Every finding on record at Christ the King Manor

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of 35 residents reviewed (Resident 93).Findings include:A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 93, dated June 2, 2026, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner), and had diagnoses that included cerebral infarction (a loss of blood flow to the brain causing physical deficits). Physician's orders for Resident 93, dated December 18, 2026, included an order for the resident to receive 3.5 milligrams (mg) of warfarin (blood thinning medication) daily for a mechanical heart valve (surgically implanted artificial valve that require lifelong blood-thinning medication). A review of Resident 93's Medication Administration Record (MAR) for December 2025, revealed that the resident did not receive any warfarin from December 18 through December 21, 2025. Physician's orders for Resident 93, dated May 12, 2026, included an order for the resident to receive 4 mg of warfarin on May 12, 2026, 3.5 mg of warfarin on May 13, 2026, 4mg of warfarin on May 14, 2026, and 3.5mg warfarin on May 15, 2026. A review of Resident 93's MAR, dated May 2026 revealed that staff administered 7.5 mg of warfarin on May 12, 2026, no warfarin on May 13, 2026, 7.5mg warfarin on May 14, 2026, and no warfarin on May 13, 2026, or May 15, 2026. Interview with the Director of Nursing on June 4, 2026, at 1:08 p.m. confirmed that a medication error occurred in December and the resident did not receive the warfarin as ordered and that the physician's orders for warfarin were not followed in May 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to review and revise care plans for two of 35 residents reviewed (Residents 12, 14). Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated April 7, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for her daily care needs and had diagnoses that included diaphragmatic hernia with obstruction (a defect in the diaphragm, which is the muscle separating the chest from the abdomen, that allows abdominal organs to push into the chest cavity and become trapped, twisted, or blocked, preventing the normal passage of food). Physician's orders for Resident 12, dated April 3, 2026, included an order for the resident to receive a full liquid diet with thin consistency liquids. A care plan for Resident 12, dated April 3, 2026, indicated that the Resident had anemia (low levels of healthy red blood cells), and a large hiatal hernia with food impaction (food is lodged, or trapped in a body cavity or passage). The resident was to be encouraged to eat food rich in iron such as green leafy vegetables, meat, eggs, poultry, nuts, grains, cereal and dried beans. A care plan for Resident 12 dated April 7, 2026, indicated that the Resident had the potential for altered nutrient utilization because of a large hiatal hernia with mechanical impaction. Staff were to provide and serve a full liquid diet. Interview with the Nursing Home Administrator on June 4, 2026, at 2:33 p.m. confirmed that Resident 12's care plan did not accurately reflect the resident's active care needs and should have been revised. A Quarterly MDS assessment for Resident 14, dated May 2, 2026, indicated that the resident was cognitively impaired and required assistance from staff for daily care needs. The resident's care plan, dated May 5, 2026, indicated that the resident had behaviors.A nursing note for Resident 14, dated May 3, 2026, indicated that the resident stated he wanted to harm himself.Interview with Nurse Aide 1 on June 2, 2026, at 2:05 p.m. revealed that Resident 14 makes self-harm threats when he gets frustrated and has made similar statements in the past.There was no documented evidence that Resident 14's care plan was updated to reflect his statements of self-harm or what interventions the staff should use when he makes these statements.Interview with the Director of Nursing on June 4, 2026, and 2:28 p.m. confirmed that Resident 14's care plan should have been updated to reflect his statements of self-harm.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(5) Nursing services.

Based on facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of 35 residents reviewed (Resident 12). Findings include:A facility policy for administration of medications dated January 4, 2026, included that it is the responsibility of the nursing professional to be aware of classifications, action, correct dosage and side effects of medication before administration. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated April 7, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for her daily care needs and had diagnoses that included diaphragmatic hernia with obstruction (a defect in the diaphragm, which is the muscle separating the chest from the abdomen, that allows abdominal organs to push into the chest cavity and become trapped, twisted, or blocked, preventing the normal passage of food). Physician's orders for Resident 12 dated April 3, 2026, included an order for the resident to receive 0.5 milligrams (mg) of lorazepam (federally regulated controlled drug used to treat anxiety) one tablet by mouth in the morning for anxiety, one-half tablet by mouth at bedtime for anxiety. Physician's orders dated April 3, 2026, also included an order for the resident to receive 0.5 mg of lorazepam one-half tablet by mouth as needed for anxiety/restlessness for 14 days. Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) sheet dated April 5, 2026, revealed that on April 6, 2026, at 8:20 p.m. one tablet of 0.5 mg of lorazepam was signed out to be administered for the bedtime dose. There was no documented evidence that that one half of the tablet was administered and one half of the tablet was wasted. Review of the controlled drug record sheet dated April, 2026, revealed that on April 7, 2026, at 12:00 a.m. one tablet of 0.5 mg of lorazepam was signed out to be administered. Review of the Medication Administration Record (MAR) dated April 2026 revealed that one-half tablet was to be administered. There was no documented evidence that that one half of the tablet was administered and one half of the tablet was wasted.Review of the controlled drug record sheet dated May, 2026, revealed that on May 22, 2026, one tablet of 0.5 mg of lorazepam was signed out to be administered for the bedtime dose. There was no documented evidence that that one half of the tablet was administered and one half of the tablet was wasted.Interview with Director of Nursing on June 4, 2026, at 3:56 p.m. confirmed that one tablet of 0.5mg was signed out on the controlled drug record to be administered when one-half tab was to be administered on the above mentioned dates and times, and there was no documented evidence that that one half of the tablet was administered and one half of the tablet was wasted.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies, investigative reports, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure timely medication administration per physician's orders for one of four residents reviewed (Resident 2). This deficiency will be cited as past noncompliance.Findings include: The facility's policy regarding medication administration, dated January 4, 2026, revealed that all medications will be administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) dated January 31, 2026, for Resident 2 revealed that the resident was severely cognitively impaired, required assistance from staff for daily care, required transfer assistance of two staff members, and used a wheelchair for mobility. An anemia care plan for Resident 2, dated January 28, 2025, indicated the resident will maintain laboratory values within acceptable parameters. A congestive heart failure care plan, dated January 28, 2026, revealed Resident 2 had congestive heart failure and to receive bumetanide (help flush excess fluid from body). Care plan dated September 26, 2025, revealed that Resident 2 required a behavior management plan related to verbally disruptive behavior with interventions, with a goal that these undesirable behaviors will be monitored or managed with interventions to include outpatient behavioral health. Interventions to include administer medications as ordered. Physician's orders for Resident 2, dated November 11, 2025, included an order for the resident to receive one milligram (mg) of bumetanide (helps body flush out excess fluid) by mouth two times a day . Physician's orders for Resident 2, dated January 24, 2026, included an order for the resident to receive one mg of risperidone (behavior medication), (one half tablet) by mouth one time a day; and two 325 mg tablets of acetaminophen (pain reliever) by mouth three times a day for pain. Review of Resident 2's medication administration record for February, 2026, revealed that on February 1, 2026 the resident did not receive bumetanide, risperidone, and acetaminophen at 2:00 p.m. No adverse effects were reported or documented. The physician was notified the following day of the missed medication administration, with no new orders given.Interview with Nursing Home Administrator and Director of Nursing on March 17, 2026, at 1:42 p.m. confirmed that the medications were not administered but should have been.A review of the facility's plan of correction included the following: Education on medication administration was sent to all licensed practical nurses and registered nurses who pass medications as a reminder that all medications are required to be given in a timely manner. Education also provided via the Point Click Care system for communication. Education to pull the Medication Administration Record (MAR). New system to alert staff if medications are not given. Reminder to this staff that at the end of the shift they should be pulling a MAR to ensure that all residents have green-colored boxes and nothing red which would indicate something not signed or given to a resident. Encouraged to ask questions if unclear. Audits of medication administration for residents completed weekly for three weeks. Interviews with nursing staff on February 11, 2026, revealed that they had been educated on medication administration. A review of the facility's corrective actions revealed that they were in compliance with F684 on February 16, 2026. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 42 residents reviewed (Residents 17, 52, 63, 64, 98, 103, 117). Findings include: The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section O0110G1b (non-invasive mechanical ventilator) and Section O0110G3b (CPAP- Continuous positive airway pressure - a machine that uses mild air pressure to keep breathing airways open while sleeping) was to be checked if a CPAP device was used while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 17, dated March 25, 2024, included an order for the resident to use a CPAP with humidification at bedtime with oxygen at 2 Liters per minute (L/min) every night. A quarterly MDS for Resident 17, dated April 20, 2024, revealed that Section O0110G1b and Section O0110G3b were not checked indicating that the resident did not use a CPAP device during the seven-day assessment period. Review of the MAR for Resident 17 dated April 2024 revealed that the resident used a CPAP device every night during the seven-day assessment period. Interview with the Director of Nursing on June 13, 2024, at 7:46 a.m. confirmed that Section O0110G1b and Section O0110G3b of Resident 17's quarterly MDS assessment, dated April 20, 2024, should have been checked to indicate that he used a CPAP device during the seven-day assessment period but was not. The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section N0415C should be checked if the resident received an antidepressant medication, Section N0415G was to be checked if the resident received a diuretic medication, and Section N0415H was to be checked if the resident received an opioid (pain medication) medication during the seven-day assessment period. Physician's orders for Resident 52, dated May 15, 2024, included an order for the resident to receive 2 milligrams (mg) of Bumetanide (diuretic) one time a day and 10 mg of Fluoxetine (an antidepressant) one time day. Physician's orders, dated April 5, 2024, included an order for the resident to receive 50 mg of Tramadol (opioid pain medication) once daily at bedtime. A quarterly MDS for Resident 52, dated May 21, 2024, revealed that Section N0415C, Section N0415G, and Section N0415H where not checked, indicating that the resident did not receive a diuretic medication, an antidepressant medication, or an opioid medication during the seven-day look-back assessment period. Review of the MAR for Resident 52, dated May 2024 revealed that the resident received 2 mg of Bumetanide once a day, 10 mg of Fluoxetine once a day, and 50 mg of Tramadol once a day during the seven-day assessment period. Interview with the Director of Nursing on June 13, 2024, at 7:45 a.m. confirmed that Section N0415C, Section N0415G, and Section N0415H of Resident 52's quarterly MDS assessment for May 15, 2024, was checked incorrectly and should have been checked to indicate that she received a diuretic, antidepressant, and opioid medication during the seven-day assessment period. The Long-Term Care Facility RAI User's Manual, dated October 2023, revealed that Section O0110J1b was to be checked if the resident was receiving dialysis treatment while a resident at the facility during the seven-day assessment period. Physician's orders for Resident 63, dated August 2, 2023, included an order to ensure communication forms are sent with the resident to dialysis every Monday, Wednesday, and Friday, and to ensure the form is received back upon return. A quarterly MDS for Resident 63, dated June 5, 2024, revealed that section O0110J1b was not checked, indicating that the resident did not receive dialysis treatment during the seven-day assessment period. Interview with the Director of Nursing on June 13, 2024, at 9:46 a.m. confirmed that section O0110J1b of Resident 63's quarterly MDS assessment, dated June 5, 3024, was not checked to indicate that she was receiving dialysis treatments while a resident at the facility during the seven-day assessment period and it should have been. The RAI User's Manual, dated October 2023, revealed that if a resident used oxygen, then Section O0110C was to be checked if it applied. Physician's orders for Resident 64, dated February 23, 2024, and March 21, 2024, included orders for the resident to use a CPAP with oxygen at 2 liters per minute (lpm) during the evening and night shift and to receive 2 liters of oxygen per minute every shift. Review of Resident 64's MAR for March 2024 revealed that the resident used a CPAP device during the evening and night shift and received 2 liters of oxygen every shift from March 1 to 31, 2024. However, a quarterly MDS assessment, dated May 29, 2024, revealed that Section O0110G1b and Section O0110G3b were not checked, indicating that the resident did not use a CPAP device during the review period, and Section O0110C was not checked, indicating that the resident did not receive oxygen during the review period. Interview with the Director of nursing on June 13, 2024, at 7:45 a.m. confirmed that Resident 64's quarterly MDS of May 29, 2024, was coded incorrectly. The RAI User's Manual, dated October 2023, revealed that if the resident had a fall since admission, entry or re-entry, or a prior assessment, then Section J1800 was to be coded (1) Yes, and Section J1900 was to be completed. If the resident had a fall with no injury since admission, entry or re-entry, or a prior assessment then J1900A was to be coded with the number of falls. If the resident had a fall with an injury (skin tears, abrasions, lacerations, superficial bruises, hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900B was to be coded with the number of falls. If the resident had a fall with a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) since admission, entry or re-entry, or a prior assessment then Section J1900C was to be coded with the number of falls. An investigation report and nursing note for Resident 98, dated March 27, 2024, at 10:53 p.m. revealed that the resident was found lying on the floor in the resident's room. He was having some pain with his knee and was reluctant to bend it. An x-ray result, dated March 28, 2024, revealed that the resident had an acute fracture of the right hip. A significant change MDS assessment for Resident 98, dated April 6, 2024, revealed that Section J1800 was incorrectly coded zero (0) - No, indicating that the resident had no falls since admission, entry or re-entry, or the prior assessment. By coding Section J1800 as (0) No, the computerized MDS software did not allow Sections J1900C to be completed to reflect that the resident had a fall and fracture. Interview with the Director of nursing on June 13, 2024, at 7:45 a.m. confirmed that Resident 98's significant change MDS assessment of April 6, 2024, was coded incorrectly. An investigation report and nursing note for Resident 103, dated May 14, 2024, at 6:57 a.m. revealed that the resident was found lying on the floor beside his bed and had a 3.0 centimeter (cm) superficial scratch to his forehead. A significant change MDS assessment for Resident 103, dated May 18, 2024, revealed that Section J1900 was coded (1) indicating that the resident had one fall with a major injury. Interview with the Director of nursing on June 12, 2024, at 1:25 p.m. confirmed that Resident 103's admission MDS assessment of May 18, 2024, was coded incorrectly. A discharge MDS for Resident 117, dated April 28, 2024, revealed that section A2105 indicated the resident was discharged to a short-term general hospital. Physician's orders for Resident 117, dated April 28, 2024, included an order to discharge to home. Interview with the Director of Nursing on June 13, 2024, at 9:46 a.m. confirmed that Section A2105, Resident 117's discharge MDS assessment, dated April 28, 2024, should have been checked to indicate that the resident was discharged to home. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for two of 42 residents reviewed (Residents 24, 67). Findings include: A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated April 20, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis of dementia. Physician's orders for Resident 24, dated April 16, 2024, included an order for staff to cleanse the resident's left buttocks with wound cleanser then apply Chamosyn ointment (used to protect skin from wetness, urine, or stools) to her Peri wound (the area around the wound) and place Xeroform (a fine mesh gauze occlusive dressing impregnated with petrolatum and 3 percent Xeroform) to her open wounds. Then place an ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds) every day and evening shift and as needed with each incontinence. Physician's orders for Resident 24, dated April 15, 2024, included an order for the resident to receive 0.25 milliliters (ml) of morphine sulfate (used to treat moderate to severe pain) every three hours as needed for pain/shortness of breath. Physician's orders for Resident 24, dated June 7, 2024, included an order for staff to administer the as needed Roxanol (the brand name for morphine) 15-20 minutes prior her to wound care every shift. Resident 24's Treatment Administration Record (TAR), dated June 2024, indicated that the night shift staff documented as administering the as needed Roxanol 15-20 minutes prior her to wound care June 7 through 11, 2024. However, there was no documented evidence in the resident's clinical record and/or TAR that the night shift completed any wound care. Interview with the Director of Nursing on June 12, 2024, at 12:15 p.m. confirmed that there was no documented evidence that the night shift completed any wound care on Resident 24 and that they should not be documenting the administration of the Roxanol 15-20 minutes prior to her wound care. A quarterly MDS assessment for Resident 67, dated April 25, 2024, revealed that the resident was understood, could understand others, and had a feeding tube. A care plan for the resident, dated February 9, 2024, revealed that the resident requires supplemental tube feed (a way to provide nutrition when you cannot eat or drink safely by mouth) and fluids via percutaneous endoscopic gastrostomy (PEG -the placement of a feeding tube through the skin and the stomach wall) tube to meet nutritional/hydration needs. Staff were to give 240 milliliters (ml) of Glucerna (a tube feeding formula) daily for inadequate oral intake via PEG-tube as ordered. A care plan, dated May 6, 2024, revealed that the resident has a potential nutritional problem related to impaired oral intake and the need for a mechanically altered diet. Staff was to provide and serve supplements as ordered: Give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal. Physician's orders for Resident 67, dated November 8, 2023, included an order for staff to give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal. Physician's orders for Resident 67, dated November 2, 2023, included an order for staff to flush the resident's PEG-tube with 30 ml of warm water before and after each feeding. Resident 67's Medication Administration Records (MARs), dated May and June 2024, indicated that staff did not give the 240 ml of Glucerna 1.5 Cal via Peg-tube on May 7, 2024, at 8:30 a.m.; on May 12, 2024, at 8:30 a.m. and 12:30 p.m.; on May 17, 2024, at 8:30 a.m.; on May 19, 2024, at 8:30 a.m.; on May 20, 2024, at 8:30 a.m. and 6:30 p.m.; on May 21, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on May 22, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on May 23, 2024, at 8:30 a.m.; on May 24, 2024, at 8:30 a.m.; on May 25, 2024, at 8:30 a.m. and 6:30 p.m.; on May 26, 2024, at 12:30 p.m.; on May 27, 2024, at 12:30 p.m.; on May 30, 2024, at 6:30 p.m.; on May 31, 2024, at 12:30 p.m.; on June 1, 2024, at 8:30 a.m.; on June 2, 2024, at 8:30 a.m.; on June 3, 2024, at 6:30 p.m.; on June 6, 2024, at 6:30 p.m.; on June 7, 2024, at 8:30 a.m., 12:30 p.m., and 6:30 p.m.; on June 8, 2024, at 6:30 p.m.; on June 9, 2024, at 6:30 p.m.; on June 10, 2024, at 8:30 a.m. and 12:30 p.m.; on June 11, 2024, at 8:30 a.m., and 12:30 p.m.; and on June 12, 2024, at 8:30 a.m. However, Resident 67's TARs, dated May and June 2024, indicated that the staff documented as flushing the resident's PEG-tube with 30 ml of warm water before and after each feeding on the above dates and times. Interview with the Director of Nursing on June 13, 2024, at 7:50 a.m. confirmed that staff documented as flushing the resident's PEG-tube with 30 ml of warm water before and after each feeding on the above dates and times when the resident did not receive the 240 ml of Glucerna 1.5 Cal via Peg-tube. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an enteral feeding was administered in accordance with physician's orders for one of 42 residents reviewed (Resident 67). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated April 25, 2024, revealed that the resident was understood, could understand others, and had a feeding tube. A care plan for the resident, dated February 9, 2024, revealed that the resident required supplemental tube feed (a way to provide nutrition when you cannot eat or drink safely by mouth) and fluids via percutaneous endoscopic gastrostomy (PEG -the placement of a feeding tube through the skin and the stomach wall) tube to meet nutritional/hydration needs. Staff were to give 240 milliliters (ml) of Glucerna (a tube feeding formula) daily for inadequate oral intake via PEG-tube as ordered. A care plan, dated May 6, 2024, revealed that the resident has a potential nutritional problem related to impaired oral intake and the need for a mechanically altered diet. Staff was to provide and serve supplements as ordered: Give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal (a system used to explain the amount eaten). Physician's orders for Resident 67, dated November 8, 2023, included an order for staff to give 240 ml of Glucerna 1.5 Cal via PEG-tube after meals for impaired oral intake when she consumes less than three points of her meal. Resident 67's amount eaten record for April and May 2024 indicated that the resident ate four points during the lunch meal and five points during the supper meal on April 15, 2024; ate three points during the lunch meal on April 29, 2024; ate six points during the lunch meal on May 7, 2024; ate four points during the supper meal on May 15, 2024; ate three points during the lunch meal on May 19, 2024; ate three points during the lunch meal on May 23, 2024; and ate four points during the supper meal on May 27, 2024. However, Resident 67's Medication Administration Records, dated April and May 2024, indicated that she received the 240 ml bolus feeding of Glucerna 1.5 Cal on the above dates. Interview with the Director of Nursing on June 13, 2024, at 9:56 a.m. confirmed that Resident 67 received the 240 ml bolus feeding of Glucerna 1.5 Cal on the above dates when her meal points were three and/or above and that she should not have been given the 240 ml bolus feeding of Glucerna 1.5 Cal. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure communication between a dialysis provider and the nursing staff for two of 48 residents reviewed (Residents 69, 109). Findings include: The facility's policy regarding dialysis, dated July 3, 2023, indicated that a communication form was sent to the dialysis unit with each visit. The facility's contract, dated September 13, 2019, indicated that both parties shall ensure that there is documented evidence of collaboration of care and communication between the long-term care facility and the dialysis unit. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 69, dated June 8, 2023, indicated that she was alert and oriented; was independent with hygiene, bed mobility, and transfers; and she received dialysis. A diagnosis record for Resident 69, dated February 24, 2021, included diabetes and end-stage renal disease. Physician's orders for Resident 69, dated October 4, 2021, and her current care plan, dated August 5, 2021, indicated that she was to receive dialysis every Monday, Wednesday, and Friday at 10:00 a.m. There was no documented evidence of routine collaboration of care and communication between the long-term care facility and the dialysis unit on the days when she received dialysis services. Interview with the Director of Nursing on July 19, 2023, at 3:10 p.m. revealed that the staff send communication forms with this resident since she is alert and oriented; however, the forms are not returned daily after dialysis. Interview with the Assistant Director of Nursing on July 19, 2023, at 3:25 p.m. confirmed that there was a record of physician's orders from dialysis with recent changes, dated April 24, 2023, and July 6, 2023; however, there was no documented evidence of routine communication and collaboration of care between the long-term care facility and the dialysis unit for Resident 69. An Admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 109, dated July 10, 2023, revealed that the resident is usually understood and understands, is cognitively intact, required extensive assist for daily care needs, received dialysis, and had diagnosis that included end-stage renal disease. Physician's orders for Resident 109, dated July 3, 2023, included an order for the resident to have dialysis every Tuesday, Thursday, and Saturday. As of July 19, 2023, there was no documented evidence of routine communication and collaboration of care between the long-term care facility and dialysis unit for Resident 109. Interview with the Director of Nursing on July 19, 2023, at 2:00 p.m. confirmed that the facility does not receive communication forms from the dialysis unit for collaboration of care and communication between the long-term care facility and dialysis unit. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of the facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor a resident's blood pressure as ordered prior to medication administration for one of 48 residents reviewed (Resident 115). Findings include: The facility's policy for administration of medication, dated July 23, 2023, indicated that medication that requires blood pressure parameters is to be obtained and charted on the medication administration record. A diagnosis record for Resident 115, dated April 17, 2023, included diagnoses of atrial fibrillation (irregular heart rhythm) and heart failure. Physician's orders for Resident 115, dated May 14, 2023, included an order for the resident to receive 3.125 milligrams (mg) of Carvedilol (Coreg), one tablet by mouth two times a day for atrial fibrillation and to hold it if the systolic blood pressure (SBP is the pressure when your heart contracts and pushes out blood) is less than 100 or the heart rate is less than 60 beats per minute. The Medication Administration Record (MAR) for Resident 115 for May and June 2023 indicated that the afternoon dose of Carvedilol was not given on May 14, 19, 29, 31 or June 4, 6, 9, 12, 2023. There was no documented evidence in Resident 115's clinical record as to why the medication was not given on the dates listed, and no documented evidence that the resident's blood pressure was taken as ordered for all afternoon doses from May 14, 2023 through June 11, 2024. Interview with the Director of Nursing on July 20, 2023, at 7:48 a.m. confirmed that there was no documented evidence to indicate why the afternoon doses of Carvedilol were not given on the dates listed, and also confirmed that the blood pressure should have been obtained and documented prior to the administration of every dose of carvedilol. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for two of 48 residents reviewed (Residents 5, 50). Findings include: The facility's policy for fall and incident reporting, dated July 3, 2023, indicated that post fall and incident assessment charting will be completed in the resident's electronic record by the registered nurse on duty. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 5, dated June 26, 2023, revealed that the resident was usually understood and could usually understand, was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included chronic kidney disease. A fall report for Resident 5, dated February 10, 2023, at 10:39 a.m., completed by the registered nurse, revealed that the resident had a witnessed fall on February 6, 2023, at 6:15 p.m. The fall report revealed that two nurse aides reported that the resident went to stand and his legs gave out, resulting in him sliding from his recliner to the ground. Upon assessment the resident was sitting on the ground with his legs extended out in front of him. His head was resting on the recliner, the recliner was slightly elevated, and the walker was in front of him. There was no documented evidence in Resident 5's clinical record of the registered nurse's post-fall assessment. A quarterly MDS for Resident 50, dated June 3, 2023, revealed that the resident was usually understood and could understand, was cognitively impaired, required extensive assist for daily care needs, and had diagnoses that included a displaced fracture of the lateral malleolus of right fibula (bone located in the lower leg). A fall report for Resident 50, dated April 12, 2023, at 3:00 p.m., completed by the registered nurse, revealed that the resident had an unwitnessed fall in his bathroom. The resident was trying to transfer without assistance and fell . The resident's call light was not on and he was last seen by staff when they put him on the commode. He was wearing shoes and maneuvered to his right side. The resident stated that he hit his head on the wall. No bruising, bumps, or open areas were noted. The resident's skin was warm and dry. The resident had a rug burn approximately 1.0 centimeter (cm) by 1.0 cm below right knee and abrasions to left anterior thigh. He was alert and oriented to self only. The resident was anxious and was grabbing at the wall and commode trying to pull himself up. The resident was lying in front of his toilet with his head facing the doorway. He denied pain at that time. Neurological checks were intact. The resident was afebrile and his hips and pelvis were palpated with no reports of pain. His legs were equal in length with no internal rotation noted. He was moving all extremities per baseline. The resident was transferred back to his recliner via mechanical lift. There was no documented evidence in Resident 50's clinical record of the registered nurse's post-fall assessment. Interview with the Director of Nursing on July 19, 2023, at 3:42 p.m. confirmed that there was no documented evidence of the registered nurse's post-fall assessments in Resident 5's and 50's clinical records. 28 Pa Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 48 residents reviewed (Residents 72, 114). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410H Opioid Medications (narcotic medications used to treat pain) was to be coded for the number of days the resident used an opioid during the seven-day assessment period. Physician's orders for Resident 72, dated March 24, 2022, included an order for the resident to receive Hydrocodone acetaminophen (an opioid used for pain) every day. The resident's Medication Administration Record (MAR) for April 2023 revealed that the resident received Hydrocodone acetaminophen seven days during the look-back assessment period. A Quarterly MDS for Resident 72, dated April 27, 2023, revealed that Section N0401H was coded (0), indicating that the resident did not receive opioid medication for seven days during the look-back assessment period. An interview with the Director of Nursing on July 20, 2023, at 1:05 p.m. confirmed that the assessment mentioned above was coded incorrectly. The RAI User's Manual, dated October 2019, revealed that the nurse was expected to listen to the resident, ask primary caregivers about the resident's speech, review the medical record, and determine the quality of the resident's speech. Section B0600 (Speech Clarity) was to be coded with a zero (0) for clear speech, a one (1) for unclear speech, and a two (2) for no speech. Section B0700 (Makes Self Understood) was to be coded zero (0) if the resident was understood, one (1) if the resident was usually understood, two (2) if the resident was sometimes understood, and three (3) if the resident was rarely/never understood. The section was not to be coded as rarely/never understood if the resident completed any of the resident interviews, as the interviews were conducted during the look-back period and should be factored in when determining the residents' ability to make himself/herself understood during the entire seven-day look-back period. Section B0800 (Ability to Understand Others) was to be coded zero (0) if the resident understands others, one (1) if the resident usually understands others, two (2) if the resident sometimes understands others, and three (3) if the resident rarely/never understands others. Section C0100 (Should a Brief Interview for Mental Status Be Conducted) was to be coded zero (0) No if the resident was rarely/never understood or one (1) Yes if the resident could participate in the interview. Section J0200 (Should Pain Assessment Interview Be Conducted) was to be coded zero (0) No if the resident was rarely/never understood and one (1) Yes if the resident interview should be attempted. An admission MDS assessment for Resident 114, dated May 8, 2023, revealed that Section B0600 (Speech Clarity) was coded with a (3), indicating that the resident had no speech, Section B0700 was coded three (3), indicating that she rarely/never understood, and Section B0800 was coded three (3), indicating that the resident was rarely/never understood by others. However, Section C0100 was coded yes (1), indicating that the mental status interview should be attempted. Interview on with the Director of Nursing on July 20, 2023, at 1:42 p.m. confirmed that Resident 114's MDS was coded incorrectly. 28 Pa. Code 211.5(f) Clinical records.

Based on review of facility policy and clinical records, as well as observations and staff interviews, it was determined that the facility failed to enure proper signage related to isolation precautions was posted for one of 48 residents reviewed (Resident 108). Findings include: The facility's policy for initiating isolation precautions, dated July 3, 2023, indicated that when isolation precautions are implemented, the licensed practical nurse or charge nurse assigned to the resident shall post the appropriate signs on the room entrance so that all personnel will be aware of the isolation precautions. The facility's policy for visitation of residents requiring isolation precautions, dated July 3, 2023, indicated that visitors must follow instructions issued by the registered nurse supervisor or charge nurse. An isolation notice requesting all visitors to speak with the nurse prior to visiting the resident will be posted at the entrance of the resident's room. A diagnosis record for Resident 108, dated June 3, 2023, included the diagnosis of a sacral pressure ulcer, Stage 4 (a wound caused by pressure which may extend into the muscle, tendon and bone). A physician's consultation note for Resident 108, dated April 12, 2023, indicated that the resident had a Stage 4 pressure ulcer and a culture from the pressure ulcer showed heavy methicillin resistant staphylococcus aureus (MRSA, a drug resistant bacteria that is difficult to treat). Physician's orders for Resident 108, dated June 3, 2023, included an order for the resident to be on contact precautions due to MRSA of the wound. Observations of Resident 108's room on July 17, 2023, at 11:01 a.m. and July 18, 2023, at 8:27 a.m. and 1:12 p.m. revealed that she had personal protective equipment (PPE) hanging on the door for use; however, there was no signage regarding isolation precautions per the facility's policy. Interview on July 18, 2023, at 1:28 p.m. with Registered Nurse 1 confirmed that she was on isolation for MRSA of the wound and that there should have been a sign on the door but was not. Interview with the Director of Nursing on July 19, 2023, at 3:01 p.m. confirmed that there should have been signage on the door about isolation. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure proper pain management for one of 48 residents reviewed (Resident 115). Findings include: The facility's policy for pain management, dated July 3, 2023, indicated that the goal of pain management is to relieve the physical and psychological symptoms associated with pain while maintaining the resident's functional level. The resident is to have a plan of action formulated which may include non-pharmacological intervention and pharmacological (medication) interventions. The resident may request a non-narcotic or narcotic as ordered by the physician. When completing a pain assessment, if pain is indicated, the resident should be offered non-pharmacological intervention if appropriate. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 115, dated July 13, 2023, indicated that he was confused, had pain, had not received any non-medication interventions for pain, but did receive as-needed and routine pain medication, was unable to respond to what level of pain he had and if the pain interfered with his rest or sleep at night. A diagnosis record for Resident 115, dated April 17, 2023, included Parkinsons (degenerative disorder of the nervous system which effects the motor system) and spinal stenosis (narrowing of the spinal canal which can cause pressure on the spinal cord) of the lumbar region (lower back). A physician's order for Resident 115, dated April 17, 2023, included an order for the resident to receive one 5-325 milligrams (mg) tablet of Hydrocodone-Acetaminophen by mouth every 4 hours as needed for a pain level of 6-10 (where 1 is the least amount of pain and 10 is the most severe pain). The Medication Administration Record (MAR) for Resident 115 for May 2023 indicated that on May 1, 2023, at 10:26 p.m. and May 22, 2023, at 12:45 a.m. he was administered one 5-325 mg tablet of Hydrocodone-Acetaminophen for a pain level of 7, which was ineffective. There was no documented evidence of any other interventions being attempted, of the physician being notified, or of any further pain monitoring until May 2, 2023, at 2:15 a.m. and May 23, 2023, at 6:29 a.m. (4-6 hours later). Interview with the Director of Nursing on July 19, 2023, at 3:47 p.m. confirmed that there was no documented follow up by staff when the medication for Resident 115 was ineffective and that they should have attempted something else, notified the physician, and documented their follow up in the clinical record. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop an individualized care plan for one of 48 residents reviewed (Resident 50). Findings include: The facility's policy regarding care plans, dated July 3, 2023, indicated that the facility would develop a written plan of care that was individualized for each resident's daily care routines and would be available to staff personnel who had responsibility for providing care or services to the resident. Physician's orders for Resident 50, dated June 21, 2023, included orders for the resident to have an indwelling foley catheter (a tube inserted directly into the bladder). There was no documented evidence that a care plan was developed to address Resident 50's care needs related to the indwelling foley catheter. Interview with the Director of Nursing on July 19, 2023, at 2:00 p.m. confirmed that Resident 50 did not have a care plan that addressed the care and services needed for an indwelling foley catheter. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to have a professional (registered) nurse assess a resident's skin for one of 13 residents reviewed (Resident 6). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated November 25, 2022, indicated that the resident was cognitively impaired, required extensive assistance from staff for her daily care tasks, and had no skin impairments. A nursing note, dated December 5, 2022, at 10:45 p.m. revealed that Resident 6 had a small rash on her abdomen, lower back, thighs and right shoulder and the registered nurse was informed. There was no documented evidence that Resident 6's skin was assessed by a registered nurse after it was determined that the resident had a small rash on her abdomen, lower back, thighs and right shoulder. A nursing note, dated December 10, 2022, at 12:08 p.m. revealed that Resident 6 had a rash on her back, abdomen and her skin folds (areas of skin to skin contact) and was complaining of the areas being itchy. The physician was notified and orders were obtained. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on December 13, 2022, at 4:15 p.m. confirmed that she was not aware that Resident 6 had a rash on December 5, 2022, and that there no was no evidence that a skin assessment was completed by a registered nurse. She confirmed that a registered nurse should have assessed the resident's skin at that time. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for three of 13 residents reviewed (Residents 1, 4, 5). Findings include: A nursing note for Resident 1, dated December 3, 2022, revealed that the resident complained this morning that her belly, back, breast and feet were itchy. Lotion was applied and was not effective. The registered nurse was notified. This was a rapid new onset. There was no documented evidence in Resident 1's clinical record that the registered nurse documented her assessment at the time of the resident's change in condition on December 3, 2022, until December 13, 2022, when she entered her assessment as a late entry. Interview with the Assistant Director of Nursing on December 13, 2022, at 12:55 p.m. revealed that she was contacted December 3, 2022, regarding the rash on Resident 1. She drove into the facility and looked at the rash along with the other registered nurse. At 1:26 p.m. she indicated that she went and placed a late note in Resident 1's clinical record regarding her assessment of Resident 1's skin rash. A nursing note for Resident 4, dated November 14, 2022, at 2:10 p.m. revealed that the resident had blotchy rash on his upper trunk and extremities, and denies any itching. The supervisor was made aware. There was no documented evidence in Resident 4's clinical record that the registered nurse documented an assessment at the time of the resident's change in condition on November 14, 2022, until November 15, 2022, at 8:17 p.m., when a late-entry note was entered. A nursing note for Resident 4, dated December 3, 2022, at 10:57 a.m. revealed that the resident was covered in a full body rash. The resident was up all night by the nurses' station, as he was unable to rest because of his itching. The resident was starting to bruise and had open scabs on his skin from the itching. He currently has moisturizing lotion in place with no positive change. The registered nurse was notified. There was no documented evidence in Resident 4's clinical record that the registered nurse documented her assessment at the time of the resident's change in condition on December 3, 2022, until December 13, 2022, when a late-entry note was entered. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 12, 2022, indicated that the resident was alert and oriented, could make himself understood and could understand others, required extensive assistance from staff for his daily care tasks, and had no skin impairments. A nursing note for Resident 5, dated December 4, 2022, at 8:15 a.m. revealed that the resident's family was updated of the possibility of scabies, as he had a rash, and [MEDICATION(S)] cream was being used. The family was aware that he was scratching yesterday. There was no documented evidence in Resident 5's clinical record that the registered nurse documented her assessment at the time of the resident's change in condition on December 3, 2022, until December 13, 2022, at 1:19 p.m., when a late-entry note was entered. Interview with the Director of Nursing on December 13, 2022, at 5:00 p.m. confirmed that there were no documented assessments by the registered nurse at the time of their change in condition for the above residents and that they were all late entries into the resident's clinical records. 28 Pa. Code 211.5(f) Clinical records.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding residents while standing for one of three residents reviewed (Resident 3). Findings include: The facility's policy regarding feeding residents, dated July 14, 2022, indicated that resident rights and dignity are maintained at all times during the feeding process. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2022, revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for the resident, dated August 1, 2022, revealed that the resident had an activities of daily living self-care performance deficit related to confusion, disease process, and limited mobility. Observations during the supper meal on October 4, 2022, at 5:41 p.m. revealed that Resident 3 was seated at a dining table in the dining room on the MSU Unit. Nurse Aide 1 served the resident her supper meal. Nurse Aide 1 then proceeded to cut up the items on the resident's plate into bite-size portions. Nurse Aide 1, while standing at the resident's side, gave the resident a bite of her supper meal. Nurse Aide 1 then left the resident and went to obtain another resident's supper meal to deliver the meal to the resident. After delivering the meal to the other resident, Nurse Aide 1 returned to Resident 3's side and gave her another bite of her supper meal. Nurse Aide 1 again left the resident's side to obtain another supper meal to be delivered to another resident. Nurse Aide 1 continued to return to Resident 3's side and give the resident a bite and then leave to deliver another resident's supper meal. Nurse Aide 1 continued this until all of the residents on the unit received their supper meal. At 5:50 p.m. Nurse Aide 1 came back to Resident 3, and while standing at the resident's side, began feeding the resident her supper meal again. Interview with Nurse Aide 1 on October 4, 2022, at 6:25 p.m. confirmed that they try to stay with the resident to assist them with feeding, but due to not having adequate staff, as well as other residents that may require assistance with feeding, that they have an all hands on deck approach. So they cannot sit with the residents when they need to help pass out other meals. Nurse Aide 1 confirmed that she should have sat down at the level of the resident to feed and not be standing. Interview with the Director of Nursing on October 4, 2022, at 8:15 p.m. confirmed that she would prefer for staff to sit when they feed residents. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care in accordance with professional standards of practice and facility policy, by failing to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The facility's policy regarding Intake and Output (I&O - the measurement of a resident's fluid intake by mouth, feeding tubes, or intravenous catheters, and output from kidneys, gastrointestinal tract, drainage tubes, and wounds), dated October 1, 2021, indicated that I&O were to be monitored accurately to ensure adequate hydration levels per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 2, 2022, indicated that the resident was alert and oriented, could make herself understood and could understand others, had a feeding tube, was on a mechanically altered diet, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated May 3, 2022, indicated that staff were to monitor and document the resident's I&O per the facility policy. Review of Resident 2's I&O records for June 16 to July 14, 2022, revealed that there was no documented evidence that Resident 2's I&O was monitored or recorded every shift in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An annual MDS assessment for Resident 32, dated April 27, 2022, indicated that the resident was severely cognitively impaired, had no speech, and was rarely or never understood, had a feeding tube, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised June 9, 2022, indicated that the resident was dependent on staff for tube feedings and water flushes, and to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 32's I&O records for June 15 to July 14, 2022, revealed that there was no documented evidence that Resident 32's output was being monitored and recorded every shift in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An admission MDS assessment for Resident 62, dated June 1, 2022, indicated that the resident was severely cognitively impaired, could make himself understood and could understand others, required extensive assistance with bed mobility, transfers, and toileting, received diuretic (water pill) and antibiotic medications, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised June 1, 2022, indicated that staff were to monitor and document the resident's I&O due to the potential for fluid deficit related to increased fluid needs related to an open wound with drainage and a wound vac (a machine that uses a suction pump, tubing and a dressing to remove excess exudate and promote healing in wounds). Review of Resident 62's I&O records for June 14 to July 13, 2022, revealed that there was no documented evidence that Resident 62's output was being monitored or recorded every shift in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A quarterly MDS assessment for Resident 93, dated June 21, 2022, indicated that the resident was alert and oriented, could make himself understood and could understand others, required supervision with eating, received a diuretic medication, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated April 12, 2021, indicated that staff were to monitor and document the resident's I&O per the facility policy. Review of Resident 93's I&O records for June 15 to July 13, 2022, revealed that there was no documented evidence that Resident 93's output was being monitored or recorded every shift in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An admission MDS assessment for Resident 111, dated June 29, 2022, indicated that the resident was cognitively intact, could make herself understood and could understand others, required extensive assist with bed mobility, transfers, dressing and toileting, was independent with eating, received a diuretic medication, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised June 28, 2022, indicated that staff were to monitor and document the resident's I&O related to diuretic use. An interview with the Registered Dietitian on July 14, 2022, at 10:51 a.m. indicated that the I&O monitoring was ordered due to fluid retention and weight gain, and that she monitors the intake of fluids but nursing staff are assessing for [CONDITION(S)]. Review of Resident 111's I&O records for June 24 to July 14, 2022, revealed that there was no documented evidence that Resident 111's I&O was being monitored or recorded every shift in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing on July 14, 2022, at 11:07 a.m. confirmed that there was no documented evidence that I&O was monitored every shift per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment for Resident 114, dated July 2, 2022, revealed that the resident was understood and could understand, and required limited assistance from staff for her daily care tasks. A care plan for the resident, dated May 17, 2021, and revised June 10, 2022, revealed that the resident was at risk for unintended weight loss and that staff were to obtain the resident's weight as ordered, and monitor per the facility's policy. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 114's clinical record, including Medication Administration Records (MARs) and Treatment Administration Records (TARs), revealed no documented evidence that the resident had her weights obtained as ordered and/or that the resident had refused to have her weight obtained. Review of nurse aide documentation revealed that on May 8, and 21, 2022, and June 4, and 18, 2022, it was documented that the resident was not available. However, there was no documented evidence that the resident was not in the facility during those dates. Interview with the Director of Nursing on July 13, 2022, at 10:15 a.m. confirmed that there was no documented evidence that Resident 114 had her weights obtained as ordered and that she spoke with the nurse aide that attempted to obtain the resident's weight on those dates and the nurse aide indicated that the resident did not want to get out of bed, so she marked it as the resident not being available to obtain her weight. She indicated that the nurse aide should have marked that the resident refused if she was unable to obtain the resident's weight at that time. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, manufacturer's instructions, United States Food and Drug Administration food safety guidance and dietary menus, as well as observations and staff interviews, it was determined that the facility failed to ensure that food items were stored and prepared in accordance with professional standards for food service safety in the main kitchen. Findings include: The United States Food and Drug Administration guidance regarding the best way to thaw ground beef (undated) indicated that thawed ground beef should be used or refrozen with in one or two days. A facility policy regarding food storage, dated October 1, 2021, indicated that when thawing frozen meat, poultry, or fish in the refrigerator, allow a minimum or 24 to 48 hours, and cook immediately after thawing. Observations in the main kitchen's walk-in refrigerator on July 11, 2022, at 10:28 a.m. revealed a large foil-covered metal pan that was labeled hamburger, 30 pounds, pulled July 2, for peppers. Inside the large metal pan was a five-pound package of ground [NAME]. Interview with the Dietary Manager at that time confirmed that only 25 pounds of the [NAME] was used for peppers and that the remaining five pounds should have been discarded. Interview with the Dietary Manager on July 12, 2022, indicated that frozen ground meat is thawed over five to six days, then the facility would use the thawed meat within six days. A facility menu for the week of July 4 through July 10, 2022, revealed that stuffed peppers were served for dinner on July 7, 2022. Interview with the Independent Market Alliance Foodservice representative on July 13, 2022, at 4:39 p.m. confirmed that after thawing [NAME], the product should be used within one to two days, following the guidance of the United States Food and Drug Administration. Interview with the Dietary Director on July 14, 2022, at 9:45 a.m. indicated that she was waiting on a call back from the manufacturer to receive guidance for use of ground [NAME] after thawing. The Dietary Director revealed that there is no written policy regarding the timeliness of using thawed meat, as it was an unwritten rule that they would use frozen to thawed meat up to six days after being thawed. There was no other guidance or manufacturer's instructions provided during the survey regarding the use of thawed ground [NAME]. Manufacturer's instructions for the RN model nugget ice machine (undated) revealed that that the drain tube was to have an air gap between the opened, trapped and vented drain. Observations in the main kitchen on July 11, 2022, at 10:47 a.m. revealed that the ice machine's drainage tube was lying on the yellow grate over the floor pan drain. Interview with the Director of Maintenance at that time confirmed that there was no air gap between the drainage tube and the drain as required and that the tubing was lying on the yellow grate. 28 Pa. Code 211.6(f) Dietary services.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete nurse aide registry verification for one of five new nurse aides reviewed (Nurse Aide 1). Findings include: The facility's policy regarding abuse prevention, dated October 1, 2021, indicated that the facility would take necessary steps to prevent the employment of individuals who have been convicted of abusing, neglecting, or mistreating individuals. The facility would investigate the histories of individuals being considered for hiring by checking references. In addition, the facility would further investigate all potential employees by making inquiries with the State Nurse Aide Registry when appropriate, checking with the appropriate licensing boards, and checking the criminal history background of all newly hired employees. The personnel file for Nurse Aide 1 revealed that she was hired on April 26, 2022, and there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to hire. Interview with the Nursing Home Administrator on July 14, 2022, at 2:30 p.m. confirmed that there was no documented evidence that Nurse Aide 1's standing on the Pennsylvania Nurse Aide Registry was verified prior to their hire. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, incident reports, and investigation documentation, as well as staff interviews, it was determined that the facility failed to complete an assessment for potential safety hazards with the use of an electric lifting recliner chair for one of 27 residents reviewed (Resident R7), resulting in a fall and hip fracture for the resident. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R7, dated August 9, 2017, revealed that the resident was confused, required extensive assistance for transfers, did not walk, had falls, and had [DIAGNOSES REDACTED]. to think, remember and function) and Parkinson's disease (a progressive disorder of the nervous system that affects movement). Nursing notes and incident reports for Resident R7 revealed that on August 14, 2017, at 3:30 p.m. the resident fell from his electric lifting recliner chair. The recliner was noted to be up in the air with the resident lying in front of the recliner chair, and a possible cause was due to the remote control being within the resident's reach. An X-ray revealed that the resident had a fractured left hip. There was no documented evidence that the electric lifting recliner chair was assessed for safety prior to its use. A witness statement from Nurse Aide 2, dated August 15, 2017, revealed that Resident R7 was put in his electric lifting recliner chair and chair's controller was put in the side pouch on the chair. Interview with the Director of Nursing on October 18, 2017, at 9:51 a.m. confirmed that there was no documented evidence that Resident R7's electric lifting recliner chair was assessed for safety prior to the resident using it. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices Previously cited 6/16/17, 2/2/17, 11/2/16, 9/22/16 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 6/16/17, 2/23/17, 2/2/17, 11/2/16, 9/22/16

Based on review of facility policies, a list of contents from the facility's emergency drug supply and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with effective pain management for one of six residents reviewed (Resident CR4), resulting in severe unrelieved pain for the resident. Findings include: The facility's policy regarding pain management, dated February 17, 2017, indicated that the goal of pain management was to relieve the physical and psychosocial symptoms associated with pain, while maintaining the resident's functional level. Nursing notes for Resident CR4, dated May 2, 2017, at 1:34 a.m. revealed that the resident experienced a fall in his room at 9:30 p.m. on May 1, 2017, was found lying on his right side, and had no apparent injuries. The resident's care plan for pain, dated May 1, 2017, indicated that the staff were to assess the resident's need for scheduled [MEDICATION NAME] (pain medications) and notify the physician about changes. physician's orders [REDACTED]. Resident CR4's Medication Administration Records (MAR's) and nursing notes, dated May 2, 2017, revealed that staff administered [MEDICATION NAME] for complaints of right hip and back pain that was rated as a 10 at 4:00 a.m. and 11:00 a.m., and Tylenol at 8:28 a.m. for complaints of pain all over that was rated as a 5. A nursing note, dated May 2, 2017, at 12:30 p.m. revealed that the [MEDICATION NAME] was ineffective and the resident continued to complain of pain that was rated as an 8. A nursing note for Resident CR4, dated May 2, 2017, at 2:47 p.m. revealed that the resident's attending physician visited and gave new orders for pain medications, which included to continue 650 mg of Tylenol every four hours as needed for pain rated as 1-4 on a scale of 1-10, continue 50 mg of [MEDICATION NAME] four times daily as needed for pain rated as 5-7 on a scale of 1-10, and to give 2.5/325 mg of [MEDICATION NAME]/[MEDICATION NAME] (commonly called [MEDICATION NAME] - a combination of a narcotic pain medication and Tylenol) every four hours as needed for severe pain rated as 8-10. A physician's progress note, dated May 2, 2017, revealed that the physician stressed to the nursing staff that the resident needed to be checked more frequently to see if he needed [MEDICATION NAME] (medications for pain). A nursing note for Resident CR4, dated May 2, 2017, at 10:27 p.m. revealed that the resident continued to complain of pain all over, the pharmacy was contacted regarding the order for [MEDICATION NAME], and the pharmacy indicated that it would be sent with the delivery that evening. A nursing note at 10:47 p.m. indicated that the resident's current pain level was an 8 (severe), but the resident had not received any pain medications. Resident CR4's MAR for May 2017 revealed no documented evidence that any medications were administered for his complaints of unrelieved severe pain all over from May 2, 2017, at 11:00 a.m. until May 2, 2017, at 10:53 p.m. (a period of 11 hours and 53 minutes) when [MEDICATION NAME] was administered. A nursing note at 10:54 p.m. indicated that at that time the resident's pain level was rated as a 9 and described by the resident as horrible. Review of a contents list for the facility's emergency drug supply, dated May 31, 2017, revealed that various doses of [MEDICATION NAME] were available, including the dosage that Resident CR4 was ordered. Nursing notes for Resident CR4, dated May 3, 2017, at 5:25 a.m. indicated that the resident was medicated with [MEDICATION NAME] for severe pain in the right hip, at 6:20 a.m. the resident reported that the pain was still severe, and a nursing note at 10:20 a.m. revealed that [MEDICATION NAME] was ineffective. There was no documented evidence that the resident's attending physician was notified when he continued to complain of severe pain, until May 3, 2017, at 2:02 p.m., when the resident was seen by a nurse practitioner (advanced practice registered nurse with the authority to prescribe medications and diagnostic studies). The note indicated that the nurse practitioner ordered an X-ray of the right hip, and the results of the X-ray, dated May 3, 2017, revealed that the resident had a fractured right hip. A nursing note, dated May 4, 2017, at 10:37 a.m. indicated that the resident was transferred to the hospital for further evaluation and treatment and was admitted for surgical repair of the right [MEDICAL CONDITION]. Interview with Registered Nurse 1 on June 14, 2017, at 2:00 p.m. confirmed that [MEDICATION NAME] was available in the facility's emergency drug supply on May 2, 2017, and nursing staff were to check the contents of the emergency drug supply when an ordered medication was not yet available from the pharmacy. If the medication was not part of the emergency drug supply, the staff were to contact the physician to determine if he/she wanted to order an alternate medication. Interview with the Director of Nursing on June 14, 2017, at 3:15 p.m. also confirmed that [MEDICATION NAME] was available in the facility's emergency drug supply system on May 2, 2017, and staff should have obtained the medication and administered it timely to Resident CR4. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 9/22/16, 10/16/15. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/2/17, 11/2/16, 9/22/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/17, 11/2/16, 9/22/16, 10/16/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/23/17, 2/2/17, 11/2/16, 9/22/16, 10/16/15.

Based on review of clinical records, incident reports, and investigation documentation, as well as staff interviews, it was determined that the facility failed to complete an assessment for potential safety hazards with the use of a wheelchair for one of six residents reviewed (Resident R5), resulting in a fall and hip fracture for the resident. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R5, dated February 25, 2017, revealed that the resident required extensive assistance for transfers and had [DIAGNOSES REDACTED]. The resident's care plan, dated February 27, 2017, indicated that due to the stroke, he required the assistance of one staff person for transfers. A nursing note and incident report for Resident R5, dated May 6, 2017, revealed that the resident was being assisted from the bed to a wheelchair by a nurse aide when he lost his balance and fell , hitting the left side of his head on the over-bed table. He was found lying on the floor next to his bed with his head resting on the cross bar of the over-bed table. The resident stated that the wheelchair brakes were not tight. The resident had bruising to the left occipital (back of the head) and to the left top of his head, and a two centimeter (cm) scratch behind his left ear. The incident report indicated that the possible cause of the fall was that the wheelchair brakes were not tight prior to the transfer. A witness statement completed by Nurse Aide 2, dated May 6, 2017, indicated that she was transferring Resident R5 from the bed to his wheelchair at 4:45 p.m. to help him go to the bathroom, and that the possible cause of the fall was that the wheelchair brakes were extremely difficult to push. A nursing note for Resident R5, dated May 8, 2017, indicated that the resident was complaining of left lower body pain, and the physician ordered an X-ray of his pelvis, left hip, and left leg. A nursing note, dated May 9, 2017, at 12:09 a.m. revealed that on May 8, 2017, at 10:45 p.m., the physician was contacted with the results of the X-ray, which showed a fractured left hip, and an order was given to send the resident to the emergency department. Interview notes for Resident R5, dated May 15, 2017, indicated that he was informed that his wheelchair locks were adjusted when he was in the hospital on May 8 through 12, 2017, and he was angry and stated that nobody had looked at his chair. Interview with Resident R5 on June 15, 2017, at 12:30 p.m. revealed that he was being assisted out of bed to go to the bathroom when he slid down onto the bed-side table. He indicated that he believed that the wheelchair brakes were not locked. Interview with Nurse Aide 2 on June 16, 2017, at 3:30 p.m. revealed that she was transferring Resident R5 to take him to the bathroom and the wheelchair brakes were locked, but the wheelchair brake locks kicked out. She stated that she did not realize that this was a new wheelchair for the resident. A purchase order provided by the facility, dated March 13, 2017, indicated that Resident R5's wheelchair was ordered. However, there was no documented evidence that the wheelchair was checked when the facility received it, and prior to the resident receiving the wheelchair for use. Interview with the Director of Nursing on June 15, 2017, at 12:40 p.m. confirmed that there was no documented evidence that Resident R5's wheelchair was checked prior to the resident receiving the wheelchair for use. She stated that the resident's wheelchair brakes were adjusted twice after the incident, and that following the incident, the facility developed a policy regarding checking new equipment prior to distribution to residents. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 2/2/17, 11/2/16, 9/22/16, 10/16/15. 28 Pa. Code 211.5(f) Clinical records. Previously cited 2/2/17, 9/22/16, 10/16/15. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/23/17, 2/2/17, 11/2/16, 9/22/16, 10/16/15.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide the necessary care and services to maintain a resident's physical well-being for one of 30 residents reviewed (Resident CR22) resulting in actual harm for the resident, failed to ensure that physician-ordered medical devices were applied as ordered for one of 30 residents reviewed (Resident R8), and failed to ensure that communication was maintained with a Hospice provider for one of 30 residents reviewed (Resident R20). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR22, dated July 19, 2016, revealed that the resident required the extensive assistance of two people for mobility and had [DIAGNOSES REDACTED]. A nursing note for Resident CR22, dated August 27, 2016, at 2:03 p.m. revealed that the resident called out to passing staff for help, and she was noted to be sitting with her back against the wall. When staff stood the resident up, she cried out in pain and was unable to bear weight. The resident was transferred to the hospital and admitted with a right [MEDICAL CONDITION]. A nursing note, dated August 30, 2016, at 7:54 p.m. revealed that the resident returned from the hospital and her medications included Xarelto (a blood thinner) and aspirin (pain relief medication that thins the blood). A nursing note for Resident CR22, dated September 11, 2016, at 12:55 a.m. revealed that the resident had dark, liquid stool (bowel movement) squirting from her rectum that was guaiac positive (a test to check for the presence of blood in the stool). A nursing note, dated September 11, 2016, at 6:33 p.m. revealed that the resident had two more episodes of liquid stool that looked darker and loose; and a nursing note, dated September 12, 2016, at 12:00 a.m. revealed that the resident had a large amount of black diarrhea that was guaiac positive. A nursing note, dated September 13, 2016, at 1:20 a.m. revealed that the resident had a moderate amount of diarrhea that was black and tested positive for blood. There was no documented evidence that the physician was notified about Resident CR22's change in condition until a facsimile (fax) form, dated September 13, 2016, at 9:44 a.m. was sent to the physician and indicated that the resident had dark, loose stools that were guaiac positive and she was on Xarelto (a blood thinning medication) and aspirin. There was no evidence that the physician responded to the fax until an order was received on September 14, 2016, at 9:30 a.m. to discontinue Xarelto and aspirin and to test the resident's stools for the presence of blood three more times. However, a nursing note, dated September 14, 2016, at 1:26 p.m. indicated that an order was received to discontinue Xarelto and aspirin and to test the resident's stools for the presence of blood one more time. A nursing note for Resident CR22, dated September 15, 2016, at 2:39 a.m. revealed that the resident was not herself and could not move her right leg or straighten it. She complained of pain in the right hip, so she was medicated with [MEDICATION NAME] (a narcotic pain medication). The note also indicated that the resident looked very pale and lethargic (sluggish), so the nurse checked the resident's vital signs and could not hear a blood pressure. A second nurse was not able to hear the resident's blood pressure after two attempts, so a registered nurse (RN) tried with a different blood pressure cuff and still could not hear the resident's blood pressure. It was also reported to the RN that the resident looked pale and that she had been having positive blood in her stool all weekend and that staff were concerned because she did not look well and was not acting like her normal self. A nursing note for Resident CR22, dated September 15, 2016, at 9:06 p.m. revealed that the resident was very anxious at 7:45 p.m. and said that she could not breathe. The note indicated that the nurse sat and talked with the resident. A nursing note for Resident CR22, dated September 16, 2016, at 1:22 a.m. revealed that [MEDICATION NAME] (used to treat chest pain and heart failure) was given for a sudden onset of chest pain, pressure and tightness at 1:10 a.m. and was ineffective. The resident's blood pressure was 88/46 millimeters of mercury (mmHg)(normal is 120/80 mmHg). The physician was notified, and a new order was received to give the [MEDICATION NAME] unless the systolic blood pressure (the top number) went under 80 mmHg. A second dose of [MEDICATION NAME] was given at 1:20 a.m. and the resident said she felt a little better. Her blood pressure was 74/42 mmHg. A [MEDICATION NAME] was given to the resident at 1:30 a.m. and at 2:33 a.m. she was sleeping. A nursing note for Resident CR22, dated September 16, 2016, at 6:49 a.m. revealed that she was given [MEDICATION NAME] (narcotic pain medication) for complaints of chest pain and discomfort, and at 7:24 a.m. she continued to complain of moderate to severe pain in the chest area. The note indicated that the resident's skin was pale, cool, dusky and sweaty, and she had [MEDICAL CONDITION] (a build-up of fluid in the extremities that when gently pushed with a finger, a depression will remain) of both feet and ankles. A nursing note for Resident CR22, dated September 16, 2016, revealed that the resident was given [MEDICATION NAME] at 10:45 p.m. for complaints of chest pain. Her blood pressure was 88/50 mmHg. At 10:55 p.m. the resident requested a nebulizer treatment (a medication delivered in the form of a mist and inhaled into the lungs) for complaints of shortness of breath, at 11:15 p.m. she received a [MEDICATION NAME] for complaints of hip pain, and at 11:54 p.m. staff administered [MEDICATION NAME] (a medication used to treat anxiety) for severe anxiety. A nursing note for Resident CR22, dated September 17, 2016, at 7:29 a.m. revealed that the resident had been anxious at the beginning of the night, slept intermittently, and was more restless than usual. She was given a nebulizer treatment (a respiratory treatment administered as a mist) at 7:15 a.m. for complaints of shortness of breath. A nursing note, dated September 18, 2016, at 12:00 a.m. revealed that the resident was anxious and confused to time and place and was asking to go to the maintenance shop and to take her back to room [ROOM NUMBER]. A nursing note, dated September 18, 2016, at 12:15 a.m. revealed that Resident CR22 was given [MEDICATION NAME] (an antianxiety medication) for severe anxiety. There was no documented evidence in Resident CR22's clinical record that the physician was notified and/or notified timely about the resident's continued changes in condition, including continuing low blood pressure, chest pain, shortness of breath, and anxiety. A nursing note for Resident CR22, dated September 18, 2016, at 2:45 a.m. revealed that the resident was found without a pulse and spontaneous respirations, and her pupils were fixed and dilated (they did not respond to light). She was pronounced dead at 2:50 a.m. Resident CR22's death certificate, dated September 19, 2016, revealed that the immediate cause of her death was [MEDICAL CONDITION] infarction (a [MEDICAL CONDITION] - occurs when blood flow stops to a part of the heart causing damage to the heart muscle). Interview with the Director of Nursing on September 22, 2016, at 2:50 p.m. confirmed that the licensed nursing staff did not provide the necessary care and treatment to Resident CR22 to maintain her physical well-being during the times when she had blood in her stool, low blood pressures, chest pain, shortness of breath and anxiety. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R8, dated April 26, 2016, and a quarterly MDS assessment dated [DATE], indicated that the resident required extensive assistance from staff for mobility. An undated [DIAGNOSES REDACTED]. Physician's admission orders [REDACTED]. The resident's Medication Administration Record [REDACTED]. Observations on September 20, 2016, at 5:12 p.m. revealed that Resident R8 was in bed and did not have TED hose on. Interview with Licensed Practical Nurse 5 on September 20, 2016, at 5:12 p.m. confirmed that Resident R8 should have had TED hose on as ordered by the physician. Interview with the Director of Nursing on September 21, 2016, at 8:35 a.m. confirmed that Resident R8 should have had TED hose on as ordered by the physician, and there was no documented evidence that TED hose had ever been applied. The facility's policy regarding hospice services, dated August 10, 2016, indicated that the Hospice agency would maintain a medical record at the appropriate nursing station for each resident and hospice notes would be updated promptly. A contract between the facility and the hospice provider, dated February 5, 2004, contained an addendum which indicated that the facility would maintain records related to the provision of hospice services for the resident. physician's orders [REDACTED]. Interview with the Director of Nursing on September 21, 2016, at 3:45 p.m. revealed that she was under the impression that the hospice nurse was to place copies of the hospice nursing notes in the resident's chart on the next visit to the facility. 42 CFR 483.25 Provide Care/services For Highest Well Being. Previously cited 10/16/15. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 10/16/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to prevent injury during falls for one of 30 residents reviewed (Resident R1) who had a history of [REDACTED]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs) for Resident R1, dated August 1, 2016, revealed that the resident was confused at times, had moderate hearing difficulty, required extensive assistance with care, had a history of [REDACTED]. Nursing notes for Resident R1, dated November 20, 2015, through September 19, 2016, revealed that the resident experienced 36 falls, eight with injuries, in the past 10 months. A nursing note regarding a fall on December 18, 2015, revealed that the resident fell from her bedside commode and had redness to her bilateral breasts. A nursing note regarding a fall on January 17, 2016, revealed that the resident was found on the floor in her room with a television lying on her right arm and the dresser was tipped over onto the television; the resident had a hematoma (collection of blood outside the blood vessels) and bruising of her right wrist. A nursing note regarding a fall on February 2, 2016, revealed that the resident fell while transferring from her chair to her bed and had an abrasion (superficial damage to the skin) to her right lower back. A nursing note regarding a a fall on March 11, 2016, revealed that the resident fell in her room and yelled for help. When staff entered the room, the resident was standing by her bed with blood all over the area, and she had a laceration (a deep cut or tear in skin or flesh) to the middle of her nose, her nose was bleeding, and she complained of a moderate headache. A nursing note for a fall on June 7, 2016, revealed that the resident fell in her room and had bruising on her right hip. There was no documented evidence that the above falls for Resident R1 were evaluated for possible causes, and no evidence that new interventions to prevent further falls and/or injuries were implemented. A nursing note for a fall on June 28, 2016, revealed that Resident R1 fell in her room and had two lacerations, one between her eyes, and one at the top of her nose. There was bleeding from her nostrils and her nose was crooked to the left side of her face. The resident was transferred to the hospital and X-rays determined that she had a broken nose and a closed reduction (procedure to set a broken bone without surgery) was necessary. A nursing note for a fall in the bathroom near the main entrance for Resident R1 on July 31, 2016, revealed that the resident had a reddened area and a slight abrasion to her mid-back, and a nursing note for a fall in the resident's room on September 12, 2016, revealed that she had a laceration to the bridge of her nose with bruising. Resident R1's fall care plan, dated August 1, 2016, revealed that she was instructed to call for assistance her with transfers and to keep her personal items within reach. There was no documented evidence that the resident's falls were evaluated for possible causes or that further interventions to prevent injuries and/or falls were implemented. Interview with the Director of Nursing on September 21, 2016, at 8:30 a.m. confirmed that Resident R1's falls were not evaluated. She indicated that Resident R1 has had so many falls that they did not feel that there was anything else that they could do. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 10/16/15. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/16/15, 9/18/14.