, anticoagulation treatment, and incontinent behaviors. Interventions to keep the resident's skin intact included weekly skin assessments performed during regularly scheduled showers set per facility policy, providing extensive assistance to turn and reposition at least every two hours, more often as needed or requested, pressure relieving cushion to wheelchair, and to notify the nurse immediately of any new areas of skin breakdown during bath or daily care. A physician order [REDACTED]. Review of the resident's May 2011 Turning and Repositioning Record indicated that the resident was on a turning and repositioning program and to encourage/assist to turn and reposition. There was no time interval (care planned at least every two hours) for repositioning the resident noted on the record. Staff signed off once every shift that the resident was repositioned. Review of the resident's Weekly Skin Integrity Inspection Form dated, May 20, 2011 (no time indicated), noted that the resident's skin was intact. Review of the resident's May 2011 Personal Hygiene Record indicated that personal hygiene was provided twice daily. As needed personal care was noted as being provided once on May 11, 2011, once on May 15, 2011, and once on May 18, 2011. Further review of the resident's May 2011 Point Click Care Records revealed no documented evidence of the daily inspections of the resident's skin that were to completed during personal care as per facility policy. There was no documented evidence that the facility had promptly identified declines in the resident's skin integrity prior to the finding of an unstageable pressure sore. Interview with the director of nursing (DON) on July 29, 2011, at 11:00 a.m., was unable to provide documented evidence that planned interventions, including timely turning and repositioning and thorough daily skin checks, were effectively and consistently implemented to prevent the development of the unstageable pressure ulcer to the resident's sacrum. Clinical record review revealed that Resident 167 was readmitted to the facility on [DATE], with diagnoses, which included dementia (a condition of mental deterioration). Review of a nursing re-admission assessment dated [DATE], revealed that the resident was readmitted to the facility with a blood filled blister on the right heel measuring 1.6 centimeters x 1.6 centimeters. Review of a quarterly MDS assessment dated , April 19, 2011, indicated that the resident was cognitively impaired, required extensive staff assistance for activities of daily living, which included bed mobility, transfers, dressing, toilet use and personal hygiene. The quarterly MDS assessment also indicated that the resident was incontinent of bowel and bladder, had limited range of motion to upper and lower extremities and was at risk for developing pressure ulcers. Review of a Braden scale tool for predicting pressure ulcer risk dated, March 16, 2011, indicated that the resident scored an 11 (a score of 12 or less represents high risk). A physician's orders [REDACTED]. Observations of Resident 167 on July 26, 2011, from 11:55 a.m. through 1:10 p.m. revealed that the resident was seated in his geri-chair (a type of chair used for safety and comfort) without his Prevalon boots on. His boots were observed on his bed throughout the entire observation period. Observations of the resident on July 27, 2011, from 10:05 a.m. through 2:40 p.m. revealed that the resident was again seated in his geri-chair without his Prevalon boots on. In the morning, his boots were observed on his bedside chair and in the afternoon, the boots were observed on his bed. Interview with the DON on July 29, 2011, at 8:45 a.m., confirmed that the boots were not consistently placed on the resident as ordered by the physician. 28 Pa. Code 211.10(a)(c) Resident care policies previously cited 7/20/2011 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services previously cited 7/20/11

Based on review of clinical records and facility policies and procedures, and staff interviews, it was determined that the facility failed to consistently and accurately monitor fluid intake and implement timely and adequate measures to prevent dehydration for one of six residents reviewed (Resident CR1). Findings include: The review of the facility's "HYDRATION" policy/procedure reviewed/revised January 18, 2011, revealed standard intake monitoring will be documented every shift for all residents regardless of the route of fluid intake. The residents who need to be closely monitored for dehydration include residents with: signs and symptoms of an acute infection, sudden decline or decreased intake of food and fluid by mouth, sudden unexplained weight loss, thickened liquids with decreased consumption, any other identified potential for dehydration. The review of the "INTAKE AND OUTPUT MONITORING POLICY" reviewed/revised July 1, 2011, revealed that each resident admitted to the facility will be monitored daily for intakes greater than 1200 cc (cubic centimeters) and outputs if the resident has a catheter or suprapubic catheter. The RD (registered dietician) will determine if the resident is meeting their needs. If the resident is not meeting their needs, individualized interventions will be initiated per RD recommendation. All residents with the following criteria will be initiated on fluid monitoring per RD recommendation to include but not be limited to; residents placed on antibiotic therapy for the duration of the therapy, residents not meeting their fluid needs and other reasons identified by the health care team which may put the resident at increased risk. Intakes will be reviewed daily per hydration policy. The RD will then communicate with the health care team, regarding the need for additional fluids for the resident and update the care plan accordingly. The clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], following a hospitalization and with multiple [DIAGNOSES REDACTED]. He also has a history of a rectal bleed. According to an admission Minimum Data Set Assessment (tool completed at specific intervals to identify care needs) dated July 7, 2011, the resident was cognitively impaired, required extensive assistance of one for eating, was on a mechanically altered therapeutic diet and had a Stage II pressure sore. He was admitted to the facility on [DATE], with a pressure ulcer on the sacrum (stage not identified) measuring 1.5 cm (centimeter) x 1.5 cm and identified as opened/ red. He also had a 2.5 cm x 2.25 cm open red/yellow area at the 5th toe amputation site. The admission physician orders [REDACTED]. The resident was also prescribed a nutritional supplement,[MEDICATION NAME] A review of a nutritional assessment dated [DATE], revealed that the resident's weight was 142.8 pounds, which required 1885 calories and 1625-1950 ccs fluid in 24 hours. It was also noted that he was on [MEDICATION NAME] as an appetite stimulant and that speech therapy and occupational therapy were to evaluate him. His nutritional needs were estimated to promote wound healing and improvement in protein stores. His diet included a carbohydrate controlled mechanical soft diet. He was noted with chewing problems. It was further noted that dietary would follow meal and fluid intakes and advise as indicated. A Dysphagia Evaluation was conducted on June 27, 2011 due to difficulty swallowing foods. As a result of this evaluation a physician's orders [REDACTED]. He was also experiencing periods of increased sleeping and increased lethargy which required medication discontinuation and adjustments throughout his stay at the facility. According to his meal intake records from June 27, 2011 through discharge on July 7, 2011, the resident consumed the following amount of meals: Breakfast Lunch Dinner 6/27/2011- 0-25% 26%-50% 26%-50% 6/28/2011- 0-25 % 0-25% 76-100% 6/29/2011- 0-25% Refused 0-25% 6/30/2011- 51-75% 51-75% 26-50% 07/01/2011 26-50% 76-100% 51-75% 07/02/2011 51-75% Refused 51-75% 07/03/2011 26-50% 51-75% 26-60% 07/04/2011 0-25% 0-25% 51-75% 07/05/2011- 51-75% 26-50% 0-25% 07/06/2011- 0-25% 51-75% 26-50% 07/07/2011- Refused Resident not available Resident not available Although the resident was admitted on [DATE], there was no documented evidence of meal intakes recorded from June 24, 25, 26, 2011. Review of the resident's intake/output records from admission until discharge revealed the following: Intake Output 6/24/2011 not available not available 6/25/2011 not available not available 6/26/2011 600 ccs/24 hours not available 6/27/2011 1200 not available 6/28/2011 1440 not available 6/29/2011 380 not available 06/30/2011 1260 not available 07/01/2011 1520 925 ccs/24 hours 07/02/2011 960 1000 ccs 07/03/2011 1140 800 07/04/2011 1400 940 07/05/2011 880 850 07/06/2011 1140 1000 07/07/2011 400 ccs (discharge date ) 400 Review of an initial Hydration Risk Evaluation, initiated June 27, 2011, revealed that the resident's fluid needs are 1625 ccs. The section indicating special circumstances which may require increased or decreased fluid needs was left blank, despite the resident's history of [MEDICAL CONDITION], requiring an appetite stimulant, pressure ulcer, decreased fluid intake and extended periods of sleeping/lethargy per nursing documentation. The admission intake monitoring (7 days) section of this assessment, revealed that the resident's fluid intakes were not assessed as part of this hydration risk assessment from the resident's date of admission but was initiated on 06/27/2011 through 07/03/2011. This assessment indicated that the resident was not meeting his estimated fluid needs. The interventions noted on this assessment (dated July 5, 2011) were to encourage PO (oral) fluids between and with meals, monitor acceptance and continue intake monitoring. It was noted [MEDICATION NAME] will add 16 ounces of fluid and the Supershake adds 8 ounces. According to laboratory testing dated June 29, 2011, the following was revealed: BUN 27 mg/dl (normal 6-20 mg/dl) [MEDICATION NAME] 1.1 mg/dl (0.7-1.5 mg/dl) Sodium 148 mmol/ dl (normal 135-146 mmol/dl) Chloride 116 mmol/dl (98-111 mmol/dl). A review of hospital laboratory values for the above lab values prior to his admission to the facility on [DATE], were within normal limits. Review of a dietary progress note dated June 30, 2011, revealed that the resident's oral intakes were reviewed and were less than 50 % over the 3 day review period. There was no reference to the resident not consuming fluids in amounts to meet estimated fluid requirements. The next dietary note was dated July 1, 2011, which indicated that SF (sugar free) health shakes were ordered twice a day with breakfast and lunch as a supplement. It could not be ascertained how much of the Sugar Free Health shakes the resident consumed since the amount consumed was incorporated into the overall meal intake percentages. This was confirmed by the Director of Nursing during interview on July 20, 2011, at 2 PM. The last dietary note available for review prior to the resident's discharge from the facility, was on July 6, 2011 which indicated that the resident's meal intakes averaged less than 50 % for meals. " Intakes do vary throughout the day and from day to day. Speech therapy was in place. His po intakes are averaging 1069 ccs per day which does not meet his estimated fluid needs. [MEDICATION NAME] is in place which may stimulate intakes. Vitamin in place to aid in wound healing. Diet remains puree nectar thick liquid carb control. Labs from (6/29/2011) are all elevated. There was a change in the wound noted. The right sacrum measures 2.6 cm x 2.6 cm x less than 0.2 cm with no drainage. This area increased from the last week. The area on the sacrum and left buttocks have merged and measures 10 cm x 5.6 CM x less than 0.1 cm with some slough noted. His nutritional needs were estimated at 2342 calories, protein needs estimated at 91.5 grams of protein. His weight is 135.2 pounds and does show weight loss since admission., The intervention will be to provide a super shake one daily at lunch time to provide additional nutrition. Will [MEDICATION NAME] 8 ounces twice daily (mixed with nectar thick water) to aid in wound healing. [MEDICATION NAME] will also add additional 16 ounces of fluid per day. Will also add magic cup as a hs snack. Supplementation will provide 770 calories and 18 grams of protein. Will continue with sugar free health shakes one twice?? daily at breakfast and lunch. This will provide an additional 400 calories and 12 grams of protein. It was noted that dietary will follow intakes and tolerance to supplements. Will continue to monitor wound progress and will show no further decline in skin integrity through the next review." He had a physician's orders [REDACTED]. By the end of the survey on July 20, 2011, there was no documented evidence available for review to indicate that the facility had assessed the resident for alternate forms of hydration to increase the resident's fluid intake and prevent dehydration. This lack of evaluation of alternate forms of hydration support was confirmed in an interview with the Director of Nursing on July 20, 2011, at 2:30 PM. The Administrator and the Dietitian also stated during interview on July 20, 2011, at 1:45 PM that the facility policy indicates if a resident consumes less than 1200 ccs of fluid for 3 days the physician will be notified of potential decreased fluids and that the resident did not trigger as such for 3 consecutive days. However, the resident's estimated fluid needs to maintain adequate hydration status based on his body weight were assessed at 1640 ccs. The resident was discharged to another long term care facility on July 7, 2011, but shortly after his admission he was sent out to the emergency room , on that same date, July 7, 2011. Review of the hospital record revealed that on July 7, 2011, he was seen in the emergency room for [DIAGNOSES REDACTED]. the body, i.e. sodium, potassium, magnesium and [MEDICATION NAME]), hypercapnia (more than normal amount of carbon [MEDICATION NAME] in the blood), metabolic acidosis (a condition when the body produces too much acid or kidneys are not removing enough), [MEDICAL CONDITION] (inadequate supply of oxygen) and [MEDICAL CONDITION] (increased sodium in the blood). His laboratory values as of 12:32 PM on July 7, 2011 were as follows: BUN 102 mg/dl (greater than 75 mg/dl is a critical level), Creatinine 4.8 mg/dl ( greater than 3.0 mg/dl is a critical level), Potassium 5.5 mmol/L (3.5-5.1 mmol/L), Sodium was 160 (normal is 136-145 mmol/L) , Chloride 131 mmol/L -(normal 98-107 mmol/l), WBC was 27.67 thous/ul (normal is 4.8-10.8 thous/ul) and he had many bacteria from his urinalysis. He was admitted to the Intensive Care Unit after being seen in the emergency roiagnom on [DATE]. The facility failed to demonstrate accurate and consistent monitoring of the resident's fluid and meal intake and hydration status and failed to develop and implement prompt and adequate measures to increase the resident's fluid intake and prevent dehydration. 28 Pa Code:211.5(f)(g)(h)Clinical records. Previously cited 9/24/2010. 28 Pa Code:211.6(c)Dietary services. 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5)Nursing services. previously cited from survey of 5/25/11.