Every finding on record at Delaware Valley Skilled Nursing & Rehabilitation C

Based on clinical record and select facility policy review and staff interview, it was determined that the facility failed to provide effective pain management and administer pain medication as prescribed by the physician and failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication as prescribed for two resident out of 15 residents reviewed (Resident 10 and Resident 2). Findings include: A review of the facility's policy entitled Pain Management Policy with a policy review date of May 13, 2025, indicated that the physician will order appropriate nonpharmacological and medical interventions to address the individual's pain. A clinical record review revealed Resident 10 was admitted to the facility on February17, 2025, with diagnoses that include Spina Bifida, (a neural tube (the embryonic structure that develops into the brain and the spinal cord that forms the central nervous system) defect that occurs when the fetus's spine does not close completely during early development causing symptoms of incontinence, loss of feeling and leg paralysis ) and Major Depressive Disorder (A mental health condition characterized by persistent feelings of sadness, loss of interest in activities and various emotional and physical problems). A review of Resident 10's quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 22, 2026, revealed that Resident 10 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15indicates cognition is intact) A review of Resident 10's clinical record revealed physician's order for the resident to receive Oxycodone HCL oral tablet 15 mg. (Oxycodone HCL) (Oxycodone is a Schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) was initiated on November 24, 2025, with instructions to administer one tablet every 8 hours as needed for chronic severe pain. A review of Resident 10's electronic Medication Administration Record (eMAR - is used to document medications taken by each resident) from December 2025 to March 2026, revealed that Oxycodone 15 mg was administered without any documented attempts of nonpharmacological interventions one hundred and sixty-six times throughout December 2025, and March 2026. An interview was conducted with the NHA (Nursing Home Administrator) on March 12, 2026, at 2:00 PM, to review the above findings related to the facility failure to assure that licensed nursing staff attempted non-pharmacological interventions prior to administering analgesic pain medication that included opioids. A review of Resident 2's clinical record revealed admission to the facility on December 16, 2025, with diagnoses that included peripheral vascular disease (PVD is a progressive disorder that restricts blood flow to the arms, legs, or other body parts and occurs when blood vessels narrow, become blocked, or spasm), type 2 diabetes (T2DM occurs when the body cannot use insulin correctly and sugar builds up in the blood and occurs due to the pancreas not make enough of a hormone called insulin that helps sugar enter the cells) with diabetic neuropathy (is a type of nerve damage that can happen with diabetes due to prolonged high blood sugar levels resulting in nerve damage throughout the body, but most often damages nerves in the legs and feet), new right below knee amputation (a BKA involves the surgical removal of the leg below the knee, often due to severe injury, infection, or poor blood flow, and requires a comprehensive rehabilitation process), and chronic pain. The resident was cognitively intact. A review of the resident's plan of care-initiated December 17, 2025, indicated the resident had chronic pain related to neuropathy and post right BKA with desired outcome for the resident to experience adequate relief of pain or ability to cope with incompletely relieved pain. Interventions/tasks included providing the resident with non-pharmacological interventions to treat pain as indicated, monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (mild, moderate, severe scale); Anatomical location; Onset; Duration (e.g. continuous, intermittent); Aggravating factors; relieving factors. A review of physician's orders dated December 18, 2025, at 2:45 PM, revealed an order for oxycodone HCL (an opioid pain medication used to relieve moderate to severe pain), give one table by mouth every 8-hours as needed (PRN) for moderate pain. A review of Resident 2's Medication Administration Record (MAR, or eMAR for electronic versions, is the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional and is a part of a patient's permanent record on their medical chart and the health care professional signs off on the record at the time that the drug or device is administered) dated December 2025 and January 2026 revealed PRN oxycodone HCL ordered to manage moderate pain was administered on the following dates and times without documented attempted non-pharmacological interventions prior to administration of an opioid: December 30, 2025, at 2:16 PM, December 31, 2025, at 11:30 AM, and December 31, 2025, at 9:00 PM, January 1, 2026, at 6:30 AM, January 1, 2026, at 9:33 PM, January 2, 2026, at 7:30 PM, January 4, 2026, at 3:00 AM, January 4, 2026, at 11:11 AM, January 4, 2026, at 9:30 PM, January 5, 2026, at 3:31 AM, January 6, 2026, at 11:50 AM, January 8, 2026, at 2:14 PM, January 9, 2026, at 8:25 PM, January 10, 2026, at 6:28 PM, January 14, 2026, at 9:21 PM, January 15, 2026, at 9:35 AM, January 15, 2026, at 8:57 PM, January 16, 2026, at 3:15 PM, January 16, 2026, at 11:30 PM, January 17, 2026, at 11:31 AM, January 17, 2026, at 8:41 PM, January 18, 2026, at 11:22 AM, January 19, 2026, at 12:58 PM, January 20, 2026, at 4:06 PM, January 21, 2026, at 1:33 PM, January 21, 2026, at 9:37 PM, January 23, 2026, at 1:51 AM, January 23, 2026, at 2:24 PM, January 23, 2026, at 11:23 PM, January 24, 2026, at 2:00 PM, January 24, 2026, at, 10:00 PM, January 25, 2026, at 11:56 AM, January 25, 2026, at 8:51 PM, January 26, 2026, at 12:00 PM, January 27, 2026, at 1:37 PM, January 27, 2026, at 8:23 PM, January 28, 2026, at 2:00 PM, and January 29, 2026, at 11:38 AM. The facility failed to ensure licensed nursing staff attempted and recorded non-pharmacological interventions prior to the administration of an opioid pain medication, oxycodone HCL, to manage Resident 2's pain. During an interview with the facility's Nursing Home Administrator (NHA) on March 13, 2026, at 10:00 AM, the above information was reviewed and confirmed. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

Based on clinical record review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality as required by the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure Licensed Practical Nurses (LPNs) administering intravenous (IV) therapy via a peripherally inserted central catheter (PICC) possessed the required education, competency, and supervision for one of 15 residents reviewed (Resident 63).Findings include: A review of the Pennsylvania Code, Title 49, Chapter 21.145 (Functions of the Licensed Practical Nurse), revealed that an LPN must perform nursing functions based on appropriate knowledge, skill, and competency, and may administer IV therapy only after completing the required IV therapy education and training. The regulation further requires that IV therapy be performed under the direction and supervision of a licensed professional nurse (RN) or other authorized health care provider. The regulation specifies that LPNs may only perform IV-related functions, including medication administration and flushing of IV access devices, when they have demonstrated competency and received appropriate training. A review of facility policies titled Medication Administration Policy 5.09: Intravenous Administration of Fluids and Electrolytes and Medication Administration Policy 5.10: Administering Medications Through Primary and Secondary Administration Sets, last reviewed May 13, 2025, revealed that intravenous medications and fluids are to be administered by nurses who are knowledgeable and competent in infusion therapy. The policy further indicated the facility would follow the Nurse Practice Act to ensure compliance with RN and LPN scope of practice requirements. Clinical record review revealed that Resident 63 was admitted to the facility on [DATE], with diagnoses including sepsis, unspecified organism (a serious, life-threatening condition caused by the body's response to infection, which can lead to organ failure). A review of Resident 63's significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 1, 2026, revealed that Resident 63 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates significant difficulties with memory, orientation, and thinking). A review of Resident 63 clinical record revealed a physician's order dated December 27, 2025 for Ceftriaxone Sodium 2000 milligrams to be administered intravenously once daily for five days via a PICC line (a peripherally inserted central catheter, which is a long, flexible tube inserted into a vein in the arm and advanced into a large central vein near the heart to allow for long-term IV medication administration). Additional physician orders dated December 27, 2025, directed that the PICC line be flushed with 10 milliliters (mL) of normal saline (a sterile saltwater solution used to maintain patency, meaning to keep the line open and prevent blockage) before and after medication administration and during each shift Review of the Electronic Medication Administration Record (eMAR) (technology that automatically documents the administration of medication into the medical record) revealed the following: On December 28, 2025, and December 31, 2025, Employee 3 Licensed Practical Nurse (LPN) documented the administration of the normal saline solution to Resident 63 through the PICC line on day shift. On December 28, 2025, Employee 4, LPN, documented administration of normal saline via the PICC line during the evening and night shifts. On December 29, 2025, and December 31, 2025, Employee 5, LPN, documented administration of normal saline via the PICC line during the evening shift. On December 30, 2025, Employee 6, LPN, documented administration of normal saline via the PICC line during the evening and night shifts. Despite documentation that multiple LPNs performed IV-related care through a PICC line, further review of personnel records and facility-provided documentation failed to demonstrate that Employees 3, 4, 5, and 6 completed the IV therapy education required under Pennsylvania Code S21.145(b). There was no evidence of documented competency validation (confirmation that staff demonstrated the ability to safely perform a skill), no evidence of supervision by a registered nurse as required, and no evidence of facility-based training specific to PICC line management and IV medication administration. During an interview on March 13, 2026, at 9:50 AM the Nursing Home Administrator confirmed the facility could not provide documentation that the LPNs administering IV therapy via PICC lines had completed the required IV therapy education or demonstrated competency. The administrator further confirmed the facility did not maintain documentation verifying compliance with State Board of Nursing requirements for LPN IV therapy practice. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to provide necessary care and services to ensure appropriate assessment and ongoing monitoring of a surgical wound in accordance with professional standards of practice for one of fifteen residents reviewed (Resident 2). Findings include: A review of the facility policy titled Skin Policy, last reviewed May 13, 2025, indicated that upon admission, licensed nursing staff complete a head-to-toe skin assessment and document all findings in the nursing clinical assessment. The policy indicated staff document all skin impairments and wounds in the Skin Assessment Section of the admission Screener and on the skin assessment forms, to include measurements (length, width, and depth, including tunneling or undermining, which refers to channels or areas of tissue destruction under the skin), and a detailed description of the wound bed (the visible tissue within the wound), including the presence of drainage (fluid coming from the wound), slough (dead tissue that appears yellow or white and may delay healing), eschar (dead tissue that appears black or brown and is typically dry and firm), odor, and pain. The policy further indicated that staff document all findings in the clinical record. The policy also indicated licensed nursing staff complete weekly skin assessments and document findings on the appropriate skin and wound assessment tool. A review of the clinical record revealed Resident 2 was admitted on [DATE], with diagnoses including peripheral vascular disease (a condition that reduces blood flow to the limbs), type 2 diabetes mellitus (a condition where the body cannot properly regulate blood sugar), diabetic neuropathy (nerve damage caused by prolonged high blood sugar, often affecting the feet), and a recent right below-knee amputation (surgical removal of the leg below the knee). A review of the admission assessment dated [DATE], at 4:49 PM, completed by Employee 1, Registered Nurse (RN), identified multiple pressure injuries to the resident's coccyx and other skin impairments left lower leg, left heel and groin. A nursing progress note completed by Employee 2 RN, dated December 16, 2025, at 6:53 PM, noted Resident 2 had an incision site to the stump with 26 staples on admission. A review of physician's orders dated December 16, 2025, directed licensed nursing staff to provide wound care (cleanse the right lower leg-stump with normal saline solution, pat dry, apply dressing, wrap with Kling and ace bandage to help reduce swelling, keep incision clean and dry) to the surgical site and to monitor and document the condition of the wound every shift, including the wound bed (the visible tissue within the wound), drainage (fluid from the wound), odor, surrounding skin, and any signs of infection. However, review of the clinical record from December 18, 2025, through February 6, 2026, revealed repeated documentation by licensed nursing staff indicating the surgical wound had not been evaluated. The facility failed to provide documented evidence that staff assessed and monitored the wound as ordered by the physician and required by professional standards of practice. Further review of the clinical record revealed a wound assessment completed by the facility's contracted wound care certified registered nurse practitioner (CRNP) dated January 6, 2026, at 9:28 PM. The assessment indicated Resident 2 had a surgical wound to the right below-knee amputation stump. The wound was identified as full thickness (involving all layers of the skin) and measured 0.1 centimeters in length, 17.0 centimeters in width, and 0.1 centimeters in depth, with a calculated area of 1.7 square centimeters. The wound bed (the visible tissue within the wound) consisted of 100 percent epithelial tissue (new skin-forming tissue), with stapled edges and intact surrounding skin. The assessment noted a light amount of sanguineous drainage (thin, red fluid primarily composed of blood), no odor after cleansing, and minimal pain reported by the resident. A review of a vascular surgeon follow-up dated January 7, 2026, at 8:30 AM indicated the surgical incision showed signs of necrosis (death of tissue due to lack of blood supply) and dehiscence (partial or complete reopening of a surgical wound) following removal of staples. The wound was cleansed and redressed, and new physician orders were issued for daily wound care and ongoing monitoring for signs of infection, worsening necrosis, or further dehiscence, with instructions to transfer the resident to the emergency room if these conditions occurred. A follow-up evaluation was scheduled in one week. Despite these findings and physician orders, the clinical record continued to lack evidence that licensed nursing staff performed or documented routine assessments of the wound. A vascular consultation dated January 27, 2026, indicated delayed wound healing and noted the potential need for surgical debridement (removal of dead tissue to promote healing). On February 6, 2026, Resident 2 was transferred to the hospital due to poor wound healing and dehiscence. The resident required surgical debridement and placement of a wound vacuum device (a treatment that uses suction to promote wound healing). Resident 2's clinical record dated January 7, 2026, through February 6, 2026, revealed licensed nursing staff continued to repeatedly document skin issue had not been evaluated, located right below knee amputation site, issue type surgical wound present on admission. During an interview on March 12, 2026, at 10:45 AM the Director of Nursing and the facility's contracted wound care certified registered nurse practitioner confirmed that licensed nursing staff were responsible for monitoring and documenting the condition of Resident 2's surgical wound. Review of information provided by the contracted wound care provider included a photograph dated January 13, 2026, which showed blackened tissue (necrosis, or death of tissue due to lack of blood supply) along the surgical incision with surrounding redness, indicating deterioration of the wound. The facility provided evidence that licensed nursing staff completed wound treatments to the right below-knee amputation site as ordered. However, the facility failed to provide documented evidence that staff completed a comprehensive assessment of the surgical site upon admission or that staff monitored and documented the condition of the wound as ordered by the physician, including changes in the wound's appearance as it declined. During an interview on March 13, 2026, at 9:30 AM the above findings were reviewed with the Nursing Home Administrator. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.5(f)(ix) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services .

Based on a review of select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and implement nutritional interventions for one resident out of 15 residents reviewed (Resident 47).Findings include: A review of a facility policy entitled Resident Heights and Weight Policy last reviewed by the facility May13, 2025, indicated residents will be weighed upon admission to facility and on day two after admission. After the second day weight, all newly admitted residents will be weighed weekly for four weeks and then on a monthly basis unless otherwise specified. The resident weights will be recorded in the electronic medical record. Reweighs will be obtained for any residents whose weight fluctuates by plus or minus five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 pounds. The licensed nurse will notify the Director of Nursing or designee, Physician, and Registered Dietitian of significant weight changes of 5 percent loss or gain in one month, or a 7.5 percent loss or gain in 3 months, or a 10 percent loss of gain in 6 months. The resident's representative will be notified of significant weight loss and any recommendations from the resident's provider and registered dietitian. The registered dietitian will notify the charge nurse of any significant weight changes and follow up with documentation in the resident's medical record. Clinical record review revealed Resident 47 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia (a condition involving progressive decline in memory and thinking due to multiple causes), displaced intertrochanteric fracture of the left femur (a break in the upper portion of the thigh bone near the hip). A review of Resident 47's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 12, 2026, revealed Resident 47 was severely cognitively impaired with a BIMS score of 99 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 99 indicates the resident was unable to complete the interview ) was not on a therapeutic diet, and was able to feed self after set up. A review of Resident 47's comprehensive care plan, initiated June 17, 2025, identified the resident at risk for nutritional decline related to dementia, fracture of the femur, hypothyroidism (a condition in which the thyroid gland does not produce enough hormones, which can slow metabolism), and anemia (a condition in which the body lacks enough healthy red blood cells to carry adequate oxygen). The care plan identified the desired outcome that the resident would maintain adequate nutritional status, as evidenced by stable weight without significant weight changes. The care plan directed staff to monitor, record, and report to the physician signs and symptoms of malnutrition (a condition resulting from inadequate intake of nutrients necessary for health), including emaciation (extreme thinness due to loss of body fat and muscle), muscle wasting (loss of muscle mass and strength), and weight loss parameters of three pounds in one week, greater than five percent in one month, greater than 7.5 percent in three months, and greater than 10 percent in six months. Additional interventions included providing the diet as ordered and requiring the Registered Dietitian (RD, a licensed nutrition professional) to evaluate the resident and make dietary recommendations as needed. A nutritional assessment completed by the Registered Dietitian on July 24, 2025, documented the resident weighed 146.2 lbs. with a Body Mass Index (BMI, a calculation using height and weight to estimate body fat and assess weight status) in the overweight range. Despite this, the resident was identified as at risk for malnutrition due to underlying diagnoses and required continued monitoring. The record did not contain documented evidence that the physician or resident representative was notified of this risk. A review of a nutritional assessment completed by the facility's Registered Dietitian (RD) dated July 24, 2025, revealed the resident was ordered a regular diet with regular texture and thin liquids (standard food consistency and liquids that do not require thickening for swallowing safety), along with Prosource (a concentrated oral liquid protein supplement used to increase protein intake) twice daily and Ensure (a commercially prepared oral nutritional supplement used to provide additional calories and nutrients) twice daily. The RD documented the resident's height as 64 inches and weight as 146.2 pounds and calculated estimated daily nutritional needs of approximately 1700 calories (a measure of energy required by the body to maintain weight and bodily functions), 72 grams of protein (a nutrient necessary for tissue repair and maintenance), and 1700 milliliters of fluids (a measure of daily hydration needs), with staff instructed to encourage fluid intake. The assessment further documented the resident's Body Mass Index (BMI, a calculation based on height and weight used to screen for weight categories and potential health risks) was in the overweight range. Despite this classification, the RD identified the resident as at risk for malnutrition (a condition resulting from inadequate intake or utilization of nutrients necessary for health) due to underlying diagnoses and documented fair meal intake, with continued monitoring planned. The clinical record did not contain documented evidence that the physician or Resident 47's responsible party was notified of the identified nutritional risk or the interventions initiated. A review of the weight record revealed the following: On September 2, 2025, at 11:19 AM, the resident weighed 146.4 lbs. On October 8, 2025, at 2:30 PM, the resident weighed 139.4 lbs., reflecting a 4.7 percent weight loss. The facility did not obtain a reweight as required by policy. On October 23, 2025, at 12:47 PM (two weeks after previous weight), the resident weighed 120.2 lbs., reflecting a significant weight loss. The weight record revealed that on October 23, 2025, the resident's weight was 120.2 pounds, reflecting a loss of 19.2 pounds (approximately 13.8 percent) from the October 8, 2025, weight of 139.4 pounds, which met the facility's definition of significant weight loss. The facility did not obtain a reweight as required by policy to verify the accuracy of this significant change. No weight was documented for the month of November 2025. The next recorded weight was obtained on December 2, 2025, at 130.6 pounds. Due to the absence of a November weight and lack of required reweights, the clinical record did not demonstrate that the facility ensured the accuracy of the recorded weights or consistently monitored the resident's weight trends. A review of facility-provided documentation reports revealed significant gaps in meal and fluid intake documentation: September 2025: Breakfast intake was not documented for 17 of 30 days, and breakfast fluid intake was not documented for 18 of 30 days. Lunch intake and fluid intake were each not documented for 20 of 30 days. Dinner intake and fluid intake were not documented for 3 of 30 days. October 2025: Breakfast intake and fluid intake were not documented for 11 of 31 days. Lunch intake and fluid intake were not documented for 12 of 31 days. Dinner intake and fluid intake were not documented for 4 of 31 days. The clinical record did not contain evidence that the Registered Dietitian identified and addressed the significant weight loss between October 8, 2025, and October 23, 2025. A dietary note dated October 31, 2025, at 12:08 AM, eight days later, documented a change to feeding assistance to promote PO intake (PO, meaning by mouth). There was no documented evidence that the physician or resident representative was notified of the significant weight loss or intervention changes. The record did not demonstrate timely development or implementation of additional nutritional interventions following identification of significant weight loss. During an interview on March 13, 2026, at 10:45 AM, the above findings were reviewed with the Nursing Home Administrator. At that time, the facility did not provide additional documentation demonstrating consistent meals or fluid intake monitoring, timely weight monitoring, or reweights as required by facility policy for Resident 47. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one of 15 residents reviewed (Resident 10). Findings include: A review of the facility policy titled Controlled Substances, last reviewed March 13, 2025, revealed the facility will comply with all applicable laws, regulations, and requirements related to the handling, storage, disposal, and documentation of Schedule II and other controlled medications (Schedule II controlled medications are drugs regulated by the federal government that have accepted medical use but a high potential for abuse and dependence, requiring strict tracking and accountability). A clinical record review revealed Resident 10 was admitted to the facility on February17, 2025, with diagnoses that include Spina Bifida, (a birth defect in which the spinal column does not close completely, which may result in paralysis, loss of sensation, and incontinence) and Major Depressive Disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities and various emotional and physical problems). A review of the clinical record revealed a physician's order for Resident 10 to receive Oxycodone HCL oral tablet 15 mg (Schedule II opiate narcotic medication) was initiated on November 24, 2025, with instructions to administer one tablet every 8 hours as needed for chronic severe pain. A review of facility clinical records revealed the facility utilizes a Controlled Drug Receipt/Record/ Disposition Form to track, monitor, and reconcile each controlled medication. Review of facility documentation indicated the facility utilized a Controlled Drug Receipt/Record/Disposition Form to track, monitor, and reconcile controlled medications. The facility utilized a Medication Administration Record (MAR), which is a legal document used to record medications administered to a resident, including the date, time, medication, dose, administering staff, and clinical rationale. A comparison of Resident 10's Controlled Drug Receipt/Record/Disposition Form with the MAR from December 2025 through March 2026 revealed discrepancies between the two systems used to track controlled medications: Twelve entries were documented on the Controlled Drug Receipt/Record/Disposition Form indicating Oxycodone HCL 15 milligrams was removed or utilized; however, there was no corresponding documentation on the MAR to indicate the medication was administered to Resident 10 on the following dates and times: January 14, 2026, at 5:30 PMJanuary 15, 2026, at 5:30 PMJanuary 27, 2026, at 5:00 AMJanuary 28, 2026, at 5:00 PMFebruary 7, 2026, at 5:30 AMFebruary 8 ,2026, at 6:30 AMFebruary 13, 2026, at 5:00 PMFebruary 14, 2026, at 6:00 AMFebruary 16, 2026, at 7:00 AMFebruary 18, 2026, at 5:15 PMMarch 8, 2026, at 6:00 PMMarch 8, 2026, at 5:45 AM One entry was documented on the MAR indicating Oxycodone HCL 15 milligrams was administered on March 7, 2026, at 6:03 PM; however, there was no corresponding documentation on the Controlled Drug Receipt/Record/Disposition Form to indicate the medication was removed or accounted for. These discrepancies demonstrated that the facility failed to ensure that controlled medication records were consistently reconciled and accurately reflected administration and disposition of a Schedule II controlled substance. An interview was conducted on March 12, 2026, at 2:00 PM with the Director of Nursing. The above findings related to discrepancies between the Controlled Drug Receipt/Record/Disposition Form and the MAR for Resident 10's controlled medication were reviewed. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure that psychotropic (medications that affect mood, behavior, or mental processes) medications were used in accordance with regulatory requirements by failing to implement and document non-pharmacological interventions and failing to ensure appropriate duration and rationale for as-needed (PRN) psychotropic medication orders for two of 15 residents reviewed (Residents 6 and 63).Findings include: A review of the policy entitled, Behavioral Assessment, Intervention, and Monitoring last reviewed May 13, 2025, indicated the facility will provide and residents will receive behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy statement indicated that the facility would adhere to regulatory requirements related to the use of medications to manage behavioral changes. Federal requirements for the use of psychotropic medications expect that these medications are used only when necessary to treat a specific, documented condition. These requirements further expect that individualized non-pharmacological interventions (approaches that do not involve medications, such as environmental adjustments, redirection, or comfort measures) are implemented and evaluated for effectiveness prior to the administration of as-needed (PRN) psychotropic medications, unless clinically contraindicated (not appropriate due to a medical reason). Additionally, these requirements limit PRN psychotropic medication orders to 14 days unless the prescriber documents a clinical rationale for continued use and specifies the duration of the extended order in the medical record. A review of Resident 63's clinical record revealed Resident 63 was admitted to the facility on [DATE], with diagnoses including sepsis, unspecified organism sepsis (a serious, body-wide infection that can lead to organ failure). A review of Resident 63's significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 1, 2026, revealed that Resident 63 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates significant difficulties with memory, orientation, and thinking).A review of Resident 63's clinical record revealed a physician order dated December 26, 2025, for Ambien (drug used to help one fall and stay asleep) 5 milligrams (mg) every 24 hours, at bedtime as needed (PRN) for sleep. A review of Resident 63's electronic medication administration record (eMAR technology that automatically documents the administration of medication into the medical record) revealed the medication was administered on January 27, 2026, at 8:20 PM, February 25, 2026, at 7:31 PM, and February 27, 2026, at 8:53 PM. The record lacked documentation that non-pharmacological interventions were attempted prior to each administration.A review of Resident 63's clinical record revealed an order dated February 24, 2026, for Lorazepam (medication used to treat anxiety by producing a calming effect) 0.5mg every 12 hours as needed for anxiety. Review of the March 2026 eMAR indicated the medication was administered on March 1, 2026, at 11:30 PM, March 3, 2026, at 4:29 PM, and March 9, 2026, at 1:24 PM. The record lacked documentation that non-pharmacological interventions were attempted prior to each administration.Review of the February 24, 2026, Lorazepam order failed to identify a documented clinical rationale or specified duration extending the order beyond 14 days. The clinical record confirmed Resident 63 received the medication beyond the 14-day limit without required prescriber documentation of the justification for its use. A review of the clinical record revealed Resident 6 was admitted on [DATE], with diagnoses including gastrostomy (a surgically created opening into the stomach for nutrition or medication administration) and schizophrenia (a chronic mental disorder affecting thinking, perception, and behavior, often including hallucinations or delusions). A review of Resident 6's quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 6 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates intact cognition). A review of Resident 6's clinical record revealed a physician order dated January 3, 2026, for Lorazepam 1mg, apply topically (placed on the skin) every six hours as needed for agitation (a state of restlessness or emotional distress) and hallucinations (seeing or hearing things that are not present). Review of the January 2026 eMAR indicated the medication was administered to Resident 6 on January 9, 2026, at 1:32 AM, January 12, 2026, at 1:58 AM, January 14, 2026, at 8:39 PM, and January 21, 2026, at 1:32 PM. Review of the February 2026 eMAR indicated administration on February 7, 2026, at 10:06 PM, February 8, 2026, at 1:22 PM, February 10, 2026, at 4:18 PM, and February 13, 2026, at 10:48 PM. The record lacked documentation of non-pharmacological interventions prior to each administration. Review of Resident 6's January 3, 2026, physician order failed to identify a documented clinical rationale or specified duration extending the order beyond 14 days (after January 17, 2026). The clinical record confirmed the medication continued to be administered beyond the 14-day limit without required prescriber documentation or justification for its use.An interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on March 12, 2026, at 1:30 PM to review the above findings related to the administration of as-needed psychotropic medications without documented non-pharmacological interventions and the continuation of these medications beyond 14 days. During a separate interview with the Nursing Home Administrator (NHA) on March 13, 2026, at 9:40 AM, the facility did not provide documentation demonstrating that non-pharmacological interventions were implemented prior to the administration of as-needed psychotropic medications or documentation supporting a prescriber rationale and specified duration for continuation of these medications beyond 14 days. 28 Pa. Code 211.2(d)(3)(5) Medical Director. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on facility policy and clinical record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of infection for one of 15 residents reviewed (Resident 3).Findings include: According to the Centers for Disease Control and Prevention (CDC) (2024), Enhanced Barrier Precautions are measures to reduce the spread of multi-drug-resistant organisms (MDRO) (bacteria that are resistant to multiple antibiotics and are difficult to treat) in nursing homes. Enhanced Barrier Precautions require gown and glove use during resident care activities that have been demonstrated to result in transfer of MDROs to the hands and clothing of healthcare personnel. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The CDC (2024) identifies residents who are considered at a higher risk of acquiring an MDRO and further explains that residents with chronic wounds are among those at higher risk. The CDC (2024) further elaborates regarding higher risk categories by providing examples of residents at higher risk including those with chronic wounds. Review of the facility policy entitled, Infection Control Program-Enhanced Barrier Precautions, last reviewed May 13, 2025, revealed that Enhanced Barrier Precautions were to be used with any high-risk resident such as residents with a wound or indwelling device. According to the policy, Enhanced Barrier Precautions are indicated during high contact care activities including during wound care, providing hygiene, and changing briefs and linens. EBP includes the use protective gowns and gloves during high-risk activities and is intended to remain in place for the entire duration of the resident's stay, devices are removed, or wounds heal. Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included orthopedic aftercare for surgical amputation (specialized care and rehabilitation provided to patients who have undergone surgical procedures, including surgical removal of a limb). A review of Resident 3's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 12, 2026, revealed that Resident 3 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 7 through 3 indicates significant difficulties with memory, orientation, and thinking). Clinical record review of a document entitled Wound Assessment Report revealed Resident 3 had six chronic, arterial wounds (open skin areas caused by reduced blood flow leading to tissue damage and delayed healing) located on the left lateral foot, left foot, great toe, left heel, right lateral foot, right metatarsophalangeal joints (the joint area between the toes and the foot), right lower leg, and Achilles region. On March 10, 2026, at 1:45 PM, observation of Resident 3 in the resident room revealed no evidence that Enhanced Barrier Precautions were implemented. Protective gowns and gloves were not readily available for staff use upon entry to the room for high-contact care activities, including wound care. Clinical record review failed to identify a physician order for Enhanced Barrier Precautions. The resident's comprehensive care plan did not include Enhanced Barrier Precautions as an intervention to address the resident's multiple chronic wounds and increased risk for transmission of infection. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on March 11, 2026, at 1:45 PM. The above information was reviewed at that time. The facility did not demonstrate that Enhanced Barrier Precautions were implemented for Resident 3. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, review of employee personnel records, review of facility policies and procedures, and staff interviews, it was determined the facility failed to develop, implement, and maintain an effective training program to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely manage a peripherally inserted central catheter (PICC line) for 1 resident (Resident 63) of 15 residents reviewed.Findings include:Federal regulation requires that a facility develop, implement, and maintain an effective training program for all new and existing staff. The facility must use the facility assessment, which is an evaluation the facility conducts to identify the resident population served to determine the amount and types of training necessary to ensure staff competencies meet the needs of the residents as identified in their care plans and the facility assessment. A review of the facility policies entitled Medication Administration. Policy 5.09 Intravenous Administration of Fluids and Electrolytes and Medication Administration. Policy 5.10, Administering Medications Through Primary and Secondary Administration Sets last reviewed May 13, 2025, reveals intravenous fluids, electrolytes, and medications will be administered by nurses knowledgeable and competent in infusion therapy to ensure proper assessment and monitoring. The general guideline of the policies indicates the facility will verify with the Nurse Practice Act regarding RN/LPN scope of practice for intravenous therapy. Clinical record review revealed Resident 63 was admitted on [DATE], with diagnoses including sepsis (a serious infection that can spread throughout the body and lead to organ failure). A review of Resident 63's significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 1, 2026, revealed that Resident 63 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates significant difficulties with memory, orientation, and thinking). Resident 63 returned from the hospital with a Peripherally Inserted Central Catheter (PICC) line in the right upper arm. A PICC line is a long, flexible tube inserted through a vein in the arm and advanced into the larger veins near the heart. It allows medications, such as intravenous antibiotics, to be delivered directly into the bloodstream for extended periods. A review of physician orders dated December 27, 2025, required administration of Ceftriaxone Sodium (an intravenous antibiotic used to treat serious bacterial infections) daily for five days through the PICC line. The orders also required the PICC line to be flushed with 10 milliliters (mL) of normal saline (a sterile saltwater solution used to keep the catheter open and prevent blockage) before and after medication administration and during each shift. A review of Resident 63's December 2025 electronic Medication Administration Record (eMAR, serves as the legal record used to document medications administered) revealed the antibiotic was documented as administered four times, and normal saline flushes were documented 14 times through the PICC line by licensed nursing staff.Further review of the eMAR revealed the following licensed nurses documented accessing the PICC line to administer normal saline flushes:On December 28, 2025, and December 31, 2025, Employee 3 Licensed Practical Nurse (LPN) documented administering a normal saline flush through the PICC line.On December 28, 2025, Employee 4 LPN documented administering a normal saline flush through the PICC line. One December 29, 2025, and December 31, 2025, Employee 5 LPN documented administering a normal saline flush through the PICC line.On December 30, 2025, Employee 6 LPN documented administering a normal saline flush through the PICC line.Review of personnel records revealed the following:Employee 3, LPN, hired April 9, 2021, with most recent annual education dated April 9, 2025, had no documented education, training, or competency validation related to PICC line management.Employee 4, LPN, hired November 7, 2023, with most recent annual education dated May 2, 2025, had no documented education, training, or competency validation related to PICC line management.Employee 5, LPN, hired October 5, 2022, with most recent annual education dated November 11, 2025, had no documented education, training, or competency validation related to PICC line management.Employee 6, LPN, hired September 19, 2024, with most recent annual education dated October 30, 2025, had no documented education, training, or competency validation related to PICC line management.There was no evidence that the facility provided a structured training program, competency validation (a process used to confirm a staff member can safely and correctly perform a task), or ongoing education specific to PICC line care for licensed nursing staff. During an interview on March 13, 2026, at 9:50 AM, the surveyor requested documentation from the Nursing Home Administrator demonstrating education and competency validation for licensed nursing staff providing care to residents with PICC lines. The Nursing Home Administrator confirmed the facility could not provide evidence of such training or competency validation and confirmed the facility had not developed or implemented a training program specific to PICC line management. Pennsylvania State Board of Nursing regulations (Title 49, Chapter 21) require Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) performing intravenous therapy, which includes administration of medications and care involving PICC lines, to complete a board-approved education program, receive supervised clinical instruction, and undergo ongoing competency assessments. LPNs may perform only those intravenous therapy functions for which they have documented knowledge, skills, and abilities under appropriate supervision.The facility failed to develop, implement, and maintain an effective training program based on its facility assessment to ensure licensed nursing staff possessed the knowledge and competencies necessary to safely provide care to residents requiring PICC line management.Cross refer F 65828 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, facility policy, controlled drug shift count records, and staff interviews, it was determined the facility failed to implement procedures to ensure the timely acquisition and administration of a prescribed intravenous (IV) antibiotic for one of 16 sampled residents (Resident 34), and maintain accurate controlled drug shift count documentation on one of two medication carts reviewed, thereby failing to promote accountability and medication safety. Finding included: A review of a facility policy entitled Medication Availability last reviewed by the facility May 2024, indicated a procedure if a medication is not available the facility's procedure required staff to check the Cubex (is an automated medication dispensing machine system used for healthcare management that helps deter delayed medication administration and improve inventory management for healthcare facilities). If the prescribed medication was not available, staff were to contact the pharmacy for delivery status and request STAT (immediate) delivery and place a call into the satellite pharmacy (decentralized pharmacy program) and if the medication is unavailable notify the physician and obtain an order to hold until available or alternative medication is ordered, notify the RR (resident representative), and document outcomes in the nurses' notes. A clinical record review revealed Resident 34 was readmitted from the hospital to the facility on [DATE], at approximately 2:29 PM, with diagnosis that included, sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and UTI (urinary tract infection is a general term for infectious diseases in which bacteria enter the urethra, the passage through which urine passes, and propagate inside the body). Additionally, the resident returned to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart) for medication administration. A physician's order dated March 19, 2025, directed administration of Meropenem (antibiotic)1 gram IV via PICC line every 12 hours for five days. A review of nurses' administration note dated March 19, 2025, at 9:28 PM, revealed that Meropenem was not available for administration to the resident. Further review of a nurses' administration note dated March 24, 2025, at 10:09 PM, revealed that Meropenem was not on unit for administration. Review of the Medication Administration Record (MAR) for March 2025 revealed missed doses of Meropenem on March 19, 2025, at 9:00 PM, and again on March 24, 2025, at 9:00 PM. Nursing notes documented that the medication was not available on both dates. The clinical record lacked documentation that the physician or resident representative was notified of the missed doses. As a result, the resident did not receive the full course of the prescribed antibiotic therapy. During an interview with the Nursing Home Administrator (NHA) on May 1, 2025, at 10:30 AM, the NHA acknowledged the facility could not provide documentation confirming that the missed antibiotic doses were administered or that the physician had been notified. The NHA further confirmed the facility had backup pharmacy resources in place that should have been contacted to prevent a missed dose. A review of the facility policy titled Controlled Narcotic Sign-off Sheet, last reviewed in May 2024, indicated that Schedule II medications were to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required on the shift count sheet to verify accuracy and completion. A review of the controlled medication shift change log for the 100-unit medication cart revealed missing signatures as follows: April 25, 2025: Third shift outgoing nurse failed to sign indicating the count was completed and accurate. April 26, 2025: Day shift oncoming nurse and outgoing nurse both failed to sign indicating the count was completed and accurate. An interview with Employee 1 Licensed Practical Nurse (LPN) on April 30,2025 at 8:35 AM confirmed the narcotic sheet was not signed off by the off going and oncoming nurses on the above dates. During an interview with Employee #1, Licensed Practical Nurse (LPN), on April 30, 2025, at 8:35 AM, it was confirmed that the shift count sheet had not been signed by the responsible nurses on the noted dates. In a separate interview conducted with the NHA on April 30, 2025, at 11:45 AM, the NHA confirmed that the facility failed to demonstrate consistent adherence to procedures for verifying and documenting controlled substance counts. 28 Pa. Code 211.9 (f)(2) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f)(x) Clinical records

Based on clinical record review, staff interview, and facility documentation, it was determined the facility failed to develop a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, mental, and psychosocial needs for one of 25 sampled residents (Resident 37), who expressed suicidal ideations. Findings include: A review of the clinical record revealed that Resident 37 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning). A progress note dated April 2, 2025, at 11:45 a.m., documented that the resident expressed suicidal ideation, stating to a staff member that she wanted to kill herself. Following this, the resident was evaluated by the facility's social services department and placed on every 15-minute checks. However, a review of the resident's comprehensive care plan, in effect as of the survey ending May 1, 2025, revealed no evidence that the facility updated the plan of care to reflect the resident's expressed suicidal ideations or implemented new interventions to address the risk of self-harm. The care plan did not include the resident's psychosocial need related to mental health risk or outline strategies to monitor, support, and ensure the resident's safety. In an interview conducted on May 1, 2025, at 11:00 a.m., the Nursing Home Administrator confirmed the facility had not developed or updated a person-centered care plan to address the resident's suicidal ideation. 28 Pa. Code 211.11(d) Resident care plan. 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 review and revise the comprehensive care plan to reflect a significant change in condition related to weight loss for one of 16 residents sampled (Resident 2). Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily functioning). A review of the resident's documented weights revealed the following: On November 4, 2024, Resident 2 weighed 203.3 pounds. On December 4, 2024, the resident weighed 189.5 pounds, which represented a 6.8% loss of body weight in 30 days. A nutrition progress note dated December 6, 2024, indicated the registered dietitian (RD) assessed Resident 2 due to the identified weight loss and continued to recommend interventions. However, the resident's current care plan, which was originally developed on August 11, 2024, identified the resident as being at nutritional risk related to dementia and a mechanically altered diet, with interventions in place at that time. Upon review of the care plan during the survey conducted April 28 through May 1, 2025, there was no documented evidence the care plan had been reviewed or revised to reflect the resident's significant weight loss identified in December 2024. There were no new interventions added or existing interventions updated to reflect the change in nutritional status or to address the resident's ongoing weight trends. An interview was conducted with the Nursing Home Administrator on May 1, 2025, at 2:30 PM. The Administrator confirmed the facility failed to update Resident 2's care plan following the significant weight loss noted in December 2024 and acknowledged the resident's plan of care should have been reviewed and revised to reflect the change in condition and the resident's current needs. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of select facility policy, clinical records and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for bowel protocol to promote normal bowel activity for one resident (Resident 42), failed to provide consistent application of prescribed therapeutic devices and preventative measures, skin sleeves, TED stockings, and heel floats for three residents (Residents 42, 46, and 48, and failed to constantly document food/fluid intakes to accurately monitor and timely identify changes in a resident's condition for one resident out of 16 sampled (Resident 24). Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week. A review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease (a progressive brain disease that destroys memory and other important mental functions), and chronic kidney disease stage 3 (moderate to severe loss of kidney function). The resident had physician orders dated March 28, 2024, for the following bowel regimen: - Milk of Magnesia Suspension (MOM) 400 mg/5ml (Magnesium Hydroxide). Give 30 ml by mouth as needed for no BM (bowel movement) in 3 days on the 7-3 shift (dayshift). - Bisacodyl Oral Tablet Delayed Release 5 mg (Bisacodyl). Give 2 tablets by mouth as needed for 24 hours after MOM if no BM. - Fleet Enema 7-19 gm/118 ml (Sodium Phosphates). Insert 1 application rectally as needed for 12hrs after Bisacodyl if no BM. A review of Resident 42's report of bowel activity from the Documentation Survey Report for May 2024, revealed the resident did not have bowel movements on May 10, 11, 12, 13, 14, 15, 2024. (6 consecutive days). Review of Resident 42's Medication Administration Record (MAR) for May 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. Review of Resident 42's report of bowel activity from the Documentation Survey Report for July 2024, revealed the resident did not have bowel movements on July 4, 5, 6, 7, 8, 2024 (5 consecutive days) and July 23, 24, 25, 26, 2024 (four consecutive days). Review of Resident 42's Medication Administration Record (MAR) for July 2024, revealed no documented evidence that nursing administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. During an interview with the Director of Nursing (DON) on August 8, 2024, at 12:05 PM, the DON confirmed the facility failed to provide nursing services consistent with professional standards and was unable to provide evidence that physician ordered bowel protocol was followed for Resident 42. Further review of Resident 42's clinical record revealed a physician's order dated March 26, 2024, for Geri-sleeves (fabric material, often lightly padded, to protect thin/fragile skin from skin tears, abrasions and light bruising) to BUE [bilateral upper extremities (arms)] at all times except for hygiene, and to check skin integrity every shift. An additional physician's order dated May 2, 2024, revealed an order for the application of TED stockings (Thrombo-Embolic Deterrent - anti-embolism stockings for the legs to help prevent blood clots) to BLE [bilateral lower extremities (legs)] one time a day for bilateral edema edema and remove per schedule. A review of Resident 42's care plan, in effect at the time of the survey ending August 8, 2024, indicated the resident was to wear Geri-sleeves on her arms at all times, and to apply TED stockings to her legs and to check skin integrity with application and removal of the devices. An observation of Resident 42 on August 7, 2024 , at 1:55 PM revealed that Resident 42 was sitting in her wheelchair in the activity room and did not have the ordered Geri-sleeves on her arms to protect her skin nor did she have the TED stockings to her legs for edema as ordered. A review of Resident 46's clinical record revealed the resident was admitted to the facility on [DATE], with diagnosis to include chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in one or more arteries in the lungs), and diabetes (failure of the body to produce insulin). A review of a physician's order dated May 29, 2024, revealed an order for TED stockings to be applied in the AM and remove at hours of sleep; check skin integrity with application and removal two times a day. Observation of Resident 46 on August 6, 2024, at 1:45 PM and August 7, 2024 , at 11:00 AM revealed that the resident was not wearing TED stockings on his legs as ordered at the time of each observation. A review of Resident 48's clinical record revealed that the resident was most recently admitted to the facility on [DATE], with diagnosis to include presence of a left artificial hip joint (hip replacement), and a wedge compression fracture of the first and second lumbar vertebra (fracture occurring at the front of the spinal vertebra of the low back). A review of physician's order dated July 24, 2024, revealed an order to maintain left hip precautions every shift status post ORIF (Open reduction and internal fixation-type of surgery used to stabilize and heal a broken bone). Hip precautions are ordered following a hip replacement to prevent dislocation. General hip precautions include: - Do not cross legs or ankles when sitting, standing or lying down. Keep feet about 6 inches apart and do not bring them all the way together. - Avoid hip flexion (forward bending) greater than 90 degrees. - Do not twist the upper body when standing or when rolling in bed (use log roll method) A review of a physician's order dated July 23, 2024, revealed an order to float heels (elevate heels above bed) every shift for prevention (prevent pressure ulcers from occurring on the heels). A review of a physician's order dated August 3, 2024, revealed an order to utilize an abductor pillow (specialty pillow used to restrict hip movement and keep hip in proper alignment as a precautionary measure to help prevent hip dislocation) between her legs at all times. A review of Resident 48's care plan, in effect at the time of the survey ending August 8, 2024, indicated that staff was to offload her heels when in bed and to utilize an abductor pillow between her legs at all times to maintain hip precautions. Observation of Resident 48 while lying in bed on August 6, 2024, at 1:00 PM revealed the resident's heels were in direct contact with the mattress and were not off loaded as ordered. The resident's left toes were pressed up against the hook of the air mattress motor which was hung over the bed footboard. Further observation revealed the resident had one bed pillow between her legs. Her knees were close together and her feet were approximately 4-inches apart, not adhering to the ordered hip precautions. No abductor pillow was positioned between her legs as ordered at the time of observation. The abductor pillow and an abductor wedge were located on the resident's floor next to the dresser drawers. Interview with Employee 1 licensed practical nurse (LPN) on August 6, 2024, at 1:10 PM confirmed the resident's heels were in direct contact with the mattress and were not off loaded. Employee 1 confirmed the resident's left lower extremity was not positioned properly and was not in adherence to the physician ordered hip precautions. A review of a facility policy entitled Measuring Resident Oral Intake last reviewed by the facility on May 23, 2024, indicated that each resident's oral intake at mealtimes and in-between meals shall be recorded and entered into the electronic medical record (eMAR - is an alternative to paper-based medical charts that serves as a legal documents collector for medical clinics and it creates and saves a record of every medicine administered to a patient over the treatment cycle). The purpose of this procedure is to accurately record the amount of food and fluids ingested by the resident after each shift. Staff will enter the amount of food and fluids into the eMAR before the end of shift by nurse aide (NA), Licensed Practical Nurse (LPN), or Registered Nurse (RN). If the resident is noted with decreased oral intake for three (3) meals or more, it is the responsibility of the nurse to report the resident's decreased oral intake to the MD/NP/PA, the registered dietitian (RD), and the resident representative (RR). A review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease ( condition where plaque builds up in the arteries and can cause heart attacks, strokes, and other complications) with presence of xenogeneic heart valve (replaces a damaged valve in the heart and made from tissue sourced from animals such as pigs or cows), chronic heart failure (is an ongoing inability of the heart to pump enough blood through the body to ensure a sufficient supply of oxygen). A review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 21, 2024, revealed that Resident 24 was cognitively intact with a BIMS (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 7-12 equates to being moderately cognitively impaired) score of 13. A nursing progress note completed by Employee 5, a RN, dated April 24, 2024, at 9:12 p.m., revealed the resident was assessed secondary to 14.4 - pound (lb.) or 5.4% weight loss in 30 days. It was noted the resident's mucous membranes were moist, skin turgor was adequate, and the resident's appetite was fair. There were no signs or symptoms of dehydration. A fluid restriction was in place and the physician was made aware. There were no new order at the tie of the progress note. The note indicated the Dietitian was monitoring the resident. The resident is her own responsible representative and is aware of the information noted . A review of Resident 24's fluid intake report revealed that the following recorded fluids that were consume: April 25, 2024 - 810 ml, April 26, 2024 - 1290 ml recorded, April 27, 2024 - 1,930 ml recorded, April 28, 2024 - 1,410 ml recorded, April 29, 2024 - 1,320 ml, April 30, 2024 - 1,590 ml, May 1, 2024 - 390 ml, May 2, 2024 - 2,040 ml, May 3, 2024 - 600 ml, May 4, 2024 - 1,020 ml, May 5, 2024 - 1,200 ml, May 6, 2024 - 1080 ml, and May 7, 2024 - 600 ml. Additionally, a review of Resident 24's meal intake report revealed from April 25, 2024, through May 7, 2024, or thirty-nine (39) meals served there were twenty (20) missed entries or 48.7% of meal intakes were not recorded or assessed by staff. Documentation that the resident refused (RR) or not applicable (NA) was recorded by for three meal entries or 7.69%. Recorded meal percentages averaged approximately 20.65%. However, this documentation could not accurately assess the resident's actual meal intakes due to missed entries and not applicable documentation. A progress note completed by Employee 6, a RN, dated May 2, 2024, at 6:44 p.m., revealed Resident 24 offered complaints of feeling tired all the time. The note indicated the resident requires assistance of two persons for transfers and with activities of daily living. The resident previously required one person for assistance, The note indicated the resident's appetite was poor and the resident reports not being able to eat and did not attend therapy in the day of this note. A progress note written by Employee 2, the facility's registered dietitian (RD), completed on May 3, 2024, at 12:38 p.m.,revealed that Resident 24's weights were reviewed, and the resident's current weight was at 240.8 pounds and triggered for significant weight loss of 21.2 pounds within t 30 days or 8.1% weight loss. The resident's weight has been decreasing since admission. The resident's oral intakes were approximately 25-50% and the resident was ordered on diuretics (or water pill is a medication that removes extra salt and water built up in the body to improve cardiac function by increasing the need to urinate) and placed on a fluid restriction. A diet supplemented with liquid protein was ordered and the RD recommended offering the resident a 1/2 of a soft sandwich with lunch and dinner due to poor meal intake. The RD noted the resident to have lower leg edema (swelling) upon admission. The weight loss can be attributed to poor oral intakes and a decrease in edema. Nursing progress notes dated from May 2, 2024, through May 6, 2024, revealed that Resident 24 continued to have poor appetite with a need for staff to encourage fluids and that the resident's transfer status declined from an assist of one staff member to an assist of two staff members with transfers and ADLs (activities of daily living). Additionally, the nursing progress notes noted that the resident had increased urinary and bowel incontinence related to diuretics. Employee 7, a RN, completed a nursing progress note dated May 7, 2024, which identified abnormal laboratory results and indicated that Resident 24's attending physician ordered to initiate IV fluids (are specially formulated liquids that are injected into a vein to prevent or treat dehydration) of normal saline (also known as 0.9% sodium chloride solution, is a commonly used intravenous fluid in medical settings and is a sterile solution containing sodium chloride in a concentration similar to that of human blood) at 80 ml per hour and an order to redraw labs and obtain a chest x-ray on May 8, 2024. The resident agreed with the orders. A note written by Employee 8, an RN, dated May 7, 2024, at 2:23 p.m., indicated she was unable to obtain IV access (IV fluids could not be started) and the resident appeared lethargic (an unusual decrease in consciousness). The MD was made aware of the inability to administer fluids and the resident was encouraged to drink more fluids. Further review of nursing progress notes revealed that on May 8, 2024, at 3:40 a.m., Employee 9, an RN, attempted again, twice, to place the IV and was unsuccessful. The resident was encouraged to drink more fluids. Additionally, on May 8, 2024, at 10:17 a.m., Employee 10, an RN, noted that Resident 24 stated she felt awful with complaints of nausea, and vomiting. Due to the abnormal labs, increasing weakness, and change in mental status, and overall condition and the inability for the facility to provide IV fluids, the MD advised the resident to be transferred to the hospital for an evaluation. An interview with Employee 11, a RD, on August 8, 2024, at 10:56 a.m., indicated he was not employed by the facility during the time of Resident 24's changes in condition. Employee 11 confirmed that meal intake monitoring for Resident 24 was not accurate due to several missed entries and not applicable documentation. A review of the resident's hospital records revealed that Resident 24 was admitted to the hospital on May 8, 2024, with a critically high potassium at 6.6 mmol/L (reference range 3.5 - 5.1 mmol/L -A potassium blood test measures the amount of potassium in the blood that reflects the function of the body's cells, nerves, heart, and muscles), acute renal failure (AKI is a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days with symptoms that include legs swelling and fatigue), dehydration (occurs as a result of abnormal water loss from the body), and endocarditis (is a life-threatening inflammation of the inner lining of the heart's chambers and valves that is usually caused by an infection). The facility failed to consistently and accurately record Resident 24's food/fluid intakes and failed to timely act on changes in condition to prevent critical lab values resulting in hospitalization . An interview with the Director of Nursing (DON) on August 8, 2024, at 11:00 a.m., confirmed that Resident 24's fluid intakes were not consistently and accurately recorded, and that staff were unsuccessful with implementing IV fluids as ordered by the physician. Additionally, the DON confirmed that staff failed to timely act on Resident 24's changes in condition that resulted in critical labs and hospitalization . 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(ii) Medical records

Based on a review of clinical records and select facility policies, and staff interviews, it was determined that the facility failed to monitor resident weights consistently and accurately to timely identify changes in nutritional parameters and failed to develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration for one resident out of six residents sampled with weight loss (Residents 43). Findings included: A review of facility policy titled Resident Heights and Weights, last reviewed by the facility on [DATE], indicated that the facility would utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss in residents. Resident weights were recorded in the electronic health record and a reweight was obtained for any residents whose weight fluctuated by plus (+) or minus (-) five pounds (lbs.) for those over 100 lbs. and plus or minus three pounds for those weighing less than 100 lbs. Any resident being tracked as at nutritional risk for significant weight loss or sudden poor intake, shall be weighed weekly or as specified by the registered dietitian. A review of Resident 43's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by problems with metabolism, such as low glucose or high toxins), muscle weakness, and Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). A review of Resident 43's comprehensive person-centered plan of care that was initiated on [DATE], and revised on February 6, 2024, identified that the resident had a nutritional problem related to need for a therapeutic diet, diagnoses of hypertension and diabetes, and resident goal to maintain adequate nutritional status as evidenced by maintaining weight within +/-5# and no signs or symptoms of malnutrition. Planned interventions included to monitor/record/report to MD as needed (PRN) signs and/or symptoms of malnutrition such as emaciation(abnormally thin) or Cachexia (weakness and wasting of the body due to severe chronic illness,) muscle wasting, significant weight loss: 3-pounds in 1 week, greater than (>) 5% in 1 month, greater than (>) 7.5% in 3 months, greater than (>) 10% in 6 months, and RD to evaluate and make diet changes and recommendations PRN. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated [DATE], revealed that Resident 43 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of ,d+[DATE] indicates cognition is intact). A review of the weight record in Resident 43's clinical record revealed the following record weights: [DATE], at 2:32 p.m. - 127 lbs. [DATE], at 9:17 a.m. - 118.6 lbs. (no re-weight recorded) [DATE], at 3:02 p.m. - 110.9 lbs. [DATE], at 1:48 p.m. - 110.8 lbs. [DATE], at 11:30 a.m. - 101.2 lbs. [DATE], 2:20 a.m. - 97.6 lbs. A review of a progress note completed by Employee 2, Registered Dietitian (RD), dated [DATE], at 1:36 p.m., revealed weight was at 118.6-pounds and triggered for significant weight loss of 8.4-pounds in 30 days. The RD documented that a re-weight was needed. Further review of Resident 43's weight record revealed that on [DATE], at 3:02 p.m., a new weight was obtained and the resident now weighed 110.9 lbs.This signified a further weight loss of 7.7-pounds or 6.4% in 2-weeks and a loss of 16.1-pounds or 12.7% in greater than 30-days. A review of a nutritional assessment initiated by Employee 2 on [DATE], and signed by Employee 2 on [DATE], at 1:08 p.m., revealed that Resident 43 was receiving a NAS (no added salt), CCHO (consistent carbohydrate) diet, regular texture, and thin liquids with fortified shakes (high calorie high protein supplement) twice (BID) per day with good acceptance. Employee 2 noted that the resident's current appetite was fair and historically good appetite. Weight: 118.7-pounds ([DATE], at 9:17 a.m.) and usual body weight 115 - 120 pounds. Employee 2 indicated a weight loss of 8-pounds in 30 days. Further review of Resident 43's nutrition progress notes in the clinical record completed by Employee 2, dated [DATE], at 11:20 a.m., revealed that a re-weight was obtained, and additional weight loss noted. The RD documented the residents current weight was110.9-pounds and oral intakes were inconsistent at ,d+[DATE]%. zTHe RD documented that Remeron (appetite stimulant medication) was discontinued in March and weight loss was most likely attributed to decreased oral intakes related to the discontinuation of Remeron (appetite stimulant). The plan was to discuss the implementation of an appetite stimulant with the IDT (interdisciplinary team). A review of Resident 43's physician's orders dated [DATE], at 2:13 p.m., revealed an order for Mighty Shake (high calorie/high protein oral supplement) twice per day was ordered related to weight loss. Further review of physician's orders dated [DATE], at 12:26 p.m., revealed an order for Megace ES (an appetite stimulate medication) oral suspension 625 milligrams per 5 milliliters (ml), give 5 ml by mouth two times a day for appetite stimulant was also included. A review of a nutrition/dietary note completed by Employee 2 on [DATE], at 8:36 a.m. revealed that weights were reviewed and current weight at 110.8-pounds with significant weight loss of 7.8-pounds (6.6%) in 30 days. BMI (body mass index) within normal limits at 20.3. Resident has a history of weight fluctuations. Oral intakes ,d+[DATE]% and diet supplemented with mighty shakes twice per day and consumes 100%. Employee 2 recommend increasing shakes to three times per day. Megace was started on [DATE] and the plan was to continue to monitor. Resident 43's weight record revealed that on [DATE], at 11:30 a.m., the resident's weight had deceased to 101.2-pounds., and on [DATE], at 2:20 a.m., the resident weighed 97.6-pounds. A review of a nutrition/dietary note completed by Employee 2 on [DATE], at 3:16 p.m., revealed that Resident 43 had weight loss of 26-pounds (20.9%) within five months. BMI low at 17.8. Current weight 97.6-pounds and oral intakes poor. Seen by speech therapy and needs assistance during meals to promote increased intakes. Diet supplemented with mighty shakes with meals and recommend Boost Glucose (diabetic oral nutritional supplement) Control twice per day. A nursing progress notes in Resident 43's clinical record completed by Employee 3, a Licensed Practical Nurse (LPN), on [DATE], at 1:56 p.m., revealed that the resident was very sleepy during lunch time and when attempting to feed the resident, food would come back out of mouth, resident was also having difficulty drawing up liquids through a straw. Employee 3 sent communication to speech therapy for re-evaluation. Further review of nursing progress notes completed by Employee 4, a RN, dated [DATE], at 12:34 p.m., revealed that orders were obtained from the attending physician to send the Resident 43 to the emergency department for evaluation. A review of Resident 43's hospital records dated [DATE], at 12:54 p.m., revealed that the resident was admitted to the hospital with diagnoses of urinary tract infection, AKI (acute kidney injury - a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days and symptoms include legs swelling and fatigue) secondary to dehydration (occurs when the body loses more fluid than consumed, and does not have enough water and other fluids to carry out normal functions), hypotension (low blood pressure), and insertion of a feeding tube (is a flexible plastic tube placed into the stomach or bowel to help with getting nutrition when unable to eat as well as needed to improve or maintain nutritional status) to meet nutrition and hydration needs. Resident 43's clinical record failed to reveal that weights and re-weights were timely obtained, assessed, and monitored to timely develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration. Additionally, the RD failed to evaluate the continued effectiveness of nutritional interventions and demonstrate that alternative methods and approaches for delivery of nutrition and hydration were presented and discussed with the resident whose cognition was intact, the resident representative with the resident's permission, interdisciplinary team (IDT), and attending physician, to deter progressive significant weight loss and dehydration. During an interview with the facility's Director of Nursing (DON) on [DATE], it was confirmed that weights and re-weights were not timely obtained as indicated in the facility's height and weight policy and that the facility failed develop/revise and implement effective nutrition management interventions to prevent further significant weight loss and dehydration. Also, the DON confirmed that the facility failed to timely identify and address Resident 43's declining oral intakes that resulted in progressive significant weight losses with need for hospitalization and placement of a feeding tube. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on review of select facility policy, meal delivery times, snack listing and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to four of four residents interviewed (Residents 4, 3, 40, and 27) and failed to offer a nourishing snack to all residents when the dinner meal is greater than 14 hours before breakfast is served. Findings include: Review of the facility policy titled HS Snack Policy last reviewed by the facility on May 23, 2024, indicated that all residents, unless medically contraindicated, will be provided a nourishing snack at bedtime daily. A nourishing snack means items from the basic food groups, whether singly or in combination with each other. During a group meeting with residents conducted on August 7, 2024, at 10:00 a.m. four out of four residents (Residents 4, 3, 40, and 27) in attendance, stated that they are not offered snacks during the evening hours before bed as desired. Resident 40 stated I've been here for several months, and they haven't offered snacks. Resident 27 stated that the facility staff used to come around with a cart after supper and ask what you wanted. That was so nice, but they don't do that anymore. All other residents in attendance agreed that no one ever offers them an evening snack. Review of meal tray delivery times revealed: Hallways: Dinner delivery finish time is 5:00 PM and breakfast delivery finish time is 7:45 AM (14 hours 45 minutes). Dining room: Dinner delivery finish time is 5:15 PM and breakfast delivery finish time is 8:00 AM (14 hours 45 minutes). The dinner meal is greater than 14 hours before breakfast is served, therefore a nourishing snack must be provided. A nourishing snack means items from the basic food groups (carbohydrate, protein and fat), either singly or in combination with each other. Review of the HS snacks sent to the nursing unit revealed the following snacks delivered: 8- Magic cups 8- ice cream 8- lactose free ice cream 15 - milk 15 - chocolate milk 8 - yogurts 20 - sandwiches 1 - Gluten free sandwich 15 - juices 2 - bottles of honey thicken liquids (if applicable) 2 - bottles of nectar thicken liquids 2 - bottles of nectar thicken liquids 2 - honey milk 20 - assorted crackers 20 - assorted cookies/chips 5 - fruit Observation on August 8, 2024 at 11:45 AM of the snack bins behind the nursing station revealed one rice crispy treat and 15 peanut butter crackers. Observation of the locked refrigerator/freezer revealed 4 sandwiches, 3 juices, and 4 milks. There was no evidence that each resident on the nursing unit was offered a nourishing snack because the mealtimes were greater than 14 hours. During an interview with the Registered Dietitian on August 8, 2024, at approximately 10:30 AM, he was unable to explain why the residents are not consistently offered a nourishing snack at bedtime due to the interval of more than 14 hours between dinner and breakfast. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services

Based on review of clinical records and select facility reports, observations and staff and resident interviews it was determined the facility failed to consistently implement measures planned to promote healing, prevent worsening and the development of pressure sores for one resident out of 16 residents sampled (Resident 43). Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of facility policy entitled New Admission or New Skin Impairment Protocol, last reviewed May 23, 2024, indicated that residents admitted or whom develop skin impairment issues will receive treatment as indicated based on location, condition, and drainage. According to policy, the registered nurse will complete an incident/accident report as per policy for residents with new identified skin impairments. Each area identified will be documented on a Wound Evaluation Flow Sheet, and documentation will include measurement, exudate (drainage), wound bed, peri-wound (area around the wound), and current treatment. A review of the clinical record revealed that Resident 43 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, heart disease, and diabetes. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 2, 2024, revealed the resident was moderately cognitively impaired and required substantial/maximum assistance from staff for transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development. A review of the weight record in Resident 43's clinical record revealed the following record weights: March 7, 2024, at 2:32 p.m. - 127 lbs. April 1, 2024, at 9:17 a.m. - 118.6 lbs. (no re-weight recorded) April 12, 2024, at 3:02 p.m. - 110.9 lbs. May 1, 2024, at 1:48 p.m. - 110.8 lbs. June 7, 2024, at 11:30 a.m. - 101.2 lbs. June 16, 2024, 2:20 a.m. - 97.6 lbs A review of Resident 43's care plan initiated March 31, 2023, revealed the resident was at risk for skin breakdown related to immobility and bowel incontinence, with interventions also dated March 31, 2023, for an air mattress-and check function every shift, apply treatment per MD orders, monitor weight and notify physician of any significant weight loss, provide routine position change through weight shifting, transfer to bed/toilet, stand at intervals with assist, routine skin care during personal hygiene with application of emollient, and weekly skin assessment. A nurse's note dated June 28, 2024, at 10:50 PM, indicated that during morning care to Resident 43, a new wound was noted on the resident's sacrum area. The wound is beefy red with 25% of slough (dead tissue), minimal bleeding, and not painful. According to the documentation, the resident was not able to explain when and how the area developed. The note indicated that wound care is provided, the resident requires every two hours repositioning and the resident is scheduled for wound care consultant rounds. A review of the facility's investigation dated June 28, 2024, at 10:35 AM, revealed that prior to June 28, 2024, the skin concern was not identified by staff who were providing care to the resident. According to the investigation, a treatment order was obtained from the physician on June 28, 2024 to cleanse the resident's sacral wound with normal saline, and apply medihoney every day shift for Stage 3 pressure ulcer (pressure sores that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). There was no evidence that during the facility investigation the wound was evaluated for size, drainage, or condition of surrounding tissue. Review of Resident 43's clinical record revealed that on July 1, 2024, the resident was sent to the emergency room due to a change in condition. Hospital documentation dated July 1, 2024, at 4:13 PM indicated that due to the resident being sent to the hospital, consideration for air mattress upon return was recommended. However, according to the current plan of care, an air mattress had been implemented since March 2023. Although the resident was identified with a significant weight loss and risk factors which increased the resident's risk of pressure ulcers the facility did not implement additional measure to prevent the development of a pressure ulcer. Interview with the interim Director of Nursing on August 8, 2024, at approximately 2:10 PM, confirmed that the facility failed to evaluate Resident 43's pressure area and implement the facility's Skin Impairment Protocol by failing evaluate the sacral area. Refer F692 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on observation, a review of clinical records, and resident and staff interview, it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis (Resident 218). Findings include: According to the National Kidney Foundation, patients receiving hemodialysis( a life saving treament for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) should keep emergency care supplies on hand. A review of the resident's clinical record revealed that Resident 218 was admitted to the facility on [DATE], with diagnoses to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Resident 218's clinical record indicated he was receiving hemodialysis through an Ash Cath(type of vascular access hemodialysis catheter) in his left arm (dialysis access site) for dialysis access every Monday, Wednesday, and Friday. Resident 218's clinical record revealed a physician order dated July 29, 2024, for an emergency kit at bedside for the dialysis access site . The resident's plan of care, dated July 30, 2024, indicated that Resident 218 required dialysis due to end stage renal disease. The care plan did not include interventions planned for emergency care of the Ash Cath to include an emergency dialysis kit at bedside despite the physician's order. Observation conducted on August 6, 2024, 12:45 PM revealed no emergency kit or supplies available at the resident's bedside. Interview with Resident 218 in his room on August 6, 2024, at 12:45 PM indicated that the resident never saw or was informed of an emergency kit for his dialysis site in his room since admission on July 29, 2024. Interview with the Director of Nursing (DON) on August 6, 2024, at 2:07 PM revealed that each resident in the facility receiving dialysis should have emergency supplies at bedside. The DON confirmed that there were no emergency supplies available at Resident 218's bedside and that facility failed to assure an emergency kit was readily available in the event of an emergency with the resident's dialysis access site. 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review, payor source data, and staff interview, it was determined that the facility failed to promptly refer a resident with a broken bridge for dental services for one Medicaid payor source resident (Resident 4) and failed to provide dental services for a resident with poor dentition and high-risk diagnosis (heart valve) with Medicaid as payor source (Resident 24). Findings included: Review of the clinical record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include diverticulitis (inflammation or infection in one or more small pouches in the digestive tract), and hypertension (high blood pressure-force of blood against the artery walls is too high). Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated May 19, 2024, revealed that Resident 4 was moderately cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 7-12 equates to being moderately cognitively impaired). Review of a nurses note dated July 1, 2024, at 7:12 AM revealed that the resident's upper bridge( fixed or removable dental restoration used to replace one or more missing teeth by joining an artificial tooth definitively to adjacent teeth or dental implaints) broke off. It was documented that Resident 4's representative was notified. A speech therapy note dated July 3, 2024, at 3:18 PM revealed that the resident was screened for two noon meals due to the broken dentaql appliance. The Speech Therapist determined that the resident was able to safely manage a regular texture diet and was scheduled to see a dentist on July 17, 2024. The speech therapy plan was to follow-up with the resident after the dental consult. There was no further documentation in the resident's clinical record regarding the completion outcome of the appointment or the reason why the appointment had not been completed as scheduled. A review of the resident's clinical record, revealed there was no indiction the Speech Therapist had followed-up after the intended July 17, 2024 appointment to review Resident 4 for meal texture tolerance or to identify the resident did not have a repaired dental appliance. There was no documented evidence that a repair or replacement of Resident 4's upper bridge had been completed at the time of the survey ending August 8, 2024. During an interview on August 8, 2024, at approximately 1:15 PM the Director of Nursing (DON) was unable to provide documented evidence that the facility had provided timely and necessary assistance to obtain dental services needed by the resident to repair or obtain a new/replacement bridge. A review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (is a condition where plaque builds up in your arteries and can cause heart attacks, strokes, and other complications) with presence of xenogeneic heart valve (replaces a damaged valve in the heart and made from tissue sourced from animals such as pigs or cows). Further review of Resident 24's clinical record admission assessment section D. Oral/Nutritional dated March 14, 2024, at 4:47 p.m., revealed that had broken/carious teeth and broken bottom dentures. Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 21, 2024, revealed that Resident 24 was cognitively intact with a BIMS score of 13. A review of Resident 24's clinical record revealed that the resident was admitted to the hospital on May 8, 2024, and diagnosed with endocarditis (is an inflammation of the inner lining of the heart chambers and valves that is usually caused by bacterial infection. Further review of Resident 24's cardiology consults included in the hospital records dated May 8, 2024, revealed cardiologist findings that the resident had poor dentition and her heart valve had large amounts of mobile vegetation (growths on the heart valves that produces toxins and enzymes that kill and break down the tissue to cause holes in the valve, and spreads outside of the heart and blood vessels present). Resident 24's clinical record failed to reveal that the facility arranged/provided dental services to address the resident's poor dental condition which had been identified on Resident 24's MDS and during hospitalization . During an interview with the facility's Director of Nursing (DON) on August 8, 2024, at 11:30 a.m., confirmed that dental services were not provided to Resident 24 to prevent hospitalization with infection related to poor dental condition. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing service

Based on review of select facility policy and reports, clinical records and resident and staff interviews, it was determined that the facility failed to demonstrate the implementation of ongoing QAPI programs, to include the use of systems for investigating and analyzing the root cause of adverse events as evidenced by one resident out of 16 sampled (Resident 41). Findings include: Review of the facility policy entitled Quality Assurance and Performance Improvement Plan last reviewed by the facility on May 23, 2024, revealed that the facility will put in place systems to monitor care and services, drawing from data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also will include tracking, investigating, and monitoring adverse events every time they occur, and action plans implemented through the plan. Goals of the QAPI plan include: 1. The facility will place proper infection control prevention to prevent or decrease the number of COVID-19 positive residents. 2. The facility will create a QAPI team and a QAPI program to address needs, concerns, and tracking and trending events. 3. The facility will continue to train staff to include competencies, in person education, mentoring, and written education. The QAPI approach/plan will also be communicated to consultants, contractors, and collaborating agencies, to ensure they understand that they each have a role in the QAPI plan. Clinical record review revealed that Resident 41 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis following stroke affecting left non-dominant side, aphasia (language disorder that affects a person's ability to communicate) following stroke, and dementia (the loss of cognitive functioning like thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of an Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 30, 2024, revealed that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 10 (score of 8-12 indicated that the resident was moderately cognitively impaired), and required extensive assistance to perform toileting and bed mobility tasks. Review of the resident's care plan, dated June 6, 2023, revealed that she required the assist of one person for toileting and commode over toilet, the assist of one person with med mobility, and the assist of one person to move between surfaces using a rollator walker. A nurses note dated June 9, 2024, at 9:07 AM indicated that Employee 13, registered nurse (RN), was called to the resident's room by Employee 1, licensed practical nurse (LPN). According to the note, while Employee 1 performed the resident's morning blood sugar check, the resident was grimacing in pain. The resident was then noted to be guarding her left arm and shoulder and refused an assessment of the left arm and shoulder. When asked to lift her left arm, the resident yelled in pain. The physician ordered an x-ray of the left shoulder. Results of x-ray determined that Resident 41 had dislocation of left proximal humerus, and orders were received to send the resident to the emergency room for an evaluation. A nursing progress note dated June 10, 2024, at 12:34 AM, indicated that the hospital performed a closed reduction of the left shoulder and that the resident would be returning to the facility from the hospital with an immobilizing sling to remain in place until seen by orthopedic doctor. Review of the facility incident report dated June 9, 2024, at 2:39 PM revealed that Resident 41 had shown evidence of pain when the nurse performed morning blood sugar check. The resident was found to be guarding her left arm and shoulder with x-ray results identifying a dislocation of the left proximal humerus. Review of the witness statement from Employee 1 (LPN) dated June 9, 2024 (no time indicated) revealed that on June 7, 2024, there were no concerns identified with Resident 41.It was indicated the resident was out of bed in her wheelchair throughout the shift and participated in activities. On June 8, 2024, according to Employee 1, Resident 14 was behavioral during a.m. care and blood sugar checks, resident shouting when being touched and did not want to get OOB [out of bed], shouting 'no, no, no'. The resident had recently begun an antibiotic for a urinary tract infection and remained in bed during shift resting and sleeping intermittently. Additionally, Employee 1 stated that on June 9, 2024, during morning care, Resident 41 was shouting and would not remove right hand off left arm and left shoulder, guarding area and grimacing. Employee 1 further stated that the resident was unable to answer appropriately. Review of the witness statement from Employee 12, nurse aide (NA), indicated that on June 6, 2024, she went into Resident 41's room to change her (no time indicated) and when she rolled the resident to the left, the resident made a sound. When asked if she was ok, the resident placed her hand on left shoulder. According to Employee 12, the resident stated she was ok, and that Employee 12 told the nurse on that hall (no nurse was named). Review of additional witness statements failed to provide evidence that any nurse was notified that Resident 41 had complained of pain or Employee 12's impression she heard an odd sound when rendering care on June 6, 2024. There was no evidence that any nursing staff recalled the resident complaining of pain prior to the concern identified on June 9, 2024. Review of witness statement obtained by Resident 41 by the Director of Nursing on June 10, 2024, at 2:30 PM, indicated that the resident could not recall what led to the injury, she shook her head no. The resident stated no when asked whether anyone hurt her or had been rough with her. Review of significant change MDS dated [DATE], revealed that Resident 41 had a decline in cognitive ability. The resident was identified as having a BIMS of 1, which indicated severe cognitive impairment. Surveyor attempted to interview Resident 41 on July 8, 2024, at approximately 9:30 AM, but was unable to obtain any information related to her previous shoulder injury. The resident response was unintelligable when she was interviewed. Review of investigation results completed by the facility, revealed that on June 13, 2024, education was provided to Employee 12 related to bed mobility training with repeat/return demonstration. There was no evidence that during the facility investigation, concerns were identified with how Employee 12 provided care to Resident 41. Further review of facility findings during the investigation, the facility determined that the nurse aides caring for resident explained how they assist the resident with transfers, toileting, and bed mobility. When toileting the resident used the upper grab bar with her left hand and her arm to pull up and the lower grab bar to assist with pushing up from her wheelchair and assisted in standing to pivot and place herself on the toilet. There were no statements or evidence available at time of survey ending August 9, 2024, that observations and/or demonstrations were performed to identify or rule out this technique, as a root cause or potential cause for the injury sustained by Resident 41. There was no evidence available at time of survey ending August 9, 2024, that the facility identified that Employee 12 failed to perform bed mobility in a safe manner or what concerns were identified that led to the required education. The facility was unable to show any corrective actions developed as a result of the QAPI review of this event, as the investigation was incomplete. There was no evidence that the facility had fully investigated the circumstances surrounding the resident's injury to fully ascertain the underlying cause or contributing factors to this incident and to demonstrate the facility's good faith efforts to prevent injury to residents. There was no evidence at the time of the survey that the facility demonstrated an effective QAPI program to include outcomes of quality of care and quality of life by investigating resident incidents and maintaining thorough documentation to support their analysis of the data collected and any corrective actions developed and implemented. 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(4) Management 28 Pa. Code 211.12(c) Nursing Services

Based on a review of clinical records and medication records, and resident and staff interview it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 16 residents sampled (Resident 14). Findings included: A review of the clinical record revealed that Resident 14 was admitted to the facility on [DATE], with diagnoses, of diabetes, hypertension, and H. pylori infection (Helicobacter pylori, bacteria that infects the stomach). A review of the resident's March 2024 Medication Administration Record (MAR) revealed that on March 23, 2024, the resident was prescribed Bismuth Subsalicylate (an over-the-counter medication to treat diarrhea, heartburn, nausea, and upset stomach) 525 mg, two tablets every 6 hours for treatment of H. pylori for 14 days. The medication was scheduled for administration at 6 AM, 12 PM, 6 PM, and 12 AM. There was no evidence that the medication was administered to the resident on March 23, 2024, at 12 AM or 6 AM, on March 25, 2024, at 12 PM or 6 PM, or on March 26, 2024, at 12 PM. According to documentation in the resident's March 2024 MAR, the medication was not available from pharmacy for administration to the resident. A list of over-the-counter medications supplied by the facility was provided during the survey of on March 27, 2024, which revealed that Bismuth Subsalicylate 525 mg liquid was included on the list of available OTC medications. There was no evidence that the resident's physician was consulted to ascertain if an alternate form of the medication, the liquid, may be adminstered to the resident instead of the tablets. Interview with the Nursing Home Administrator on March 27, 2024, at 1 PM, confirmed that the licensed staff failed to administer the prescribed medication to Resident 14. The NHA further confirmed that the facility should have contacted the physician regarding the alternate form of the medication readily available in the facility for administration to the resident. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services 28 Pa. Code 211.9 (d)(j.1)(1)(2)(3)(5) Pharmacy services

Based on review of clinical records, select facility policy and investigative reports, and staff interview, it was determined that the facility neglected to provide one resident with the necessary care and services to prevent injury and maintain physical health out of 16 sampled. (Resident 4). Findings include: A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. A review of Resident 4's clinical record revealed admission to the facility on [DATE], with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), osteoarthritis, and heart disease. Resident 4's plan of care, last revised by the facility October 30, 2022, indicated that the resident has an ADL (activity of daily living) self-care performance deficit related to activity intolerance related to CHF (congestive heart failure). Planned interventions were to provide the assistance of two staff members to turn and reposition the resident in bed as necessary and that the resident requires a full mechanical lift and assist of two staff members for transfers. A review of a facility investigation report dated February 5, 2024, at 3:30 PM revealed that Employee 3, a nurse aide, rolled the resident in bed, to put a new brief under him. Resident 4 then shifted his hips and rolled off the bed. Employee 3 tried to stop the resident from falling out of bed but was unable to prevent the resident's fall. Resident 4 sustained a large skin tear and abrasion to his head. The physician ordered the resident to be transported to the emergency room for evaluation. The resident returned to the facility with sutures to the right parietal (side) region of his head and right forearm. A review of Employee 3's witness statement dated February 5, 2024, revealed that the employee was assigned to Resident 4 to provide care and services on the day of the fall. According to Employee 3's statement, when he was putting a new brief under the resident, the resident rolled his hip and fell off the bed. He fell on to the floor. Employee 3's statement did not indicate the presence of another staff member while repositioning the resident in bed to provide ADL care. There was no evidence that another staff member was assisting with the resident's turning and repositioning in bed at the time of the resident's fall. The facility failed to ensure that two staff members were present while repositioning and turning the resident in bed, as care planned, and the resident rolled out of the bed onto the floor and sustained minor injuries. A review of a Report Form for Investigation of Alleged Abuse, Neglect, or Misappropriation of Property (PB-22) submitted by the facility to the Pennsylvania Department of Health on February 5, 2024, revealed the facility completed their investigation and concluded that neglect was substantiated due to Employee 3's failure to follow the resident's plan of care which indicated that another staff member was required when assisting in the resident's bed repositioning. An interview with the Nursing Home Administrator and Director of Nursing on March 27, 2024, at approximately 1:00 PM confirmed that the facility failed to ensure that Resident 4 was free from neglect. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1. Resident 4 was sent to emergency room post fall and returned to the facility in stable condition. Employee 3 was immediately suspended and after conclusion of the investigation was terminated. 2. The Director of Nursing or designee completed an audit of bed mobility status and transfers assist of two to ensure it was in place on the plan of care and Kardex for all residents. 3. The Director of Nursing or designee educated the nursing staff to follow plan of care and Kardex for resident's bed mobility status and transfers assist of two. Physician's orders will be put in place for residents with transfer and bed mobility assist of two. 4. The Director of Nursing or designee will complete random observational audits to ensure staff are following the plan of care and Kardex for resident's bed mobility status and transfers assist of two. Random audits will be completed daily times 5 days, weekly times 3 weeks and monthly times 2 months. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee The committee will determine the need for further audit and/or recommendations. The facility's completion date for the above corrections was February 9, 2024, which was verified during the survey completed March 27, 2024. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services

Based on review of clinical records, select resident incident/accident reports and information submitted by the facility and staff interview, it was determined that the facility failed to provide safe and adequate staff supervision with activities of daily living to a resident, with identified positioning difficulties, resulting in an avoidable fall during which the resident sustained multiple traumatic injuries for one resident out of seven sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated February 20, 2022, revealed that the resident required extensive assistance of two staff for bed mobility, transferring, and dressing, and required supervision of one staff member when moving about on the nursing unit. The clinical record revealed that the resident was receiving occupational therapy services beginning March 2, 2023. A review of this occupational therapy evaluation and progress notes revealed that the resident had poor sitting balance. It was noted that the resident had poor positioning issues when sitting, such as sliding forward from her wheelchair seat, and not having proper head support. The resident was identified to have limited trunk flexion (returns the trunk to the anatomical position from trunk extension or produces a forward movement of the spine). A review of an occupational therapy discharge summary dated March 22, 2023, revealed that the resident was discharged from occupational therapy services on March 17, 2023, and at the time of discharge, the resident could tolerate sitting in her wheelchair with positioning devices in place. A nursing progress note dated May 15, 2023, at 6:39 AM, but written and entered into the clinical record on May 18, 2023, at 7:52 AM, revealed that nursing found the resident on the floor of the resident's room, lying on her stomach with the right side of her face on the floor and her right arm underneath her. It was noted that the resident was unresponsive for 10 to 15 seconds. The resident's right cheek and right eye were swollen, and she complained of right arm pain. According to the late entry nurse's note, Employee 1, a nurse aide, was attempting to dress and then transfer the resident from bed, without the assistance of a second staff member. Employee 1 reported that the aide sat the resident on the side of the resident's bed to pull the resident's shirt down and to place a lift pad under her. Employee 1 indicated that Resident 1 fell forward and the employee was unable to stop the resident's fall. The resident fell to the floor, hitting the right side of her face. The physician was notified, and an order was obtained to transfer the resident to the hospital. A review of a corresponding incident report dated May 15, 2023, at 6:30 AM revealed that the resident was found on the floor in her room on her stomach. The resident was noted to lose consciousness after the fall for 10 to 15 seconds. Resident 1 had swelling to her right cheek and right eye and complained of pain in her right arm. The report noted that resident was supposed to be an assist of two staff member with a full mechanical lift for all transfers. Employee 1's witness statement indicated that the employee was trying to get the resident up (from bed). The employee stated that she sat the resident on the side of the bed to pull her shirt down and the resident started to fall forward. Employee 1 stated that she tried to catch her, but it was too late. The facility's investigation revealed that there was a sit to stand lift present in the resident's room when Resident 1 fell . However, at the time of the incident, the resident was to be transferred with the use of full mechanical lift, as a sit to stand lift was determined to be unsafe for the resident. The facility conducted a telephone interview on May 15, 2023, with Employee 1 during which the employee stated that she did not bring the sit to stand lift into the resident's room at the time of the resident's fall, but that it was already in the resident's room located near the closet. However, when the facility informed Employee 1 that they were going to review the video footage to validate her story, Employee 1 admitted to bringing the sit to stand lift into the room intending to use the lift to transfer the resident out of bed. Employee 1 stated that she just sat the resident on the side of the bed to pull her shirt down and the resident fell forward. An undated witness statement from Employee 2, a nurse aide, revealed that Employee 3, LPN (license practical nurse) approached Employee 2 at 5:15 AM (on May 15, 2023) for help with Resident 1 since the resident is hard to manage. At that time Employee 2 and Employee 3 provided bowel and bladder toileting, washed the resident, completely dressed the resident, and changed her sheets. Employee 2 indicated that the resident's shirt, at that time, was all the way down. Employee 2 stated that there were no lift machines in the resident's room at that time. Employee 3's witness undated statement indicated that the employee assisted Employee 2 with providing care to the resident on the day of the resident's fall. When she entered the room later at 6:15 AM she saw the resident face down on the floor. The employee further indicated she did see Employee 1 go to the 400 hall of the nursing unit to get the sit to stand lift before the fall had occurred. A review of the resident's hospital records dated May 15, 2023, revealed that the resident was being moved and was dropped and landed flat and hit her head on the floor with a loss on consciousness for 15 seconds. The resident sustained a right orbital floor fracture (trauma to the orbital rim pushes the bones back, causing the bones of the eye socket floor buckle to downward), multiple maxillary sinus fractures (a break to the area under the eye next to the nose usually caused by blunt force trauma), right middle finger proximal phalanx fracture (a break, of a small bone in the finger), right ulna fracture (a break in the forearm), and right femoral fracture (a break in the thigh bone). The resident also had multicompartment intracranial hemorrhage (brain bleed) including bilateral subarachnoid (a bleed in the area that surrounds the brain), intraparenchymal (bleeding in the functional part of the brain) and subdural (bleeding in the area between the brain and the skull) with intraventricular extension (bleeding extended into the ventricles{ a communicating network of cavities within the brain}). An interview with Employee 4, Director of Rehab, on June 6, 2023, at approximately 11:00 AM reveled that the resident had been re-evaluated in October 2022 for the use of a full mechanical lift as the resident was no longer safe using a sit to stand lift. Employee 4 stated that the resident was not safe to sit upright alone and had poor sitting posture. Employee 4 stated that the resident needed assistive interventions to be seated in a reclined wheelchair to sit safely. Employee 4 confirmed that the resident would not need to sit on the side of the bed for a transfer using the full mechanical lift, nor would the resident need to sit on the side of the bed for staff to pull her shirt down. While dressing the resident, the resident's shirt could have been pulled down while the resident was still lying in the bed. According to information dated May 17, 2023, submitted by the facility, Employee 1 maintained that she was only providing assistance with dressing and she did not intend to use the device (sit to stand lift). However, Resident 1 required the assistance of two staff with dressing and had poor upper body trunk control. Employee 1 was attempting to dress, and preparing to transfer the resident out of bed, without the assistance of another staff member. Employee 1 was terminated on May 16, 2023. An interview with the Nursing Home Administrator on June 6, 2023, at approximately 2:15 PM confirmed that Employee 1 failed to provide care, consistent with Resident 1's assessed needs and planned care for dressing and transfers, resulting in Resident 1's fall from bed and multiple traumatic injuries. 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services 28 Pa. Code 211.11 (d) Resident care plan

Based on clinical record review and staff interview it was determined that the facility failed to promptly notify the physician of an elevated PT (Prothrombin time test which is a test to evaluate blood clotting; an elevated number higher than range means it takes longer than usual to clot) with PT INR [(international normalized ratio; a type of calculation based on PT test results; often used to see how well [MEDICATION(S)] (an anticoagulant medication) is working] laboratory result, which resulted in the resident continuing to receive the same dosage of [MEDICATION(S)], causing [MEDICATION(S)] toxicity and GI bleed requiring hospitalization for one of three sampled residents (Resident A1). Findings include: A review of Resident A1's clinical record revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident A1's Clinical Laboratory Report Final Report noted a collection date of July 26, 2021, at 8:10 AM and Reported Date July 26, 2021 at 1:54 PM. The report indicated that the resident's PT was high 37.7 (reference range 12.0-14.6) and PT INR result was 4.0 (Coumadinized Patients range 2.0-3.0). Further review of the clinical record revealed no documented evidence that the facility had notified the physician of the resident's elevated PT/INR result to allow the physician to further evaluate the resident's current order for [MEDICATION(S)]. A review of the resident's July 2021 MAR (medication administration record) revealed that the resident continued to received [MEDICATION(S)] 2.5 mg daily from July 21, 2021, until the resident's hospitalization on [DATE]. A change in condition note dated, July 30, 2021 at 10:13 AM, indicated that the resident had a large amount of blood with several blood clots saturated in the resident's brief. Nursing noted Unclear of origin of bleeding, but possible vaginal. Resident complained of dizziness at this time. Blood pressure 70/66 mm Hg(120/80 mm Hg is normal), [MEDICATION(S)] (medication used to treat high blood pressure) held at this time. Physician notified and recommended resident to be transferred to the emergency room for evaluation. A nurses note dated July 30, 2021, noted that the resident was admitted to the hospital for a rectal bleed. Review of the Hospital History and Physical dated July 30, 2021, indicated that the resident was diagnosed with lower GI (gastrointestinal) bleed secondary to [MEDICATION(S)] toxicity. The resident's PT was noted to be 62.9 (H) normal 9.5 -11.5 seconds and INR was 6.7 (HH) normal 0.8 -1.2. Interview with the director of nursing on August 3, 2021 approximately 2:15 p.m. confirmed that the physician was not notified of the resident's elevated PT/INR lab results received by the facility on July 26, 2021, to evaluate the resident's prescribed [MEDICATION(S)] order to minimize the resident's risk for abnormal bleeding and prevent serious complications with [MEDICATION(S)] usage. 483.50(a)(2)(i)(ii) Lab Services Physcian Order/Notify of Results 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services Previously cited 4/27/21