Every finding on record at Dunmore Health Care Center

Based on a review of facility policy, clinical record review, medication administration records, physician orders, and staff interview, it was determined the facility failed to document that individualized non-pharmacological interventions were attempted prior to the administration of a PRN (as needed) psychotropic medication and failed to obtain and document the prescribing practitioner's clinical rationale and duration supporting continuation of the PRN psychotropic medication beyond the federally permitted 14-day period for one of 19 residents reviewed (Resident 35).Findings Include: Federal requirements for the use of psychotropic medications expect that psychotropic medications are used only when necessary to treat a specific, documented condition. A PRN (as needed) psychotropic medication order is limited to 14 days unless the prescribing practitioner documents the clinical rationale for extending the order and specifies the duration of the extension. Non-pharmacological interventions are approaches that do not involve medications, such as reassurance, redirection, environmental modifications, distraction techniques, or comfort measures. When clinically appropriate, these interventions should be attempted and documented prior to administering a PRN psychotropic medication. A review of the facility's policy titled Psychoactive Medication Policy reviewed June 25, 2026, indicated that all residents receiving psychoactive medications will have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medication monitored and documented. The policy further revealed that individualized non-pharmacological approaches are provided as part of a supportive physical and psychological environment and are directed toward preventing, relieving, or accommodating a resident's distressed behavior. Clinical record review revealed Resident 35 was admitted on [DATE], with diagnoses including depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue) and anxiety (the body's natural response to stress, characterized by feelings of tension, worried thoughts, and physical changes). A review of Resident 35's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 23, 2026, revealed that Resident 35 was moderately cognitively impaired with a BIMS score of 12 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8 through 12 indicates moderate cognitive impairment). Review of physician orders revealed an order dated May 22, 2026, for Hydroxyzine 25mg (antihistamine that has anxiolytic or anti-anxiety properties. When prescribed to treat anxiety or other behavioral or psychological symptoms, it is considered a psychotropic medication under the federal requirements governing PRN psychotropic medications) administer 1 tablet by mouth at bedtime as needed for anxiety for 14 days. Review of physician orders further revealed the order was changed on June 19, 2026, to Hydroxyzine 25 mg, administer one tablet by mouth twice daily as needed. Review of the Medication Administration Record (MAR) revealed the PRN Hydroxyzine was administered on the following occasions:May 26, 2026, at 12:45 AMJune 1, 2026, at 8:28 PMJune 5, 2026, at 8:41 PMJune 6, 2026, at 10:56 PM Review of the clinical record failed to identify documentation that non-pharmacological interventions were attempted or ineffective prior to administration of the PRN psychotropic medication on any of the seven occasions. As a result, the facility could not demonstrate that less restrictive interventions were considered before the medication was administered. Review of the clinical record failed to identify documentation that individualized non-pharmacological interventions were attempted or found to be ineffective before the PRN Hydroxyzine was administered on any of the four identified occasions. Therefore, the facility could not demonstrate less restrictive interventions were considered before administering the psychotropic medication. Review of the clinical record further failed to identify documentation from the prescribing practitioner providing the clinical rationale for continuing the PRN Hydroxyzine order beyond the 14-day federal limitation. In addition, the record failed to identify documentation specifying the duration of the extension. During an interview on July 9, 2026, at 12:30 PM, the surveyor reviewed the above findings with facility staff. The facility could not provide documented evidence that non-pharmacological interventions were attempted before the PRN Hydroxyzine was administered on the four identified occasions and no documented clinical rationale or specified duration from the prescribing practitioner supporting continuation of the PRN psychotropic medication beyond 14 days. 28 Pa. Code 211.2(3) Medical director.28 Pa. Code 211.5(ii)(xi) Clinical records.28 Pa. Code 211.8(e) Use of restraints.28 Pa. Code 211.9(1) Pharmacy services.

Based on select facility policy, a review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure licensed nurses administered medications according to physician ordered parameters for 1 of 19 residents reviewed (Resident 45). Findings include: A review of the facility policy titled, General Dose Preparation and Medication Administration, last reviewed June 25, 2026, indicated medications will be administered as ordered by the physician and vital signs (e.g., blood pressure and pulse) should be obtained if ordered by the physician. Resident 45 was admitted to the facility on [DATE], with diagnoses to include hypertension (a chronic condition in which the force of blood pushing against artery walls is consistently too high) and hyperlipidemia (abnormally high levels of fats, like cholesterol and triglycerides, in the blood). A review of the physician's orders revealed an order dated June 24, 2026, for midodrine (a prescription medication used to treat symptomatic hypotension, or low blood pressure) 10 mg, one tablet by mouth three times daily. The order directed staff to hold (not administer) the medication if the resident's systolic blood pressure (the top number of a blood pressure reading, representing the pressure in the arteries when the heart contracts) was greater than or equal to 120 mmHg (millimeters of mercury) or if the diastolic blood pressure (the bottom number of a blood pressure reading, representing the pressure in the arteries while the heart is resting between beats) was greater than or equal to 80 mmHg. A review of the medication administration records and documented blood pressure readings revealed facility staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the physician's ordered parameters requiring the medication to be withheld. Specifically, staff administered the medication on the following dates despite blood pressure readings at or above the physician's hold parameters: June 24, 2026, at 6:00 p.m.: blood pressure 125/72 (systolic above the ordered hold parameter).June 25, 2026, at 10:00 a.m.: blood pressure 125/74 (systolic above the ordered hold parameter).June 26, 2026, at 10:00 a.m.: blood pressure 122/80 (both the systolic and diastolic met or exceeded the ordered hold parameters).July 1, 2026, at 6:00 p.m.: blood pressure 112/80 (diastolic met the ordered hold parameter).July 5, 2026, at 2:00 p.m.: blood pressure 126/66 (systolic above the ordered hold parameter).July 5, 2026, at 6:00 p.m.: blood pressure 122/68 (systolic above the ordered hold parameter).July 6, 2026, at 10:00 a.m.: blood pressure 126/68 (systolic above the ordered hold parameter).July 6, 2026, at 2:00 p.m.: blood pressure 126/68 (systolic above the ordered hold parameter). An interview with the Nursing Home Administrator on July 9, 2026, at 1:30 PM reviewed the above findings. The Nursing Home Administrator acknowledged facility staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld. 28 Pa. Code 211.5(f)(ix) Medical Records.28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services.

Based on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure injuries for one of 19 residents reviewed (Residents 5).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. A review of the facility policy entitled Pressure Injury Prevention and Management Policy, last reviewed by the facility on June 25, 2026, revealed it was the policy of the facility that residents admitted with existing pressure injuries will receive necessary treatments and services consistent with professional standards of practice to promote wound healing and prevent infection. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses including chronic peripheral venous insufficiency (a condition in which the veins in the legs are unable to efficiently return blood to the heart with symptoms that include swelling in the legs or ankles, pain or throbbing in the legs, aching or tiredness in the legs, skin darkening or reddening, development of sores or ulcers) and cellulitis (a bacterial infection of the skin and underlying tissues, causing redness, swelling, warmth, and pain) right lower leg. A review of Resident 5's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2026, revealed that Resident 5 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). The MDS revealed at the time of assessment, Resident 5 had one unstageable pressure ulcer (a serious wound where full-thickness skin and tissue loss has occurred, but the true depth of the damage cannot be determined because it is obscured by dead tissue) that was present on admission. A review of physician orders revealed an order dated July 3, 2026, at 4:31 PM, directing staff to apply xeroform gauze (a sterile, non-adherent wound dressing) to the distal aspect of the right buttock wound, pack the wound with Kerlix gauze soaked in Dakin's solution (an antiseptic solution used to clean wounds and reduce bacteria), and secure the dressing with an ABD pad (a thick, highly absorbent dressing) twice daily and additionally as needed for soiled or dislodged dressings. An observation conducted on July 8, 2026, at 1:15 PM, in the presence of the Assistant Director of Nursing (ADON), revealed Resident 5's right buttock wound was not covered with xeroform gauze and contained no wound packing as ordered by the physician. A second observation conducted on July 9, 2026, at 8:51 AM, in the presence of Employee 1, Licensed Practical Nurse (LPN), revealed the dressing was visibly soiled with a yellow-colored substance, and the wound packing was protruding from the wound. During the observation, Employee 1 confirmed the wound dressing was soiled and acknowledged being unable to determine when the treatment had last been changed because the dressing was not dated or timed. During an interview on July 9, 2026, at 11:30 AM, the Assistant Director of Nursing reviewed and acknowledged the above findings. The facility failed to ensure Resident 5 received the physician-ordered wound treatment necessary to promote healing of an unstageable pressure injury. The physician-ordered xeroform dressing and wound packing were not in place during observation, and the wound dressing was later observed to be soiled with packing protruding from the wound without documentation identifying when the treatment had last been changed. The facility failed to provide treatment and services consistent with professional standards of practice to promote healing and prevent complications of a pressure injury. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, review of selected facility policies, and staff interview, it was determined the facility failed to provide pain management in accordance with physician orders and facility policy by failing to administer opioid pain medication within the physician-prescribed pain intensity scale and by failing to attempt and document non-pharmacological interventions before administering as needed (PRN) opioid pain medication for two of 19 residents reviewed (Residents 30 and 47).Findings include: A review of the facility policy titled Pain Management Protocol, last reviewed by the facility on June 25, 2026, indicated residents will be assessed for the presence and severity of pain using an appropriate pain assessment scale, such as a numeric pain rating scale, facial pain scale, or verbal descriptor scale. A numeric pain rating scale measures pain intensity from 0 through 10, with 0 indicating no pain and 10 indicating the worst pain imaginable. The policy indicated non-pharmacological interventions (treatments used to help relieve pain without medication, such as repositioning, applying ice or heat, relaxation techniques, distraction, or other comfort measures) should be attempted before administering PRN (as needed) pain medication. If non-pharmacological interventions are ineffective and multiple PRN pain medications are available based on pain severity, staff are to administer the medication corresponding to the physician-ordered pain intensity. The policy also required documentation of medication administration and the resident's response in the electronic Medication Administration Record (eMAR), an electronic record used to document medications administered to each resident. A review of Resident 30's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including hydrocephalus (a condition caused by an abnormal buildup of cerebrospinal fluid around the brain), neuropathy (damage to the nerves that can cause numbness, tingling, burning, or pain, most commonly in the hands and feet), and chronic back pain. A review of physician orders revealed an order dated May 12, 2026, at 11:22 AM, for oxycodone hydrochloride (HCl) 5 milligrams (mg) (an opioid medication used to treat moderate to severe pain), to administer one tablet by mouth every four hours as needed for severe breakthrough lower back pain rated 7 through 10. A review of the resident's electronic Medication Administration Record (eMAR) dated June 1, 2026, through June 30, 2026, revealed licensed nursing staff administered oxycodone outside the physician-prescribed pain intensity range on the following dates: A review of the resident's electronic Medication Administration Record (eMAR) dated June 1, 2026, through June 30, 2026, revealed licensed nursing staff administered oxycodone outside the physician-prescribed pain intensity range on the following occasions: June 13, 2026, at 1:43 PM, oxycodone 5 mg was administered for a documented pain level of 4.June 14, 2026, at 11:39 AM, oxycodone 5 mg was administered for a documented pain level of 5.June 30, 2026, at 9:15 PM, oxycodone 5 mg was administered for a documented pain level of 6. These documented pain ratings were below the physician-ordered range of 7 through 10 for administration of oxycodone.The facility failed to ensure licensed nursing staff administered Resident 30's opioid pain medication according to the physician's prescribed pain intensity scale. During an interview on July 8, 2026, at 10:55 AM, the Director of Nursing (DON) reviewed the above findings and confirmed the facility failed to ensure licensed nursing staff administered oxycodone in accordance with the physician's order for Resident 30. A review of Resident 47's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including aftercare following right total knee replacement surgery and chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste and excess fluid from the blood). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 4 , 2026, revealed that Resident 47 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 13-15 indicates cognition is intact). A review of physician orders revealed an order dated June 1, 2026, for oxycodone-acetaminophen 5 mg/325 mg (oxycodone is an opioid narcotic medication used to treat pain, and acetaminophen is a pain reliever and fever-reducing medication), to administer one tablet by mouth every four hours as needed for moderate to severe pain rated 4 through 10. A review of the resident's electronic Medication Administration Record (eMAR) for June 2026 revealed licensed nursing staff administered the PRN opioid medication without documenting a pain rating and without documenting attempted non-pharmacological interventions on the following dates: June 1, 2026, at 7:44 PMJune 2, 2026, at 2:21 AMJune 2, 2026, at 8:44 AMJune 2, 2026, at 12:54 PMJune 2, 2026, at 5:08 PMJune 2, 2026, at 9:09 PMJune 3, 2026, at 1:10 AMJune 3, 2026, at 5:28 AMJune 3, 2026, at 9:31 AMJune 3, 2026, at 2:26 PMJune 3, 2026, at 8:42 PM The facility failed to document the resident's pain level before administering the PRN opioid medication and failed to document that non-pharmacological interventions were attempted before administering the medication, as required by the physician's order and the facility's pain management policy. During an interview on July 8, 2026, at 11:00 AM, the Director of Nursing reviewed the above findings and confirmed the facility failed to ensure Resident 47's pain management was provided in accordance with physician orders, facility policy, and accepted standards of practice, including assessment of pain severity and documentation of attempted non-pharmacological interventions before administering PRN opioid pain medication. 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 a review of clinical records, facility policy, and staff interviews, it was determined the facility failed to assess bowel and bladder function, identify residents' patterns of incontinence, and develop individualized toileting programs to restore or maintain normal bowel and bladder function to the extent possible for two of 10 residents reviewed (Residents 1 and 8).Findings include: A review of the facility policy titled Continence Management Program, last reviewed April 15, 2026, revealed that upon admission, the admitting licensed nurse is responsible for completing a head-to-toe assessment (a comprehensive physical assessment of the body from head to feet), including an interview with the resident and a review of underlying medical conditions that may affect the resident's ability to participate in a continence management program. The policy indicated that nursing staff will identify each resident who is incontinent and assess, plan, and implement appropriate treatment and services to restore or maintain as much normal urinary and bowel function as possible. The policy revealed that a continence evaluation is conducted to determine whether a 72-hour bowel and bladder tracking record is indicated to identify the resident's pattern of continence and incontinence. The licensed nurse is responsible for instructing nursing assistants to complete the tracking documentation. After a pattern has been identified, the licensed nurse is responsible for completing a new continence evaluation and developing an individualized toileting program based on the resident's identified needs. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included overactive bladder and muscle weakness. A review of Resident 1's quarterly Minimum Data Set assessment (MDS. a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 9, 2026, revealed the resident was completely dependent on staff for toileting, including transfers on and off the toilet and personal hygiene after toileting. The MDS documented that the resident was always incontinent of urine and had no toileting program in place. A review of the resident's care plan initially dated May 7, 2024, revealed the resident was at risk for skin breakdown due to urinary incontinence. The care plan indicated the resident had an overactive bladder and was at risk of infection. A review of Resident 1's progress notes revealed the resident had received ongoing treatment beginning August 2, 2025, for a wound to the right posterior thigh caused by moisture-associated skin damage (MASD). A review of Resident 1's wound care note dated November 12, 2025, documented the right thigh wound had resolved. A review of the clinical record revealed no documented continence evaluation, or bladder assessment was completed between November 12, 2025, and April 15, 2026. The clinical record revealed no individualized toileting program, or scheduled toileting interventions were developed to reduce urinary incontinence or prevent moisture-associated skin damage despite the resident's documented urinary incontinence and previous skin breakdown. A review of Resident 1's progress notes dated April 15, 2026, at 2:10 PM documented the resident had developed a new abrasion to the right thigh. A treatment order was obtained to apply medical-grade honey (a sterile topical wound treatment made from purified honey to used to promote healing and reduce bacteria in the wound), apply zinc oxide (a protective skin barrier cream used to shield the skin from moisture) to the surrounding skin, and cover the wound with an ABD pad (a highly absorbent dressing used to protect and absorb drainage from wounds) daily and as needed. A wound care assessment completed April 15, 2026, at 6:23 PM revealed the resident's right posterior thigh wound had reopened. The assessment documented the resident was incontinent of urine and spent prolonged periods sitting in a wheelchair, resulting in irritation that caused the wound to reopen. A wound care progress note dated May 8, 2026, at 12:21 PM documented the resident remained at risk for skin breakdown and moisture-associated skin damage due to urinary incontinence and inability to perform self-care. A review of Resident 1's clinical record revealed no documented continence evaluation, or bladder assessment was completed before or after the recurrence of the moisture-associated skin damage. The clinical record revealed no individualized toileting program had been developed despite the resident's documented urinary incontinence and recurrent skin breakdown associated with prolonged moisture exposure. A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included status post traumatic subdural hemorrhage (bleeding between the brain and the skull following a head injury), dementia (a condition affecting memory, thinking, and decision-making), and anxiety. A review of Resident 8's admission Minimum Data Set assessment dated [DATE], revealed the resident was always incontinent of bowel and bladder. A review of the clinical record revealed no documented bowel or bladder assessment or continence evaluation was completed following the resident's admission to identify the resident's pattern of incontinence. The clinical record revealed the facility failed to assess the resident's bowel and bladder status upon admission and failed to identify the resident's continence patterns in order to develop an individualized toileting program designed to restore or maintain normal bowel and bladder function to the extent possible.A review of the Resident 8's care plan, initiated June 2, 2026, identified urinary incontinence related to urgency and the need for assistance with toileting. The only intervention directed staff to check the resident for wetness and change the resident as needed. Resident 8's care plan contained routine hygiene measures but did not include an individualized toileting schedule, continence management program, bowel or bladder retraining interventions, or interventions based on an identified pattern of incontinence. During an interview conducted on June 12, 2026, at approximately 2:15 PM the Nursing Home Administrator and Director of Nursing confirmed the facility was not completing bowel and bladder assessments to identify residents' continence patterns or develop individualized toileting programs. They confirmed the facility had not completed continence evaluations for Residents 1 and 8 as required by facility policy. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of facility policy, Resident Council meeting minutes, grievance documentation provided by the facility, and resident and staff interviews, it was determined the facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. The facility did not ensure ongoing communication or timely follow-up regarding issues presented by residents in resident council, and resident interviews for four of 10 residents reviewed. (Residents 2, 3, 4, 5).Findings include: A review of the facility policy titled Call Light Resident Communication Systems, last reviewed December 17, 2025, revealed it is the facility's policy to provide residents with a means of communicating with staff. The policy indicated it is the expectation of the facility staff to respond to the residents' needs and requests promptly. A review of a grievance dated April 6, 2026, revealed Resident 3 reported that at approximately 6:15 AM a nurse aide answered the resident's call bell, turned the call bell off without asking what assistance was needed, and left the room. Documentation of the facility's follow-up indicated the nurse aide received education regarding the proper response to resident call bells. A review of a grievance dated April 8, 2026, revealed Resident 4 reported that both the resident and the roommate rang their call bells for what they believed was one hour before a nurse responded. Facility documentation indicated the event occurred around the evening meal, call bell audits (reviews used to measure how quickly staff respond to residents' requests for assistance after a call bell is activated) were initiated on the 3:00 PM. to 11:00 PM shift for a duration of one week, and the grievance was documented as resolved on April 8, 2026. A review of Resident Council meeting minutes dated April 15, 2026, revealed the residents in attendance again voiced concern regarding prolonged call bell response times, and a grievance form was initiated. A review of the grievance dated April 15, 2026, revealed Resident 2 reported that on April 13, 2026, nurse aides took longer than 15 minutes to respond to the resident's call bell during the 3:00 PM to 11:00 PM shift. Documentation completed by the Nursing Home Administrator indicated call bell audits were initiated on the evening shift and second-floor staff received education regarding timely responses to call bells. The grievance was documented as resolved on April 17, 2026, based on the initiation of audits and staff education. However, a review of Resident Council meeting minutes dated May 21, 2026, revealed residents continued to report prolonged call bell response times, particularly during the 3:00 PM to 11:00 PM shift. The meeting minutes documented that call bell audits had already been initiated, indicating the previously documented corrective actions had not resolved residents' ongoing concerns. A review of Resident Council meeting minutes dated June 10, 2026, revealed residents reported call bell response times were getting better. However, the facility was unable to provide documentation demonstrating residents had been informed of the outcome of the grievances or that residents were satisfied with the facility's resolution of the concerns raised through the grievance process. A review of Resident 2's clinical record revealed the resident was admitted on [DATE], with diagnoses including weakness and altered gait and mobility (difficulty walking and moving safely). A review of Resident 2's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 5, 2026, revealed that Resident 2 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates no cognitive impairment). The MDS revealed Resident 2 required extensive assistance with toileting hygiene, including cleansing after urination or a bowel movement. During an interview on June 23, 2026, at 9:28 a.m., Resident 2 stated staff frequently took an extended time to answer the call bell. Resident 2 reported requiring assistance while using the toilet and stated that on multiple occasions the resident waited longer than 40 minutes for assistance with toileting hygiene. Resident 2 stated the prolonged wait caused leg pain from remaining seated on the toilet. The resident reported she has experienced elongated wait times, causing her to urinate on herself due to no response to her request for assistance. A review of Resident 5's clinical record revealed the resident was admitted on [DATE], with diagnoses including a fracture of the left clavicle (collarbone) and fracture of one rib on the left side. A review of Resident 5's admission MDS dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15, indicating no cognitive impairment. During an interview conducted on June 23, 2026, at 9:22 AM revealed the resident was recently admitted to the facility but required assistance to use the bathroom due to the limited mobility of his left side due to the movement restrictions of his left arm. Resident 5 reported that on the evening before the interview the resident waited for what it felt like 45 minutes after activating the call bell before staff responded. Resident 5 further stated there did not appear to be enough staff available during the evening shift and that lengthy call bell response times were common. The facility provided call bell audit records; however, the audits did not identify prolonged response times consistent with the concerns repeatedly expressed by residents. Additionally, the facility was unable to provide documentation demonstrating it interviewed residents who did not attend Resident Council meetings to determine whether call bell response times had improved after implementation of corrective actions. The facility was also unable to provide documentation demonstrating residents were informed of the status or outcome of the grievances or that residents were satisfied the concerns regarding prolonged call bell response times had been adequately resolved. During an interview on June 23, 2026, at 3:25 PM the above findings were reviewed with the Nursing Home administrator regarding the lack of resolution and outcome of grievances related to prolonged call bell response times. 28 Pa. Code 201.18 (e)(1)(4) Management. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observations, a review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to securely store medications and restrict resident access to medications in accordance with facility policy for one of two nursing units (Unit 2) and one of ten residents reviewed (Resident 7), creating the potential for accident hazards.Findings included: A review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, last reviewed December 17, 2025, revealed it is the facility policy that all medications and biologicals including bedside medications or biologicals are stored in a locked compartment within the resident's room. A review of the facility policy titled Self-Administration of Medications, last reviewed December 17, 2025, revealed it is the facility policy that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in a resident's room, the medication of residents permitted to self-administer is stored on a central medication cart or in the medication room. A clinical record review revealed Resident 7 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 27, 2025, revealed that Resident 7 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A review of the clinical record revealed no documentation that Resident 7 had been assessed or approved to safely self-administer medications. An observation conducted on June 23, 2026, at 9:15 a.m. revealed a box containing a tube of medicated hemorrhoidal ointment (a medication used to relieve itching, burning, swelling, and discomfort caused by hemorrhoids) with an applicator sitting unsecured on Resident 7's windowsill. The tube did not display resident-specific directions for use or application instructions. The manufacturer's labeling for the hemorrhoidal ointment directs that the medication is intended for rectal or external use only, should not be taken by mouth, and instructs users to seek immediate medical assistance if the product is swallowed. During an interview on June 23, 2026, at 9:15 AM, Resident 7 indicated that staff apply the ointment for him. A review of the physician's orders revealed an order dated June 3, 2026, directing staff to apply the hemorrhoidal ointment rectally up to four times daily as needed. An observation conducted on June 23, 2026, at 9:24 a.m. in room [ROOM NUMBER] revealed a tube of medicated barrier cream and a tube of Peleverus cream (topical medications commonly used to protect skin from moisture-related damage and to treat fungal skin conditions) sitting unsecured on the windowsill. Neither tube displayed resident-specific directions for use or application instructions. An observation conducted on June 23, 2026, at 9:26 a.m. in room [ROOM NUMBER] revealed a tube of medicated barrier cream and a tube of medical-grade Manuka honey (a wound treatment used to promote healing and protect damaged skin) sitting unsecured on the windowsill. Neither product displayed resident-specific directions for use or application instructions. During an interview on June 23, 2026, at 3:26PM, the above information was reviewed with the Nursing Home Administrator. The facility failed to ensure medications were stored in accordance with its policies and failed to ensure only residents who had been assessed and determined capable of safely self-administering medications had access to medications kept in resident rooms. As a result, unsecured medicated creams and ointments were accessible within resident rooms on Unit 2, creating the potential for accidental misuse, inappropriate application, ingestion, or use by unauthorized individuals. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observation, review of clinical records, and resident and staff interviews it was determined the facility failed to provide services consistent with professional standards of practice by failing to implement the physician-ordered bowel management protocol and to notify the physician when ordered interventions were not effective for one resident (Resident 19) out of 21 residents reviewed.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 Resident 19 ' s clinical record revealed active physician orders dated May 8, 2025, for a bowel regimen (a prescribed sequence of interventions to promote regular bowel movements and prevent constipation) as follows:Milk of Magnesia (MOM) Suspension 400 mg/5ML (Magnesium Hydroxide): Give 30 ml by mouth as needed for constipation if there is no BM (bowel movement) after the third day.Bisacodyl suppository; 10 mg: Insert 1 suppository rectally as needed for constipation if no BM on the fourth day and no result from MOM.Enema (Fleet enema-sodium phosphate enema): Insert 1 application rectally as needed for constipation if no BM on the fifth day and no result from the suppository, notify the physician if no bowel movement occurs. A review of Resident 19 ' s bowel tracking records for September 2025 revealed the resident did not have a documented bowel movement on September 18, 19, 20, 21, or 22, 2025.A review of Resident 19 ' s Medication Administration Record (MAR) for the same period revealed no documented evidence that nursing staff administered the physician-ordered Milk of Magnesia, suppository, or enema as indicated. There was also no documentation that the physician was notified after the fifth day without a bowel movement, as required by the physician ' s orders.An interview with the Director of Nursing (DON) conducted on October 1, 2025, at 11:10 AM, confirmed there was no evidence that the bowel protocol was implemented or that the physician was notified of the lack of bowel activity during the five-day period. September 18, 19, 20,21 and 22, 202528 Pa. Code 211.12 (d)(1)(3)(5) Nursing services28 Pa. Code 211.5(f)(i)(ix)Medical records

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen two employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, and 2).Findings include:According to regulatory requirements under SS483.12(a)(3) and 483.12(b)(1) the facility must have written procedures for screening prospective employees, to include reviewing: the employment history (e.g., dates of employment position or title), particularly where there is a pattern of inconsistency; information from former employers, whether favorable or unfavorable; and/or documentation of status and any disciplinary actions from licensing or registration boards and other registries. A review of the facility's Resident Abuse policy last reviewed by the facility May 29, 2025, revealed the requirement for screening potential employees included obtaining references from two previous employers.Review of employee personnel files revealed the following:Employee 1 (Licensed Practical Nurse): Hired on August 06, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer.Employee 2 (Nurse Aide): Hired on June 17, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Interview with the Nursing Home Administrator (NHA) on October 1, 2025, at 10:15 a.m. the NHA was unable to provide evidence that previous employers were contacted for information regarding the employees past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires.28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a)(c) Resident Rights.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.19 (1) Personnel records.

Based on clinical record review, review of select facility policies, and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to administering a narcotic pain medication prescribed on an as-needed basis for one resident (Resident 6) out of 21 sampled residents. Findings include:A review of the facility's policy entitled Pain Management Policy with a policy review date of May 29,2025, indicated that non- pharmacological interventions (methods to relieve pain that do not involve medication, such as repositioning, relaxation techniques, heat/cold therapy, or distraction) will be attempted prior to the admission of a PRN (as needed) medication, If the non-pharmacological interventions fail then when corresponding intensity ratings, the resident will be administered the medication ordered for the corresponding pain rating within the PRN order.A review of Resident 6 ' s clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) (a long-term lung condition that limits airflow due to lung damage) and Neoplasm of unspecified behavior of the bladder (a bladder tumor of uncertain type).A review of Resident 6's quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 17, 2025, revealed that Resident 6 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 13-15 indicates cognition is intact)A review of Resident 6 ' s clinical record revealed a physician ' s order dated January 16, 2025, revealed Acetaminophen 325 mg, administer two tablets (650 mg) by mouth every six hours as needed for pain or headache, not to exceed 3 grams in 24 hours. The order did not identify a pain intensity level (e.g., mild, moderate, or severe) or a numeric pain scale (0-10, where 0 is no pain and 10 is worst pain) and Oxycodone 5 mg (a narcotic pain medication), twice daily as needed for severe pain rated 7-10.A review of Resident 6 ' s electronic Medication Administration Record (eMAR) (a digital record used to document each resident ' s medications) for September 2025 revealed that Oxycodone 5 mg was administered without documented attempts of non-pharmacological interventions and without documentation of pain level or reassessment on the following dates and times:A review of Resident 6 ' s electronic Medication Administration Record (eMAR) (a digital record used to document each resident ' s medications) for September 2025 revealed that Oxycodone 5 mg was administered without documented attempts of non-pharmacological interventions and without documentation of pain level or reassessment on the following dates and times:September 1, 2025 - 3:51 PMSeptember 9, 2025 - 8:25 PMSeptember 15, 2025 - 3:51 PMSeptember 16, 2025 - 7:19 PMSeptember 18, 2025 - 9:58 PMSeptember 19, 2025 - 4:32 AMSeptember 22, 2025 - 2:21 PMIn each instance, there was no documentation that staff assessed Resident 6 ' s pain level before administering the medication or that any non-pharmacological interventions were attempted prior to giving the opioid.An interview was conducted with the NHA (Nursing Home Administrator) on August 15, 2025, at 9:30 AM, 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.in accordance with facility policy.28 Pa. Code 211.5(f)(ii)1(viii)(ix) Medical records.28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services.

Based on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (1 East Hall).Findings include:A review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, last reviewed by the facility on May 29, 2025, indicated that if a multi-use medication vial/injectable (containers intended for multiple uses for one or more patients that require puncture of the rubber stopper or seal to withdraw doses on different occasions) has been opened and accessed, the vial is to be dated and discarded within 28 days unless the manufacturer specifies a different expiration timeframe for that opened vial.An observation of the medication cart located on the 1 East Hall unit, conducted on October 1, 2025, at 8:22 AM in the presence of Employee 3 (Licensed Practical Nurse), revealed one (1) multi-dose insulin pen of Insulin Aspart (a short-acting insulin medication used to lower blood sugar levels in individuals with diabetes mellitus) and three (3) multi-dose insulin pens of Insulin Glargine (a long-acting insulin medication used to lower and stabilize blood sugar levels over an extended period) that had been opened and were available for resident use but were not dated with the date opened or expiration date. Each pen had a manufacturer-provided label with a designated space for documenting the date opened and the corresponding expiration date, which had been left blank.Further observation revealed one (1) multi-dose insulin pen of Insulin Glargine (a long-acting insulin used to control blood sugar levels in residents with diabetes) with a sticker affixed to the pen that was blank, indicating it had been opened and was currently in use but lacked documentation of the date opened or expiration date.A review of the manufacturer ' s storage and safety instructions for Insulin Glargine revealed that once opened, the pen must be discarded after 28 days (the time period after which a medication is no longer considered safe or effective due to potential chemical degradation or loss of sterility). The manufacturer ' s guidance specifies that the date the pen is opened and the corresponding expiration date (defined as the final date a medication may be used safely and effectively before it is to be discarded) must be recorded to ensure compliance with manufacturer recommendations.An interview with Employee 3 (LPN) conducted on October 2, 2025, at 8:24 AM, confirmed that the three (3) multi-dose insulin pens of Insulin Glargine and one (1) Insulin Aspart pen were open, in current use, and not dated to reflect the date opened or the calculated expiration date. Employee 3 acknowledged that the multi-dose pen of Insulin Glargine was in use but had never been dated when opened.An interview with the Nursing Home Administrator (NHA) on October 2, 2025, at approximately 11:00 AM, confirmed that staff adhere to the facility policy regarding the dating and storage of multi-dose insulin pens in accordance with manufacturer labeling and expiration requirements.28 Pa. Code 211.9(a)(1)(k) Pharmacy services28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the attending physician failed to document a clinical rationale for declining the pharmacist ' s identified irregularities in the medication regimen for one resident (Resident 49) out of five sampled residents reviewed for unnecessary medications.Findings include:A review of the clinical record revealed that Resident 49 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia without behavioral disturbance (a condition characterized primarily by memory loss and cognitive decline without significant behavioral changes), encephalopathy (a general term describing brain disease or malfunction that can cause symptoms ranging from mild confusion to severe cognitive impairment or coma), respiratory failure (a serious condition in which the lungs cannot adequately oxygenate the blood), and a history of multiple falls.A review of a consultation report completed by the facility ' s consultant pharmacist dated July 7, 2025, revealed that Resident 49 was receiving three or more central nervous system (CNS) active medications. CNS-active medications affect the brain and spinal cord, which control most body functions. These medications include drugs such as sedatives, antidepressants, antipsychotics, narcotic pain relievers, and muscle relaxants. Use of multiple CNS-active drugs can increase the risk for falls, confusion, and fractures in older adults.The pharmacist noted that Resident 49 was receiving:Lorazepam 0.5 mg one tablet twice daily, a benzodiazepine used to relieve symptoms of anxiety.Duloxetine Hydrochloride 30 mg one capsule twice daily, an antidepressant in the class of Serotonin and norepinephrine reuptake inhibitors (SSNRI) used to treat depression and nerve pain.Quetiapine Fumarate 25 mg one tablet daily, an antipsychotic medication; andTramadol Hydrochloride 25 mg one tablet twice daily, an opioid pain reliever.The pharmacist ' s review indicated that Resident 49 had recently sustained a fall on June 24, 2025, and recommended that the attending physician re-evaluate the medication regimen and consider a gradual dose reduction (GDR) of Duloxetine to 20 milligrams twice daily (BID).(A gradual dose reduction, or GDR, refers to the stepwise tapering of a medication dosage to determine whether symptoms, conditions, or risks can be managed with a lower dose or discontinued altogether, as required under CMS regulations for unnecessary drugs.)The attending physician responded to the pharmacist ' s recommendation on July 11, 2025, and declined to implement the recommended GDR of Duloxetine. However, the physician did not document an acceptable clinical rationale in the resident ' s medical record to justify declining the pharmacist ' s recommendation.The above was reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 1, 2025, at 4:00 PM.28 Pa. Code 211.9 (k) Pharmacy services.28 Pa. Code 211.12 (c) Nursing services.28 Pa. Code 211.2 (d)(3) Medical Director.

Based on a review of controlled drug shift count records, facility policies, and staff interviews, it was determined that the facility failed to ensure accurate documentation of controlled (Schedule II) medications (controlled medications are drugs regulated under the federal Controlled Substances Act due to their potential for abuse or dependence, with Schedule II drugs having a high potential for abuse but accepted medical use) by both the oncoming and off-going nurses (the licensed nurses assuming or ending responsibility for a medication cart at the change of shift) for two of two medication carts observed (First Floor [NAME] Hall and First Floor East Hall).Findings include:A review of the facility policy entitled Inventory Control of Controlled Medications, last reviewed May 29, 2025, revealed that controlled drugs (medications regulated under federal and state law due to their potential for abuse) must be inventoried and documented under proper security and in accordance with state and federal regulations. The policy further indicated that Schedule II controlled medications (drugs such as oxycodone or hydromorphone that have a high potential for abuse but legitimate medical use) are to be counted jointly by the oncoming and off-going nurses at each shift change and recorded on the narcotic shift count sheet (a document used to verify the exact number of controlled medications at the end and beginning of each shift).A review of the facility ' s Narcotic Logbook (a bound or electronic record used to document the receipt, administration, and shift-to-shift count of controlled drugs) for the First Floor [NAME] Hall medication cart revealed the following omissions:September 19, 2025- the night-shift oncoming nurse failed to sign the narcotic count.September 20, 2025 - the nightshift off-going nurse failed to sign the narcotic count.September 22, 2025 - the day-shift oncoming and off-going nurses failed to sign the narcotic count.September 26, 2025 - the night-shift oncoming and off-going nurses failed to sign the narcotic count.September 28, 2025 - the evening-shift off-going nurse failed to sign the narcotic count.An interview with Employee 1 (LPN) Licensed Practical Nurse, conducted October 1, 2025, at 8:45 A.M., confirmed that the narcotic sheets were not signed by both nurses on the above dates.A review of the Narcotic Logbook for the First Floor East Hall medication cart revealed similar documentation omissions:September 15, 2025 - day-shift oncoming nurse failed to sign.September 20, 2025 - day-shift oncoming nurse, evening-shift off-going nurse (two entries), and night-shift oncoming and off-going nurses failed to sign.September 21, 2025 - night-shift oncoming and off-going nurses failed to sign.October 1, 2025 - day-shift oncoming nurse failed to sign.An interview with Employee 2 (LPN) conducted October 1, 2025, at 8:35 A.M., confirmed that the narcotic sheets were not signed off by the oncoming and off-going nurses for the above dates.An interview on October 1, 2025, at 11:00 AM, the Nursing Home Administrator verified it is the expectation of the facility staff to demonstrate consistent implementation of procedures for promoting accurate controlled drug records.28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service.28 Pa Code 211.9 (c)(k) Pharmacy services.28 Pa Code 211.5(f)(x) Clinical records.

Based on review of clinical records, select resident incident report, and staff interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to thoroughly conduct and document the results of a professional nursing assessment regarding the clinical status of a resident following a change in condition for one resident (Resident 1) out of 8 residents reviewed. Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of Resident 1's clinical record revealed an admitted to the facility December 5, 2018, with diagnoses to include aphasia (a language disorder that affects the ability to speak and understand what others say. It usually happens suddenly after a stroke or traumatic brain injury). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 7, 2024, revealed that Resident 1 was cognitively impaired and required substantial assistance with activities of daily living. A review of nursing documentation dated September 10, 2024, at 7:38 p.m., revealed Resident 1's daughter expressed concern about her mother's condition to Employee 1 (LPN). Employee 1 noted the resident was clammy, and lethargic. Resident 1's vital signs were taken and her Oxygen saturation (the amount of oxygen you have circulating in your blood) was 87%. The normal range is 95 to 100%. Resident 1's daughter asked the RN supervisor on duty Employee 2, to assess her mother. The resident's nursing progress note stated that Employee 2 was present on unit to assess the resident. However, there was no documented evidence that an assessment was completed. Further review of the clinical record revealed no additional documentation regarding Resident 1's condition until September 11, 2024, at 9:10 a.m., when Employee 3 (RN) noted the resident's condition had not improved and contacted the physician. STAT (immediate) labs were ordered, and results returned at 11:53 a.m. indicated an elevated white blood cell count of 32.68 K/ul (thousands per microliter of blood normal adult 4.0 K/ul -11.0 K/ul or 4000-11000 cells per microliter), consistent with an active infection. However, the resident was not transferred to the hospital until 2:01 p.m. on September 11, 2024. Resident 1 was later diagnosed and treated for sepsis (a condition that arises when the body's response to infection causes injury to its own tissues and organs) returning to the facility on [DATE]. There was no documented evidence that a thorough and timely nursing assessment was conducted following the resident's initial change in condition. Additionally, the facility failed to escalate care in a timely manner, which delayed appropriate medical intervention. The facility failed to ensure nursing services were provided consistent with professional standards. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, at 11:30 a.m. confirmed that the facility nursing staff didn't timely assess and timely send the resident to the hospital for her documented change in condition resulting in the lack of provided nursing services consistent with professional standards 28 Pa Code 211.12 (1)(3)(5) Nursing Services

Based on clinical record review and staff interview, it was determined the facility failed to maintain accurate clinical records for one of 18 residents sampled (Resident 19). Findings include: A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). A review of a care plan initiated July 18, 2022, for cognitive deficit revealed the resident has a diagnosis of Dementia with Lewy Bodies (Lewy body dementia causes a decline in mental abilities that gradually gets worse over time. People with Lewy body dementia might see things that aren't there. This is known as visual hallucinations. They also may have changes in alertness and attention). The facility was noted to have changed clinical record systems on April 8, 2024. The above noted care plan was not completely transferred, to include the dementia care plan for Resident 19, from the initial electronic medical record system to the system currently in use at the facility at the time of the survey ending December 12, 2024. During an interview conducted on December 11, 2024, 11:00 AM, the Director of Nursing (DON) confirmed that Resident 19's current care plan was incomplete. She stated that the facility changed electronic records systems on April 8, 2024, and all the resident medical information was not transferred from the prior electronic clinical records to the current system. The DON stated she did not know how many of the current residents at the time of the survey had complete medical records. 28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antidepressant medication for one resident out of five sampled residents for unnecessary medication use. (Resident 19). Findings included: A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). A review of Resident 19's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 21, 2024, revealed the resident was severely cognitively impaired. A review of current Physicians orders dated April 4, 2024, revealed orders for Mirtazapine 15 mg (an antidepressant medication) by mouth at bedtime for depression, Trazadone 200 mg (an antidepressant medication) by mouth at bedtime for depression, and Sertraline 50 mg (an antidepressant medication) by mouth at bedtime for depression. A review of a pharmacy consultation report dated October 14, 2024 completed by the consultant facility pharmacist recommended a gradual dose reduction (GDR) of the residents Mirtazapine 7.5 mg antidepressant medication. The GDR request was declined by the RN nurse practitioner on October 17, 2024. The documented reasoning was resident recently hospitalized secondary to behavior against staff. A GDR is contraindicated. A review of a pharmacy consultation report dated November 15, 2024 completed by the consultant facility pharmacist recommended a gradual dose reduction (GDR) of the residents Trazadone antidepressant medication. The GDR request was declined by the physician assistant on November 19, 2024. The documented reasoning stated Residents psych medications are managed by the consultant psychiatrist. Please defer to this physician for medication management. Further review of the pharmacy consultant report failed to include a resident specific rationale to justify the continued use of the multiple antidepressants in use for this resident. In addition, there was no documented evidence at the time of the survey to justify the concurrent use of multiple antidepressant medications for this resident. An interview with the Director of Nursing (DON), on December 11, 2024, at approximately 1:00 PM, confirmed the facility failed to ensure that Resident 19's attending physician provided clinical justification/rationale for the continued administration of antidepressant medication and the concurrent use of multiple antidepressant medications. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director

Based on a review clinical records and facility provided documents it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to complete and accurate medical records. Findings include: A review of a facility policy for Quality Assurance and Performance Improvement (QAPI) program reviewed December 4, 2024, revealed the purpose of QAPI in the facility is to take a proactive approach to continually improving delivery of care and services and to engage residents, caregivers, and other clinical/operational partners in maximizing quality of life and quality of care. The facility will conduct performance improvement projects to examine and improve care and services which have been identified as opportunities for improvement. A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). A review of a care plan initiated July 18, 2022 for cognitive deficit indicated the resident has a diagnosis of Dementia with Lewy Bodies (Lewy body dementia causes a decline in mental abilities that gradually gets worse over time. People with Lewy body dementia might see things that aren't there. This is known as visual hallucinations. They also may have changes in alertness and attention). The facility was noted to have changed clinical record systems on April 8, 2024. The above noted care plan was not completely transferred, to include the dementia care plan for Resident 19, from the initial electronic medical record system to the system currently in use at the facility at the time of the survey ending December 12, 2024. During an interview conducted on December 11, 2024, 11:00 AM, the Director of Nursing (DON) confirmed that Resident 19's current care plan was incomplete. She stated that the facility changed electronic records systems on April 8, 2024 and all the resident medical information was not transferred from the prior electronic clinical records to the current system. The DON stated she did not know how many of the current residents at the time of the survey had complete medical records. During an interview December 12, 2024, the DON and NHA confirmed the ongoing issue regarding the transfer of medical records into the current electronic medical record was not part of the ongoing quality assurance program at the facility. The facility's quality assurance monitoring plans designed to ensure solutions were sustained, failed to identify the continuing deficient practice with these quality requirements and prevent deficient practice. Refer F744, F842 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 201.18(e)(1) Management

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for two out of 18 residents (Resident 18 and 19). Findings include: A review of Resident 18's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 18's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 23, 2024, revealed the resident was severely cognitively impaired. A review of the resident's current care plan, initially dated November 21, 2024, revealed no documented evidence the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage, modify or decrease the resident's dementia-related behavioral symptoms. A review of Resident 19's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included acute dementia. A review of Resident 19's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 21, 2024, revealed the resident was severely cognitively impaired. A review of the resident's care plan initiated July 18, 2022 for cognitive deficit indicated the resident had a diagnosis of Dementia with Lewy Bodies (Lewy body dementia causes a decline in mental abilities that gradually gets worse over time. People with Lewy body dementia might see things that aren't there. This is known as visual hallucinations. They also may have changes in alertness and attention). A review of the resident's current care plan, initially dated April 15, 2024, in effect at the time of the survey ending December 12, 2024, revealed no documented evidence the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage this resident's dementia-related behaviors. The resident's care plan for dementia failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage, modify or decrease the resident's dementia-related behavioral symptoms. Interview with Nursing Home Administrator on December 12, 2024, at approximately 10:00 AM, confirmed the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address the resident's dementia care. 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of select facility policy, clinical records, and staff interviews it was determined that the facility failed to develop and implement individualized measures for the toileting needs of two residents out of 18 sampled residents for bowel and bladder management (Residents 27 and 74). Findings included: A facility policy entitled Continence Management Programs last reviewed by the facility December 2, 2024, indicated that the facility will design a plan to manage incontinence that is developed according to the resident's needs and capabilities. Upon admission, the admitting Nurse will complete a head-to-toe assessment which includes interview of resident and review of underlying conditions such as potential or actual diagnoses that may affect the ability to participate in a continence management program. The nursing staff will identify each resident who is incontinent, assess, and plan appropriate treatment and services to achieve or maintain as much normal urinary and/or bowel function as possible. Additionally, the policy indicted that a Continence Evaluation will be conducted to determine if a 72-hour Bowel and Bladder Tracking is indicated. If tracking is indicated, the licensed Nurse will instruct the nursing assistants (NA) to fill out the form. When a new pattern has been identified, a new Continence Evaluation will be completed and the licensed nurse will develop a toileting plan, determining the approaches needed to achieve the goal(s), establish the type of staff intervention needed to meet each resident's goal(s), select equipment and aids needed to be successful and note the interventions, and review the plan as needed to identify any necessary modifications. A review of Resident 27's clinical record revealed that the resident was most recently readmitted to the facility on [DATE], with diagnoses 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), COPD (chronic obstructive pulmonary disease an ongoing lung condition caused by damage to the lungs and the damage results in swelling and irritation), and morbid obesity (is a complex chronic condition that can lead to several serious health issues). A review of the resident's Admission/Readmission Observation completed by Employee 1 RN (registered nurse) dated September 27, 2024, at 4:49 PM, revealed the resident always was incontinent of urine and always incontinent of bowel and required adult incontinence briefs to manage incontinence. Additionally, at the time of the readmission observation assessment, Employee 1 initiated a Continence and Retraining/Scheduled Toileting and Decision/Determination Observation form that indicated bladder and bowel were to be assessed due to readmission. Resident 27's had a history of UTI's (urinary tract infections), functionally was unable to walk to the bathroom which required the use of a wheelchair for locomotion, and usually aware of her toileting needs. However, Resident 27's Continence and Retraining/Scheduled Toileting and Decision/Determination Observation form failed to reveal that staff completed a 72-hour bladder and bowel tracking form to assess the resident's continence to potentially implement a scheduled toileting program, as practicable, or develop individualized incontinence management schedule. A review of Resident 27's comprehensive person-centered plan of care revealed the facility failed to indicate the resident's bladder and bowel continence status or her individualized toileting/incontinence management program to ensure the resident's highest practicable level of independence and dignity. During an interview with the Assistant Director of Nursing (ADON) on December 12, 2024, at 9:17 AM, revealed that the facility could not provide documented evidence that Resident 27's bladder and bowel continence/incontinence was assessed, and that a 72-hour bladder and bowel tracker was completed as per facility policy. A review of the clinical record revealed that Resident 74 was admitted to the facility on [DATE], with diagnoses that included esophageal cancer (a tumor that occurs in the tube which connects from throat to the stomach resulting in difficulty in swallowing, chest pain, cough, sudden weight loss and heartburn), metabolic encephalopathy (is a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and protein calorie malnutrition (is the state of inadequate intake of food), A review of the resident's Admission/Readmission Observation completed by the ADON dated October 31, 2024, at 5:05 PM, revealed that the resident was able to stand and pivot from wheelchair with assistance, was alert and oriented and understands clear-comprehension, and always continent of urine with use of urinal. The resident's bowel continence section was not completed. A review of Resident 74's admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 5, 2024, revealed that the resident was cognitively intact with a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 15 (12 to 15 indicates cognitive intact), required substantial/extensive assistance from staff for transfers, and toileting, and toileting hygiene. Additionally, the admission MDS was coded to indicate that a trial urinary and trial bowel toileting program was not attempted and was occasionally incontinent of urine, frequently incontinent of bowel, and was not on a bladder or bowel toileting program. Resident 74's clinical record failed to reveal any documented evidence that continence/incontinence status was assessed to develop and implement an individualized toileting or incontinence management program to ensure the resident's highest practicable level of independence and dignity. An interview with the Assistant Director of Nursing (ADON), on December 12, 2024, at 9:30 AM, revealed the facility could not provide documented evidence that upon admission Resident 74's bladder and bowel continence/incontinence was assessed, and that a 72-hour bladder and bowel tracker was completed as per facility policy, and plan of care was fully developed to reflect the resident's toileting needs. At the time of the interview with the ADON, it was confirmed that upon admission the facility failed to assess Resident 27 and Resident 74's bladder and bowel continence/incontinence and failed to complete a 72-hour bladder and bowel tracker as per facility policy, and that the facility failed to fully develop a plan of care to reflect the resident's toileting needs to ensure the resident's highest practicable level of independence and dignity. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(a)(d) Resident care policies

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence for one resident out of 18 sampled (Resident 6). Findings include: A review of policy entitled Restorative Nursing Referral and Process Policy last reviewed by the facility on December 4, 2024, revealed it is the policy of the facility that Residents who could benefit from the nursing restorative program can be identified at the following times: -on admission -when other assessments are required, such as an MDS assessment -from the 24 hour report and the change of shift report -at morning stand up meeting -at care plan meeting and other resident-focused meetings -at risk management meetings such as behavior management, nutrition at risk -during restorative weekly meetings. The procedure to include, a referral from the therapy department, goals can be written in the initial evaluation for resident participation in the restorative program. It was indicated the restorative program is a nursing program and is at the discretion of the nursing restorative coordinator. Further a care plan will be developed for a restorative program. Clinical record review revealed that Resident 6 was admitted to the facility on [DATE], with diagnoses which included diabetes and muscle weakness. A quarterly MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 20, 2024, revealed the resident to be cognitively intact with a BIMS score of 15 (BIMS (Brief Interview for Mental Status) is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. A score of 13-15 indicates cognitively intact) and required staff assistance for activities of daily living. A review of a physical therapy discharge summary dated May 23, 2024, revealed a recommendation of discharged from therapy services and start restorative nursing program (RNP) for range of motion of bilateral lower extremities. A review a care plan for ADL functional status/rehabilitation dated May 22, 2024, restorative nursing interventions to include active range of motion to left lower extremities for 30 repetitions and passive range of motion to right lower extremity for 30 repetitions. A review of nursing staff documentation dated November 1, 2024, through November 30, 2024, revealed that staff completed RNP exercises for Resident 6 daily for between 2 minutes and 30 minutes daily. There were no nursing evaluations of the RNP program to include resident progress, the continuation of the services or the need to revise the program from the inception of the program May 22, 2024, through the end of the survey December 12, 2024. During an interview on December 11, 2024, at approximately 11:00 AM, the Assistant Director of Nursing confirmed residents RNP programs should be evaluated monthly and documented in the medical record. She stated that she had not reviewed any of the programs since taking over the program in May 2024. During an interview December 12, 2024 at 10:00 AM, the Nursing Home Administrator confirmed it is the facility's responsibility and policy to ensure residents receive appropriate services and assistance to maintain or improve mobility with the maximum practicable independence. 28 Pa. Code: 211.12(d)(3)(5) Nursing services

Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to provide a resident with the necessary amount of staff assistance with activities of daily living, bed mobility, to safely provide resident care based on the resident's current functional abilities and prevent a fall during the provision of resident care, resulting in a fractured nose, for one resident out of 18 sampled (Resident 46). Findings included: A review of Resident 46's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a history of a malignant neoplasm of the brain [is a cancerous brain tumor], chronic pain syndrome, and anxiety. Resident 46's initial fall risk plan identified that the resident was at risk for falls characterized by a history of falls, injury and /or multiple risk factors related to decreased mobility with a noted goal to minimize risks for falls and minimize injuries related to falls. Planned fall prevention interventions were to apply a perimeter mattress and check placement each shift, bed in the lowest position, and to implement preventative fall interventions/devices. The resident was noted to have an ADL/self-care deficit related to pain/decreased mobility with a planned intervention that included transfer with assistance of two with mechanical lift. An MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 29, 2023, revealed that the resident was cognitively intact and required extensive assistance with support of two plus-persons physical assistance for bed mobility and toilet use and extensive assistance of one-person physical assist. A physical therapy (PT) screen dated August 9, 2023, revealed that the resident had a decline in bed mobility and a physical therapy (PT) evaluation and treatment to improve bed mobility and overall function was planned. Resident 46's Physical Therapy Discharge Summary completed by Employee 5, a physical Therapist (PT) for dates of service from August 9, 2023, through September 14, 2023, revealed that the resident's discharge status for bed mobility was maximum assistance, total dependence with attempts to initiate and noted that the resident had increased pain, which limited progress. An incident report for a witnessed fall completed by Employee 6, a registered nurse (RN), dated September 16, 2023, at 4:54 PM, revealed that she was called to Resident 46's room after the resident reportedly fell off the bed while being changed by Employee 7, a nurse aide. Upon arrival to the room, the resident was lying on his back {on the floor}, on the left side of the bed with a bloody nose and a small abrasion was noted on the bridge of the resident's nose. Staff assisted the resident up via Hoyer lift back to bed and assessed to have been alert and oriented times four and vital signs were within normal limits (WNL). Initial neurological check was completed and WNL. Resident 46 reported that when Employee 7 was turning him on to his left side to change his soiled brief that he {Resident 46} lost his grip while holding on to a chair {and fell out of bed}. A review of a fall witness statement completed by Employee 7, a nurse aide, dated September 16, 2023, no time indicated, revealed that Resident 46 informed his aide before dinner that he needed to be changed before his relatives arrived. Employee 7 noted I proceeded to clean him {Resident 46}, while I was wiping his bottom, the resident slipped off the bed and landed on his face and right shoulder. I immediately called for help at 4:54 PM, and nursing responded immediately and proceeded to evaluate him and during the evaluation the resident stated that his right arm gave way. Further review of the fall incident report revealed that the physician was notified of Resident 46's witnessed fall and new orders were given to transfer the resident to the emergency room for further evaluation and treatment. A review of a nursing progress note completed by Employee 6, RN, dated September 16, 2023, at 9:36 PM, revealed that the resident was being discharged from the ER with a diagnosis of a non-displaced nasal (nose) fracture with a consult to ENT (ear, nose, and throat specialist) required for repair and to hold Eliquis (blood thinner) through Monday. A review of the facility's Post Fall Huddle Form completed by Employee 8, a RN, dated September 17, 2023, revealed that the root cause of Resident 46's fall from bed was that the air mattress was compressed. The immediate keep safe intervention was an assist of two staff for ADL care. A review of the resident's task summary report dated September 2023, revealed that on September 16, 2023, the date of the incident, the resident's air mattress was last check for proper function at 7:44 AM. There was no documented evidence that the air mattress was checked after 7:44 AM, on September 16, 2023. At the time of survey ending January 19, 2024, the facility was unable to state why Resident 46's safety and fall prevention plan was not revised to reflect physical therapy's discharge status/recommendations for services ending September 14, 2023. indicating that the resident required maximum assistance with bed mobility. The facility failed to provide the necessary staff assistance with bed mobility based on the resident's current functional abilities for bed mobility and the noted declines in the resident's functional status identified prior to the resident's fall to ensure safety during the provision of care. An interview with the Director of Nursing (DON) on January 18, 2024, at approximately 2:35 PM, confirmed that the resident was not provided ADL care based on the resident's current mobility requirements after declines in the resident's functional abilities related to increased pain levels to ensure safety to prevent the fall resulting in non-displaced nasal fractures. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, the DON/designee reviewed all residents ADL care plans to ensure there was bed mobility assistance level. To prevent this from recurring, the DON/designee educated all licensed nursing staff to ensure that on admission or change in condition, that the care plan is updated to reflect bed mobility assistance level and that the letter K is present by tasks to ensure NA can view. To monitor and maintain on-going compliance, the DON/designee reviewed five resident care plans weekly times four weeks and then monthly times two to ensure bed mobility assistance level was completed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. The facility's corrective action plan was completed September 25, 2023, and confirmed during the survey of January 19, 2024. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of select facility policy, incident investigations and clinical records and staff interviews it was determined that the facility neglected to provide the necessary care, services and staff assistance required to prevent physical harm to residents during transfers of two residents (Residents 1 and 2) resulting in serious physical injury, a fractured leg, for one resident (Resident 2) out of five sampled residents. Findings include: A review of the facility's policy Pennsylvania Resident Abuse dated as reviewed October 3, 2022, states the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to avoid physical harm, mental anguish, or emotional distress. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses, which included Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar, abnormal mobility, and muscle weakness. A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated June 15, 2022, indicated that the resident's cognition was moderately impaired and the resident required the assistance of two staff member for activities of daily living (ADLS are routine activities people do every day without assistance, including eating, bathing, getting dressed, toileting, transferring) in the areas of transfers, toileting, and personal hygiene. A review of the resident's current plan of care, initially dated February 24, 2022, revealed a problem/need of a self-care deficit related to decreased mobility. Planned interventions included the use of a mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with the assistance of two staff for transfers. A review of Resident 1's Kardex (file system that gives a brief overview of each resident to inform nurses aide of the care to provide the resident) revealed that the Kardex also directed the staff caring for Resident 1 that he required assistance of two people and mechanical lift for transfers. A nursing progress note dated September 1, 2022, at 1:30 PM indicated that nurse aide staff approached the nursing station reporting to licensed nursing staff that the mechanical lift tipped over and Resident 1 was on the floor. A review of the facility's investigation report dated September 1, 2022, revealed that Employee 1 NA (nurse aide) came to the nursing station crying stating that the Hoyer lift tipped over and the resident was on the floor. Employee 1 was transferring without two people. Employee 1 transferred the resident by herself using the mechanical lift, when the lift tipped over with the resident in the sling attached to the mechanical lift. A review of a witness statement from Employee 1 dated September 1, 2022, revealed that the employee stated she and another employee transferred Resident 1 to the shower chair using the mechanical lift. After the shower, Employee 1 stated she then took the resident back to his room on the shower chair, did not lock the shower chair wheels, and hooked the resident up to the mechanical lift to transfer the resident from the shower chair into the lift. The employee stated that the resident and mechanical lift tipped sideways during this transfer attempt. A review of a PB-22 (Report for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property) revealed that on September 1, 2022, the facility initiated an investigation for potential neglect of the resident. The facility determined that Employee 1 transferred the resident independently, which was not in accordance with the resident's plan of care. During this transfer attempt, the mechanical lift tipped causing the resident to fall to the floor. The facility sent the employee home at that time. The facility substantiated neglect of Resident 1 and prohibited Employee 1, an agency nurse aide, from returning to work in the facility. An interview with the Director of Nursing (DON) on October 20, 2022, at approximately 4:25 PM revealed that Employee 1 knew that Resident 1 required the use of two people and a mechanical lift for transfers. The DON stated that agency nursing staff they are trained on patient safety when first beginning work at the facility and verified that Employee 1 was aware of the need for two staff to transfer the resident using the lift. A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set assessment dated [DATE], indicated that the resident's cognition was severely impaired and the resident required the assistance of two staff members for activities of daily living. A review of the resident's current plan of care, initially dated October 22, 2015, revealed a problem/need of risk for falling related to decreased mobility. Planned interventions included the requirement for two staff and a Hoyer lift (mechanical lift) with all this resident's transfers. A review of Resident 2's Kardex revealed that the Kardex directed the staff caring for Resident 2 that the resident required assistance of two people and a mechanical lift for transfers. Nursing progress notes September 26, 2022, at 3:26 PM revealed that the resident was lying in bed, yelling out in pain from the right knee and right thigh area, when attempting to turn and reposition. Resident 2 was unable to perform range of motion (the movement of a joint by bending and flexing) in her right leg. The physician was notified, and orders were obtained for an x-ray. An x-ray report dated September 26, 2022, at 5:17 PM revealed that the resident had an acute complete displaced fracture (break) of the femoral shaft (bone between the hip and knee). A nursing note dated September 26, 2022, at 7:00 PM indicated the resident was transferred to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a facility investigation revealed that on September 26, 2022, at 3:26 PM it was brought to the nurse's attention that the resident was yelling out in pain, when staff were attempting to roll or move the resident's right lower extremity (right leg). The resident was expressing pain when the nurse palpated (felt) Resident 2's right knee and right thigh. A review of a witness statement from Employee 2, a nurse aide, dated September 27, 2022, at 1:15 PM revealed that the employee stated a little bit after 1:00 PM Employee 2 assisted Employee 3, a nurse aide, with transferring Resident 2 back to bed. Employee 2 further stated Employee 3 was attempting readjust the lift sling that was under Resident 2 when the resident started to say ouch. Employee 2 stated they positioned the wheelchair by the resident's bed and transferred the resident from the wheelchair to the bed without the use of the mechanical lift. Employee 2 stated that the resident had pain when they went to roll her on to her side while in bed and again said ouch. When Employee 2 and Employee 3 rolled the resident on to her left side, Employee 2 stated they noticed the resident's leg was different from the other leg. Employee 2 stated that at that time, Employee 3 stated that she would report it to licensed staff. Employee 2 stated that she did not go back into the resident's room for the rest of her shift. A review of a witness statement from Employee 3, nurse aide, dated September 27, 2022, at 10:00 AM revealed that the employee stated that someone brought the resident to the resident's room around 1:15 PM. Employee 3 stated that she and Employee 2 transferred the resident from the wheelchair into her bed without using the (mechanical) lift. Employee 3 stated she and Employee 2 placed their arms under the resident's arms and grabbed her pants to transfer her from the wheelchair to the bed. Employee 3 stated that the resident was complaining of pain before lunch and then again after the transfer to her bed. Employee 3 also did not go back into the room to check on the resident for the rest of the shift. There was no documented evidence that either Employee 2 or Employee 3 had alerted licensed and professional nursing staff of Resident 2's complaints of pain during and after this manual transfer. A witness statement from Employee 4, nurse aide, dated September 27, 2022, revealed that Employee 4 stated she and another staff member went into Resident 2's room to change her. The employee indicated that when she touched the resident's right leg to remove her pants, she screamed out in pain. The employee stated the resident had a weird out of it look so the employee alerted the nurse of the resident's condition. A review of a PB-22 (Report for Investigation of Alleged Abuse, Neglect, and Misappropriation of Property) revealed on September 26, 2022, the facility conducted an abuse investigation for neglect. The facility determined that both Employee 2 and Employee 3 did not follow the resident's plan of care for transfers. Employees 2 and 3 transferred the resident without using the mechanical lift. The facility substantiated neglect of Resident 2 and terminated both Employee 2 and Employee 3. An interview with the DON on October 20, 2022, at approximately 7:30 PM revealed that Employee 2 and Employee 3 had been educated on proper lift transfers after the event that occurred during transfer of Resident 1 on September 1, 2022. The DON stated that Employees 2 and 3 knew they were to follow the resident's plan of care and use the lift as indicated on the resident's care plan and Kardex An interview with the Nursing Home Administrator on October 20, 2022, at approximately 8:30 PM confirmed that the facility failed to ensure that Employees 2 and 3 neglected to provide Resident 2 with necessary care to prevent physical harm resulting in a fractured leg. The NHA also verified the Employee 1 neglected to assure the presence of a second staff member as required to safely transfer Resident 1 and avoid the potential for physical harm to the resident. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: Resident 2 was transported to the hospital for evaluation To identify other residents that have the potential to be affected, the DON/designee interviewed interviewable residents to ensure they feel safe in the facility. The DON/designee interviewed interviewable residents to identify how staff transfer them and validated their answers with the care. The DON/designee completed skin evaluations and pain assessments on non interviewable residents. The DON/ designee educated nursing staff on ensuring they know where to find resident specific transfer status. Kardex competencies were completed with non-licensed nursing staff. Care plan competencies were completed with licensed nursing staff. The DON/ designee educated staff on the resident abuse policy. The DON/designee educated nursing staff on mechanical lift policy. Further agency staff will be educated on mechanical lift policy. The DON/ designee educated nursing staff on ensuring a licensed nurse is present when any mechanical lift transfer is needed. To monitor and maintain ongoing compliance, the DON will interview five interview table residents weekly to ensure how staff are transferring residents matches their plan of care and documentation weekly for four times then monthly for two times. The DON will complete skin and pain evaluations on five non interviewable residents weekly for four times the monthly for two times. The DON will observe five resident transfers to ensure they match the care plan weekly for four times then monthly for two times to ensure it matches the plan of care. The DON when will interview five staff members on the abuse policy weekly for four times then monthly for two times. The DON will observe five staff to ensure they can access the care plan and Kardex for resident transfer status weekly times for times then monthly for two times. The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations. The facility's completion and compliance date was September 28, 2022. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1)(3) Management 28 Pa. Code 201.29(a)(c) Resident Rights 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services

Based on review of clinical records, the facility's diet manual and menus and select facility investigative reports and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet this resident's individual needs for safe swallowing resulting in a choking episode and aspiration pneumonia for one resident out of 16 sampled (Resident 65). Findings include: A review of the clinical record of Resident 65 revealed admission to the facility on [DATE], with diagnoses, which include dysphagia (difficulty swallowing) [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. A review of the resident's plan of care for activity of daily living self-care performance deficit initiated February 6, 2017, and revised February 28, 2020, revealed that the resident is able to feed self with set-up and cueing/encouragement from staff. The resident had a physician diet order dated [DATE] for a low concentrated sweets/ no added salt, mechanical soft texture, thin consistency liquids. A review of the resident's quarterly MDS Assessment (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated [DATE], indicated that the resident was cognitively intact and required minimal assistance of one person for eating. An incident report dated [DATE], at 12:33 PM indicated that Resident 65's family summoned nursing staff at lunch time to tell them that the resident was choking at the lunch meal. The resident had been eating lunch in her room with the family present. Upon a nurse's arrival to the room, the resident was awake, verbal and her family was giving her fluids. Resident 65 suddenly became non-verbal, visibly choking and cyanotic (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The nurse called for assistance. The [MEDICATION(S)] maneuver was initiated and a meatball was expressed. The resident became unresponsive with no pulse and CPR was initiated per family request. Spontaneous breathing, color and pulse returned prior to EMT (emergency medical tech) arrival at the facility. The physician was contacted and the resident was transferred to the hospital for possible aspiration. The report continued to state that Resident 65 was on a mechanically soft diet, with soft formed meatball included on the diet. The resident required variable assistive levels, but is suggested to be a one assistance for same. After interview with the family, they stated that the resident picked up a meatball off the tray and popped it into her mouth before we could stop her. A review of an employee witness statement from Employee 1 (LPN) dated [DATE] revealed that the employee stated this nurse was called to Resident 65's room. Resident 65's family stated that they think their mother was choking. Upon entering the resident's room, the resident was verbally responsive. The family was forcing liquids, into the resident' mouth. Employee 1 stopped the resident's family from giving the resident liquids. Resident 65 began choking and turned cyanotic. The [MEDICATION(S)] maneuver was initiated. Employee 1 called for help. CPR initiated until object (a meatball) was expelled. A review of a nurses note dated [DATE] at 12:33 PM revealed, nurse called to room by family. The family stated that they think their mother is choking. Upon entering the resident's room, the family was pushing fluids into the residents mouth. The resident became nonverbal and cyanotic. The [MEDICATION(S)] maneuver was initiated. Call for help, resident put back to bed. Resident unresponsive, not breathing, pulse checked, CPR initiated and continued until EMTS arrived at the building. A nurse's note dated [DATE] at 1:59 PM revealed upon entering the resident's room, The nurse (Employee 1) was at the bedside with the family. The RN assessed the resident, visible choking, face and lips cyanotic, emergency (911) services called. [MEDICATION(S)] maneuver was performed, a whole meatball was expelled. The resident was placed flat on her back, she was unresponsive, no palpable pulse, CPR started per the family request . While waiting for EMT's, spontaneous breathing, pulse and skin color returned. EMTs arrived at the facility. The family requested hospital evaluation. The resident was transferred to the hospital for evaluation and admitted at that time. A review of hospital documentation revealed that the resident was admitted to the hospital and treated with antibiotics for aspiration pneumonia. She was readmitted to the facility on [DATE]. A review of the facility diet manual dated as reviewed by the facility [DATE] revealed a dysphagia, mechanically altered diet characteristics were described as this level consists of foods that are moist, soft-textured, and easily formed into a bolus (a small rounded mass of a substance, especially of chewed food at the moment of swallowing). Meats are ground or are minced no larger than one quarter-inch pieces; they are still moist, with some cohesion. A review of the menu meal extensions for the Spring/Summer revealed that on [DATE], at the lunch meal for Dysphagia 2/ Mechanical soft texture included reportedly served to Resident 65 at the meal during which was the resident choked was planned to receive; 2 - #8 scoops (scoop size measurement for portion size control) of ground meatballs with sauce, spaghetti noodles, Italian green beans, # 20, scoop of pureed bread and pudding parfait. The facility did not obtain interviews from any dietary employees concerning the preparation of Resident 65's meal or any staff interviews regarding the set up of Resident 65's lunch meal, to ascertain if the correct food form was served (ground meatballs) and set up of Resident 65 's lunch meal tray. An interview with the CDM (certified dietary manager) on [DATE], at 11:00 a.m. revealed that she was unable to state or confirm the diet consistency served to Resident 65 for lunch meal on [DATE], during which Resident 65 choked on a whole meatball. The facility's investigation failed to include an evaluation of the specific food items served to the resident and the manner in which they were prepared to determine if the resident received food in form and consistency to meet the resident's chewing and swallowing needs and to effectively plan the resident's therapeutic mechanically altered dietary regimen to prevent recurrence of a similar nature. The facility's investigation into the resident's choking incident also failed to identify if the resident was assisted by one staff member during the lunch meal on [DATE], when the resident choked as noted on the resident's care plan and MDS assessment. According to the facility's menu extensions, the resident was to be served ground meatballs. However, the resident choked and expelled a whole meatball. Interview with the corporate registered nurse consultant on [DATE] at approximately 1 PM, failed to provide evidence to demonstrate that the resident had been served form in a form to meet the resident's individual needs and was unable to provide evidence of a thorough investigation into the resident's choking incident, including an evaluation of the preparation and service of the resident's mechanically altered diet and necessary staff assistance at meals. 28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services. 28 Pa. Code 211.6(a)(d) Dietary Services

Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to assure that a resident was provided the necessary assistance devices for transport to prevent a fall resulting in serious injury, a fractured right orbital bone, for one of four residents reviewed (Resident 2) and the sufficient level of staff assistance, to prevent a fall for one of four residents (Resident 44). Findings include: A review of clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses, which included unspecified dementia without behavioral disturbance (the loss of memory and other mental abilities severe enough to interfere with normal activities of daily living - ADLs - everyday tasks that include bathing, eating, dressing) and history of falls. An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 5, 2021, revealed that the resident was moderately cognitively impaired and required supervision with locomotion on unit and the physical assistance of one person. A review of Resident 2's clinical record revealed the resident had a history of falling. A review of an incident report dated August 14, 2021, at 9:13 a.m., revealed that the resident was in the day room, located across from the nurses' station on the second floor, and last observed at approximately 9:00 a.m. The resident was found on the floor of the day room on her right side with an injury to her face, at approximately 9:15 a.m The resident told staff she was going to see her grandson. Further review of the facility incident report revealed that the resident's wheelchair did not have leg rests on it as the resident required. Further review of facility documentation regarding Resident 2's fall, revealed that the resident's wheelchair did not have leg rests attached, and the root cause of the fall was due to not having leg rests on her wheelchair. A review of a progress notes in the resident's clinical record dated August 14, 2021, revealed that the resident was sent to the emergency room and found to have sustained a fracture of the right orbit and zygoma bones (the bones surrounding the eyes) as the result of the fall. A review of hospital documentation dated August 14, 2021, revealed that resident had an x-ray, which indicated the resident had a fracture of her right zygoma as well as the lateral wall of the orbit on the right (the zygoma and orbit are bones surrounding the eye, the zygoma is the bony arch of the cheek connecting to the orbital bones which surround the eye). The facility failed to provide effective safety interventions by failing to assure that leg/footrests were attached to the resident's wheelchair as the resident required to safely self-propel in the wheelchair. The resident was attempting to self-propel herself in the wheelchair without leg rests attached to her wheelchair, which led to her fall during which she sustained a fracture. A review of the clinical record revealed that Resident 44 was admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] and muscle weakness. A physician's order dated January 29, 2020, indicated that staff were to use a mechanical lift (an assistive device that is utilized in nursing homes to transfer patients between a bed and a chair or other similar resting places) with the assist of two staff when transferring the resident. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2021 revealed that the resident's cognition was intact and that she required extensive assistance with two persons for bed mobility (how the resident moves to and from lying position, turns side to side and positions their body while in bed or alternate sleep furniture) and for transfers between surfaces including to/or from: bed, chair, wheelchair and/or standing position. A review of an incident report dated August 11, 2021, revealed that Employee 1 was providing toileting assistance to Resident 44, by herself, and asked the resident to roll to her left side. The resident rolled to her left side and proceeded to roll out of bed. The report noted that the resident required an assist of 2 for bed mobility per physician's orders, her plan of care and facility policy. The report also indicated that the employee (Employee 1) did not follow the resident's care plan by having another person assist her with the resident's care, resulting in this resident's fall Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 1 on August 11, 2021, revealed that the nurse aide stated, I rolled her over on her left side to provide care, while I was providing care the resident opened her bedside table and proceeded to fall out of bed. An interview with the NHA (nursing home administrator) on September 21, 2021, at approximately 1:30 PM confirmed the facility failed to provide effective safety interventions, leg rests on the wheelchair, for a resident who was a fall risk, resulting in a fall with serious injury and nursing staff failed to use safe nursing technique when providing care to the resident in her bed. This deficiency is cited as past non-compliance. The facility's corrective action plan was to identify other residents with the potential to be affected, to identify which residents self-propel their wheelchairs with their legs to self-propel. and to identify resident's current status for bed mobility and toileting assistance. To identify residents with the potential to be affected the DON/designee assessed all residents who self-propel their wheelchairs that would require leg rests for transport and assessed the status of all resident's bed mobility and toileting assistance. To prevent this from recurring the DON /designee educated all staff on ensuring leg rests are present for those residents that cannot self-propel and to nursing staff on providing appropriate level of staff assistance for toileting and bed mobility. To monitor and maintain ongoing compliance the IDT/designee will complete observation audit weekly x 4 weeks then monthly x 2 to ensure all residents who require leg rests, have leg rests present during transport and interviewing and observing residents to ensure the appropriate level of care is being provided. The facility's immediate corrective action plan was completed August 17, 2021. 28 Pa Code 211.12 (a)(d)(1)(3)(5) Nursing services

Based on a review of clinical records and select facility policies and procedures, and staff interview, it was determined that the facility failed to timely identify and address contributing risk factors to skin breakdown and promptly and consistently provide care and services necessary to promote healing and prevent infection and worsening of pressures sores, which resulted in the resident's hospitalization for [CONDITION(S)] due to an infected pressure injury for one resident out of seven residents sampled with pressure injuries (Resident 35). Findings include: According to the United States 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 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 the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean would environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. The National Pressure Ulcer Advisory Panel defines an unstageable pressure injury as obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (is dead skin tissue that may have a yellow or white appearance) and/or eschar (is characterized by dark, crusty tissue at either the bottom or the top of a wound). The Pressure Ulcer Advisory Panel defines the Braden Scale as a validated assessment tool commonly used to quantify an individual's degree of risk for developing a pressure ulcer. Each assessment parameter is measured on a scale from high risk of 1 to low risk of 3 or 4. The parameters include sensory perception, moisture, activity, mobility, nutrition, and friction and shear, with a possible total score range of 4 to 23. The lower the total score, the higher the risk for pressure ulcer development. Individuals are at risk for developing pressure ulcers if the total score is less than 17 and need to be assessed on a regular basis. Review of the facility's policy titled, Skin and Wound Care Best Practices, with a facility policy review date of January 2021, revealed that the purpose is to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. Skin care and pressure injury prevention is to include repositioning at a frequency determined by risk assessment to avoid pressure to boney prominences (areas where bones are close to the surface and areas that are under the most pressure, thus increase risk for developing pressure injuries). Additionally, providing routine preventative skin care with pH balanced cleansers and moisturizers and barrier products where indicated. On admission, the nurse will conduct a full body assessment and a second full body assessment will be scheduled within the first twenty-four hours of admission. The licensed nurse will complete a weekly skin check. Pressure injuries and wounds will be treated with evidence-based interventions as ordered by the provider. Review of the facility's policy titled, Urinary Incontinence Management, with a facility policy review date of January 2021, revealed that the Unit Manager/Designee will determine the appropriate program for the resident. The Unit Manager/Designee will write a program for the individual resident, implement a care plan, and implement a toileting program. On admission, readmission, quarterly, and upon significant change an, Evaluation for Continence, Retraining/Scheduled Toileting, form is to be completed to assess continence. If the resident is deemed incontinent, a review of medications, diagnoses, mental status, communication, and physical function will be assessed to rule out causes of incontinence related to any of these areas. If unable to rule out any of these causes, further evaluation of the potential causes and development of a plan to address and/or resolve. If interventions are not working, a new evaluation and tracking form is to be completed. The facility was not able to provide a policy for bowel incontinence management. A review of Resident 35's clinical recorded revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 35's Admission Minimum Data Set assessment (MDS- is a federally mandated standardized assessment process completed periodically to plan resident care) dated January 14, 2021, section C Cognitive Patterns, revealed that the resident had a BIMS score (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis) of 15, which indicated that the resident is cognitively intact or has no cognitive deficits. Section G Functional Status revealed that Resident 35 required extensive assistance of two plus persons physical assist to perform bed mobility and required extensive assistance of two plus persons physical assist for toilet use (i.e. cleanses self after elimination and change pad/brief). Section H Bladder and Bowel and section H0200 Urinary Toileting Program, revealed no attempted trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) upon admission/entry to the facility. Section H0300 Urinary Continence revealed that Resident 35 was always incontinent of urine and Section H0400 Bowel Continence noting that the resident was always incontinent of bowel without a toileting program in place to manage bowel incontinence. Section H0500 Bowel Toileting Program indicated that Resident 53 was not on a toileting program to manage the resident's bowel continence. Review of Resident 35's clinical records, Admission/Readmission Evaluation - V 2, dated January 7, 2021, at 5:30 PM revealed that the resident had a Stage II (is characterized by partial-thickness skin loss into but no deeper than the dermis without presence or visibility of adipose (fat) or deeper tissues, granulation tissue, slough and eschar) pressure sore to the buttocks with redness and serous drainage (is a thin, watery and clear substance exiting the wound) present upon admission. Review of the, Evaluation for Continence and Retraining/Scheduled Toileting, form dated January 7, 2021, at 5:30 PM revealed that Resident 35 was evaluated for bladder and bowel continence upon admission to the facility. The evaluation noted that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A 72-hour bowel and bladder tracking was initiated. Review of the, Documentation Survey Report, for January 2021, revealed that the facility failed to complete the initial 72-hour bowel and bladder tracking required to identify Resident 35's bladder and bowel habits or patterns and assist in the development of an individualized plan of care for bowel and bladder continence care. The resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's wound physician conducted a wound telemedicine initial evaluation of the resident on January 8, 2021, which noted that the focused wound exam (site 1) was an unstageable deep tissue injury (DTI) of the right buttocks that measured 6.8 centimeters (cm) in length by 2.2 centimeters (cm) in width by 0.1 centimeters (cm) in depth and a measured surface area of 14.96 centimeters squared (cm2). The wound physician noted the presence of light serous exudate (a protein-rich fluid, such as serum or pus, that has leaked from blood vessels or been discharged by cells or tissues) with 50% of other viable tissue (dermis) and 50% skin. Focused wound exam (site 2) indicated that the resident had an unstageable deep tissue injury (DTI) to the left buttocks that measured 2.2 centimeters (cm) in length by 1.0 centimeters (cm) in width by 0.1 centimeters (cm) in depth and a measured surface area of 2.20 centimeters squared (cm2) with light serous exudate with 50% (dermis) of other viable tissue and 50% skin. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly Wound Assessment v1 - V 5, dated January 8, 2021, at 6:30 PM revealed that Resident 35 had a community acquired unstageable pressure injury to the right buttocks that measured 6.8 centimeters (cm) in length by 2.2 centimeters (cm) in width by 0.1 centimeters (cm) in depth. It was described as present on admission with scant serous drainage with no odor present and appeared to have a pink wound bed. Another community acquired unstageable pressure injury to the left buttocks that measured 2.2 centimeters (cm) in length by 1.1 centimeters (cm) in width by 0.1 centimeters (cm) in depth was also described as present on admission with scant serous drainage with no odor present and appeared to have a pink wound bed. A, Braden Scale Pressure Ulcer Risk Assessment, form of the resident was completed on January 14, 2021(seven days after admission), at 3:30 PM revealed that Resident 35 had slightly impaired sensory perception, which indicated that the resident was able to respond to verbal commands, but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. The degree to which the resident's skin was exposed to moisture was noted to be very moist, meaning that the resident's skin is often, but not always moist with the need for bed linen to be changed at least once a shift. Resident 35's degree of physical activity was documented as being chairfast, the ability to walk was severely limited or non-existent and cannot bear own weight and/or must be assisted into chair or wheelchair. The resident's ability to change and control body position was noted to be completely immobile, does not make even slight changes in body or extremity position without assistance. His usual food intake pattern was noted as adequate and the resident eats over half of most meals. Friction and shearing was identified as a problem, due to requiring moderate to maximum assistance in moving, complete lifting without sliding against sheets is impossible, and frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. The facility's wound physician conducted a wound telemedicine follow-up evaluation on January 19, 2021, that revealed that the unstageable deep tissue injury (DTI) of the right buttocks, site 1, and the unstageable deep tissue injury (DTI) to the left buttocks, site 2, had resolved. However, a focused wound exam of a new area, (site 3), noted an unstageable (due to necrosis) to sacrum that measured 5.0 centimeters (cm) in length by 12.0 centimeters (cm) in width by 0.2 centimeters (cm) in depth and a measured surface area of 60.0 centimeters squared (cm2). The physician indicated the presence of light serous exudate and 20% thick adherent black necrotic tissue [(eschar) an area of dead tissue on the skin] with 80% slough (is dead skin tissue that may have a yellow or white appearance). The physician noted that the sacral wound was in an [CONDITION(S)] stage that was unable to progress to a healing phase because of the presence of a biofilm (a form of infection that is made up of living microbes that are capable of forming colonies). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly Wound Assessment v1 - V 5, dated January 26, 2021, at 12:05 PM revealed that the unstageable area to the sacrum was a deep tissue (DTI) that measured 5.0 centimeters (cm) in length by 10.0 centimeters (cm) in width by 0.2 centimeters (cm) in depth with moderate drainage with slough and necrotic tissue in the wound bed and no odor present. The treatment continued as Santyl and follow up with the facility's wound physician with an in-house visit next week. Weekly Wound Assessment v1 - V 5, dated February 3, 2021, at 12:13 PM revealed that the pressure area was a deep tissue (DTI) unstageable to the sacrum that measured 7.0 centimeters{increase in length} (cm) in length by 10.0 centimeters (cm) in width by 0.2 centimeters (cm) in depth with heavy purulent (is a type of fluid that is released from a wound that is often described as being milky in appearance and is almost always a sign of infection) drainage with slough and necrotic tissue in the wound bed and a strong odor present. The DON documented that the pressure area was assessed noting increased depth with a foul odor to the unstageable wound and the wound was irrigated and cleansed with normal saline and wound cultures were requested. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment continued as Santyl Ointment 250 unit/gram (Collagenase) apply to sacrum wound topically one time a day for wound healing and to cleanse left and right buttock with normal saline, pat dry and apply Calcium Alginate with border gauze daily or as needed (PRN). Resident 35's clinical record revealed that the sacral wound culture and sensitivity was collected on February 4, 2021, at 10:00 AM. A nursing note dated February 6, 2021, at 2:36 PM revealed that a dressing change to the sacrum was performed as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The final sacral wound culture and sensitivity results were reported on February 8, 2021, at 7:09 AM and revealed that the culture had the following organisms present: moderate Proteus mirabilis (A) [bacteria generally found in the intestinal tract and is part of the normal human intestinal flora], moderate Escherichia coli (A) [(abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals and are a large and diverse group of bacteria], and moderate Staphylococcus aureus (MRSA) [methicillin-resistant Staphylococcus aureus refers to those strains of. Staphylococcus aureus bacteria that have acquired resistance to multiple antibiotics that can enter through breaks in the skin resulting in systemic infections]. The susceptibility results indicated that the bacteria present in the wound was resistive [bacteria that become resistant to antibiotics are more difficult to treat, requiring higher doses or alternative medications] to [MEDICATION(S)] (is a broad-spectrum antibacterial agent with activity against a range of Gram-positive and Gram-negative bacteria and atypical organisms), [MEDICATION(S)] (is an antibiotic in the class of antibiotics known as macrolide antibiotics which also includes [MEDICATION(S)] (Zithromax, Zmax) and [MEDICATION(S)] to prevent bacterial cells from growing and multiplying by interfering with their ability to make proteins while not affecting human cells), and [MEDICATION(S)] G (is narrow spectrum antibiotic used to treat infections caused by susceptible bacteria such as staph infections). physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is used to treat a wide variety of bacterial infections such as pneumonia, [CONDITION(S)], infections of urinary tract, ear, and abdomen by preventing the growth of microorganisms to cure the infection] tablet 800-160 milligram (mg), give one tablet by mouth two times a day for sacral wound for ten days. Resident 35's, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated February 8, 2021, at 2:00 PM revealed a late entry in the clinical record that noted that Resident 35 had a 102° Farenheit fever with Tylenol administered as ordered by the physician. Resident 35 continued to have elevated temperatures on February 8, 2021 into February 9, 2021. Review of the wound physician's, Wound Evaluation & Management Summary, dated February 9, 2021, revealed that the physician performed wound debridement (is the process of removing unhealthy tissue from the body) to the sacral wound to remove the necrotic (dead) tissue and establish the margins of viable tissue (living cells). The focused wound exam to the unstageable pressure area on the sacrum (site 3) measured 7.0 centimeters (cm) in length by 7.0 centimeters (cm) in width by 3.0 centimeters in depth with a surface area that measured 49.0 cm2 and had undermining that measured 3 centimeters (cm) at twelve o'clock. The physician noted light serous drainage with 20% thick adherent deviated necrotic tissue, 60% granulation issue, and 20% bone exposure. The physician ordered to irrigate with 1/4 strength Dakin's (is an antiseptic solution containing sodium hypochlorite that was developed to treat infected wounds) prior to dressing change and continue with Santyl and dry dressing. A nursing note dated February 10, 2021, at 1:58 AM revealed that the resident's needs could no longer be met at the facility due to persistent elevated temperatures for three days and worsening sacral wound. The resident was sent to an acute care facility and admitted on that date. Review of Resident 35's acute care hospital records revealed that the resident was admitted to the hospital with [CONDITION(S)] due to an infected sacral pressure ulcer and multiple strokes. Review of hospital records entitled, Wound Care, dated February 11, 2021, at 4:57 PM revealed that the sacrum ulcer measured 5 centimeters (cm) in length by 5 centimeters (cm) in width by 2.0 centimeters (cm) in depth that covered the sacro-coccygeal area with undermining present at ten o'clock for 4 centimeters (cm) and eleven-two o'clock for 3 centimeters (cm). It was noted that the wound edges were regular, circular with dark purple non-blanchable discoloration and denudation around the periphery of the wound. The wound bed was described as having dark grey slough in the center with the bone palpated. The hospital wound care specialist further noted that the resident had been incontinent of moderate loose brown stool with the total area of concern measuring 15.0 centimeters (cm) by 12 centimeters (cm). Resident 35's, physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . coli bacteremia and noted CT scan [computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body] results that showed stercoral [CONDITION(S)] (is a rare and life-threatening [CONDITION(S)] condition associated with severe constipation and fecal impaction, which results in pressure necrosis of the colonic wall) with need for multiple antibiotic therapies. A Foley catheter was placed due to incontinence. Observation on April 22, 2021, at 11:05 AM of Employee 3, LPN and Employee 4, RN during Resident 35's wound treatment revealed that upon entering Resident 35's room a foul odor was detected. Employees 3 and 4 turned the resident on his right side to perform the treatment. When turned, the resident moaned and was exhibiting signs of pain/discomfort. Employee 4 removed the old dressing and packing from the wound. The wound presented with bloody drainage and the center of the wound was beefy red. Employee 4 measured, with a disposable measuring tape, the central pressure injury on the sacrum with approximate measurements at 9.6 centimeters (cm) in length x 8.0 centimeters (cm) in width x 4.6 centimeters (cm) in depth. Employee 4 stated that she did not measure the actual depth and reported that it was deeper than what was measured. This area was observed to be beefy red with yellow slough. Another pressure area was observed at approximately five o'clock that measured 2.2 centimeters (cm) x 1.9 centimeters (cm) with observed eschar present. Additionally, there was another pressure area present at approximately eleven o'clock that measured 2.0 centimeters (cm) x 2.0 centimeters (cm) with slough. The outer area was blanchable and measured 18 centimeters (cm) x 14 centimeters (cm). Employee 3 and Employee 4 reported that the facility's wound physician was following these multiple pressure areas as one total area, instead of three separate areas. The observation confirmed that the resident's pressure sore had worsened/deteriorated since Resident 35's initial admission to the facility on [DATE]. Review of the, Documentation Survey Report, for January 2021, February 2021, March 2021 and April 2021 (through on-site survey date of April 22, 2021), revealed that the facility failed to monitor the resident's bowel and bladder activity. The facility failed to provide an effective bowel and bladder management/incontinence management plan to prevent worsening of Resident 35's pressure ulcer. At the time of the survey ending April 22, 2021, the facility was unable to provide documented evidence to demonstrate that the nursing staff was providing timely incontinence check and change at the frequency necessary to prevent irritation and complications to the resident's skin and deterioration of the resident's pressure area. Interview with the Director of Nursing (DON) on April 22, 2021, at 12:45 PM revealed that she attends the weekly wound rounds with the wound care physician and performs documentation of the doctor's visits on the facility's, Weekly Wound Assessment v1 - V 5, form. The DON stated that Resident 35's wound likely deteriorated and became infected due to the resident's frequent episodes of incontinence of urine and stool. The DON confirmed that the facility was unable to provide evidence that the facility had effectively addressed this risk and contributing factor to the resident's skin injuries to prevent deterioration of the pressure injuries and acquired infection. 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcers Previously cited 12/7/18, 7/31/19, 1/24/20 28 Pa. Code 211.5(f) Clinical records Previously cited 12/7/18, 7/31/19, 1/24/20 28 Pa. Code 211.5(g)(h) Clinical records Previously cited 12/7/18, 1/24/20 28 Pa Code 211.10(a)(d) Resident care policies Previously cited 12/7/18 28 Pa code 211.12(a)(c)(d)(3)(5) Nursing services Previously cited 12/7/18, 7/31/19, 10/30/19, 1/24/20, 3/3/20