Every finding on record at Concordia at Villa St Joseph

Based on review of facility policy, observations, and resident and staff interviews it was determined that the facility failed to provide activity of daily living assistance for six of 29 residents (Resident R1, R2, R3, R4, R5, and R6).Findings include: Review of the facility policy Accessibility and Timely Response dated 1/1/26, indicated All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. During an observation of the Ebensburg Nursing Unit on 6/19/26, at approximately 11:15 a.m. multiple call lights were observed to be alarming, with both red and white lights illuminated above resident doors. At this time, Activities Employee E1 was observed in the hallway where four call lights were illuminated. When asked about the call lights not being responded to, Activities Employee E1 stated, I'm Activities. When asked if she was still able to respond to call light to ensure resident's safety in case they had fallen or respond to non-nursing request, Activities Employee E1 stated, Well, I guess I could. During an observation on 6/19/26, at approximately 11:20 a.m. the surveyor approached the nursing station and asked the staff member standing at the desk what the call lights that were illuminated red meant. The staff member stated, I think that means they are in the bathroom, I'm not an aide. When asked what her position was, the staff member stated, I'm a Unit Clerk. At this time, Unit Clerk Employee E2 then exited the nurses' station and the unit without responding to any of the alarming call lights. During an observation of the call light monitor at the nurse's station on 6/19/26, at approximately 11:23 a.m. revealed call lights were illuminated on the monitor for Resident R1, Resident R2, Resident R3 and R4's room, and Resident R5. During an observation on 6/19/26, at approximately 11:25 a.m. the call lights still illuminated on the Ebensburg Nursing Unit, Social Services Employee E3 was observed walking past Resident R1 and R2's rooms without stopping to ensure resident safety or attempting to respond to a possible non-nursing request. During an interview on 6/19/26, at approximately 11:35 a.m. Resident R6 stated that call light responses can take up to a half hour. During an interview on 6/19/26, at approximately 12:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide activity of daily living assistance for failed to provide activity of daily living assistance for six of 29 residents. 28 PA. Code:201.18(b)(2) Management.28 PA. Code:201.29(a) Resident's Rights

Based on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for three of five sampled residents (Residents R2, R8, and Resident R9). Findings include: The facility Use of psychotropic medications policy dated 4/28/25, and last reviewed 1/1/26, indicated that a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These medications should only be used to treat the resident's medical symptoms. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically ineffective, the indication for use is inadequate. The facility Gradual dose reduction of psychotropic drugs policy dated 4/28/25, last reviewed 1/1/26, indicated that gradual dose reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions or risk can be managed by a lower dose. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated the medication, the facility will attempt a GDR in two separate quarters (with at least one month between attempts), unless contraindicated. GDR will be documented in the clinical record. Rationale for clinical contraindications may be documented in the clinical record. Review of Resident R2's admission record indicated he was admitted [DATE]. Review of Resident R2's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 12/8/25, indicated Resident R2 had diagnoses that included Parkinson's Disease (a progressive disorder of the central nervous system which affects movement and includes tremors), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), Dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning), and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination). Review of Resident R2's care plans, last reviewed 1/6/26, indicated that Resident R2 uses psychotropic medications with the reason being behavioral management. Review of Resident R2's physician orders dated 6/6/25 and 6/7/25 indicated the following: Give one Seroquel 25mg in the morning for Major depressive disorder Give two Seroquel 25mg at bedtime for Major depressive disorder Review of Resident R2's physician visits dated 11/20/25, 1/27/26, and 2/25/26 indicated that Resident R2 had no behaviors and to continue his Seroquel dosage. Review of Resident R2's clinical progress notes October 2025 to March 2026 did not include any behaviors related to the use of Seroquel. During an interview on 3/4/26, at 10:23 a.m. Director of Nursing (DON) was asked about Resident R2 GDR documentation and the GDR process: I round with the psychiatrist. He retired at the end of January 2026. The Psychiatrist would see the residents after a medication adjustment, monitor the residents and discuss quarterly during the medication reduction meeting. That is our process. During an interview on 3/4/26, at 10:37 a.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E7 was asked about the GDR process: we currently are going through transition. Before, a psychiatrist would come in and complete a review of medications and consider a GDR. During an interview on 3/4/26, at 11:28 a.m. Director of Nursing (DON) provided documents/email communications mentioning GDR discussion with the facility multi-disciplinary team regarding Resident R2. However, specific behaviors, a documented clinical rationale for using a psychotropic medication, or the effects should Resident R2 medications be modified was not documented. During an interview on 3/4/26, at 11:31 a.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E7 was asked for Resident R2's behaviors notes and gradual dose reduction (GDR) documents and stated: I cannot find anything that you requested. During an interview on 3/4/26, at 11:40 a.m. Nurse aide Employee E8 was asked if Resident R2 had any behaviors for the past six months, and she stated: I have not seen any behaviors. Resident R2 is very sweet. Some behaviors when he first came in though. During an interview on 3/4/26, at 2:22 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication and document in the resident record the reason for continued use for Resident R2 as required. Review of Resident R8 admission record indicated she was admitted on [DATE]. Review of Resident R8 admission record indicated diagnosis of unspecified mood disorder (symptoms predominate that are characteristic of a depressive disorder and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning) depression (involves a depressed mood or loss of pleasure or interest in activities for long periods of time) and anxiety disorder (excessive, frequent and unrealistic worry about everyday things). Review of Resident R8 MDS dated [DATE], indicated resident R8 has diagnoses of CAD (coronary artery disease a common type of heart disease affects the main blood vessels that supply blood to the heart), anxiety (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities.). Review of Resident R8 clinical record MAR (medication administration record - a record documenting residents' medication) for January 2026 indicated: Alprazolam (used to relive symptoms of anxiety) Tablet 0.25 MG Give 1 tablet by mouth every 24 hours as needed for Anxiety -Start Date- 01/26/2026 1237 -D/C Date- 02/23/2026 0958 Review of the MAR indicated medication was given 1/26/26, 1/27/26, 1/28/26 and 1/30/26. Review of the MAR failed to include what behaviors Resident R8 was experiencing and other attempts to relive potential behaviors prior to Resident R8 being given the psychotropic medication. Review of Resident R8 progress notes for January 2026 failed to include a description of behaviors, or non- pharmacological interventions that were given to resident R8 prior to the psychotropic medications. Review of Resident R9 admission record indicated she was admitted on [DATE]. Review of Resident R9 MDS assessment dated [DATE], indicated Resident R9 has diagnoses of adult failure to thrive (a state of decline that is multifactorial and may be cause by chronic concurrent diseases and functional impairment), depression (causes a persistent feeling of sadness and loss of interest) and malnutrition (deficiencies, excesses, or imbalances in a person's /intake of energy and /or nutrients.) Review of Resident R9 MDS, BIMS (Brief Interview Mental Status) indicated a score of 9 (moderate impairment). Review of Resident R9 clinical record psychotropic medication informed consent dated 11/18/25, indicated: sertraline 150mg and anti-anxiety - hydroxyzine. Review of the consent form showed Resident R9 signed for the consent of the medications. During an interview on 3/5/26, at10:39 a.m. Nursing Home Administrator and Director of Nursing confirmed that the facility failed to give non-pharmacological interventions to Resident R8 and failed to have a guardian or responsible party sign for Resident R9. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.2(a)(c) Physician services. 28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services. 28 Pa. Code: 211.12(c)(d)(5) Nursing services.

Based on review of clinical records, and staff interview it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for three of four residents (Resident R36, R73, R157).Findings include: Interview with the Director of Nursing on 3/4/26, at 1:00 p.m. indicated the facility does not have a policy regarding quality of care or change in condition. Review of the admission record indicated Resident R36 admitted to the facility on [DATE]. Review of Resident R36's Minimum Data Set (MDS- a periodic assessment of care needs) dated 2/23/26, indicated the diagnoses of hepatic encephalopathy (a reversible serious brain dysfunction caused by liver failure where the liver cannot filter toxins, mainly ammonia from the blood), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and liver cancer. Review of hospital discharge documentation indicated rifaximin (a broad-spectrum antibiotic used to treat diarrhea and reduce the risk of over-hepatic encephalopathy recurrence) 550 mg (milligram) by mouth twice a day from 2/5/26, through 4/5/26. Review of Resident R36's physician order dated 2/18/26, indicated rifaximin 550 mg (milligram) give one tablet by mouth every morning and at bedtime for anti-infective agent for 30 days. Review of Resident R36's Medication Administration Record (MAR) dated February 2026, indicated rifaximin 550 mg give one tablet by mouth every morning and at bedtime. The medication was not documented as ever being received by the resident. Review of Resident R36's progress note dated 2/19/26, at 2:22 p.m. indicated this writer called the pharmacy this afternoon to inquire as to why the Rifaximin 550 mg did not come from the pharmacy today. Upon research, it is noted upon admission that the medication is to be supplied by the family and ordered while he was still in the hospital. It will arrive as soon as possible and the family will bring it to us to give to resident. Review of Resident R36's progress note dated 2/24/26, indicated rifaximin remains on hold, to be supplied by the family. This writer asked resident's family for an update about the medication. It is apparently over one thousand dollars for a supply, and they are looking into the situation further. Interview on 3/4/26, at 9:59 a.m. Licensed Practical Nurse (LPN) Employee E2 indicated the family is trying to get the medication for us. Review of the admission record indicated Resident R73 admitted to the facility on [DATE]. Review of Resident R73's MDS dated [DATE], indicated diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), high blood pressure, and anxiety. Review of Resident R73's physician order dated 2/12/26, indicated Lispro Pen (short acting insulin) inject as per sliding scale: if 0 - 70 = 0 initiate hypoglycemic protocol; 71 - 140 = 0; 141 - 180 = 1; 181 - 220 = 2; 221 - 260 = 3; 261 - 300 = 4; 301 - 340 = 5; 341 - 999 = 6 give 6 units and recheck in 30 minutes, if still >340 contact physician. Review of Resident R73's clinical record indicated the facility failed to notify the physician of abnormal glucose levels greater than 341 as ordered on the following days:3/1/2026 16:15 383.0 mg/dL notification not documented.2/25/2026 16:00 369.0 mg/dL notification not documented.2/23/2026 19:34 394.0 mg/dL notification not documented. 2/20/2026 19:41 387.0 mg/dL notification not documented.2/19/2026 21:07 348.0 mg/dL notification not documented.2/18/2026 20:30 386.0 mg/dL notification not documented.2/14/2026 20:15 357.0 mg/dL notification not documented. Review of the admission record indicated Resident R157 admitted to the facility on [DATE], with diagnoses of depression and diabetes (a condition that causes blood sugar to rise). Review of Resident R157's physician order dated 2/25/26, indicated to change incisional wound vac every 3 days. Place versatile or Adaptec or similar dressing, black sponge over the incision. Set wound vac at 80 mm/hg continuous suction. Replace knee immobilizer. Review of Resident R157's care plan dated 2/25/26, revealed the resident had psudomonous/ candida parapsiolsis infection to right knee. Interventions included to apply wound vac as prescribed. The care plan failed to include the wound vac settings or order to change the wound vac. During an interview on 3/1/26, at 10:11 a.m. Resident R157 wound vac was not on and operating. The wound vac was observed not to be plugged in. During an interview on 3/2/26, at 10:12 a.m. Licensed Practical Nurse (LPN), Employee E9 confirmed Resident R157's wound vac was not on and functioning. LPN, Employee E9 confirmed the facility failed to provide the wound vac as ordered. Interview on 3/4/26, at 11:00 a.m. the Director of Nursing confirmed that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and follow physician orders for three of four residents (Resident R36, R73, R157). 28 Pa. Code: 201.14(a) Responsibility of Licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (d)(5) Nursing Services.

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care of the resident for five of eight residents reviewed (Resident R21, R28, R147, and R157). Findings include: Review of the facility policy Baseline Care Plan dated 1/1/26, indicated the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of the admission record indicated Resident R21 admitted to the facility on [DATE], with the diagnoses of pneumonia (lung infection), Parkinson's disease (disorder of the nervous system that results in tremors), and enterocolitis due to clostridium difficile (C-diff - contagious bacteria causing severe, watery diarrhea, abdominal pain, fever, and nausea). Review of Resident R21's physician order dated 2/12/26, indicated contact precautions for C-diff. Please clarify with physician when isolation precautions can end. Review of Resident R21's baseline care plan dated 2/12/26, failed to include instructions for care and management of contact precautions for Cdiff. Review of the admission record indicated Resident R28 admitted to the facility on [DATE], with the diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and lymph edema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system). Review of Resident R28's MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R28's physician orders dated 2/15/26, indicated:-cleanse left buttock open area with saline, apply calcium alginate (highly absorbent fiber derived from brown seaweed, used as a primary wound dressing for moderate to heavy exudating wounds) and border gauze daily in the morning.-cleanse open areas of left shin with saline, apply calcium alginate and border gauze daily.-cleanse skin tear of left upper elbow area with saline apply xeroform gauze (non-adherent dressing) and border gauze in the evening. Review of Resident R28's baseline care plan dated 2/15/26, failed to include person centered instructions for care and management of left buttock, left shin, and left elbow wounds. Interview on 3/4/26, at 1:00 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed Resident R21's and Resident R28's baseline care plans failed to include instructions needed to provide effective and person-centered care of each resident. Review of the clinical record indicated Resident R147 was admitted to the facility on [DATE], with diagnoses of pneumonia, anxiety disorder, and encounter for follow up after examination after completed treatment for conditions other than malignant neoplasm. Review of Resident R147's care plan dated 2/20/26, revealed the resident had an alteration in gastrointestinal status due to a new peg tube (A percutaneous endoscopic gastrostomy tube, is a feeding tube inserted into the stomach through the abdominal wall, used for patients who cannot eat by mouth.). On 2/23/26, a total of three days after the resident was admitted to the facility, interventions were initiated to administer tube feed per order. The care plan failed to include the physician order or size of the resident's G-Tube. Interview with the Registered Nurse Assessment Coordinator, Employee E1 on 3/3/25, at 12:50 p.m. confirmed Resident R147's physician orders for the administration of tube feeds or the size of the resident's G-Tube were not included in the resident's baseline care plan. RNAC, Employee E1 confirmed the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered for Resident R147. Review of the admission record indicated Resident R157 admitted to the facility on [DATE], with diagnoses of depression and diabetes (a condition that causes blood sugar to rise). Review of Resident R157's physician order dated 2/25/26, indicated to change incisional wound vac every 3 days. Place versatile or Adaptec or similar dressing, black sponge over the incision. Set wound vac at 80 mm/hg continuous suction. Replace knee immobilizer. Review of Resident R157's care plan dated 2/25/26, revealed the resident had pseudomonas/ candida parasitosis infection to right knee. Interventions included to apply wound vac as prescribed. The care plan failed to include the wound vac settings or order to change the wound vac. During an interview on 3/2/26, at 1:55 p.m. Licensed Practical Nurse Assessment Coordinator, Employee E7 confirmed the facility failed to ensure Resident R157's baseline care plan included wound vac settings and an order to change the wound vac. 28 Pa Code 211.10(a) Resident care policies.

Based on review of facility policy, facility documents, clinical records, and staff interview it was determined that the facility failed to conduct a thorough investigation of an injury of unknown origin to eliminate possible neglect for one of four residents (Resident R74). Findings include: Review of the facility policy Abuse, Neglect, and Exploitation, dated 1/1/26, indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Identification of Abuse, Neglect and Exploitation: Possible indicators of abuse include, but are not limited to: Physical injury of a resident, unknown origin. Review of the admission record diagnosis indicated: sciatica left side (nerve pain from injury or irritation to your sciatica nerve), other abnormalities of gait and mobility (gait disorders are an abnormal walking pattern with many possible causes like an injury, sore, an inner ear (balance)issue or nerve damage), and age-related osteoporosis without current pathological fracture (Bones to become weak and brittle so brittle that a fall or even mild stresses such as bending over or coughing can cause a break. Osteoporosis-related breaks most commonly occur in the hip, wrist or spine). Review of the facility documentation progress notes dated 3/1/26, indicated: Hospital nurse called at 0005 (5:00 a.m.) to report radiology report of LEFT femur broken. Resident R74 to be admitted . Review of the facility documentation indicated that Resident R74 progress notes dated 3/1/26, Pt with history of left side sciatica and inability to ambulate. Pt reports new onset worsening pain to left hip. Reports she can't move leg. She is anxious. She wants to go to hospital. Review of witness statements indicated Resident R74 was moved into bed by a sit to stand (a type of transfer device for residents) by Nurse Aide (NA) Employee E10 and afterwards complained of pain. During an interview on 3/4/26, at 12:55 p.m. NA Employee E10 indicated: I took Resident R74 to the bathroom utilizing the sit to stand lift. I took the resident back to bed with the sit to stand, placed her in the bed, afterwards she complained of pain - I notified the nurse. Review of facility provided documentation indicated witness statements from staff were completed. Further review failed to include that the facility identified the injury of unknown origin as potential neglect or that an investigation was completed to rule out neglect. During an interview on 3/5/26, at 10:46 a.m. Director of Nursing (DON) indicated that the investigation was completed, and the facility had collected the witness statements but there was no further documentation, nor could documentation be provided to show that neglect was investigated and ruled out. During an interview on 3/5/26, at 10:50 a.m. Nursing Home Administrator and DON were informed that the facility failed to conduct a thorough investigation of an injury of unknown origin to eliminate possible neglect for one of four residents (Resident R74). 28 Pa Code: 201.18 (e)(1)(2) Management. 28 Pa Code: 201.29 (a)(c) Resident Rights. 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three medication rooms. (Fontbonne Medication Room). Findings include: Review of the facility policy Medication Storage in the facility dated [DATE], indicated medications and biologicals are stored safely, securely, and properly. Medications requiring refrigeration or temperatures between 36F and 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, and disposed of. During an observation on [DATE], at 1:29 p.m. the Fontbonne Medication room contained the following expired supplies: -(3) 1ml 28g 1/2 safety syringe with needle expired [DATE] -(5) 28g 1/2 1 ml safety syringe needle expired [DATE] -(1) BD vacutainer push button blood collection set 0.6 x19mmx305 mm expired [DATE] During an observation on [DATE], at 1:29 p.m. the temperature of the medication fridge located in the Fontbonne Medication room was 48F. During an interview on [DATE], at 1:30 p.m. Licensed Practical Nurse Employee E11 confirmed that the above supplies were expired, and the medication fridge temperature was not in range as required. Interview on [DATE], at 1:37 p.m., the Nursing Home Administrator confirmed that the facility failed to discard expired medical supplies and ensure all drugs and biologicals were stored under proper temperature controls for one of three medication rooms. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(2)(3) Nursing services.

Based on review of facility policy, clinical records, staff interviews, and resident observations it was determined that the facility failed to maintain a peripheral intravenous (IV) catheter site consistent with professional standards of practice for one of three residents (Resident R29).Findings include:Review of the facility policy Intravenous Therapy dated 1/1/26, indicated the facility will adhere to accepted standards of practice regarding infusion practices. IV sites are checked every shift and as needed for signs and symptoms of infection or inflammation.Review of the admission record indicated Resident R29 admitted to the facility on [DATE].Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/26, indicated the diagnoses of renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), pneumonia (lung infection) and urinary tract infection.Review of Resident R29's physician order dated 2/28/26, indicated sodium chloride intravenous solution0.9 % (percent). Use 500 ml (milliliters) intravenously every shift for dehydration. To be run as a 500ml bolus (at once) and then remaining 500 mls at 75 mls/hour for a total of 1000mls.Observation on 3/1/26, at 9:35 a.m. Resident R29 was lying in bed. The left lower arm had a peripheral IV inserted. The site was not labeled with a date or time. The extension tubing connected to the IV catheter itself was not clamped off, and failed to have a cap, or injection site at the end. Blood was noted to be backed up in the extension tubing.Observation and interview with Licensed Practical Nurse (LPN) Employee E3 confirmed the appearance of the IV site, that it was not clamped off, failed to have a cap, or injection site at the end, and that blood was noted to be backed up in the extension tubing.Interview on 3/1/26, at 2:45 p.m. information was disseminated to the Director of Nursing that the facility failed to maintain a peripheral intravenous catheter site consistent with professional standards of practice for one of three residents (Resident R29).28 Pa. Code 201.18(b)(3) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3) Nursing services.

Based on review of facility policy, clinical record review, observations, and staff and resident interviews, it was determined that the facility failed to ensure that residents with an enteral feeding tube (a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of three residents reviewed (Residents R147).Findings include: Review of [NAME] manufacture guidelines titled How to bolus feed dated 3/20, stated bolus feeding is a way of receiving a set amount of feed as required, without use of a feeding pump. This is given over a period of time, as advised by your healthcare professional, using an enteral feeding syringe. Materials required include a 60ml enteral feeding syringe, clean jug for decanting your feed, water for flushing the feeding tube before and after the feed, and the prescribed feed. Once opened, cover your feed and put it in the fridge (when not being used). Sterile feed can be used for up to 24 hours (nonsterile for up to 4 hours).1 After this time throw the feed away if you do not use it. Review of the Jevity 1.5 Cal Product Information manufacturer guidelines dated 2024, revealed Jevity 1.5 Cal is a calorically dense, high protein, fibre-fortified liquid formula proving complete, balanced nutrition for people who may benefit from increased calories and protein. It was indicated all formulated liquid diet products, regardless of administration system, require careful handling because they can support microbial growth. Follow these instructions for clean technique and proper setup to reduce the potential for microbial contamination. For tube feedings, follow health care professional instructions for flow rate, volume and need for additional fluids. Care should be taken to avoid contamination during preparation and administration. Pump feeding is recommended, use a 10Fr or larger tube. For gravity feeding, use a 12 Fr or larger tube. Review of the facility provided undated Administration of Enteral Feedings-Gastrostomy or Jejunostomy Tube (G-Tube or J-Tube) education, indicated for enteral feeding via bolus administration the formula is opened and the amount ordered is added to the tube. Open the clamp and allow the formula to flow into the stomach. Once complete, clamp the tube. Flush tube. Review of the clinical record indicated Resident R147 was admitted to the facility on [DATE], with diagnoses of pneumonia, anxiety disorder, and encounter for follow up after examination after completed treatment for conditions other than malignant neoplasm. Review of Resident R147's care plan dated 2/20/26, revealed the resident had an alteration in gastrointestinal status due to a new peg tube (A percutaneous endoscopic gastrostomy tube, is a feeding tube inserted into the stomach through the abdominal wall, used for patients who cannot eat by mouth.). On 2/23/26, a total of three days after the resident was admitted to the facility, interventions were initiated to administer tube feed per order. The care plan failed to include the physician order or size of the resident's G-Tube. Review of a physician order dated 2/24/26, indicated to administer 360 milliliters (ml) Jevity 1.5 liquid nutritional supplement via Peg Tube, bolus feed, four times a day. During an interview and observation on 3/3/26, at 12:06 p.m. Resident R147 stated I do have one complaint, I am hungry all the time. Resident R147 indicated 360 ml four times a day is not enough, it should be 400. Resident R147 stated my stomach is growling all the time. Resident R147's Jevity 1.5 was observed being administered via gravity in from the pole with tubing and dripping slowly. The resident stated, this one is very slow. 360 ml was still observed in the bag. During an interview on 3/3/26, at 12:12 p.m. Registered Nurse (RN), Employee E6 stated Resident R147's tube feeding was hung around 11:10 a.m. and stated, I came in 5 to 10 minutes ago and noticed it was not going through. RN, Employee E6 confirmed Resident R147 was not receiving his tube feed by bolus as ordered. During an interview on 3/3/26 at 12:33 p.m. RN, Employee E6 stated in the beginning the pump was used to administer Resident R147's tube feed, however the pump was not efficient. RN, Employee E6 stated it typically takes an hour for the tube feed to be administered using a bag and tubing and it attached to the pole. During an interview on 3/3/26, at 12:37 p.m. RN, Employee E6 confirmed Resident R147 tube feedings were ordered to be administered via bolus. During an observation on 3/4/26, at 11:16 a.m. Resident R147's syringe hanging on the tube feeding pole was undated and the tube feed tubing failed to have a cap attached to the end. The resident's tube feed bottle was observed sitting on the window seal. During an interview on 3/4/26, at 11:23 a.m. RN, Employee E6 confirmed the above observations. During an interview on 3/5/26, at 2:05 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications as required for one of three residents (Residents R147). 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa. Code: 211.12(d)(1) Nursing services.

Based on review of facility policy and facility documents, clinical records, staff and family interviews it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of one of four abuse allegations (Resident R74).Findings include: Review of the facility policy Abuse, Neglect, and Exploitation, dated 1/1/26, indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Identification of Abuse, Neglect and Exploitation: Possible indicators of abuse include, but are not limited to: Physical injury of a resident, unknown origin. Review of the admission record indicated Resident R74 was admitted to the facility on [DATE]. Review of the admission record diagnosis indicated: sciatica left side (nerve pain from injury or irritation to your sciatica nerve), other abnormalities of gait and mobility (gait disorders are an abnormal walking pattern with many possible causes like an injury, sore, an inner ear (balance)issue or nerve damage), and age-related osteoporosis without current pathological fracture(Bones to become weak and brittle so brittle that a fall or even mild stresses such as bending over or coughing can cause a break. Osteoporosis-related breaks most commonly occur in the hip, wrist or spine). Review of the facility documentation progress notes dated 3/1/26, indicated: Hospital nurse called at 0005 (5:00 a.m.) to report radiology report of LEFT femur broken. Resident R74 to be admitted . Review of the facility documentation indicated that Resident R74 progress notes dated 3/1/26, Pt with history of left side sciatica and inability to ambulate. Pt reports new onset worsening pain to left hip. Reports she can't move leg. She is anxious. She wants to go to hospital. Review of witness statements indicated Resident R74 was moved into bed by a sit to stand ( a type of transfer device for residents) by Nurse Aide (NA) Employee E10 and afterwards complained of pain. During an interview on 3/4/26, at 12:55 p.m. NA Employee E10 indicated: I took Resident R74 to the bathroom utilizing the sit to stand lift. I took the resident back to bed with the sit to stand, placed her in the bed, afterwards she complained of pain - I notified the nurse. Review of facility provided documentation indicated witness statements from staff were completed. Further review failed to include that the facility identified the injury of unknown origin as potential neglect or that an investigation was completed to rule out neglect. During an interview on 3/5/26, at 10:46 a.m. Director of Nursing (DON) indicated that the investigation was completed, and the facility had collected the witness statements but there was no further documentation, nor could documentation be provided to show that neglect was investigated and ruled out. During an interview on 3/5/26, at 10:50 a.m. Nursing Home Administrator and DON were informed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of one of four abuse allegations (Resident R74). 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to thoroughly clean and disinfect a contact isolation room with the appropriate disinfectant for one of three residents (Resident R21). Findings include: Review of the facility policy Management of C. Difficile Infection Procedure dated 1/1/26, indicated the facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C diff) infections. Use disposable equipment whenever possible. Thoroughly clean and disinfect with a sporicidal disinfectant (chemical disinfectants designed to destroy highly resistant bacterial and fungal spores). Review of the admission record indicated Resident R21 admitted to the facility on [DATE], with the diagnoses of pneumonia (lung infection), Parkinson's disease (disorder of the nervous system that results in tremors), and enterocolitis due to clostridium difficile (C-diff - contagious bacteria causing severe, watery diarrhea, abdominal pain, fever, and nausea). Review of Resident R21's physician order dated 2/12/26, indicated contact precautions for C-diff. Please clarify with physician when isolation precautions can end. Observation of Resident R21's room on 3/3/26, at 12:54 p.m. indicated signage of contact isolation on the closed door of the room. Interview on 3/3/26, at 12:54 p.m. Housekeeping Employee E4 indicated We scrub around the toilet and the sink really well. When asked if there was anything special required to clean a room with contact isolation due to C-diff. Interview on 3/3/26, at 12:55 p.m. Housekeeping Employee E4 further indicated we use [NAME] Facility Plus disinfectant. When asked if it contained bleach, housekeeper indicated they were not sure. Review of Midlab's EPA's (Environmental Protection Agency) Reg No. 45745-11-45745 for [NAME] Facility Plus disinfectant, the product's ability to kill on hard, non-porous inanimate surfaces, did not include effectiveness against killing Cdiff. Interview on 3/3/26, at 1:23 p.m. Environmental Services Director confirmed the [NAME] Facility Plus disinfectant was not effective against killing C-diff according to the manufacturer's EPA Reg No. 45745-11-45745 sheet. Interview on 3/3/26, at 2:45 p.m. interview with the Nursing Home Administrator information was disseminated to indicate the facility failed to thoroughly clean and disinfect a contact isolation room with the appropriate disinfectant for one of three residents (Resident R21). 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.28 (b)(e)(1) Management. 28 Pa Code: 211.10 (d) Resident care policies.

Based on review of facility policy, and facility documents and staff and resident interviews it was determined that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for one of five residents (Resident R142).Findings include: Review of the facility Resident and Family Grievances policy dated 1/1/26, indicated the Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. A resident or family member may voice grievances with respect to care and treatment that has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay. Grievances may be voiced in form of verbal complaint to a staff member. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated form or assist the resident or family member to complete the form. Forward the grievance form to the Grievance Official as soon as practicable. Review of the facility's January Resident Council Minutes dated 1/19/26, revealed Resident R142 attended the resident council meeting and expressed a concern related to maintenance. It was indicated when the heater controls are on low, the room gets very hot. Roommate opens window and Resident R142 is cold. Difficult to adjust and create a comfortable environment. During an interview on 3/2/26, at 12:02 p.m. Resident R142 confirmed she expressed a concern in January's Resident Council meeting regarding room temperatures. Review of January 2026, facility provided Grievance log failed to include Resident R142 grievance. Interview on 3/2/26, at 2:12 p.m. the Nursing Home Administrator confirmed that the facility failed to document, resolve, and provide response to resident and/or their responsible party regarding concerns for one of five residents (Resident R142). 28 Pa. Code 201.14(b) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 PA Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical records, and staff and resident family interviews it was determined that the facility failed to meet residents pain needs for two of two residents reviewed (Resident R5 and Resident R159). Findings include: Review of facility policy Pain Management dated 1/1/26, indicated: The facility must ensure that pain managements provided to residents who require such services, consistent with professional standards of practice, and the residents' goals and preferences. Resident R5 was admitted to the facility on [DATE]. Review of Resident R5 MDS (minimum data set - a periodic assessment of resident needs) dated 12/11/25, indicated diagnosis of a-fibrillation (an irregular and often very rapid heart rhythm), and myelodysplastic syndrome (group of disorders caused by blood cells that are poorly formed or don't work properly.) Review of Resident R5 clinical record indicated: resident to wear below lower extremities lymphedema (swelling that happens when something affects your lymphatic system) garments during the day off at night. Review of Resident R5 clinical record progress notes dated 3/3/26, indicated: review of progress notes show resident complain of pain around 3am -lymphedema socks were still on. Review of Resident R5 clinical record to include MAR/TAR (medication administration record and treatment administrator record - forms used to documents residents' medications and treatments) failed to include lymphedema garments to be place on or off. During an interview on 3/5/26, at 10: 50 a.m. Director of Nursing (DON) stated that she just added an order on the MAR for the nurses to remove the lymphedema garments at night and that prior to her adding it during the meeting it was not indicated on the MAR/TAR. During an interview on 3/5/26, at 10:50 a.m. Nursing Home Administrator (NHA) and DON were informed that the facility failed meet Resident R5 pain needs by failing to remove lymphedema socks. Resident R159 was admitted to the facility on [DATE]. Review of Resident R159 admit record indicated diagnosis of heart failure (occurs when the heart muscle doesn't pump blood as well as it should), unspecified fracture of T11-T12 vertebra, sequela (fracture of spine), and atrial fibrillation (an irregular and often very rapid heart rhythm.) During observations on 3/1/26, from 9:57 a.m. Resident R159 was heard:crying out in pain saying, I know there's a pill you can give me for this pain, I give you permission, please ask them to give me a pill I don't want to have to feel this pain something to put me to sleep. During an interview on 3/1/26, at 10:10 a.m. Resident R159 family member indicated that Resident R159 yells out, but not typically like this - and she came in with a broken spine earlier this week. During an interview on 3/1/26, at 10:13 a.m. LPN (Licensed Practical Nurse) Employee E12, indicated that she was the only nurse on the unit, she was passing medications on the other side of the nursing unit. LPN Employee E12 was told during shift change that Resident R159 was given pain medications and she checked the MAR, and she was able to give her pain medication. Review of Resident R159 physician orders indicated: HYDROmorphone HCl Oral Liquid 1MG/ML (Hydromorphone HCl)Give 1 mg sublingually every 1 hours asneeded for moderate to severe pain/SOB/ restlessness If allergic to morphineor renal failure.For moderate to severe (4-10) pain/shortness of breath/ restlessness.*If ineffective after two 1 mg doses, thencall hospice 800.720.2557 for additional OxyCODONE HCl Tablet 10 MGGive 10 mg by mouth every 4 hours asneeded for Pain-Start Date-02/26/2026 1743 LORazepam Oral Tablet 0.5 MG(Lorazepam)Give 0.5 mg by mouth every 4 hours asneeded for terminalrestlessness/anxiety/shortness of breath*If ineffective after two 0.5 mg doses,then call hospice 800.720.2557 foradditional orders.-Start Date-02/26/2026 1749 OxyCODONE HCl Tablet 10 MGGive 10 mg by mouth every 4 hours asneeded for Pain-Start Date-02/26/2026 1743 Review of Resident R159 MAR for February 2026 indicated: Hydromorphone HCI Oral Liquid 1 MG/ML was last given at 2/28/26, at 2:44 p.m. Lorazepam Oral Tablet 0.5 MG not given on 2/28/26.Oxycodone HCI Tablet 10 MG last given at 7:38 a.m. During an interview on 3/1/26, LPN Employee E12, confirmed Resident R159 was in need of pain medication and pain medication could be given, and that during report (update on residents during shift change) previous staff indicated that pain medications were given to Resident R159. During an interview on 3/5/26, at 10:57 a.m. NHA and DON were informed that the facility failed to meet Resident R159 pain needs. 28 Pa. Code 211.10(c ) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility documentation, resident and staff interviews it was determined that the facility failed to observe resident rights for four of four residents.Findings include: Review of facility policy Resident Rights dated 1/1/26, indicated: Respect and Dignity - The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Review of facility documentation Resident Council Minutes dated 9/22/25, indicated: Call bells DON told group to re- hit call bell if staff doesn't come back timely. During a resident group interview 3/2/26, at 11:20 a.m. residents were asked about the process for call bell's and how they are answered. Residents indicated that when they hit the call bell staff will come in and ask what they need and turn off the call bell. When asked if the resident needs have been met, they said it depends on what they need and if they need to get another staff person. When asked if the staff leave the call bell on till they see if they can meet the need the residents indicated no- they turn off the call bell and then try to meet the need. Residents were asked about the call light staying on till the staff know if they can meet the residents need - residents indicated that would be amazing if the call light could stay on till the need is met. During an interview on 3/5/26, 10:48 a.m. approximately with Nursing Home Administrator (NHA) and Director of Nursing (DON) indicated that the understanding of 9/22/25, resident council meeting and how the staff respond to call bell's is to come in turn off the call light and find out the resident needs. During an interview NHA and DON indicated that they were unclear on when the call bell light would get turned off. During an interview on 3/5/26, at 10:57 a.m. NHA and DON were informed that the facility failed to observe resident right s for four of four residents. 28 Pa. Code: 201.29(a) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1). Findings include: Review of the facility Certified Nursing Assistant job description indicated The Certified Nursing Assistant assists the licensed nursing staff by providing direct resident care related to activities of daily living. Communicates observations and findings to the Charge Nurse. Review of the facility policy Incident and Accidents last reviewed 1/2/25, indicated injuries will be assesses by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. Review of Employee counseling reports dated 11/17/25, indicated two Nurse Aids (NA) were re-educated on residents that have a fall will require an evaluation from a Registered Nurse (RN) prior to assisting that resident into a bed or chair. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine). Interview completed on 12/20/25, at 11:25 a.m. upon asking Resident R1 concerning a fall that occurred in November he stated I was getting ready for bed, I used a walker, I stood up grabbed my walker went to pivot and I just kind of slumped down, the aid was by me, I went down slow not hard, just slowly on my left side she made sure I was alright and went and got another aide they used the lift to get me back in bed. Review of facility investigative report and nursing notes on 12/20/25, indicated Resident R1 had a fall on 11/15/25, Resident R1 was returned to bed utilizing a mechanical lift by two NA's the notes failed to include notification to the Registered Nurse (RN) or practitioner for assessment of injury prior to returning Resident R1 to bed. Interview completed on 12/30/25, at 12:40 p.m. the Director of Nursing confirmed that the facility failed to make certain that residents were provided appropriate treatment and care by failing to assess a resident after a fall for one of four residents (Resident R1). 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (c)(d) Resident Care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on facility policy, clinical record review, and interview, the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter (a thin, flexible tube inserted into the bladder through a small hole in the lower belly to drain urine) and balloon inflation amount (secures catheter to bladder) for one of three residents (Resident R1).Findings include: Review of the facility policy Indwelling Catheter Use and Removal last reviewed 1/2/25, indicated the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 9/17/25, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), heart failure (the heart doesn't pump the way it should) and obstructive uropathy (restricts flow of urine). Section H0100 indicated indwelling foley catheter use. Review of Resident R1's physician order dated 9/30/25, indicated to change suprapubic catheter every four weeks the order failed to include specifications for size and balloon inflation amount for the suprapubic catheter. Review of Resident R1's care plan with revision on 12/18/25, indicated suprapubic catheter use and failed to include specifications for size and balloon inflation amount for the suprapubic catheter. Interview completed on 12/30/25, the Director of nursing confirmed the facility failed to have a physician order and care plan with specifications relating to size of suprapubic catheter and balloon inflation amount for one of three residents (Resident R1). 28 Pa. Code 201. 18(b)(1) Management.28 Pa code:211.10(c)(d) Resident care policies.28 Pa Code:211.12(c)(d)(1)(2)(5) Nursing services .

Based on manufacturer's instructions, clinical record reviews, and staff interviews it was determined that the facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for a resident with a Life Vest (a wearable defibrillator designed to protect residents from sudden cardiac death), and placed two of two residents in immediate jeopardy in which health and safety were impacted (Resident R314, and R49). Findings include: Review of the [NAME] Life Vest Patient Manual updated 2021, indicated the following: Wear all day and all night Life Vest slides on and off like a backpack. If the garment fits loosely, call [NAME] (manufacturer). The garment should be snug against the skin. Remove Life Vest to bathe, shower, or change the garment, Turn on Life Vest by inserting the battery. Always have the garment on before inserting the battery. Every 24 hours, change and recharge the batteries. There are two batteries. Always charge one while using the other. Place the charger in a safe place where it can be plugged in. Battery should slide in easily. Do not force the battery into the monitor. Practice changing the battery. Act quickly for siren alerts. Press the response buttons. This alert signals that Life Vest has detected a life -threatening rapid heart rhythm. Only the patient should press the response button. If a treatment is received by the Life Vest, leave the Life Vest on and call the doctor. Call [NAME] for a new electrode belt, and check display for any messages and take action. Read the display for [NAME] alerts and follow the instructions on the screen. When connecting and disconnecting the electrode belt be careful not to bend the pins. Remove the battery from the monitor before you remove the garment. Remove the electrode belt from the garment and insert it into a clean garment. Make sure the silver sides of the therapy pads (with the green label) face the mesh of the pocket. Snap the pockets closed. Position and secure the vibration box to the garment. Attach the round electrodes to the garment. Match the colors on the backs of the electrodes to the colors on the garment. Electrodes and therapy pads should press against bare skin. The mesh fabric pockets, and silver side of the therapy pads (with green labels) MUST TOUCH BODY for the device to work properly. Do not put the monitor, electrode belt, battery or charger in water; do not get components wet. Call [NAME] immediately if a Call for Service- Message Code 102 appears on the Life Vest screen. A replacement device will be provided within 24 hours from your notification to [NAME]. Wash the garment every 1-2 days. Do not use bleach or fabric softener. If prompted to download data, follow the instructions to do so. Review of Resident R314's clinical record revealed a Printable Discharge Form dated 2/12/25, that included correspondence between the facility and the discharging hospital, in which the hospital had documented, I was just told the patient has a life vest, she has it here. Will that be, okay? On 2/12/25, at 10:53 a.m. the facility responded, that is fine. Resident was accepted to facility and admitted later that day. Review of the clinical record indicated Resident R314 was admitted to the facility on [DATE]. Review of Resident R314's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. During Resident R314's interview on 2/24/25, at 11:15 a.m. a charging station for Life Vest batteries was observed on the window ledge and resident confirmed that she was wearing a Life Vest. During an interview on 2/24/25, at 12:10 p.m. Nurse Aide (NA) Employee E3 stated, I'm not sure what a Life Vest is. If I'd see it maybe I'd know. During an interview on 2/24/25, at 12:15 p.m. NA Employee E4 stated, She came with it. The resident educated me on it. During an interview on 2/24/25, at 12:30 p.m. Licensed Practical Nurse (LPN) Employee E5 stated, This is the first time I've worked in this hallway. I've taken care of them before in the past. Nobody has educated me about Resident R314's Life Vest. We usually don't take Life Vest residents but sometimes they sneak in. During an interview on 2/24/25, at 12:45 p.m. Registered Nurse (RN) Employee E6 stated, What I recall is that you just have to keep the battery charged up, I think daily. When asked what the alarms on the Life Vest meant, RN Employee E6 stated, What alarms, I don't know. When asked if the NA are allowed to shower the resident, RN Employee E6 stated, I don't think so. When asked if staff are allowed to turn off the alarms, RN Employee E6 stated, I believe you can, you just have to go back and see what its saying. Review of Resident R314's care plan on 2/24/25, at 12:50 p.m. failed to reveal instructions for care and operation of Resident R314's Life Vest. Review of Resident R314's current orders on 2/24/25, at 12:55 p.m. failed to reveal a physician order for a Life Vest. Review of Resident R49's clinical record revealed a Printable Discharge Form dated 2/6/25, that included correspondence between the facility and the discharging hospital, that stated that Resident R49 will be getting a Life Vest on discharge. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS dated [DATE], indicated diagnoses of high blood pressure, septicemia (an infection of the blood), and heart failure. Review of Resident R49's clinical record revealed a Nursing Progress note dated 2/10/25, that stated Life Vest intact. Review of Resident R49's clinical record conducted on 2/24/25, at 12:59 p.m. did not include orders, or care plan for a Life Vest. During an observation and interview on 2/24/25, at 2:03 p.m. in Resident R49's room, a charging station for Life Vest batteries was noted to be on the window ledge, which Resident R49 confirmed, and that he was indeed wearing a Life Vest which he had upon admission to the facility. During an interview on 2/24/25, at 2:11 p.m. NA Employee E10 stated that she has been educated on Life Vests before But not here. At my other job. During an interview on 2/24/25, at 2:13 p.m. RN Employee E11 stated that she did not receive any type of education on the safety and operation of the Life Vest. During an interview on 2/24/25, at 2:17 p.m. LPN Employee E12 stated that she had not received education on the Life Vest for Resident R49. During an interview on 2/24/25, at 2:20 p.m. NA Employee E13 stated that she was assigned to Resident R49 that day. When State Agency (SA) asked NA Employee E13 if she was aware that Resident R49 had a Life Vest, she replied A what?, and indicated that she was unaware of what that meant. When SA asked her if she was aware if Resident R49 could remove the Life Vest she replied That's information I wouldn't know. That would go to the nurses, not me. On 2/24/25, at 3:42 p.m. the Nursing Home Administrator (NHA) was made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, that placed two residents (Resident R314, and R49) in immediate jeopardy in which health and safety were impacted, and a corrective action plan was requested. During an interview on 2/24/25, at 3:42 p.m. the Director of Nursing (DON) stated We identified a second Life Vest that we didn't even know we had. The hospital just sends them to us and doesn't notify us. On 2/24/25, at 5:49 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate Action: - Clinical staff will complete education on the care and operation of Life Vests by 2/25/25, at 12:00 p.m. and before they work their next shift, that includes but is not limited to what the different alarms mean, the dangers of electrical shock, the care of the batteries, the care of the garment for laundering, and special needs for bathing. - The facility will demonstrate competency of all clinical staff through completion of a test following the education. Testing will be completed by 2/25/25, at 12:00 p.m. and before staff work their next shift. - A resident centered comprehensive care plan outlining the care of Resident R314, and R49 related to the Life Vest has been completed. - A care plan addressing the Life Vest, and the management of the Life Vest has been completed for Resident R314, and R49. - The facility obtained physician orders for the implementation of the Life Vest. - Clinical staff will be educated on the policies and procedures related to the use of the Life Vest and education will be confirmed by 2/25/25, at 12:00 p.m. and prior to staff working their next shift. Residents: - Resident R314's physician's orders and care plan were updated. - Resident R49's physician's orders and care plan were updated. System Correction: - The facility will produce a policy related to the Life Vest and will provide in an education to staff by 2/25/25, at 12:00 p.m. and prior to the start of their next shift. - The facility will provide a policy/procedure related to the admission of residents with anticipated equipment needs that will be provided to clinical staff and admissions team by 2/25/25, at 12:00 p.m. and prior to the start of their next shift. Monitoring: - Audits will be conducted of five clinical staff for one day beginning 2/25/25 to demonstrate competency of caring for a resident with a Life Vest. - Audits will continue to include five staff weekly to demonstrate competency of caring for a resident with a Life Vest for 2 weeks or until substantial compliance is achieved. - Education and initial audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation in a meeting conducted on 2/25/25. During an interview on 2/25/25, at 10:10 a.m. NA Employee E21 verified that she had received education on the Life Vest and stated, I never worked with one before, so it was helpful. During an interview on 2/25/25, at 10:12 a.m. RN Employee E22 also verified that she had received education on the Life Vest and stated that it was her first time that the facility had educated her on the topic. During an interview on 2/25/25, at 10:16 a.m. NA Employee E23 verified that she received education on the Life Vest and added Life Vest is all new to me. During an interview on 2/25/25, at 10:17 a.m. NA Employee E13 verified that she had received education on the Life Vest and stated I didn't know anything about it (prior to receiving the education). These are things that we should know. During a clinical record review on 2/25/25, at 10:45 a.m. Resident R314, and R49 had physician orders and care plans for Life Vest. Review of facility documents on 2/25/25, revealed that the facility had 136 clinical employees and that 131 had received Life Vest education. The remaining employees were to receive their education prior to the start of their next shift. 124 employees had received education on Life Vest and had been administered a written test to verify their knowledge. The remaining employees will take the test prior to the start of their next shift. During employee interviews on 2/25/25, from 10:05 a.m. through 1:30 p.m. 29 employees confirmed they had received education on the safe care, operation, and policies of the Life Vest as stated above. 26 of these employees had also completed a written test on Life Vest prior to the start of their next shift. Three employees verified that they had received the education at home but were to take the written test when they came into the facility prior to the start of their next shift. Review of facility documents on 2/25/25, verified that a policy was produced for Life Vest and that policy was reviewed for the admission process of residents with anticipated equipment needs. Review of facility documents on 2/25/25, verified that audits were conducted for five clinical staff members to demonstrate competency of caring for a resident with a Life Vest. The Immediate Jeopardy was lifted on 2/25/25, at 1:49 p.m. when the action plan was verified. During an interview on 2/25/25, at 1:50 p.m. the NHA confirmed that the facility failed to ensure that nursing staff have the specific competencies, and skill sets necessary to provide care for a resident with a Life Vest, and placed two residents in immediate jeopardy in which health and safety were impacted (Resident R314, and R49). 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(a)(b)(1)(e)(1) Management. 28 Pa Code 201.29(a)Resident rights. 28 Pa Code 211.5(f) Clinical records. 28 Pa. Code: 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(2)(5) Nursing services.

Based on review of observations and staff interview, it was determined that the facility failed to provide a dignified dining experience for one of three unit dining rooms observed. (Carondelet Resident R14), and failed to protect and value residents' private space ([NAME] Resident R110, R215, and Fontbonne Resident R8) Findings include: Review of the facility policy Resident Rights dated 1/2/25, indicated that residents have the right to be treated with respect and dignity. During an observation of the Carondelet dining room on 2/24/25, at 11:54 p.m. it was revealed that Resident R14 was being assisted with lunch. Employee E19 was standing beside Resident R14 while feeding her. During an interview on 2/24/25, at 12:25 p.m. Employee E19 confirmed the facility failed to provide a dignified dining experience for Resident R14. During an observation on [NAME] Unit on 2/24/25, at 12:09 p.m. Nurse Aide (NA) Employee E20 was seen entering Resident 110's room without knocking or requesting permission to enter. During an observation on [NAME] Unit on 2/24/25, at 12:11 p.m. NA Employee E20 was seen entering Resident 215's room without knocking or requesting permission to enter. During an interview on 2/24/25, at 12:11 p.m. NA Employee E20 confirmed that she failed to knock prior to entering Resident R110, and R215's rooms which failed to protect and value the residents' private space. During an observation on Fontbonne Unit on 2/26/25, at 1:28 p.m. Licensed Practical Nurse (LPN) Employee E2 was performing a wound dressing change and failed to close the door for privacy for Resident R8. During an interview on 2/26/25, at 2:05 p.m. LPN Employee E2 confirmed that she failed to close the door to provide privacy during a wound dressing change for Resident R8. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. 28 Pa. Code: 201.29(a)Resident Rights.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents sampled with facility-initiated transfers (Residents R29, R70, R75, Closed Resident Record CR265, and Closed Resident Record CR266). Findings include: Review of facility policy Transfer and Discharge (Including AMA) dated 1/2/25, indicated for a transfer to another provider, for any reason, the following must be provided to the receiving provider: contact information of the practitioner who was responsible for the care of the resident, resident representative information, advance directive information, all other information necessary to meet the resident's needs, all special instructions and/or precautions for ongoing care, the resident's comprehensive care plan, and all other information necessary to meet the resident's needs. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated diagnoses of atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly, urinary tract infection and bacteremia (bacteria in your blood). Review of Resident R29's clinical record indicated that the resident was transferred to the hospital on 2/14/25. Review of Resident R29's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated diagnoses which included sepsis (condition that occurs when the body's immune system overreacts to an infection), bacterial pneumonia and dysphagia (swallowing difficulties). Review of Resident R70's clinical record indicated that the resident was transferred to the hospital on [DATE]. Review of Resident R70's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's MDS dated [DATE], indicated diagnoses of high blood pressure, Gastroesophageal Reflux Disease (GERD - when stomach acid frequently flows back into the esophagus), and hyperlipidemia (high levels of fat in the blood). Review of Resident R75's clinical record indicated that the resident was transferred to the hospital on 1/13/25. Review of Resident R75's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Closed Resident Record CR265 was admitted to the facility on [DATE]. Review of Closed Resident Record CR265's MDS dated [DATE], indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and fusion of spine, lumbar region. Review of Closed Resident Record CR265's clinical record indicated that the resident was transferred to the hospital on 1/9/25. Review of Closed Resident Record CR265's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of the clinical record indicated Closed Resident Record CR266 was admitted to the facility on [DATE]. Review of Closed Resident Record CR266's MDS dated [DATE], indicated diagnoses of Peripheral Vascular Disease, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (high levels of fat in the blood). Review of Closed Resident Record CR266's clinical record indicated that the resident was transferred to the hospital on [DATE]. Review of Closed Resident Record CR266's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. During an interview on 2/28/25, at 11:23 a.m. Corporate Clinical Coordinator Employee E7 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five of five residents as required. 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of five resident hospital transfers (Residents R29, R70, R75, Closed Resident Record CR265 and Closed Resident Record CR266). Findings include: Review of facility policy Bed Hold Policy dated 1/2/25, indicated the facility will have a process in place to ensure residents and/or their representatives are made aware of the facility's bed-hold policy and reserve bed payment policy well in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated diagnoses of atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly, urinary tract infection, and bacteremia (bacteria in your blood). Review of Resident R29's clinical record indicated that the resident was transferred to the hospital on 2/14/25 and returned to the facility on 2/21/25. Review of Resident R29's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/14/25. Review of the clinical record indicated Resident R70 was admitted to the facility on [DATE]. Review of Resident R70's MDS dated [DATE], indicated diagnoses which included sepsis (condition that occurs when the body's immune system overreacts to an infection), bacterial pneumonia and dysphagia (swallowing difficulties). Review of Resident R70's clinical record indicated that the resident was transferred to the hospital on [DATE] and returned to the facility on 1/13/25. Review of Resident R70's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's MDS dated [DATE], indicated diagnoses of high blood pressure, Gastroesophageal Reflux Disease (GERD - when stomach acid frequently flows back into the esophagus), and hyperlipidemia (high levels of fat in the blood). Review of Resident R75's clinical record indicated that the resident was transferred to the hospital on 1/13/25 and returned to the facility on 1/21/25. Review of Resident R75's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/13/25. Review of the clinical record indicated Closed Resident Record CR265 was admitted to the facility on [DATE]. Review of Closed Resident Record CR265's MDS dated [DATE], indicated diagnoses of high blood pressure, Peripheral Vascular Disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and fusion of spine, lumbar region. Review of Closed Resident Record CR265's clinical record indicated that the resident was transferred to the hospital on 1/9/25 and did not return to the facility. Review of Closed Resident Record CR265's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/9/25. Review of the clinical record indicated Closed Resident Record CR266 was admitted to the facility on [DATE]. Review of Closed Resident Record CR266's MDS dated [DATE], indicated diagnoses of Peripheral Vascular Disease, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and hyperlipidemia (high levels of fat in the blood). Review of Closed Resident Record CR266's clinical record indicated that the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Closed Resident Record CR266's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on [DATE]. During an interview on 2/28/25, at 11:23 a.m. Corporate Clinical Coordinator Employee E7 confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for five of five resident hospital transfers as required. 28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for three of ten residents (Resident R49, R228, and R314). Findings include: Review of facility's policy Care Plan Revisions Upon Status Change dated 1/2/25, indicated the facility is to provide a process for reviewing and revising the care plan. Care plans may be modified as needed by a staff member. The care plan will be updated with the new or modified interventions. Review of the clinical record revealed that Resident R49 was admitted to the facility on [DATE]. Review of Resident R49's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/16/25, indicated diagnoses of high blood pressure, septicemia (an infection of the blood), heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Resident R49's care plan dated 2/9/25, failed to reveal a care plan with goals and interventions for a Life Vest. During an interview on 2/24/25, at 3:42 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Resident R49. Review of the clinical record revealed that Resident R228 was admitted to the facility on [DATE]. Review of Resident R228's MDS dated [DATE], indicated diagnoses of fractured knee joint, fractured shin, and history of falling. Review of resident R228's clinical record revealed a physician's order dated 2/16/25, for gluten (a protein found in wheat, rye, and barley) free, and lactose (a natural sugar found in cows' milk) restricted diet. Review of Resident R228's care plan dated 2/16/25, failed to reveal a person-centered care plan that contained the above diet order. During an interview on 2/27/25, at 9:38 a.m. Registered Dietitian Employee E24 confirmed that the facility failed to develop a person-centered care plan for Resident R228's diet order. Review of the clinical record indicated Resident R314 was admitted to the facility on [DATE]. Review of Resident R314's MDS dated [DATE], indicated diagnoses of heart failure, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. During Resident R314's interview on 2/24/25, at 11:15 a.m. a charging station for Life Vest batteries was observed on the window ledge and resident confirmed that she was wearing a Life Vest. Review of Resident R314's care plan, dated on 2/12/25, failed to reveal a care plan with goals and interventions for a Life Vest. During an interview on 2/24/25, at 3:42 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Resident R314. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility neglected to provide the appropriate device to prevent a fall while staff was transporting a resident in a wheelchair, that resulted in actual harm of a head injury for one of four residents (Resident R1). Findings include: Review of the facility Abuse, Neglect, and Exploitation policy dated 10/17/22, indicated it is the facility policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Review of the facility Safe resident handling/Transfers policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents. Review of the Nurse Aide (NA) Job Description undated, indicated the certified nurse aide assists by providing direct resident care related to activities of daily living, including ambulating, transferring, and turning and reposition. Review of the Neighborhood Assistant job description dated 9/22/21, indicated the neighborhood assistant provides dining assistance and performs activities with residents, outside of mealtimes, and appropriately documents resident's participation. It was indicated the neighborhood assistant commits to ethical standards and complies with code of conduct, state and federal regulations, accreditation standards, and the facility's policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 9/15/23, revealed diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anemia (a deficiency of healthy red blood cells in blood.). Section G: Functional Status indicated Resident R1 utilized a wheelchair for mobility. Review of the SBAR Event facility documentation dated 10/12/23, at 6:15 p.m. entered by RN, Employee E6 indicated Neighborhood Assistant, Employee E1 assisted Resident R1 in her wheelchair without leg rests. Resident R1 was unable to hold her foot up and her leg went under the wheelchair, and she fell forward and hit her head on the floor face first. It was documented that possible and/or actual contributing factors include unsafe transfer techniques. It was indicated the resident sustained a hematoma to the left side of her head. Recommendations included to reeducate staff about leg rest use. Review of the facility's incident report dated 10/12/23, for Resident R1 indicated the resident sustained a hematoma (solid swelling of clotted blood within the tissues) to the top of her scalp from being pushed in wheelchair without leg rests. Review of a physician's note signed 10/12/23, at 5:40 p.m. indicated Resident R1 was evaluated via video call for a fall with injury. The note stated, the resident had a fall with injury and had a small hematoma on the left side of scalp. The note further indicated to monitor with neurological checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) per protocol and notify the physician of any changes in condition. Review of a physician's order dated 10/12/23, indicated to transfer Resident R1 to the hospital for evaluation from fall for evaluation. Review of Neighborhood Assistant, Employee E5's witness statement dated 10/13/23, indicated the DON and NHA called Employee E5 at home to obtain a statement. It was indicated Neighborhood Assistant Employee E5 noticed Resident R1's call light cord was out of the wall and noticed Resident R1 was wheeling toward the door with the call light tangled around her wheelchair. It was indicated that Resident R1 asked Neighborhood Assistant, Employee E5 to take her to an activity. As she pushed her, Resident R1 fell forward in the chair. When the DON asked Neighborhood Assistant, Employee E5 was she aware she was not supposed to push people in wheelchairs, she responded, yes. When the DON asked Neighborhood Assistant, Employee E5 if she was aware that she shouldn't transport people without leg rests, she responded yes. Review of Resident R1's witness statement dated 10/13/23, stated she had the call light wrapped and tangled in her wheelchair and couldn't get out of the room. It was indicated Neighborhood Assistant, Employee E5 helped her get the call light untangled from her wheelchair and she asked her to push her. She stated as Neighborhood Assistant, Employee E5 was pushing her down the hall and she fell out of the chair. She stated her leg got caught under the chair. She stated she felt fine at first, but later got a headache and was sent to the hospital. Review of NA, Employee E7's witness statement dated 10/13/23, stated Neighborhood Assistant, Employee E5 was in the nutrition center and indicated that the call light system was pulled from the wall in Resident R1's room. It was indicated Neighborhood Assistant, Employee E5 went to untangle the call light from the resident and assisted her out of the room to activities. It was stated she was pushing her without leg rests and the resident was witnessed to throw her body forward out of chair. NA, Employee E7 indicated she witnessed the resident fall face forward onto the floor. The resident was transported back to bed and later in the shift the resident was transported to the hospital. Review of RN, Employee E6's witness statement dated 10/13/23, stated Resident R1 was in her room preparing to attend activities on the unit. It was indicated the resident was on the far side of room and had call light wrapped around wheelchair causing the call light to unplug from the wall. Neighborhood Assistant, Employee E5 untangled the call light from the wheelchair and proceeded to assist resident to activities. The resident was pushed without leg rests. The resident was holding her legs up at first and then her leg got trapped underneath of the wheelchair causing the resident to catapult out of chair. RN, Employee E6 witnessed the resident fall face forward onto the floor and stated she was unable to prevent fall, and at time of the fall the resident was noted to have been leaning on the right side of the chair and slightly forward. The resident was immediately assessed for injury and a small hematoma (a solid swelling of clotted blood within the tissues) was noted to the left side of her head. The physician was contacted, and a video call was completed. Orders for neurological checks and a physical therapy and occupational consult for wheelchair positioning were obtained. Later the resident complained of a headache and was sent out for further evaluation. Review of Resident R1's census report indicated the resident was on a hospital leave on 10/12/23 and returned to the facility on [DATE]. Review of Resident R1's hospital discharge record dated 10/12/23, indicated Resident R1 sustained a left lateral scalp soft tissue swelling and hematoma following a fall. No new orders were received, the resident was to follow-up with her physician. During an interview on 10/26/23, at 10:44 a.m. Registered Nurse (RN), Employee E1 stated leg rests must always be applied when transporting a resident on and off the unit. It was indicated if a resident can self-propel in the wheelchair, leg rests are not needed. RN, Employee E1 stated if the leg rests were removed, they must be placed back on prior to moving the resident. It was stated everyone knows that leg rests are always needed when pushing someone around, and we also educate families on use of leg rests. During an interview on 10/26/23, at 10:49 a.m. Nurse Aide (NA), Employee E2 stated leg rests are used anytime a resident is transported in a wheelchair. If leg rests are not on the wheelchair, it was stated staff should assess the room, however they are typically kept on the back of the chair in a pouch. During an interview on 10/26/23, at 10:59 a.m. NA, Employee E3 stated legs rest must be on at all times when a resident is pushed in a wheelchair. During an interview on 10/26/23, at 11:01 a.m. RN, Employee E4 stated legs rests must be applied to a resident's wheelchair before they are moved. During an interview on 10/26/23, at 11:07 a.m. Neighborhood Assistant, Employee E5 stated the call alert system was beeping and it indicated Resident R1's call bell cord was out of the wall. When Neighborhood Assistant, Employee E5 went to see what was going on, she indicated Resident R1 was sitting in the doorway in her wheelchair trying to get out. She stated she didn't realize the call bell was wrapped around her wheelchair, so she unwrapped it and plugged it back in the wall. It was indicated Resident R1 asked Neighborhood Assistant, Employee E5 to take her down the hallway. Neighborhood assistant, Employee E5 stated she forgot to look down, I just assumed, I didn't even think to look down and as she was pushing her down the hallway, Resident R1 fell out of the chair and hit her face on the floor. Neighborhood Assistant, Employee E5 stated she was active on the Nurse Aide Registry and sometime in September, she was told she had to either become Certified Nurse Aide or shower aide. During an interview on 10/26/23, at 11:45 a.m. RN, Employee E6 stated she seen Neighborhood Assistant, Employee E1 was pushing Resident R1 down the hall without leg rests. It was indicated the resident was holding her legs ups, then one of her legs dropped and she fell forward hitting her face first. RN, Employee E6 stated she immediately went to assess the resident and called a physician on video call. She stated the resident sustained a hematoma to the left side of her head and originally had no complaints. It was indicated the doctor ordered the resident to stay in the facility and to perform neurological checks as protocol and contact a physician if Resident R1 had a change in condition. RN, Employee E6 stated shortly after the resident complained of increased head pain and was sent to the emergency room for further evaluation. Review of Neighborhood Assistant, Employee E5 employee file indicated, Neighborhood Assistant, Employee E5 was hired as a Neighborhood Assistant on 9/22/21. The job description for a Neighborhood Assistant was signed on 9/22/21. A further review of the employee's file failed to reveal a Nurse Aide job description signed and dated. During an interview on 10/26/23, at 11:20 a.m. with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON), it was indicated Neighborhood Assistant, Employee E5 should have not pushed Resident R1 in her wheelchair because she is light duty. The NHA confirmed Neighborhood Assistant, Employee E1 pushed Resident R1 without leg rests which caused the resident to fall forward and sustain a head injury and had to be sent to the hospital for further evaluation. The NHA stated Neighborhood Assistant, Employee E5 had an active nurse aide license and assisted staff by helping shower residents. It was stated if a resident could walk to the shower, Neighborhood Assistant, Employee E5 may walk with them, however if they were in a wheelchair, she had to have another staff member transport. During an interview on 10/26/23, at 1:30 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility neglected to provide leg rest for Resident R1 to prevent a fall while staff was transporting in a wheelchair, which resulted in actual harm of a head injury to Resident R1. 28 Pa Code: 201.18 (e)(1)(2) Management 28 Pa Code: 201.29 (a )(c)(d) Resident Rights 28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, facility documents, and resident and staff interviews, it was determined that the facility failed to provide appropriate assistance to prevent falls, resulting in actual harm of a head injury for one of four residents reviewed (Resident R1). Findings include: Review of the facility Safe resident handling/Transfers policy dated 10/17/22, last reviewed 12/31/22, indicated it is the facility policy to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the residents. Review of the Nurse Aide (NA) Job Description undated, indicated the certified nurse aide assists by providing direct resident care related to activities of daily living, including ambulating, transferring, and turning and reposition. Review of the Neighborhood Assistant job description dated 9/22/21, indicated the neighborhood assistant provides dining assistance and performs activities with residents, outside of mealtimes, and appropriately documents resident's participation. It was indicated the neighborhood assistant commits to ethical standards and complies with code of conduct, state and federal regulations, accreditation standards, and the facility's policies and procedures. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident's care needs) dated 9/15/23, revealed diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and anemia (a deficiency of healthy red blood cells in blood.). Section G: Functional Status indicated Resident R1 utilized a wheelchair for mobility. Review of the SBAR Event facility documentation dated 10/12/23, at 6:15 p.m. entered by RN, Employee E6 indicated Neighborhood Assistant, Employee E1 assisted Resident R1 in her wheelchair without leg rests. Resident R1 was unable to hold her foot up and her leg went under the wheelchair, and she fell forward and hit her head on the floor face first. It was documented that possible and/or actual contributing factors include unsafe transfer techniques. It was indicated the resident sustained a hematoma to the left side of her head. Recommendations included to reeducate staff about leg rest use. Review of the facility's incident report dated 10/12/23, for Resident R1 indicated the resident sustained a hematoma (a solid swelling of clotted blood within the tissues) to the top of her scalp from being pushed in wheelchair without leg rests. Review of a physician's note dated 10/12/23, at 5:40 p.m. indicated Resident R1 was evaluated via video call for a fall with injury. The note stated, the resident had a fall with injury and had a small hematoma on the left side of scalp. The note further indicated to monitor with neurological checks (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness) per protocol and notify the physician of any changes in condition. Review of a physician's order dated 10/12/23, at 7:11 p.m. indicated to transfer Resident R1 to the hospital for evaluation from a fall. A review of the resident's clinical record failed to include documentation of the change in condition that occurred. Review of Resident R1's witness statement dated 10/13/23, stated she had the call light wrapped and tangled in her wheelchair and couldn't get out of the room. It was indicated Neighborhood Assistant, Employee E5 helped her get the call light untangled from her wheelchair and she asked her to push her. She stated as Neighborhood Assistant, Employee E5 was pushing her down the hall, she fell out of the chair. She stated her leg got caught under the chair. She stated she felt fine at first, but later got a headache and was sent to the hospital. Review of NA, Employee E7's witness statement dated 10/13/23, stated Neighborhood Assistant, Employee E5 was in the nutrition center and indicated that the call light system was pulled from the wall in Resident R1's room. It was indicated Neighborhood Assistant, Employee E5 went to untangle the call light from the resident and assisted her out of the room to activities. It was stated she was pushing her without leg rests and the resident was witnessed to throw her body forward out of chair. NA, Employee E7 indicated she witnessed the resident fall face forward onto the floor. The resident was transported back to bed and later in the shift the resident was transported to the hospital. Review of RN, Employee E6's witness statement dated 10/13/23, stated Resident R1 was in her room preparing to attend activities on the unit. It was indicated the resident was on the far side of room and had call light wrapped around wheelchair causing the call light to unplug from the wall. Neighborhood Assistant, Employee E5 untangled the call light from the wheelchair and proceeded to assist resident to activities. The resident was pushed without leg rests. The resident was holding her legs up at first and then her leg got trapped underneath of the wheelchair causing the resident to catapult out of chair. RN, Employee E6 witnessed the resident fall face forward onto the floor and stated she was unable to prevent fall, and at time of the fall the resident was noted to have been leaning on the right side of the chair and slightly forward. The resident was immediately assessed for injury and a small hematoma (a solid swelling of clotted blood within the tissues) was noted to the left side of her head. The physician was contacted, and a video call was completed. Orders for neurological checks and a physical therapy and occupational consult for wheelchair positioning were obtained. Later the resident complained of a headache and was sent out for further evaluation. Review of Resident R1's investigation report dated 10/13/23, indicated the Nursing Home Administrator (NHA) and Director of Nursing (DON) had a discussion with Neighborhood Assistant, Employee E5 regarding the incident that occurred with Resident R1 on 10/12/23. It was documented that Neighborhood Assistant, Employee E5 entered Resident R1's room and found her wheeling toward the door in her wheelchair with the call light on her wheelchair and pulled out of the wall. It was indicated Resident R1 wanted to go to an activity, so Neighborhood Assistant, Employee E5 pushed her in her wheelchair toward the activity and she didn't know what happened, but Resident R1 went forward out of the chair. The witness statement was typed and signed by the NHA. Review of Resident R1's census report indicated the resident was on a hospital leave on 10/12/23 and returned to the facility on [DATE]. Review of Resident R1's hospital discharge record dated 10/12/23, indicated Resident R1 had left lateral scalp soft tissue swelling and hematoma following a fall. No new orders were received, the resident was to follow up with her physician. During an interview on 10/26/23, at 10:44 a.m. Registered Nurse (RN), Employee E1 stated leg rests must always be applied when transporting a resident on and off the unit. It was indicated if a resident can self-propel in the wheelchair, leg rests are not needed. RN, Employee E1 stated if the leg rests were removed, they must be placed back on prior to moving the resident. It was stated everyone knows that leg rests are always needed when pushing someone around, and we also educate families on use of leg rests. During an interview on 10/26/23, at 10:49 a.m. Nurse Aide (NA), Employee E2 stated leg rests are used anytime a resident is transported in a wheelchair. If leg rests are not on the wheelchair, it was stated staff should assess the room, however they are typically kept on the back of the chair in a pouch. During an interview on 10/26/23, at 10:59 a.m. NA, Employee E3 stated legs rest must be on at all times when a resident is pushed in a wheelchair. During an interview on 10/26/23, at 11:01 a.m. RN, Employee E4 stated legs rests must be applied to a resident's wheelchair before they are moved. During an interview on 10/26/23, at 11:07 a.m. Neighborhood Assistant, Employee E5 stated the call alert system was beeping and it indicated Resident R1's call bell cord was out of the wall. When Neighborhood Assistant, Employee E5 went to see what was going on, she indicated Resident R1 was sitting in the doorway in her wheelchair trying to get out. She stated she didn't realize the call bell was wrapped around her wheelchair, so she unwrapped it and plugged it back in the wall. It was indicated Resident R1 asked Neighborhood Assistant, Employee E5 to take her down the hallway. Neighborhood assistant, Employee E5 stated she forgot to look down, I just assumed, I didn't even think to look down and as she was pushing her down the hallway she fell out of the chair and hit her face on the floor. Neighborhood Assistant, Employee E5 stated she was active on the Nurse Aide registry, and sometime in September, she was told she had to either become Certified Nurse Aide or shower aide, however she did not complete any retraining. During an interview on 10/26/23, at 11:45 a.m. RN, Employee E6 stated she seen Neighborhood Assistant, Employee E1 was pushing Resident R1 down the hall without leg rests. It was indicated the resident was holding her legs ups, then one of her legs dropped and she fell forward hitting her face first. RN, Employee E6 stated she immediately went to assess the resident and called a physician on video call. She stated the resident sustained a hematoma to the left side of her head and originally had no complaints. It was indicated the doctor ordered the resident to stay in the facility and to perform neurological checks as protocol and contact a physician if Resident R1 had a change in condition. RN, Employee E6 stated shortly after the resident complained of increased head pain and was sent to the emergency room for further evaluation. Review of Neighborhood Assistant, Employee E5 employee file indicated, Neighborhood Assistant, Employee E5 was hired as a Neighborhood Assistant on 9/22/21. The job description for a Neighborhood Assistant was signed on 9/22/21. A further review of the employee's file failed to reveal a Nurse Aide job description signed and dated. During an interview on 10/26/23, at 11:20 a.m. the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON), Employee E8 indicated Neighborhood Assistant, Employee E5 should have not pushed Resident R1 in her wheelchair because she is light duty. The NHA confirmed Neighborhood Assistant, Employee E1 pushed Resident R1 without leg rests which caused the resident to fall forward and sustain a head injury and had to be sent to the hospital for further evaluation. The NHA stated Neighborhood Assistant, Employee E5 had an active nurse aide license and assisted staff by helping shower residents. It was stated if a resident could walk to the shower, Neighborhood Assistant, Employee E5 may walk with them, however if they were in a wheelchair, she had to have another staff member do it. During an interview on 10/26/23, at 1:30 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility failed to provide appropriate supervision and devices to prevent falls, resulting in actual harm of a head injury for Resident R1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights

Based on review of facility policy, resident clinical record review, staff interviews, and family interview it was determined that the facility failed to provide care to prevent pressure ulcers, provide treatment and services necessary to promote healing and prevent infection of a pressure ulcer which all resulted in actual harm, the development of pressure ulcers and was a cause of death to one of five residents (Closed Record (CR) Resident R1). Findings include: Review of facility policy titled Wound Care Management Protocol last reviewed on 1/11/22, informed daily skin assessments are to be completed by the nurse and documented in the medical record when the patient has removable orthotic device or cast. Daily skin observations are completed each shift by Certified Nursing Assistants, documented in [the] medical record and verbally reported to [a] licensed nurse. Review of clinical record revealed Resident CR1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted with a (HKFA) hip/knee/foot/ankle orthotic brace to be worn for an inoperable femur fracture. Review of the MDS (Minimum Data Set - a federal mandatory periodic assessment of resident care needs) dated 4/15/22, indicated Resident CR1's BIMS (Brief Interview for Mental Status - an assessment to determine cognitive function) recorded a score of 15, indicating the resident was cognitively intact. Resident CR1 was diagnosed with orthopedic concerns, pressure ulcer risk, and had no unhealed pressure wounds, venous or arterial wounds, or other ulcer/wound/skin concerns. Review of discharge documentation from the acute care hospital dated 4/7/22, indicated that Resident CR1 did not have any skin break down upon discharge. Review of the Clinical Admission Evaluation dated 4/8/22, revealed that Resident CR1 was alert and oriented, continent of bowel and bladder, in need of peri care (cleaning of external genitalia and buttocks area) unable to move right and left lower extremities, impaired range of motion on one side, and the resident has a full plastic body cast on and is not to be removed until further notice. No outstanding bruising or abrasions are noted at this time. There are no incisions that can be seen at this time. Max assist of 2 for transfers. Review of the Braden Scale assessment (tool used to evaluate the possible risk of skin break down) dated 4/8/22, indicated that Resident CR1 scored 17 (score range from 9-23), indicating the resident was at risk for pressure ulcers. (A lower score indicates a higher risk for pressure ulcer development). Review of the Skin Observation Tool completed from 4/8/22 through 4/29/22, revealed no documented skin break down for Resident CR1. Review of the admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 4/8/22, indicated that Resident CR1 was at Risk of Impaired Skin Integrity related to decreased mobility included the goal to remain free of any new skin breakdown through next review. Interventions included float heels on Heelzup cushions (a cushion designed to suspend heels to eliminate pressure) when in bed, follow ordered lift strategies to decrease shearing force, monitor [food] intake daily, and pressure reducing cushion to chair. During an interview on 7/26/22, from 3:10 p.m. to 3:20 p.m. Registered Nurse Assessment Coordinator Employee E10 and Licensed Practical Nurse Resident Assessment Coordinator Employee E11 confirmed that Resident CR1 did not have any pressure wounds, venous or [CONDITION(S)] wounds, or other skin break down on admission. The care plan did not address care needs for resident orthotic brace and the care needed to prevent skin break down under the brace. Resident CR1's care plan failed to address the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 5/2/22, at 4:03 p.m. by RN Employee E3 indicated that Resident CR1's brace intact to right waist and leg. wound nurse notified of wound to left buttock. Review of Skilled Evaluation dated 5/2/22, at 3:39 a.m. by LPN Employee E12 indicated: Cardiovascular- Skin warm and pink with brisk capillary refill (< 3 seconds). No [CONDITION(S)] present. Skin- warm & dry, skin color WNL and turgor is normal. Currently taking skin antibiotics: No. Review of Skilled Evaluation dated 5/4/22, at 2:58 a.m. by RN Employee E9 indicated: Cardiovascular- Skin warm and pink with brisk capillary refill (< 3 seconds). No [CONDITION(S)] present. Right pedal pulse: +2 normal. Skin- warm & dry, skin color WNL and turgor is normal. Currently taking skin antibiotics: No. Left pedal pulse: +2 normal. Review of Skilled Evaluation dated 5/5/22, at 1:38 a.m. by LPN Employee E12 indicated: Cardiovascular- Skin warm and pink with brisk capillary refill (< 3 seconds). No [CONDITION(S)] present. Right pedal pulse: +2 normal. Left pedal pulse: +2 normal. Pacemaker: No. Skin- warm & dry, skin color WNL and turgor is normal. Currently taking skin antibiotics: No During an interview on 7/25/22, at 2:45 p.m. Registered Nurse Employee E3 reported that on 5/2/22, during the 3:00 p.m.-11:00 p.m. shift, two Nursing Assistants observed buttocks wound on Resident CR1 when providing incontinence care and reported the buttocks wound to Registered Nurse Employee E3. Registered Nurse Employee E3 observed a quarter size wound with a small black center and serosanguinous (yellowish fluid with small amounts of blood) drainage. Registered Nurse Employee E3 cleansed and dressed the wound and sent an email to the facility wound care nurse. Registered Nurse Employee E3 did not complete a wound assessment and did not document the findings from this interview. Review of a progress note dated 5/4/22, 1:16 p.m. by RN Employee E3 documented Resident CR1 alert and oriented lungs clear resp easy. right hip immobilizer intact foley patent draining clear medium yellow urine wound nurse in to assess buttocks. no c/o pain. Review of Skin and Wound Evaluation dated 5/4/22, indicated that Resident CR1 had a Stage 2 (partial thickness skin loss with exposed dermis-thick layer of living tissue under the skin) pressure wound that measured 2.0 x 5.7 x 0.1 cm (0.78 x 2.24 x 0.03). The evaluation note documented resident with full brace AAT (at all times), skin at risk for breakdown at all areas of contact. Open area at right lower back measures 2 x 5.7 x 0.1 (0.78 x 2.24 x 0.03). During an interview on 6/29/22, at 3:30 p.m. Wound Care Nurse Employee E2 reported observing the buttocks wound on 5/4/22. Wound Care Nurse Employee E2 reported the wound was ugly and knew treatment needed to start. Wound Care Nurse Employee E2 disclosed the buttocks wound couldn't develop into an unstageable wound without prior indication that a wound was developing. Wound Care Nurse Employee E2 disclosed if skin checks were conducted as documented in the treatment administration record, the wounds would have been noticed. During an interview on 7/1/22, at 10:03 a.m. Wound Physician Employee E1 reported being consulted when the wound was discovered and treatment began on 5/5/22. Review of Wound Physicians report dated 5/5/22, indicated that Resident CR1 was evaluated by Wound Physician Employee E1. The focused wound examination, Site 1, documented an unstageable (due to necrosis, death of body tissue) wound, 2.0 x 2.3 x 0.1 cm (0.78 x 0.91 x 0.03) of the right ischium full thickness. The wound was surgically debrided. The plan of care was to offload the wound, reposition the resident every 1-2 hours, and a low air mattress. Also, revealed Resident CR1, has a second wound, Site 2, as a Stage 2 pressure wound, 2.0 x 5.7 x 0.1 cm (0.78 x 2.24 x 0.03) of the right lower back partial thickness. The plan of care was to inform the orthopedic surgeon about the development of the wound and to evaluate for an alternative leg brace. Review of Wound Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily and as needed if soiled or dislodged every night shift and right ischium (buttocks) cleanse with NSS, apply [MEDICATION(S)], and cover with border gauze. Change daily and as needed if soiled or dislodged every night shift. Review of Wound Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Wound Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note dated 5/12/22, at 1:12 a.m. by LPN Employee E12 revealed Resident CR1: wears left waist and hip brace at all times. Resident CR1 indicated that dressing change was not performed. No dressings were in place. During an interview on 7/29/22, at 12:23 p.m. LPN Employee E12 stated Resident CR1 reported that dressings were not changed. LPN Employee E12, removed resident's brief and confirmed there was no dressing on the right buttocks wound. The brief was adhered to the wound and had to be loosened from the wound with a saline solution. Review of Wound Physicians report dated 5/19/22, revealed Resident CR1 wound Site 1 had deteriorated to 4.5 x 4.3 x 0.1 cm (1.77 x 1.69 x 0.03). The wound was surgically debrided. The Wound Physician Employee E1 documented Looks like the wound has become infected, most likely due to fecal incontinence contaminating it, a culture was taken of the purulent drainage, to tailor antibiotic management. The plan of care to offload the wound, reposition the resident, and the antibiotic [MEDICATION(S)] was prescribed for 10 days. Review of progress note dated 5/20/22, at 2:39 a.m. by LPN Employee E2 indicated size of wound has increased and will note on white board (manual communication board to relay information between staff). Review of Wound Physician report dated 5/26/22, revealed Resident CR1 was not seen due to hospitalization for wound deteriorated. During an interview on 6/29/22, at 3:50 p.m. Wound Care Nurse Employee E2 confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/29/22, at 4:45 p.m. Wound Care Nurse Employee E2 confirmed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident CR1's ADL (activities of daily living) Tasks and Intervention report documented for April 2022, revealed the resident did not receive bathing/showers twice a week (Sunday and Thursdays) on 4/10/22, 4/14/22, 4/21/22, and 4/28/22. Review of Resident CR1's ADL Tasks and Interventions report documented for May 2022, revealed the resident did not receive bathing/showers on 5/1/22, 5/5/22, 5/12/22, and 5/19/22. Review of Resident CR1's ADL Tasks and Interventions report documented for April 2022, revealed bed mobility (repositioning) did not occur on the day shift 4/11/22, 4/15/22, 4/17/22, 4/20/22, 4/23/22, 4/27/22, 4/28/22, and 4/29/22. On the evening shift bed mobility did not occur on 4/19/22. On the night shift bed mobility did not occur on 4/8/22, /12/22, 4/13/22, 4/17/22, 4/21/22, 4/22/22, 4/27/22, and 4/29/22. Review of Resident CR1's ADL Tasks and Interventions report documented for May 2022, revealed bed mobility did not occur on the day shift on 5/2/22, 5/4/22, 5/6/22, 5/7/22, 5/12/22, 5/13/22, 5/14/22, 5/17/22, 5/18/22, and 5/19/22. On the evening shift bed mobility did not occur on 5/10/22, 5/16/22, and 5/17/22. On the night shift bed mobility did not occur on 5/2/22, 5/4/22, 5/5/22, 5/7/22, 5/11/22, 5/12/22, and 5/13/22. Review of Resident CR1's ADL Tasks and Interventions report documented for April 2022, revealed the resident did not receive skin observations on the day shift on 4/11/22, 4/15/22, 4/17/22, 4/20/22, 4/23/22, 4/27/22, 4/28/22, and 4/29/22. On the evening shift on 4/19/22. On the night shift on 4/12/22, 4/13/22, 4/14/22, 4/17/22, 4/21/22, 4/22/21, 4/27/22, 4/29/22, and 4/30/22. Review of Resident CR1's ADL Tasks and Interventions report documented for May 2022, revealed the resident did not receive skin observations on the day shift on 5/2/22, 5/6/22, 5/7/22, 5/12/22, 5/13/22, 5/14/22, 5/17/22, 5/18/22, and 5/19/22. Review of Resident CR1's ADL Tasks and Interventions report documented for April 2022, revealed the resident did not receive toileting upon arising, before and after meals, at bedtime, and offered a toilet/bedpan with rounds on 10 p.m. - 6 a.m. shift and as needed on day shift on 4/11/22, 4/15/22, 4/17/22, 4/20/22, 4/23/22, 4/27/22, 4/28/22, and 4/29/22. On the evening shift on 4/8/22 and 4/19/22. On the night shift on 4/8/22, 4/12/22, 4/13/22, 4/17/22, 4/21/22, 4/22/22, 4/27/22, 4/29/22, and 4/30/22. Review of Resident CR1's ADL Tasks and Interventions report documented for May 2022, revealed the resident did not receive toileting upon arising, before and after meals, at bedtime, and offered a toilet/bedpan with rounds on 10 p.m. - 6 a.m. shift and as needed on day shift on the day shift on 5/2/22, 5/4/22, 5/6/22, 5/7/22, 5/12/22, 5/13/22, 5/14/22, 5/17/22, 5/18/22, and 5/19/22. On the evening shift on 5/10/22, 5/16/22, and 5/17/22. On the night shift on 5/2/22, 5/4/22, 5/5/22, 5/7/22, 5/11/22, 5/12/22, and 5/13/22. During an interview on 7/26/22, at 11:20 a.m. Nursing Assistant Employee E4 reported not removing Resident CR1's leg brace. Bed pan use was conducted around the leg brace. During an interview on 7/26/22, at 11:40 a.m. Nursing Assistant Employee E5 reported not removing Resident CR1's leg brace. Bed pan use was conducted around the leg brace. During an interview on 7/26/22, at 12:05 p.m. Nursing Assistant Employee E6 reported not to removing Resident CR1's leg brace. Bed pan use and bathing were conducted around the leg brace. During an interview on 7/26/22, at 12:27 p.m. Registered Nurse Employee E9 reported not removing Resident CR1's right leg brace to conduct skin checks as ordered and skin checks were conducted doing observations around the leg brace. During an interview on 7/27/22, at 10:52 a.m. Registered Nurse Employee E7 reported not removing Resident CR1's leg brace to conduct skin checks as ordered and skin checks were conducted doing observations around the leg brace. During an interview on 7/27/22, at 11:28 a.m. Licensed Practical Nurse Employee E12 reported not removing Resident CR1's leg brace to conduct skin checks as ordered and skin checks were conducted doing observations around the leg brace. During an interview on 7/27/22, at 12:08 a.m. Registered Nurse Employee E8 reported not removing Resident CR1's leg brace to conduct skin checks as ordered and skin checks were conducted doing observations around the leg brace. During an interview on 7/1/22, at 10:41 a.m. with Closed Record Resident Family 1 (CRRF1) reported noticing a wound on 4/22/22, on the buttocks of Resident CR1, the Wound Physician Employee E1 scraped the wound in the resident's room. CRRF1 reported Resident CR1 did not receive an air mattress until 5/20/22. CRRF1 reported staff would leave the resident on the bedpan, and the wound would be in the resident's waste. The wound was worsening, and on 5/21/22, CRRF1 insisted the resident be transferred to a local hospital. Review of the Resident CR1's death certificate confirmed the resident's date of death as 5/28/22. Primary cause of death was Multi-System Organ Failure, secondary cause of death was Infection of Right Ischial Pressure Ulcer. During an interview on 6/29/22, at 3:30 p.m. Wound Nurse Employee E2 confirmed the facility failed to provide care by doing physician ordered skin checks to prevent pressure ulcers, failed to follow wound physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pa. 28 Code: 201.18(b)(1) Management Pa 28 Code: 211.10(c)(d) Resident care policies Pa 28 Code 211.12(d)(1)(2)(3)(5) Nursing services