Every finding on record at Courtyard Gardens Nursing and Rehab CTR

Based on review of the clinical record, electronic hospital record review, and staff interview, it was determined that the facility failed to ensure pain management was provided in accordance with professional standards of practice for one of four residents reviewed (Resident 1), which resulted in actual harm to the Resident as evidenced by uncontrolled pain and subsequent hospitalization for pain management. Findings include:Review of Resident 1's clinical record revealed diagnoses that included chronic atrial fibrillation (a long-lasting, irregular heartbeat) and diabetes (when the body doesn't produce enough insulin).Review of Resident 1's clinical record revealed a Health Status Note written on March 31, 2025, at 4:18 AM, that the Resident was alert, and able to make her needs known.Review of Resident 1's April 2025 Medication Administration Record (MAR), revealed an order for Acetaminophen Tablet 325 mg, give 650 mg by mouth every 4 hours as needed for pain, max 3,000 mg within a 24-hour period, with a start date of February 18, 2025.Review of Resident 1's clinical record revealed a Health Status Note written by Employee 2 (Licensed Practical Nurse) on April 14, 2025, at 2:32 PM, that stated Resident 1 returned to the facility after a leave of absence and was being pushed in the hallway by a transport company in her wheelchair. Resident 1 dropped her right foot and it went under the wheelchair. The Resident was heard calling out. No redness or swelling was noted at the time. Review of Resident 1's April 2025 MAR revealed on April 14, 2025, at 3:53 PM, she had a pain level of 5 and was administered 650 mg of Acetaminophen.On April 14, 2025, at 7:15 PM, the Resident had a pain level of 5 and was administered 650 mg of Acetaminophen.Further review of Resident 1's clinical record revealed a Health Status Note written on April 14, 2025, at 9:40 PM, that Resident 1 was complaining of pain in her right ankle and was administered pain medication. There was swelling and redness noted on the right ankle, and the ankle was wrapped with ace bandage and ice was applied.There was no evidence that the physician was made aware of Resident 1 having pain.On April 15, 2025, at 1:27 AM, there was a Health Status Note that revealed Resident 1 was complaining of pain in her right ankle, with the area slight warmth to tough, slightly swollen and sensitive, and was ordered an x-ray view of the right ankle.There was no documentation indicating the physician was made aware of the Resident's pain. Further review of Resident 1's April 2025 MAR on April 15, 2025, at 4:16 AM, revealed the Resident had a pain level of 4 and was administered 650 mg of Acetaminophen.On April 15, 2025, at 7:03 AM, there was a Health Status Note that revealed Resident 1 was continuing to experience pain on the right ankle, and pain medications were administered with little effect. There was no evidence that the physician was made aware that Resident 1 experienced pain despite the prn (as needed) medications being ineffective, as well as no call was made for additional pain medications to be administered. Review of the x-ray report completed on April 15, 2025, at 9:15 AM, revealed the presence of a right bimalleolar ankle fracture.Further review of Resident 1's clinical record revealed a Health Status Note on April 15, 2025, at 11:27 AM, that the Resident would be taken at 1:30 PM to a walk-in orthopedic clinic on that day for her fractured ankle.On April 15, 2025, at 2:21 PM, there was a Health Status Note that revealed Resident 1 remained in bed that shift and voiced complaints of discomfort to her right lower extremity during repositioning and received routine pain medication at that time. There was no evidence of the physician being notified regarding Resident's 1 pain.On April 15, 2025, at 2:59 PM, there was a Health Status Note that revealed Resident 1 required surgery for her fractured ankle.Review of Resident 1's clinical record failed to reveal a physician's note or assessment about the Resident's pain.Review of Resident 1's electronic hospital records revealed she arrived at the Emergency Department (ED) on April 15, 2025, at 4:36 PM.Further review of Resident 1's hospital ED electronic records revealed that she was administered 4 mg (milligrams) of intravenous (IV) morphine (a potent opioid analgesic used for acute, severe pain) on April 15, 2025, at 5:15 PM.Additionally, while in the ED the Resident also received 50 mcg (microgram) of IV fentanyl (a potent pain reliever used for rapid, short-acting pain relief) on April 15, 2025, at 7:42 PM.Review of the ED physician History and Physical note on April 15, 2025, revealed Resident 1 presented to the ED complaining of right ankle fracture, and reported that when she was in her wheelchair yesterday (April 14, 2025) she felt that she was falling out of it. The Resident stated that her ankle rolled underneath the wheelchair while it was being pushed forward and said that she had immediate pain to her right ankle.Review of Resident 1's ED physicians musculoskeletal exam completed on April 15, 2025, revealed the Resident was experiencing significant ankle pain. Further review of Resident 1's hospital ED record revealed the Resident required hospitalization for IV pain medications, sufficient pain control not achieved.Electronic mail received from the Director of Nursing on January 27, 2026, at 10:33 AM, revealed that she felt they were attentive to Resident 1's situation regarding managing their pain at the time of the incident. The facility failed to ensure pain management was provided in accordance with professional standards of practice for Resident 1, which resulted in actual harm to the Resident as evidenced by continued pain and subsequent hospitalization for pain management. 28 Pa. Code 211.12(d)(1) Nursing services.28 Pa. Code 211.12(d)(3) Nursing services.28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review, review of select facility documentation, and staff interview, it was determined that the facility failed to implement interventions to ensure resident safety during transport, which resulted in actual harm as evidenced by an ankle fracture for one of four residents reviewed (Resident 1).Findings include:Review of Resident 1's clinical record revealed diagnoses that included chronic atrial fibrillation (a long-lasting, irregular heartbeat) and diabetes (when the body doesn't produce enough insulin).Review of Resident 1's care plan revealed a focus area related to the Resident's activities of daily living (ADL) self-care deficit related to impaired cognition, muscle weakness, and decreased mobility. Further review revealed an intervention that the Resident required assistance of one staff for locomotion on the unit in a wheelchair, and for staff to make sure the Resident's feet sit comfortably on footrest, initiated on January 23, 2023.Further review of Resident 1's care plan revealed a focus area related to the Resident being at risk for falling related to balance deficit, history of multiple falls, impaired cognition, and muscle weakness. Further review revealed an intervention that when pushing the Resident in her wheelchair, make sure footrests are in place. Remove footrests when not pushing so that she can self-propel, initiated on March 13, 2024.Review of Resident 1's clinical record revealed a Health Status Note written by Employee 2 (Licensed Practical Nurse) on April 14, 2025, at 2:32 PM, that stated Resident 1 returned to the facility after a leave of absence and was being pushed in the hallway by a transport company in her wheelchair. Resident 1 dropped her right foot and it went under the wheelchair. The Resident was heard calling out. No redness or swelling was noted at the time. Further review of Resident 1's clinical record revealed a Health Status Note written on April 14, 2025, at 9:40 PM, that Resident 1 was complaining of pain in her right ankle and was administered Tylenol for pain. There was swelling and redness noted on the right ankle, and the ankle was wrapped with ace bandage and ice was applied. Further review of the clinical record revealed no evidence that the physician was made aware. On April 15, 2025, at 1:27 AM, there was a Health Status Note that revealed Resident 1 was complaining of pain in her right ankle, with the area slight warmth to tough, slightly swollen and sensitive. The nurse practitioner was made aware and anew order was received for an x-ray of the right ankle.On April 15, 2025, at 7:03 AM, there was a Health Status Note that revealed Resident 1 was continuing to experience pain on the right ankle, and pain medications were administered with little effect.Review of the x-ray report dated April 15, 2025, at 9:15 AM, revealed the presence of a right bimalleolar ankle fracture.On April 15, 2025, at 11:27 AM, the physician was made aware of the xray results and ordered for the Resident to be sent to the orthopedic walk in clinic that day (4/15/2025). The facility received a call from the orthopedic walk in clinic at 3:00 PM that stated Resident 1's fracture will require surgery and she needed sent to the hospital emergency room. Review of Resident 1's physician's progress note on April 24, 2025, at 4:58 PM, revealed that Resident 1 was hospitalized from [DATE] through 24, 2025, due to her ankle fracture and required surgery to fix it.During an interview with the Director of Nursing (DON) on January 20, 2026, at 1:28 PM, she revealed that on April 14, 2025, Resident 1 was leaving the facility for an appointment, and the facility's main transportation was overbooked so they used an outside company to transport the Resident. The transportation company did not notify the facility that they were picking the Resident up and, when she returned, the transportation company was wheeling Resident 1 down the hallway and she dropped her feet and got caught under her wheelchair. The DON confirmed Resident 1 did not have her footrests on her wheelchair before leaving the facility or returning to the facility from her appointment. The DON revealed that the facility reached out to the transportation company and completed education with them on notifying the facility when they are picking a resident up to ensure all interventions are in place prior to leaving and returning to the facility. The DON confirmed Resident 1 broke her ankle due to not having footrests on her wheelchair.The facility failed to use leg rests on Resident 1's wheelchair to assure Resident safety during transport, resulting in an ankle fracture.28 Pa. Code 201.18(b)(1)(e)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders as well as involve the physician in treatment changes for one of two residents reviewed (Resident 2).Findings include:Review of Resident 2's clinical record revealed diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed the Resident was admitted to the facility on [DATE], with an abdominal fistula (an abnormal opening between the intestines or stomach and another organ or the skin, causing leakage of digestive fluids) which is covered with a colostomy bag (a discreet, odor-proof, disposable pouching system that collects waste from the body).Review of Resident 2's current physician orders revealed an active order for abdominal fistula care, cleanse all abdomen area and fistula site, apply the zinc oxide mixed with A&D ointment (vitamin A & D topical ointment) all over abdomen and around fistula site, then apply pantie liner or exu-dry (multi-layered wound dressing) over top of the fistula, then apply brief on top and secure. Make sure ruff tabs on brief are not touching skin, change as much as needed or when soiled, aides are allowed to check and change once shown how to apply, every shift for fistula care, with a start date of January 14, 2026. Further review of Resident 2's January 2026 TAR (Treatment Administration Record) revealed that the order above was signed off as being completed during the day, evening, and night shift by staff. Review of Resident 2's January 2026 TAR revealed an order for abdominal fistula - change Tuesday, Friday, and as needed (prn) for leaking, cleanse site with wound cleanser and apply skin prep to peri wound, place ostomy device and wafer over fistula site. Please use ostomy belt with device to assist with adherence, wear belt at all times, every day shift, with a start date of January 6, 2026, and a discontinued date of January 9, 2026.Further review of Resident 2's January 2026 TAR revealed an order for abdominal fistula care - cleanse all abdominal area and fistula site, apply the zinc oxide ointment all over abdomen and around fistula site. Then apply pantie liner over top of the fistula. Peel off back of liner then apply brief of top, press down until liner sticks to brief. Then roll Resident and secure brief around back. Make sure ruff tabs on brief are not touching skin. Change as much as needed or when soiled. Aides are allowed to check and change once shown how to apply, every shift for fistula care, with a start date of January 9, 2026, and a discontinued date of January 14, 2026.Review of Resident 2's current care plan failed to include a focus area for their abdominal fistula care or any interventions related to it.Review of Resident 2's clinical record revealed a Health Status Note on January 16, 2026, at 8:58 PM, that indicated fistula care was completed and a colostomy bag was applied.Review of Resident 2's clinical record revealed a Health Status Note on January 17, 2026, at 3:42 AM, that indicated Resident 2's abdominal fistula was covered with a colostomy bag.Review of Resident 2's clinical record revealed an Order-Administration note on January 17, 2026, at 4:10 PM, that Resident 2 had a colostomy appliance at that time.Review of Resident 2's clinical record revealed a Health Status note on January 18, 2026, at 4:17 AM, that the Resident had a colostomy bag attached to fistula, which had been checked hourly to ensure the appliance is intact.Review of Resident 2's clinical record revealed a Health Status note on January 19, 2026, at 4:02 AM, that the Resident's colostomy bag was intact.Review of Resident 2's clinical record revealed a Health Status note on January 19, 2026, at 11:50 PM, that incontinent care was provided and a new colostomy pouch was applied.Review of Resident 2's clinical record revealed a Health Status note on January 20, 2026, at 2:09 AM, that indicated the Resident's abdominal fistula was covered with a colostomy bag.During an interview with the Director of Nursing (DON) on January 20, 2026, at 1:40 PM, she confirmed that nurse aides received verbal and hands on training and education on how to complete the current physicians order for Resident 2's abdominal fistula care and were administering the treatment as ordered to Resident 2. However, the DON was unable to provide where they were documenting when they completed the treatment. DON stated they would have documented the treatment administered under the Resident's bowel and bladder - bowel elimination task , however upon review of the task, the treatment ordered was not an option to document.Further interview with the DON on January 20, 2026, at 2:00 PM, she revealed that she thought Resident 2's colostomy bag appliance had just started up again on January 19, 2026. The DON revealed that she was unsure where it was being documented in the Resident's clinical record when nurse aides are administering abdominal fistula care to Resident 2 as they are not able to document in the TAR and there was not a task in the Resident's record to indicate if fistula care was completed.During an interview with Employee 1 (Wound Nurse) on January 20, 2026, at 2:07 PM, revealed that when Resident 2 was initially admitted to the facility, the Resident was admitted with a colostomy bag to cover their fistula; however, the colostomy bag was never staying on and had liquidy stool coming out of the fistula, so the facility was trying different methods on keeping the Resident's fistula covered. Employee 1 acknowledged there was not currently an order in place for Resident 2 to have a colostomy bag and will put a PRN order in place. Employee 1 revealed that all of the nurses in the facility have discussed Resident 2's situation and determined the best situation is to have the colostomy appliance on so the smell is contained, but that it has not stayed on, so they were doing whatever was working best at the time care was provided to the Resident.Employee 1 revealed that they do not have documentation to prove when staff are applying an ostomy bag to Resident 2 and, as per the current active order, there was nowhere for nurse aides to document when they are administering abdominal fistula care to Resident 2.During an interview with the DON on January 20, 2026, at approximately 2:15 PM, she revealed that she would expect staff to be providing care to Resident 2 as ordered by the physician, and would expect staff to be documenting each time abdominal fistula care is being provided to Resident 2, including when nurse aides are administering the care as ordered.42 CFR 483.25 Quality of care28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one of one resident reviewed (Resident 2).Findings include:Review of Resident 2's clinical record revealed diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and hypertension (high blood pressure).Review of Resident 2's clinical record revealed the Resident was admitted to the facility on [DATE], with an abdominal fistula, which is covered with a colostomy bag.Review of Resident 2's current physician orders revealed an active order for abdominal fistula care, cleanse all abdomen area and fistula site, apply the zinc oxide mixed with A&D ointment (vitamin A & D topical ointment) all over abdomen and around fistula site, then apply pantie liner or exu-dry (multi-layered wound dressing) over top of the fistula, then apply brief on top and secure. Make sure ruff tabs on brief are not touching skin, change as much as needed or when soiled, aides are allowed to check and change once shown how to apply, every shift for fistula care, with a start date of January 14, 2026.Interview conducted with the Director of Nursing (DON) on January 20, 2026, at 1:40 PM, revealed that Employee 1 (Wound Nurse) conducted verbal training with nurse aides on how to administer Resident 2's order for abdominal fistula care above as it was not something they are used to doing and were initially fearful on completing the order to Resident 2. The DON revealed that nurse aides do things outside of their scope and practice sometimes, and nurse aides have told the DON they were uncomfortable completing the care to Resident 2. DON revealed that if a nurse aide told them they were not comfortable performing abdominal fistula care to Resident 2, they would have a nurse go in with them and would never force any one to administer the care if they did not feel comfortable. Interview conducted with Employee 1 on January 20, 2026, at 2:07 PM, revealed that she went over education verbally with nurse aides as well as provided hands on training on how to administer the order for Resident 2's abdominal fistula care above, but did not have any documentation of the training or education provided and did not have any signed documentation by the nurse aides who received the training.The facility failed to provide a list of nurse aides who completed training and any documentation indicating education and training was completed on how to administer Resident 2's abdominal fistula care order above.483.35 Nursing Services483.35(d) Proficiency of nurse aides

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 19 residents reviewed (Resident 36). Findings Include: Review of Resident 36's clinical record revealed diagnoses that included diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), psychosis (a mental disorder when a person has trouble telling the difference between what's real and what's not), and muscle weakness. Review of Resident 36's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of May 3, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days and that an insulin order had changed in the past 7 days. Review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed it was coded that the Resident received one insulin injection in the past 7 days Review of Resident 36's physician orders revealed a once weekly injection for diabetes, but failed to reveal any orders for insulin during the ARD lookback period for the aforementioned assessments. Further review of Resident 36's Quarterly MDS with ARD of August 2, 2024, revealed in Section N0450. Antipsychotic Medication Review it was coded no under Has a gradual dose reduction (GDR) been attempted? (GDR- stepwise decreasing of a dose of medication to determine if symptoms, conditions, or risks can be managed by a lower dose). Also, that the next section Date of last attempted GDR was disabled due to the response to the previous section. Review of Resident 36's clinical record revealed a Psychiatry Note dated September 10, 2024, noting a GDR of Resident 36's Seroquel (antipsychotic medication) had been completed on July 17, 2024. During an email correspondence with the Nursing Home Administrator and Director of Nursing (DON) on September 17, 2024, at 1:43 PM, the surveyor questioned if Resident 36's MDS assessments were accurate related to insulin use and GDR. Follow-up interview with the DON on September 18, 2024, at 10:32 AM, revealed Resident 36's MDS assessments were coded inaccurately for those sections, and she would expect resident MDS assessments to be coded accurately. 28 Pa. Code 211.5(f) Medical records

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 18, 69, and 81). Findings include: Review of facility policy, titled Care Plans, last reviewed December 28, 2023, read, in part, This facility will develop and maintain a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that include but are not limited to those identified in the comprehensive assessment. The plan of care will be reviewed in an ongoing manner and progress or lack thereof toward established goals will be documented within the medical record of the resident. If appropriate, the care plan will be revised as needed. Review of Resident 18's clinical record revealed diagnoses of muscle weakness (a lack of muscle strength) and disorders of phosphorus metabolism (a condition where blood phosphate levels are too low. Symptoms include muscle weakness, bone softening, and altered mental state). Review of Resident 18's electronic medical record revealed the diagnosis of post-traumatic stress disorder (PTSD) was added to her medical diagnoses on October 24, 2023. Review of Resident 18's physician orders on September 17, 2024, revealed an order for heel protectors to be worn while Resident in bed, with a start date of April 3, 2024. Review of Resident 18's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 18 is at risk for impaired skin integrity, including pressure injury, related to incontinence and decreased mobility: with a revision date of September 15, 2024. There is no mention of Resident 18's need for heel protectors anywhere in the care plan. Interview with the Director of Nursing (DON) on September 18, 2024, at 12:33 PM, revealed that Resident 18's care plan to contain instructions to apply heel protectors to Resident 18's heels when the Resident is in bed. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. During an interview with the DON on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan. Review of Resident 81's clinical record revealed diagnoses that included rheumatoid arthritis (an autoimmune disease that causes inflammation and damage in your joints and other body system), chronic pain, and muscle weakness. Interview with Resident 81 on September 16, 2024, at 9:55 AM, revealed she wears her splint at night to help with her rheumatoid arthritis. Review of Resident 81's physician orders revealed an order for Carrot splint to left hand at bedtime, off in AM-- skin checks every shift, every shift for skin integrity related to rheumatoid arthritis, with a start date of August 1, 2024. Review of Resident 81's care plan on September 17, 2024, revealed care plans for assistance with activities of daily living and chronic pain related to arthritis, but failed to reveal notation of her carrot splint. During an interview with the DON on September 18, 2024, at 12:26 PM, she revealed she would expect Resident 81's carrot splint to be on her care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one of four residents reviewed for pressure ulcers (Resident 69). Findings include: Review of the facility policy, titled Skin Integrity Interventions and Protocol for The Middletown Home, last reviewed on December 28, 2023, revealed that interventions for pressure ulcer preventions include: Implement pressure-relieving measures for residents at risk, including: frequent repositioning, use of pressure-reducing mattresses and cushions, proper skin care, including cleansing and moisturizing, adequate nutrition and hydration, and management of incontinence. Review of Resident 69's clinical record revealed diagnoses that included hypertension (high blood pressure) and peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage, or spasms in a blood vessel). Review of Resident 69's current physician orders revealed an order for foam boots when in bed every shift for preventative, with a start date of January 7, 2023. Observation of Resident 69 on September 16, 2024, at 9:57 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 16, 2024, at 1:19 PM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Observation of Resident 69 on September 18, 2024, at 10:14 AM, revealed Resident 69 was lying in bed, and their foam boots were on the floor beside the bed, not on the Resident. Review of Resident 69's clinical record revealed no progress notes documented by staff indicating that Resident 69 refused to wear their foam boots or requested them to be taken off during the dates and times above. Review of Resident 69's care plan on September 17, 2024, revealed a care plan with a focus area of, Resident 69 is at risk for impaired skin integrity, including pressure sores, related to decreased mobility, incontinence, and history of pressure wounds; with a revision date of June 15, 2023. The care plan failed to mention Resident 69's need for foam boots on that focus area or anywhere on the care plan. During an interview with the Director of Nursing (DON) on September 19, 2024, at 10:22 AM, she revealed she would expect Resident 69's foam boots to be on the care plan, and that she spoke to staff on Resident 69's hall who said that Resident 69 will kick their foam boots off, but staff could document in progress notes on Resident 69's clinical record when they are taken off. DON revealed they could change Resident 69's physician order to include: foam boots as tolerated. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on document review and staff interviews, it was determined the facility failed to develop a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella, a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia). Findings include: During an interview with the Nursing Home Administrator (NHA) on November 7, 2023, at 11:00 AM, the NHA was unable to provide a policy that addressed water management or a list of water management team members. During the interview with the NHA on November 7, 2023, data was requested and unable to be provided, that would support implementation of a water management program, such as Legionella risk assessment, a water system flow chart that identifies risk areas such as, testing of shower heads, the ornamental fountain, or the pond that is active during Spring and Summer. The facility was able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning of the cooling systems for pH (acidity or basicity), total alkalinity, calcium hardness, PTSA (ultra violet dye for monitoring cooling systems), and temperature. The facility was also able to provide professional water testing with a most recent date of October 26, 2023, to determine proper functioning two boilers for temperature, pH, hardness, molybdenum (a mineral), and sulfite; as well as cooling systems for conductivity, pH (acidity or basicity), total alkalinity, and calcium hardness. The company who performed the test made the following statement on the report, Standard water treatment is not meant to protect against health risks. The facility was able to show a form dated August 1, 2022, for a one time Legionella testing of the pond in the courtyard and one air condition intake grill in the facility that reported the detection of Legionella, but the final report did not detect the species of Legionella that affects humans and causes the disease in humans. The facility was unable to show control measures to prevent growth and spread of water-borne contaminants, no validation for routine environmental sample results of legionella testing, no monitoring of high risk areas, and no plan for when control limits are not met and/or control measures are not effective. During a final interview with the NHA on November 7, 2023, at approximately 11:00 AM, the NHA confirmed the facility hasn't developed a water management program. 28 Pa. Code 201.18(b)(1)(3) Management

Based on facility policy review, observations, product label review, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and four of four nourishment areas. Findings include: Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Storage of Goods, revealed, Remove goods from storage for which the expiration date has passed .All foods will be labeled with month/day/year received .Leftovers are to be covered, labeled, and dated with use by date .All foods must be labeled and dated. Review of facility policy, titled Food and Nutrition Services Policies and Procedures: Foods Brought by Family/Visitors, revealed, Perishable foods must be destroyed daily .All food items must be labeled with the resident's name and use by date and the date brought in and/or opened. Observation of the dry storage area on [DATE], at 9:39 AM, revealed: one bag of rice open without a date; one open bag of rotini without an open date; one open bag of spaghetti without an open date; and one open bag of egg noodles without an open date. Interview with Employee 3 (Dietary Supervisor) on [DATE], at 9:43 AM, revealed food containers should be labeled with an open date once opened. Observation of the walk-in freezer unit on [DATE], at 9:45 AM, revealed: four pie crusts not dated; one bag of fries open and not dated; one bag of tater tots open and not dated; three slices of pizza not dated; two bags of hoagie rolls not dated; and one pan of dessert without a label or date. Observation in the main kitchen on [DATE], at 9:50 AM, revealed a bin of flour dated use by [DATE]; and a bin of rice dated use by [DATE]. Observation of the walk-in refrigerator on [DATE], at 9:56 AM, revealed: one container of thousand island salad dressing not dated. Observation of the second walk-in refrigerator on [DATE], at 10:00 AM, revealed: one bin of celery not dated; one bag of parmesan cheese not dated; one bag of feta cheese with a use by date of [DATE]; and one monster energy drink open and labeled [NAME]. Interview with Employee 3 on [DATE], at 10:01 AM, revealed employee food and beverages should not be stored in food storage areas. Observation during initial tour of the station 2 pantry area on [DATE], at 10:08 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Observation of the refrigerator and freezer temperature logs in the station 2 pantry area on [DATE], at 10:09 AM, revealed temperatures failed to be recorded on [DATE], and 28, 2023; [DATE], and 30, 2023; and [DATE] and 4, 2023. Further observation of the station 2 pantry area refrigerator on [DATE], at 10:11 AM, revealed one carton of milk with a use by date of [DATE], and the milk was leaking on the shelf; and two nutritional juice drinks not labeled with a thawed date. Interview with Employee 3 on [DATE], at 10:12 AM, revealed nutritional drinks that are received frozen should be labeled with a thawed date once pulled from the freezer, and are good for two weeks after the thawed date. Observation during initial tour of the dining room nourishment area on [DATE], at 10:13 AM, revealed: one container of flaked cereal, one container of bran cereal, one container of toasted o's cereal, and one container of frosted wheat cereal, all labeled [DATE]. Interview with Employee 3 on [DATE], at 10:16 AM, revealed the cereal containers are to be used within a week and they have been filled since [DATE], and should be relabeled. Observation during initial tour of the station 1 pantry area on [DATE], at 10:18 AM, revealed: one container of individual jelly packets not dated; and one container of individual peanut butter packets not dated. Further observation of the station 1 pantry area refrigerator on [DATE], at 10:21 AM, revealed: one container of thickened cranberry juice with an open date of [DATE], and one container of thickened water with an open date of [DATE]; both containers state they should be discarded seven days after opening. Observation during initial tour of the kitchenette pantry area on [DATE], at 10:23 AM, revealed: four oatmeal cookies, two fudge cookies, and one brownie all not dated; and two containers of dairy creamer not dated. Further observation of the kitchenette pantry area refrigerator on [DATE], at 10:25 AM, revealed: one container of potato salad for a resident labeled [DATE] from an outside source; one container of fruit from an outside source for a resident not labeled with residents name or date; and one container of olives from an outside source for a resident not labeled with resident's name or date. Observation of the refrigerator and freezer temperature logs in the kitchenette pantry area on [DATE], at 10:27 AM, revealed temperatures failed to be recorded on [DATE], and 28, 2023; [DATE], and 30, 2023; and [DATE] and 4, 2023. Interview with Employee 3 on [DATE], at 10:28 AM, revealed she would expect food and beverages to be labeled and dated per facility policies and temperature logs to be filled daily. Interview with the Director of Nursing on [DATE], at 2:14 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policies, food items are stored in accordance with professional standards, and temperature logs are filled. 28 Pa. Code 211.6(f) Dietary services

Based on observations, record review, and staff interviews, it was determined that the facility failed to follow physician orders for two of 20 residents reviewed (Residents 38 and 53). Findings Include: Review of Resident 38's clinical record revealed diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and muscle weakness. Review of Resident 38's physician orders revealed an order for Geri Sleeves BUE (bilateral upper extremities) every shift for skin protection, may remove for care and soilage, with a start date of August 3, 2023. Observation of Resident 38 on November 5, 2023, at 1:28 PM, revealed Resident 38 asleep, sitting in a common area of the hall without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 10:18 AM, revealed Resident 38 in his room, drinking out of a cup without Geri sleeves on. Observation of Resident 38 on November 6, 2023, at 1:01 PM, revealed Resident 38 asleep in the hallway, without Geri sleeves on. Interview with the Director of Nursing (DON) on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. Review of Resident 53's clinical record revealed diagnoses that included Parkinson's Disease, dementia, and muscle weakness. Review of Resident 53's physician orders revealed an order for Geri sleeves to BL (bilateral) arms at all times every shift for altered skin integrity, may remove for care, with a start date of March 14, 2023. Observation of Resident 53 on November 6, 2023, at 10:24 AM, revealed Resident 53 asleep in a common area of the hall without Geri sleeves on. Interview with the DON on November 7, 2023, at 8:39 AM, revealed she would expect physician orders to be followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on state regulations, surveyor observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 24 residents reviewed (Resident 27). Findings Include: Review of the Pennsylvania Nursing Practice Act, Chapter 21.145. Functions of the LPN (Licensed Practical Nurse), revealed The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: The LPN may accept a written order for medication and therapeutic treatment from a practitioner authorized by law and by facility to issue orders for medical and therapeutic measures. Review facility policy, titled Medication Administration General Guidelines, dated 2006, revealed in section B. Administration, Step 2. Medications are administered in accordance with written orders of the attending physician. Review of Resident 27's clinical record revealed diagnoses that include low back pain between the lower edge of the ribs and the buttock and spinal stenosis (a narrowing of the spinal canal in the lower part of your back). Review of Resident 27's physician's orders on November 6, 2023, reveals a physician's order written on October 12, 2023, for Bengay ultra patch (a patch with pain relieving medication applied) for Resident 27's mid back, applied in the morning and removed in the evening daily. Review of Resident 27's MAR (Medication Administration Record) from the month of November 2023, revealed that on November 5, 2023, Employee 1 (LPN) documented that she removed the Bengay ultra patch from Resident 27's mid back. Observation of Resident 27 on November 6, 2023, at 8:02 AM, revealed Employee 2 (LPN) removed a patch from Resident 27's mid-back, dated November 5, 2023, so that she could apply the new patch that morning. Interview with the Director of Nursing on November 7, 2023, at 9:17 AM, revealed that she would expect the Bengay patch would have been removed from Resident 27's back on the evening of November 5, 2023, as ordered, by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on document review and staff interviews, it was determined that the facility failed to ensure each resident is informed of the items and services for which the resident may be charged and the amount of charges for those services at the conclusion of the Medicare A skilled services stay by issuing the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (SNF ABN) for two of three residents reviewed at the conclusion of the Medicare A covered stay (Residents 37 and 64). Findings Include: Review of Resident 37's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be September 22, 2023. Continued review of the form revealed the facility had not issued the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage form [SNF-ABN, CMS-10055] at the conclusion of the Medicare Part A services stay. The SNF-ABN form is the liability form issued by skilled nursing facilities as the liability notice that describes an item or service that is usually paid for by Medicare, but may not be paid because it is not medically reasonable and necessary. Review of Resident 64's SNF Beneficiary Protection Notification Review form revealed the Resident's last covered day of Medicare Part A services to be June 16, 2023. Continued review of the form revealed the facility had not issued the SNF-ABN, CMS 10055 form at the conclusion of the Medicare Part A services. An interview with Employee 4 (Social Worker) on November 6, 2023, at 10:29 AM, revealed an alternate form was used instead of the required SNF-ABN form for Residents 37 and 64. An additional interview with the Director of Nursing on November 7, 2023, at 8:41 AM, revealed an awareness that the required form had not been issued to Residents 37 and 64. 28 Pa. Code 201.14 Responsibility of licensee

Based on observation and staff interview, it was determined that the facility failed to post daily current staffing and census for the following dates: October 31, 2023; November 1, 2, 4, and 5, 2023. Findings include: During entrance to the facility on [DATE], at approximately 9:15 AM, the posted staffing was reviewed and observed to be dated October 30, 2023, and copier detail confirmed it was printed on October 30, 2023, at 2:01 AM. During an interview with the Director of Nursing on November 6, 2023, at approximately 2:00 PM, she confirmed that the staff person who is assigned to post the daily staffing forgot to create and post the staffing for October 31, 2023; November 1, 2, 4, and 5, 2023. 28 Pa. Code 201.18(b)(1)(3) Management

Based on clinical record review, policy review and interviews, it was determined that the facility failed to ensure that a resident with a pressure ulcer received care and treatments consistent with professional standards of practice for one of three Residents reviewed (Resident 1). Findings include: A review of the facility's current wound care policy, titled Wound Care Packing, last revised 7/2011, states, pack and dress wound as ordered. The policy also requires that staff date and initial the wound dressing when applied. A review of the clinical record for Resident 1, revealed clinical diagnoses that included type II diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and malignant neoplasm occipital lobe (cancer in the brain). Further review revealed that Resident 1 had a wound assessment on February 2, 2023, that revealed a Stage 4 full thickness sacral pressure ulcer (ulcer involving loss of skin layers, exposing fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). A review of Resident 1's current physician orders dated February 2023, included an order for wound care to the sacrum (the portion of the spine between the lower back and tailbone) to be completed every evening shift and as needed for drainage. The wound care orders effective February 2, 2023, specify to cleanse area on sacrum with normal saline solution, apply Dakin's (cleansing) solution 1/4 strength daily for 30 days, and gauze roll 2.25 inch apply once daily for 30 days. Review of the Treatment Administration Record revealed that on February 9, 2023, the wound care treatment was not signed off that it was completed. A statement from Employee 1 (Licensed Practical Nurse) dated February 14, 2023, revealed that Employee 1 was requested by family to perform a wound care dressing change on February 10, 2023 at approximately 11:00 AM because the dressing was saturated. Employee 1 documented in a written statement that the dressing that was removed was dated February 8, 2023. She stated that she thought the reason why the date of 2/8/23 was on the dressing was that the wound doctor was rounding on 2/9/23 and typically does wound treatments. Review of the wound doctor progress note, dated February 9, 2023, revealed a note that stated, signing off on patient who remains in the facility being seen by Hospice. Sign off without visit. During a telephone interview with the Nursing Home Administrator (NHA) on February 15, 2023, at approximately 1:48 PM, the NHA agreed that the treatment should have been completed as ordered, but didn't agree that the missed treatment should rise to the level of a deficiency. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on policy reviews, observations, and resident and staff interviews, it was determined that the facility failed to provide respiratory services consistent with professional standards of practice for two of 21 residents reviewed (Resident 32 and 89). Findings include: Review of facility policy titled Nebulizers - Use and Care dated June 2011 revealed After each use, wipe mouth piece with a paper towel, removing all moisture, and store in a plastic bag. Review of facility provided policy titled Oxygen therapy revised June 2019, revealed, Change the cannula, tubing, and humidifier bottle every week or more frequently, if needed. Review of Resident 32's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 32's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Do on day shift after removal, dated October 11, 2022; change oxygen tubing, humidifier bottle, and mask or cannula, and rinse concentrator filter with water every night shift every Sunday, date and initial, label with resident name, make sure to change and label wheelchair oxygen tank tubing, dated May 15, 2022; [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 MG/3 ML 3 ml inhale orally every four hours as needed for shortness of breath or wheezing via nebulizer while awake, dated March 31, 2022; and oxygen at 3 liters/minute via nasal cannula as needed and monitor oxygen saturation each shift that oxygen is used, dated March 31, 2022. Orders did not reveal that the Resident is independent in managing his oxygen and [CONDITION(S)]. During an interview with Resident 32 on October 31, 2022, at 10:18 AM, the following was noted: the Resident's nasal cannula for their oxygen was laying on the bed and not contained in a protective bag. It was connected to the oxygen concentrator, which was running; but the Resident was connected to their portable oxygen tank. The oxygen concentrator was noted to have gray colored, fuzzy particles on the vent on the top of the back of the concentrator; and the [CONDITION(S)] mask was laying on the night stand and not contained in a protective bag. During an observation of Resident 32's room on November 1, 2022, at 9:17 AM, the same findings were noted. During an observation of Resident 32's room conducted with Employee 2 on November 2, 2022, at approximately 9:27 AM, the following was noted: the nasal cannula that was connected to the running concentrator was laying on the bed and not contained in a protective bag; a nebulizer treatment mask was noted to be laying on the overbed table and not in a protective bag, and the [CONDITION(S)] mask remained on the nightstand and not contained in a protective bag. Resident 32 had left the facility around 8:45 AM for an outside appointment. Employee 2 confirmed that the nasal cannula, [CONDITION(S)] mask, and the nebulizer treatment should be bagged, but also shared that the Resident probably finished it before they left for their appointment, and that the nurse had not been back yet to clean it and place in the protective bag. Employee 2 further confirmed that the oxygen concentrator needed cleaned and indicated that they would get it all taken care of. Review of Resident 32's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow-up interview with Employee 2 on November 2, 2022, at 10:32 AM, Employee 2 indicated that the nebulizer treatment was cleaned and bagged; the nasal cannula was bagged; the [CONDITION(S)] mask was bagged; and the concentrator was cleaned. She further indicated that the Resident often refuses the [CONDITION(S)] and that they would be following up with the MD. During an interview with the Nursing Home Administrator (NHA), Director of Nursing, Employee 1, and Employee 2, on November 2, 2022, at 1:19 PM, Employee 2 confirmed that the concentrator vent area was dusty and had to be cleaned, and that she bagged items accordingly. The Director of Nursing confirmed that she would expect the items to be bagged when not in use. During exit conference with the NHA, Employee 1, and Employee 2, on November 3, 2022, at approximately 1:00 PM, Employee 2 indicated that although the items were not placed in the protective bags at the time of the observations, there were protective bags present in the room. Employee 2 further indicated that Resident 32 is independent with his oxygen and [CONDITION(S)]. It was shared that the concern remains because, as staff are in and out of room throughout the day, the items could be placed in their protective bags. Review of Resident 89's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident 89 on November 2, 2022, at 9:55 AM, revealed the Resident lying in bed sleeping. Further observation revealed their oxygen concentrator sitting beside the bed with oxygen tubing attached to it. The oxygen tubing was dated September 2, 2022. Review of Resident 89's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 89's Medication Administration Record/Treatment Administration revealed that staff documented that on September 8, 15, 21, and 29, 2022 and October 6, 13, 20 and 27, 2022 that the oxygen tubing was changed. Review of Resident 89's care plan on November 2, 2022, at 10:00 AM, revealed a care plan with a focus of oxygen use related to [CONDITION(S)]; and an intervention of continuous oxygen use for respirator comfort, 2 liters at rest and 4 liters with ambulation and bedtime. During an interview with the Employee 2 on November 3, 2022, at 9:00 AM, it was revealed that the expectation is that the oxygen tubing would be changed weekly, and that the facility policy would be followed. Also, Employee 2 revealed that she would expect the care plan to be updated to reflect current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Nursing Home Administrator on November 3, 2022, at 9:00 AM, it was revealed that he would exprect the facility policy to be followed. 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission for one of 26 residents reviewed (Resident 50). Findings Include: Review of Resident 50's clinical record revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 50's Admission Fall Risk assessment dated [DATE], revealed that the Resident had experienced three or more falls in the last three months prior to admission, and that their fall risk score was 24. The guidelines on the Fall Risk Assessment indicated that a score of 10 or higher represents a high risk for fall. In the section of the Fall Risk Assessment titled Indicate Care Plan Action Taken, it was marked to Initiate Plan of Care. Review of Resident 50's clinical record and facility provided incident reports, it was noted that Resident 50 had a fall on September 24, 2022, at 6:15 AM, and on October 1, 2022, at 12:30 AM. Review of Resident 50's baseline care plan revealed that a care plan was not developed for their high risk of falling until October 1, 2022. During an interview with the Nursing Home Administrator, Director of Nursing, Employee 1, and Employee 2 on November 2, 2022, at 1:02 PM, Employee 1 confirmed that the admission Fall Risk Assessment was completed on September 19, 2022; which identified the Resident was at high risk for falls and that the care plan for falls was not created until October 1, 2022. The Director of Nursing indicated that she would have expected that the baseline care plan would have included falls at the time of the initial development as indicated on the admission Fall Risk Assessment. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observations, review of policy and interview with staff, it was determined that facility failed to store, prepare and distribute food in accordance with professional standards for food service safety in Dietary. Findings included: Review of facility's policy Storage of Goods on December 3, 2021 at approximately 1:00 pm revealed foods should be dated and rotated on first in and first out basis. Leftovers are to be covered, labeled and dated with use by date. Observations on November 1, 2021 at approximately 9:30 am revealed following food items in refrigerator: A bag (VegPro) of approximately 10 whole carrots had a tear in bag and not dated. Approximately 10 onions in an opened bag with no date. Capri Vegetable Blend 1/2 full with no date. Dry Storage: Three Hamburger Rolls with no dates. 5 Sandwich Rolls with no dates 4-6 inch Rolls with no dates 8 slices of Raisin bread with no dates In the kitchen on the cook's metal prep table was a large plastic container of salt with a scoop laying inside on top of the salt. Observations on November 3, 2021 at approximately 9:00 am in refrigerator was a clear bag of 6 hard boiled eggs with no date or label. In kitchen on prep table was a large plastic container containing 1/2 full of thickener with a scoop laying on top of thickener. Interview on November 3, 2021 at approximately 10:00 am with Food Service Director and November 4, 2021 at approximately 11:30 am with Administrator concurred that all food items should be dated and labeled. 28 Pa. Code. 211.6(c)(d) Dietary services 28 Pa. Code. 207.2(a) Administrator responsibility

Based on staff interview and employee file review, it was determined that the facility failed to perform annual performance reviews on one of five Nurse Aides (NA) reviewed (NA 1). Findings include: Review of Centers for Medicare and Medicaid Services, State Operations Manual - Appendix PP, subsection 483.35(d)(7) Regular in-service education, last revised November 22, 2017, revealed that it stated, The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews . Review of facility policy titled, Per Diem (PRN) Employee Requirements, effective date July 1, 2019, revealed it stated, This policy establishes the requirements all PRN employees must meet to maintain their status . Review of section titled, Requirements for PRN Employees, of aforementioned policy revealed requirements included that the PRN employee, Must work at least two (2) holidays per a year, one major and one minor .Must work a minimum of four (4) shifts per month .Must complete all mandatory in-server trainings and adhere to policies/ procedures per state and facility requirements .Must maintain physical abilities, knowledge and skills per job description . Review of the facility policy's section titled, Guidelines for PRN employees, revealed that subsection 6 stated, PRN employees are not eligible for performance based reviews and/or increase. Review of facility documentation revealed that Nurse Aide 1 was hired by the facility on June 5, 2018. On November 4, 2021, at approximately 9:45 AM, a request was made for NA 1's most recent employee performance review. Review of submitted documentation at approximately 10:30 AM, revealed NA 1 did not have a performance evaluation during the prior year. During a staff interview on November 4, 2021, at approximately 11:00 AM, Human Resource Director 1 revealed that NA 1 was an as-needed employee and as such did not have yearly performance evaluations. An electronic communication from Human Resource Director 1 on November 4, 2021, at 11:25 AM revealed that NA 1's most recent work shift was on November 2, 2021. During a staff interview on November 4, 2021, at approximately 12:00 PM, Nursing Home Administrator confirmed that the facility did not conduct an annual performance review on Nurse Aide 1. 28 Pa code 201.2 Requirements.

Based on observations, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to develop a comprehensive plan of care for three of 24 residents reviewed (Residents 40, 64, and 80). Findings include: Review of Resident 40's clinical record on November 2, 2021, at approximately 10:20 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 40's clinical progress notes revealed that on September 28, 2021, at 10:13 PM, Registered Nurse (RN) 2 documented an assessment to the right heel which stated, .Assessment completed, an area measuring 5 x 4 x 0.1cm [centimeters - a metric unit of measure] of the right heel noted to be unstageable pressure ulcer . Review of Hospice Registered Nurse 1 progress note dated October 4, 2021, at 4:08 PM, revealed that Hospice Registered Nurse 1 observed the pressure ulcer of the right heel which was identified on September 28, 2021, and an additional pressure ulcer to the left heel; documenting, Wound Type: Pressure Ulcer - Unstageable .Unstageable, closed would left heel. Color black. about 4 cm by 2 cm. During wound dressing observations on November 3, 2021, at approximately 12:30 PM, Resident 40 was observed as having pressure ulcers to the right and left heel. Review of Resident 40's comprehensive plan of care on November 3, 2021, at approximately 1:40 PM, revealed Resident 40 did not have a care plan for the pressure ulcers on each heel. During an interview on November 4, 2021, at approximately 12:00 PM, Director of Nursing confirmed that Resident 40's comprehensive plan of care did not include the pressure ulcers on Resident 40's heels; further, that it was the facility's expectation that Resident 40 be careplanned for the pressure ulcers present on the left and right heel. Review of Resident 64's November 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 64's admission Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), dated October 8, 2021. Review of the MDS revealed Resident 64 triggered in the Care Area Assessment (CAA- MDS assessment responses detailing the need for additional assessment based on problem indicators) in the area of Pressure Ulcer. Review of the CAA Worksheet revealed the facility's intention to proceed to document the potential problem on the interdisciplinary plan of care. Review of Resident 64's interdisciplinary plan of care revealed none developed to address the resident's potential for Pressure Ulcer/Injury based on the MDS and CAA. Review of Resident 80 s' Admission MDS dated [DATE] revealed a CAA trigger in the area of Visual Function. Review of Resident 80's CAA Worksheet revealed the area triggered based on the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the CAA Worksheet revealed the facility's intention to proceed to document the potential problems related to the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 80's interdisciplinary plan of care revealed none developed to address the Visual Function. An interview with the Director of Nursing, on November 4, 2021, at 9:54 AM revealed the care plans had not been developed based on the resident assessment and were added on November 3, 2021. 28 Pa code 211.11(d) Resident care plan 28 Pa code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 27 residents reviewed (Residents 41 and 67). Findings Include: Review of Resident 41's clinical record on November 1, 2021, at approximately 1:00 PM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 41's admission Nutrition Screening and Evaluation, dated February 10, 2020, revealed that Resident 41 did not wear full or partial dentures as assessed in section V(4), Oral / Dental Status. Review of Resident 41's annual Minimum Data Set (MDS - assessment tool utilize to identify a residents' physical, emotional, and psychosocial needs and strengths), assessment reference date of January 6, 2021, revealed that the Dental assessment (section L) was coded to reflect Resident 41 had Broken or loosely fitting full or partial dentures, and no obvious or likely cavity or broken natural teeth. Review of HealthDrive Dental Group consultation document for Resident 41, exam date February 4, 2021, revealed that section titled, Dental History/Current Dental Status, revealed that Resident 41 did not wear dentures. Further, section titled, Treatment notes, revealed Resident 41 had fractures in two teeth. During a staff interview on November 4, 2021, at approximately 12:00 PM, Director of Nursing confirmed that Resident 41's annual MDS was coded incorrectly. Review of Resident 67's clinical record revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 67's admission MDS, dated [DATE], revealed that in section O, Resident 67 was marked yes to being on an invasive mechanical ventilator while a Resident at the facility. During a staff interview on November 3, 2021, at 10:47 AM the Director of Nursing stated that Resident 67 was never on a ventilator and the MDS was coded incorrectly. 28 Pa. Code 211.5(f) Clinical records.

Based on observation and interviews with staff, it was determined that the facility failed to ensure that the environment remained free of accident hazards, regarding one of three water purification units that dispensed hot water. The hot water was measured at 171.6 degrees Fahrenheit. Further observation of the area around the water purification units revealed that the only cups provided by the water dispensing unit were plastic un-insulated cups designed and labeled for cold liquids, placing the health and safety of five of 89 residents observed by the water purification units (Residents 12, 19, 20, 22, 23) and 67 of the 89 residents in the facility that were identified by the facility as capable of independently ambulating or self-propelling in their wheelchairs and passing the water purification unit to enter the Activity Room, in an Immediate Jeopardy situation. Findings include: During the initial tour of the facility on March 20, 2017, at 1:40 p.m. an observation of the water purification unit (a portable push button water dispenser) located in the hall adjacent to the entrance to the Activity Room, revealed that hot water was able to be dispensed from the water purification unit when both red buttons (labeled hot) were pushed simultaneously. The observation also revealed a cup dispenser with clear plastic cups (labeled Dart Brand Conex Plastic Cold Cups - a thin plastic un-insulated cup made for cold liquids only). The hot water dispensed from the water purification unit into the cup was too hot for the surveyor to hold. The cup was immediately placed on top of the water purification unit and a temperature of 169.2 degrees F (Fahrenheit - a temperature scale) was obtained. During an initial interview with Maintenance Staff 1, when he arrived at the water purification unit on March 20, 2017, at 1:45 p.m. Maintenance Staff 1 was requested to take the temperature of the water that was dispensed from the water purification unit. As Maintenance Staff 1 filled the cup with the hot water, he immediately placed the cup on top of the water purification unit stating it was, too hot to hold in his hand. A digital thermometer, which Maintenance Staff 1 stated was to be used for water temperature checks, recorded a temperature of 171.6 degrees F. On March 20, 2017, at 1:47 p.m. the Nursing Home Administrator (NHA) was made aware of the observation that 171.6 degree F water was being dispensed from the water purification unit. The NHA confirmed that hot water should not be coming from any of the water purification systems, and that only cold water should be available. Measurements of the height from the floor to the push buttons which were used to obtain the hot water, were measured by Maintenance Staff 1 using a facility tape measure and were found to be 44 ½ inches and 45 ½ inches from the floor and accessible to all residents, standing or sitting in their wheelchairs. Observations on March 20, 2017, at 1:40 p.m. revealed 14 residents present in the Activity Room. During an interview, Therapeutic Recreational Assistant 1 was asked if any of the residents are capable of entering the room on their own and she provided the names for 5 of the 14 residents that self-propelled to the Activity Room (Residents 12, 19, 20, 22 and 23). During an interview with Therapeutic Recreational Assistant 1 on March 20, 2017, at 1:50 p.m. she revealed that those residents who had self-propelled (use of the upper and/or the lower extremities to move about in a wheelchair independently) from their rooms and passing the water purification unit to enter the Activity Room, without the presence or assistance of the staff, included Residents 12, 19, 20, 22 and 23. An observation on March 20, 2017, at 1:58 p.m. revealed Resident 19 self-propelling out of the Activity Room, passing the water purification unit and without the presence of staff. An observation on March 20, 2017, at 2:07 p.m. revealed Resident 15 self-propelling independently from the Activity Room into the hall and passing the water purification unit. During an interview with the Director of Nursing (DON) on March 20, 2017, at 4:45 p.m. the DON presented a list of residents that included 67 of the current 89 residents in the facility that are capable of ambulating or self-propelling in their wheelchairs independently and passing the water purification unit to enter the Activity Room. The list included the 5 residents in the Activity Room that self-propel independently and another resident (Resident 15) that was observed self-propelling. On March 20, 2017, at 3:10 p.m. the Nursing Home Administrator (NHA) and the DON were notified that an Immediate Jeopardy (IJ) was identified and an immediate corrective action plan was requested to ensure the safety of the residents and prevent the potential for injury from the high hot water temperatures. An interview with Maintenance Staff 1 on March 20, 2017, at 3:30 p.m. revealed that no policy existed within the facility that addressed the water purification units. Maintenance Staff 1 revealed that the water purification unit had been disconnected and removed to the loading dock to prevent accidental use. Further interview revealed that the manufacturer guidelines that were requested on March 20, 2017, at 1:47 p.m. would be emailed (sending information by a computer) by the vender today. On March 20, 2017, at 5:40 p.m. the immediate corrective action plan was received which revealed that the water cooler that dispensed the hot water was supervised by staff until physical removal of the unit from the building at 5:30 p.m This water cooler will be back in location and service if the permanent hot water function can be disabled. Education was immediately initiated to all staff that indicated the hot water function on the water purification units (water coolers) should not be used. This was addressed through email, OnShift messaging as well as memos placed on the care units. Daily audits will be completed by the maintenance staff to ensure that the units in the building are unable to produce hot water until written confirmation is received from the vendor that the hot water dispensers have been permanently disabled. During an interview on March 21, 2017, at 8:00 a.m. Maintenance Staff 1 confirmed that the reason the water was so hot was because it was connected to the domestic hot water. During an interview with the DON on March 23, 2017, at 9:00 a.m. the DON presented a letter from the water purification vender that stated, as of 3/20/2107 the vender has noted in their system that all water systems installed at the (facility) need to have the hot water permanently disabled. At this time the two systems on B wing and C wing have this modification done. The letter also stated that when the water purification unit, that was removed, was returned to the facility and the system modified to disable the hot water. The IJ was removed on March 21, 2017, at 9:44 a.m. when the immediate plan of correction was fully implemented. The facility failed to ensure the environment remained free of accident hazards, regarding the water purification unit that was connected to the domestic hot water system, producing water at a temperature of 171.6 F and only plastic cups were provided that were intended to be used for cold liquids, placing the health and safety of the residents in Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/8/15. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 5/20/15. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 5/20/15.

Based on review of facility policy and clinical records and interviews with staff, it was determined that the facility failed to ensure that one of eight residents (Resident R1) reviewed was free from a significant medication error. Findings include: Review of the facility's Oral Medication policy dated July 28, 2011, indicated that nurses are to read the label three times before pouring medications. Review of Resident R1's clinical record revealed he was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. His primary care physician approved the recommendation and a verbal telephone order was written on July 8, 2011 for [MEDICATION NAME] 0.125mg daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nurses note dated July 18, 2011, at 1:15 p.m., revealed that Resident R1 appeared very tired and sluggish with his wife expressing concern and requesting he be put into bed. Nurses note dated July 19, 2011, at 11:50 a.m. revealed that he was sitting in his wheelchair, his head slumped and his body limp. He was arousable but very slow to respond, very lethargic and weak. Resident R1 was transferred to the hospital and subsequently admitted with a [DIAGNOSES REDACTED]./ml. (nanograms per milliliter). Therapeutic [MEDICATION NAME] levels are 0.8 - 2.0 ng/ml. Review of the facility's investigation determined that the label on Resident R1's pills revealed [MEDICATION NAME] 0.25mg (two times the ordered dose) was sent in error by the pharmacy and not identified timely by the facility. Interview with the pharmacist on July 19, 2011, at 8:45 p.m., by the Director of Nursing revealed that the faxed order received had a line through it and it was hard to decipher the dosage. The pharmacist confirmed his staff should have called to verify the correct dose but did not. The investigation also determined that the facility staff involved, Licensed Practical Nurses 1, 2 and 3, did not read the medication label according to facility policy prior to giving Resident R1 his medications each day. Interview with the Director of Nursing on August 9, 2010, at 11:30 a.m., confirmed her expectation that medications would be administered by staff according to facility policy and if done correctly, this incident would have been avoided. 28 Pa. Code: 211.5 (f) Clinical records. Previously cited: 3/17/11 28 Pa. Code: 211.10 (c) Resident care policies. Previously cited: 3/17/11 28 Pa. Code: 211.12 (d)(1)(5) Nursing services Previously cited: 3/17/11