Every finding on record at Eden Nursing & Rehabilitation Center

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer. This resulted in actual harm of the development of a facility-acquired Stage 3 (full thickness skin loss that extends into the subcutaneous fat) pressure ulcer for one of three residents (Resident R1).Findings include: Review of facility policy Prevention of Pressure Injuries dated 6/18/26, indicated the purpose of this procedure is to provide an overview of current standards of practice for pressure injury prevention. Interventions are individualized according to each resident's risk factors for pressure injury, clinical condition, and resident wishes and goals of care. General Guidelines include: assess the resident upon arrival to the facility for pressure injury risk factors, and use a standardized pressure injury screening tool to determine and document risk factors. Prevention include: keep the skin dry and hydrated, clean promptly after episodes of incontinence, avoid alkaline soaps and cleansers, use a barrier product to protect skin from moisture, use incontinence products with high absorbency, do not rub or otherwise cause friction on skin, us facility-approved protective dressings for at risk individualizes. Mobility/Repositioning: implement an early mobilization program based on activity tolerance, reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. For example, repositioning every 2-3 hours when an appropriate pressure redistribution surface is used. Review of facility policy Braden Scale - Pressure Injury Risk assessment dated [DATE], indicated a Braden Scale (a standardized assessment tool used in healthcare to evaluate a patient's risk of developing pressure injuries) risk assessment shall be completed by a licensed nurse for every resident according to the schedule below. Results shall be documented in the resident's medical record, and residents identified as at risk (Braden score of 18 or below) shall have appropriate preventative interventions initiated and incorporated into the plan of care. The Braden Scale shall be completed on admission, weekly x 4, quarterly, with significant change, and upon return from hospital. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/28/26, indicated diagnoses of anemia (low healthy red blood cells), and hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and muscle weakness. Section GG: Functional Abilities indicated Resident R1 required dependent assistance (Helper does all of the effort, resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) to roll left and right, to move from a sitting to a lying position, to move to a sitting to a standing position, and to transfer between a chair and the bed. Section M - Skin Conditions, Question M0150 indicated the resident is at risk of developing pressure ulcers/injuries and that the resident had one unstageable pressure ulcer (obscured full-thickness skin and tissue loss) and one unstageable deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue) upon admission. Review of Resident R1's admission Evaluation dated 4/21/26, indicated the following Braden Scale:Sensory Perception: 1 completed limited, unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body surface.Moisture: 2 very moist, skin is often but not always moist. Linen must be changed at least once a shift.Activity: 1 Bedfast, confined to bed.Mobility: 1 Completely immobile, does not make even slight changes in body or extreme position without assistance.Nutrition: 2 probably inadequate, rarely eats a complete meal and generally eats only about 1/2 of food offered. Protein intake includes only 3 servings of meat or dietary products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding.Friction and Shear: 2 potential problems, moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.Braden Score = 9, very high risk for development of pressure ulcers. Review of a Skin/Wound progress note dated 4/22/26, completed by Wound Service Certified Registered Nurse Practitioner (CRNP) Employee E4 stated, This patient was seen today for the first time as a consultation for evaluation of the resident's skin requested per facility staff, as a recent admission. Patient with various increased risk factors for skin breakdown including reduced mobility, generalized weakness, history of falls, poor nutritional intake, incontinence and several medical conditions that affect healing. On regular mattress, incontinent b/b (bowel and bladder). The skin of b/l (bilateral, both sides) buttocks/ischium (a paired bone forming the lower and back part of the hip bone)/sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) is without open wound or breakdown. Additional orders: pressure relief/offloading side to side offloading while in bed. Offload heels per facility protocol - consult therapy for boots. Pressure redistribution mattress per facility protocol. Wheelchair pressure redistribution cushion per facility protocol. Nutritional recommendations, patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN (as needed) prophylactic (preventative) measure. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 4/22/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 4/29/26, completed by Wound Service CRNP Employee E4 stated, On regular mattress. Incontinent b/b. Additional orders: Pressure relief/offloading. Side to side offloading while in bed. Offload heels per facility protocol - recommend wearing boots at all times while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol. Wheelchair pressure redistribution cushion per facility protocol. Nutritional recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR (electronic medical record). Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 4/29/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 5/6/26, completed by Wound Service CRNP Employee E4 stated, Consulted on 5/6 to evaluate sacral wound. New ST (stage) 3 to the sacrum. Unable to order air mattress due to safety risk, very high fall risk. Incontinent b/b. Sacral is a Stage 3 Pressure Injury. Pressure Ulcer acquired on 5/6/26 and has received a status of not healed. Initial wound encounter measurements are 5.4 cm (centimeters) length x 5.9 cm width x 0.3 cm depth. There is a small amount of sanguineous (resembling or containing blood) drainage noted which has no odor. Wound bed has 71-80%, bright red, granulation (newly formed tissue), 11-20% epithelization (restoration of the skin barrier over a wound). The periwound (skin surrounding a wound) skin exhibited excoriation (a break in the skin). The periwound skin was moist. Irregularly shaped, mixture of epithelial and granular tissue to wound base. No s/s (signs and symptoms) of infection, tender with cleansing. Wound orders: cleanse wound, d/c (discontinue) prior wound regimen and initiate the following: cleanse with normal sterile saline, pat dry, apply medical honey (medical-grade honey used for wound healing) to wound base, cover with dry dressing, Q (every day)/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol. Wheelchair pressure redistribution cushion per facility protocol - consult therapy for more effective cushion chair. Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 5/6/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 5/13/26, completed by Wound Service CRNP Employee E4 stated, Sacral peri wound improving. Unable to order air mattress due to safety risk, very high fall risk. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 6.4 cm length x 5.5 cm width x 0.3 cm depth. There is a small amount of sanguineous drainage noted with has a mild odor. The wound is improving. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol. Wheelchair pressure redistribution cushion per facility protocol - consult therapy for more effective cushion chair. Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 5/13/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 5/20/26, completed by Wound Service CRNP Employee E4 stated, Unable to order air mattress due to safety risk, very high fall risk. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 4.5 cm length x 2.9 cm width x 0.3 cm depth. There is a small amount of sanguineous drainage noted which has no odor. The wound is improving. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol. Wheelchair pressure redistribution cushion per facility protocol. Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 5/20/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 5/27/26, completed by Wound Service CRNP Employee E4 stated, Comfortable with air mattress + bolsters (a thick, long cushion) to prevent falls. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 3.4 cm length x 3.9 cm width x 0.3 cm depth. There is a small amount of sanguineous drainage noted which has no odor. The wound is improving. Irregular, elongated shape - extends down L (left) buttock. Despite larger length, there is improvement in appearance. Now two open areas measured as one with intact epithelial tissue connecting them. Tender with cleansing, no s/s infection. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol - air mattress in place and functioning, check q shift. Wheelchair pressure redistribution cushion per facility protocol. Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 5/27/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 6/3/26, completed by Wound Service CRNP Employee E4 stated, Comfortable with air mattress + bolsters to prevent falls. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 3.7 cm length x 3.4 cm width x 0.2 cm depth. There is a small amount of sanguineous drainage noted which has no odor. There is no change noted in the wound progression. The periwound skin exhibited scarring. The periwound skin did not exhibit excoriation. The periwound skin was moist The temperature of the periwound skin is WNL (within normal limits). Irregular, elongated shape - extends down L buttock. Stable in size, tender with cleansing, no s/s infection. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol - air mattress in place and functioning, check q shift. Wheelchair pressure redistribution cushion per facility protocol - WC cushion present; does get OOB (out of bed). Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 6/3/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 6/10/26, completed by Wound Service CRNP Employee E4 stated, Comfortable with air mattress + bolsters to prevent falls. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 3.1 cm length x 1.8 cm width x 0.3 cm depth. There is a small amount of sanguineous drainage noted which has no odor. The wound is improving. The periwound skin exhibited scarring. The periwound skin did not exhibit excoriation. The periwound skin was moist The temperature of the periwound skin is WNL. Irregular shaped, improving in size and appearance. Has mixture of slough (dead tissue made of bacteria, proteins, and old immune cells), granular and epithelial tissue present. Stable in size, tender with cleansing, no s/s infection. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol - air mattress in place and functioning, check q shift. Wheelchair pressure redistribution cushion per facility protocol - WC cushion present; does get OOB (out of bed). Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 6/10/26, Skin/Wound progress note. Review of a Skin/Wound progress note dated 6/17/26, completed by Wound Service CRNP Employee E4 stated, Comfortable with air mattress + bolsters to prevent falls. Incontinent b/b. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 3.6 cm length x 3.1 cm width x 0.3 cm depth. There is a small amount of sanguineous drainage noted which has no odor. There is no change noted in the wound progression. The periwound skin exhibited scarring. The periwound skin did not exhibit excoriation. The periwound skin was moist. The temperature of the periwound skin is WNL. Irregular shaped, multiple scattered openings measured as one with epithelial tissue within the measurement. Has slough and granular tissue present. Has mixture of slough, granular, and epithelial tissue present. Tender with cleansing, no s/s infection. Wound Orders: Cleanse with normal sterile saline, pat dry, apply medical honey to wound base, cover with dry dressing Q day/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol - air mattress in place and functioning, check q shift. Wheelchair pressure redistribution cushion per facility protocol - WC cushion present; does get OOB (out of bed). Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 6/17/26, Skin/Wound progress note. Review of a nursing progress note dated 6/22/26, stated, LPN (Licensed Practical Nurse) reported new onset shivering and new abscess like pockets on buttocks and left ankle with purulent (pus - a primary sign of infection) drainage. Assessed by CRNP and RN (Registered Nurse). HR (heart rate) 124, hypoxia (body tissue does not get enough oxygen) 80% RA (room air) oxygen applied 2L (liters). Slower to respond than baseline, order obtained to send to ER (emergency room). Review of a Details of Hospital Stay progress note dated 6/30/26, stated, admitted from a skilled nursing facility on 6/22/26 for confusion and suspected sepsis (the body's extreme response to an infection, a life-threatening medical emergency) in the setting of chronic wounds. On admission, he was noted to be confused with purulent drainage from a sacral wound and bilateral heel ulcers, and was found to be febrile (increased temperature), tachycardic (increased heart rate), and leukocytic (high white blood cell count, primarily caused by infections) with lactic acidosis (lactic acid builds up in blood, making it more acidic). Initial workup included blood cultures, wound cultures, urinalysis (urine culture) and comprehensive metabolic panel (blood tests to measure electrolyte levels), as well as imaging with CT chest/abdomen/pelvis, CT head, and x-rays of the bilateral calcanei. CT (Computed Tomography - medical imaging used to obtain detailed internal images of the body) imaging revealed a sacral decubitus ulcer without evidence of osteomyelitis (infection in a bone), but MRI (Magnetic Resonance Imaging - non-invasive medical imaging that uses strong magnetic fields and radio waves to create detailed images of the organs and tissues) of the sacrum demonstrated osteomyelitis involving the 2nd coccygeal segment. He was initially managed with broad-spectrum intravenous (via a vein) antibiotics including vancomycin, cefepime, and metronidazole. Resident R1 was re-admitted from the hospital to the facility on 6/30/26. Review of a Wound/Skin progress note dated 7/1/26, completed by Wound Services CRNP Employee E4 stated, Additional hospitalization 6/22/26 - 6/30/26 for sepsis secondary to L heel OM (osteomyelitis) and buttock abscess. On IV (intravenous) abx (antibiotics) until 8/1/26. No new skin breakdown from the hospital. Sacral is a Stage 3 Pressure Injury acquired on 5/6/26 and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm length x 0.4 cm width x 1 cm depth. There is a moderate amount of serous (clear or pale yellow, watery fluid, normal in wound healing) drainage noted which has no odor. The wound is improving. The periwound skin exhibited scarring. The periwound skin did not exhibit excoriation. The periwound skin was moist. The temperature of the periwound skin is WNL. Wound Orders: D/C prior wound regimen and initiate the following: cleanse with normal sterile saline - pat dry, apply 1/4 packing gauze to depth, cover with dry dressing, daily/PRN. Additional orders: pressure relief/offloading while in bed. Offload heels per facility protocol - recommend wearing boots while in bed/offload with pillows if boots are not available. Pressure redistribution mattress per facility protocol - air mattress in place and functioning, check q shift. Wheelchair pressure redistribution cushion per facility protocol - WC cushion present; does get OOB (out of bed). Nutrition recommendations: patient/staff educated on protein intake in relation to promoting wound healing. Additional recommendations: incontinence care per staff. Fall safety prevention per staff. May continue house stock barrier cream every shift and PRN as prophylactic measure. Plan of care documentation and plan of care has been made available to facility staff and medical team via EMR. Plan of care and education discussed with facility staff. Review of Resident R1's clinical record failed to include documentation that preventative measures were implemented as ordered, such as: pressure relief/offloading side to side offloading while in bed and house stock barrier cream every shift and PRN, as had been stated in the 7/1/26, Skin/Wound progress note. During an interview on 7/21/26, at 1:30 p.m. LPN Employee E3 stated, Stock barrier cream goes on the MAR (medication administration record) or TAR (treatment administration record), it is something for the nurses to sign off. During an interview on 7/22/26, at 8:37 a.m. Nurse Aide (NA) Employee E5 stated, Pressure ulcer preventative measures, like barrier creams repositioning, are communicated to us by the nurse and it is in the POC (plan of care) to document. It is also listed on the Kardex (a snapshot of resident care needs). During an interview on 7/22/26, at 8:42 a.m. LPN Employee E1 stated, I look on the orders to see preventative measures for pressure ulcers. Barrier cream is to be documented against by the nurse in the MAR/TAR. During an interview on 7/22/26, at 9:53 a.m. Wound Service CRNP Employee E4 stated, I communicate recommendations to the facility during weekly wound rounds with the wound care nurse. Treatment orders are communicated on the custom wound report that I provide to the facility every week. Wound Care Nurse Employee E6 is who implements the orders. Wound Care Nurse Employee E6 will enter all orders, treatment changes, imaging, diagnostics, medications, consults for therapy. This has always been the process. I send the custom wound report the same day as wound rounds, I send it before I leave the building. During an interview on 7/22/26, at 9:58 a.m. Infection Preventionist Employee E7 stated, Preventative pressure ulcer measures gets communicated to the nurse aides by putting it on the plan of care tasks to be documented against. All residents are placed on pressure redistribution mattresses unless a more specialty mattress is indicated. During an interview on 7/22/26, at 11:44 a.m. Wound Care Nurse Employee E6 stated, Wound Service CRNP Employee E4 and I talk during wound rounds, she will document her recommendations on the custom wound report and that gets sent to me, Infection Preventionist Employee E7, and the Director of Nursing (DON). I am responsible for updating orders, cleaning up old orders, notifying resident/resident representatives of changes, and updating the doctor. I review order changes and interventions with the nurses and nurse aides on the floor. House barrier cream is put in as an order for nurses to sign off. It should be under the treatments. Compound creams would be under the MAR. House barrier cream is the standard to order for preventative measures. Air mattresses are considered when someone has skin breakdown. Review of Resident R1's care plan initiated on 4/27/26, indicated that resident has actual impaired skin integrity related to CVA (stroke) with left side hemi and neglect, need for assistance with ADLs (activities of daily living), incontinent of B&B. Interventions included administer medications and treatments as ordered. Observe for ineffectiveness and side-effects, report abnormal findings to the provider. Complete wound evaluation to monitor the progress of the resident's skin condition. Dietitian as needed. Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration (softening and breakdown of skin around a wound due to prolonged moisture) to provider. Obtain labs and diagnostics as ordered and report abnormal findings to the provider. Provide diet and supplements as ordered, see Nutrition POC. Wound consult PRN. The care plan was revised on 5/7/26, with interventions including low air-loss mattress, check function and settings q (every) shift. Resident R1's comprehensive care plan indicated interventions of house stock barrier cream every shift and prn and side-to-side offloading while in bed were not implemented until 7/8/26. Review of Resident R1's physician orders from 4/21/26, through 7/8/26, failed to include an order to apply barrier cream every shift and as needed as prophylactic measure and failed to include an order to perform side to side offloading while in bed, per Wound Service CRNP Employee E4's recommendations. Review of Resident R1's clinical record failed to include documentation that it was communicated to the nurse aides to apply barrier cream every shift and as needed as a prophylactic measure and failed to include documentation that side to side offloading was performed, per Wound Service CRNP Employee E4's recommendations.The facility failed to provide additional documentation that the facility performed an assessment of Resident R1's wound between weekly rounds with Wound Service CRNP Employee E4. During an interview on 7/23/26, at 9:58 a.m. the DON confirmed that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer. This resulted in actual harm of the development of a Stage 3 facility-acquired pressure ulcer for Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on a review of observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions creating the potential for cross contamination in the main kitchen of the facility. Findings include: During an observation with Food Service Director Employee E9 in the main kitchen on 7/20/26, at 9:15 a.m., revealed the ice machine had a build up grime, and dark colored debris inside the ice machine. During an observation with Food Service Director Employee E9 in the main kitchen on 7/20/26, at 10 a.m. revealed Dietary Employee E16 wearing beard guard under chin. During an interview on 7/20/26, at 10:15 a.m., Dietary Manager Employee E9 confirmed that the facility failed to maintain sanitary conditions and practice proper infection control techniques to prevent cross contamination in the main kitchen.28 Pa. Code: 201.14(a) Responsibility of licensee.

Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for three of seven residents (Resident R4, R11, and R26). Findings include: Review of the facility policy Medication Regimen Reviews dated 6/18/26, indicated a licensed pharmacist reviews the medication regimen of each resident at least monthly. Review of the admission record indicated Resident R4 was admitted to the facility 10/8/25. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/8/26, indicated diagnoses of dementia (decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities), diabetes mellitus and major depressive disorder. Review of Resident R4's MRR's on the following dates were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required: 3/6/26- MRR signed by CRNP Review of the admission record indicated Resident R11 was admitted to the facility 8/28/25. Review of Resident R11's MDS dated [DATE], indicated diagnoses of depression, schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, and decreased participation in activities of daily living), and chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe). Review of Resident R11's MRR dated 2/25/26, was signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required. Interview on 7/24/26, at 9:08 a.m. Infection Preventionist Employee E7 confirmed a CRNP signed Resident R11's MRR dated 2/25/26, and not by the physician as required. Review of the admission record indicated Resident R26 was admitted to the facility 12/17/25. Review of Resident R26's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/19/26, indicated diagnoses of dementia (decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities), protein-calorie malnutrition and hyperlipidemia. Review of Resident R26's MRR's on the following dates were signed by a Certified Registered Nurse Practitioner (CRNP) and not by the physician as required: 5/5/26-MRR signed by CRNP Interview on 7/24/26, at 8:45 a.m. the Infection Preventionist Employee E7 confirmed that a CRNP signed Residents R4, R26 MRR's on the dates noted instead of the physician as required. 28 Pa Code: 201.14(a) Responsibility of licensee28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observation, and staff interviews, it was determined that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster (a long, thick cushion) is a restraint for one of two residents (Residents R1).Findings include: Review of facility policy Use of Restraints dated 6/18/26, indicated physical restraints are defined as any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/28/26, indicated diagnoses of anemia (low healthy red blood cells), and hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and muscle weakness. During an observation on 7/20/26, at 9:08 a.m. Resident R1 was observed lying in bed and the mattress had bilateral (on both sides) raised edges on the top and bottom portions.Review of Resident R1's clinical record failed to include a physician order for bolsters or a plan of care related to the use of bolsters. Further review of Resident R1's clinical record failed to identify any assessments or ongoing evaluations for the usage of bolsters on the resident's mattress. During an interview on 7/23/26, at 11:43 a.m. Infection Preventionist Employee E7 confirmed that the facility failed to assess the functional status of the individual resident to determine if the use of a bolster (a long, thick cushion) is a restraint for one of two residents (Residents R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for two of five residents (Residents R67 and R85).Findings include: Review of facility policy Call System, Residents dated 6/18/26, indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The resident call system remains functional at all times. Review of the clinical record indicated Resident R67 was admitted to the facility on [DATE]. Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/30/26, indicated diagnoses of high blood pressure, arthritis (inflammation of one or more joints, causing pain and stiffness), and muscle weakness. During an observation on 7/20/26, at 10:29 a.m. Resident R67 was observed lying in bed. Resident R67's call bell was clipped to the privacy curtain to the right of the resident, out of the resident's reach. During this observation, Resident R67 stated, How the hell am I supposed to reach that?During an interview on 7/20/26, at 10:49 a.m. Nurse Aide employee E2 confirmed Resident R67's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R67's call bell needs. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R85's MDS dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). During an observation on 7/20/26, at 9:17 a.m. Resident R85 was observed lying in bed. Resident R85's call bell was wrapped around the left side rail, however the cord for the call bell was unplugged from the wall panel and could not be activated. During an interview on 7/20/26, at 9:27 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R85's call bell cord was unplugged from the wall panel. LPN Employee E1 plugged the cord back in to the wall panel and verified that the call bell could be activated. The call bell light outside of the resident room was observed on and audible dinging could be heard at the nurse's station. During an interview on 7/20/26, at 9:27 a.m. LPN Employee E1 confirmed Resident R85's call bell was not accessible and that the facility failed to accommodate Resident R85's call bell needs. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of five residents reviewed (Closed Resident Record CR99).Findings include: Review of the clinical record indicated Closed Resident Record CR99 was admitted to the facility on [DATE]. Review of Closed Resident Record CR99's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/13/26, indicated diagnoses of high blood pressure, anxiety, and muscle weakness. Review of a physician order dated 6/17/26, indicated to obtain a CBC (Completed Blood Count - a test that measures red blood cell, hemoglobin, white blood cell, and platelet levels in the blood) and BMP (Basic Metabolic Panel - a common blood test that measures eight different substances in the blood, including electrolytes and glucose) one time only for monitoring on 6/22/26. Review of Closed Resident Record CR99's clinical record failed to reveal documentation that the CBC was obtained and completed as ordered by the physician on 6/22/26.During an interview on 7/23/26, at 1:11 p.m. Infection Preventionist Employee E7 confirmed that the facility failed to obtain laboratory services as ordered for Closed Resident Record CR99. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, observations, resident and staff interviews it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for one of five resident wheelchairs (Resident R5) and failed to have bath linens in good condition for one of three bath linen items (washcloths).Findings include: Review of the facility policy Homelike Environment dated 6/18/26, indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment;b. comfortable (minimum glare) yet adequate (suitable to the task) lighting;c. inviting colors and decor;d. personalized furniture and room arrangements;e. clean bed and bath linens that are in good condition;f. pleasant, neutral scents;g. plants and flowers, where appropriate;h. comfortable and safe temperatures (71 F - 81 F); [NAME]. comfortable sound levels. Observation on 7/20/26, at 12:11 p.m., Resident R5 was sitting in a wheelchair socializing with others. The chair's frame, seat, and wheels were corroded with grime, debris, and long hairs. Interview and observation on 7/20/26, Nurse Aide (NA) Employee E10 confirmed Resident R5's chair's frame, seat, and wheels were corroded with grime, debris, and long hairs. Review of an anonymous complaint filed with the state on 7/10/26, indicated residents do not have access to linens. Review of a Resident Council meeting held on 7/21/26, at 1:24 p.m. indicated that two of six residents stated washcloths are not well kept and residents could see right through the fabric. Observation of the facility linen storage area on 7/22/26, at 1:51 p.m. washcloths were found to be available; however, upon opening a brand-new package of washcloths, they were noted to be very thin and could see through the fabric. Interview and observation on 7/22/26, at 1:54 p.m. the Nursing Home Administrator confirmed the washcloths were very thin and could see through the fabric. 28 Pa. Code 201.14(a)Responsibility of Licensee28 Pa. Code 201.18(b)Management

Based on review of clinical records, and staff interview, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of six residents (Residents R1 and R4).Findings include: Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's admission Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/28/26, indicated diagnoses of anemia (low healthy red blood cells), and hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infraction (a stroke) affecting left non-dominant side, and muscle weakness. Review of the clinical record indicated Resident R1 was transferred to the hospital on 6/22/26, and returned to the facility on 6/30/26. Review of Resident R1's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 6/22/26. During an interview on 7/23/26, at 12:13 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for Resident R1. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of dementia (decline in cognitive function affecting memory, thinking, behavior, and the ability to perform everyday activities), diabetes mellitus and major depressive disorder. Review of the clinical record indicated Resident R4 was transferred to the hospital on 4/21/26, and returned to the facility on 4/24/26. Review of Resident R4's clinical record, the facility failed to include documented evidence that the facility provided a written notification to the Office of Long-Term Care Ombudsman for the hospitalization on 4/21/26. During an interview on 7/23/26, at 1:56 p.m. the NHA confirmed that the facility failed to provide written transfer notice to a representative of the Office of Long-Term Care Ombudsman for one of six residents as required (Resident R4). 28 Pa. Code: 201.14(a)Responsibility of licensee.28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide written summary of the baseline care plan to the resident and/or representative for two of six residents reviewed (Resident R78 and R94).Findings include: Review of the facility policy Care Plan-Baseline last reviewed 6/18/26, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following:Initial goals based on admission orders and discussion with the resident/representative. Physician orders Dietary orders Therapy services Social serviceThe baseline care plan is used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered care plan. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission. Review of the clinical record indicated Resident R94 admitted to the facility on [DATE]. Review of the Resident R94s Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/3/26, indicated the diagnoses of fracture of first lumbar vertebra, morbid obesity and cirrhosis of liver. Resident R94's clinical record lacked evidence that a written summary of the baseline care plan was reviewed on 6/12/26, 14 days after admission. Review of the clinical record indicated Resident R78 admitted to the facility on [DATE]. Review of the Resident R78's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/9/26, indicated the diagnoses of urinary tract infection, diabetes mellitus and ataxic gait (neurological condition characterized by poor muscle control). Resident R78's clinical record lacked evidence that a written summary of the baseline care plan was provided to Resident R78 and/or his/her representative. During an interview completed on 7/23/26, at 12:35 p.m. the Nursing Home Administrator (NHA) confirmed there were no evidence that a written summary of the baseline care plan was provided to Resident R78 and/or their representatives and Resident R94 within the required timeframe. 28 Pa Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Residents R64).Findings include: Review of the facility policy Splint and Assistive Device Policy dated 6/18/26, indicated every splint comes with a wearing schedule and skin-check instructions. Standard cleaning of fabrics with laundry. Nursing: Apply/remove per schedule, check skin, report concerns. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/7/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Review of Resident R64' current physician orders indicated resident to wear left resting hand splint on with morning care, off with evening care. Gentle stretch to left hand, fingers, and wrist prior to donning (putting on) the splint. Staff to check skin before and after application. Alert therapy of any skin issues or changes. Review of Resident R64's current care plan indicated resident has a functional ability deficit and requires assistance with self-care and mobility related to weakness. Wear left resting hand splint on with morning care, off with evening care. Gentle stretch to left hand, fingers, and wrist prior to donning the splint. Staff to check skin before and after application. Alert therapy of any skin issues or changes. Observation on 7/20/26, at 9:00 a.m. Resident R64 was observed resting in bed with her arms on top of the covers. The resident did not have a splint on her left hand as ordered. Observation on 7/20/26, at 12:00 p.m. Resident R64 was observed resting in bed with her arms on top of the covers. The resident did not have a splint on her left hand as ordered. Interview and observation on 7/20/26, at 12:03 p.m. Therapy Employee E12 entered Resident R64's room and indicated the splint was not on, but she was putting it on the resident now. Observation on 7/21/26, at 11:00 a.m. Resident R64 was observed resting in bed with her arms on top of the covers. The resident did have a splint on her left hand as ordered, that was covered in a light tan dried debris on the fabric. Interview on 7/21/26, at 11:05 a.m. the Nursing Home Administrator was informed the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of three residents (Residents R64). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents with an enteral feeding tube (G- Tube, a tube inserted in the stomach through the abdomen) received appropriate treatment and services to prevent potential complications for one of four residents (Resident R64). Findings include: Review of facility policy Enteral Nutrition (liquid food and medicine directly into the stomach or small intestine) dated 6/18/26, indicated adequate nutritional support through enteral nutrition is provided to residents as ordered. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/7/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Review of Resident R64's current physician orders indicated Glucerna 1.5 (liquid nutrition) at 87 ml/hr (milliliters/hour) via pump, via G tube. Start at 9:00 a.m. and stop at 9:00 p.m. to provide total volume of 1,044mls over a 12-hour period. Review of Resident R64's current care plan indicated to administer enteral nutrition per physician orders. Observation on 7/20/26, at 10:48 a.m. Resident R64 was resting in bed connected to the enteral nutrition pump. The pump's screen displayed an error message, and the pump was not infusing per order. The feeding bag was labeled as being hung at 9:00 a.m. Interview on 7/20/26, at 10:49 a.m. Licensed Practical Nurse (LPN) Employee E11 confirmed the pump was not running and she was not aware. Observation on 7/21/26, at 1:29 p.m. Resident R64 was resting in bed connected to the enteral nutrition pump. The pump's screen displayed a hold error message. Interview on 7/21/26, at 1:33 p.m. LPN Employee E13 was informed Resident R64's pump was not running. LPN Employee E13 indicated she was not aware the pump was on hold and she did not turn if to hold. Indicated that the Nurse Aides (NA's) must have put it on hold to do care and didn't turn it back on. 28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of five residents (Residents R64 and R85). Findings include: Review of the facility policy Oxygen Administration dated 6/18/26, indicated oxygen therapy is administered by way of an oxygen mask or nasal cannula. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. Review the physician's order for oxygen administration. Review of the facility policy CPAP/BiPAP Support (continuous positive airway pressure/bilevel positive airway pressure) indicated BiPAP delivers CPAP but allows separate pressure settings for expiration (EPAP) and inspiration (IPAP). Review the resident's medical record to determine their baseline and physician orders. Review of facility policy Nebulizer Tubing Storage and Replacement Policy dated 6/18/26, indicated nebulizer (a machine used to deliver aerosolized medications) tubing, medication cups, and mouthpieces/masks shall be cleaned, dried, stored, and replaced according to manufacturer recommendations and facility infection prevention practices. After each treatment, clean the medication cup and mask/mouthpiece according to facility protocol and manufacturer instructions. Once completely dry, store the medication cup and mask/mouthpiece in a clean, dry, covered container or resealable plastic bag designated for that resident. Review of the admission record indicated Resident R64 admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 7/7/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and high blood pressure. Review of Resident R64's current physician orders indicated BiPAP every night at bedtime and as needed. BiPAP setting: Inspiratory Pressure: 15. Expiratory Pressure: 6. Oxygen: 5 Liters at bedtime. Oxygen at 5 lpm (liters per minute) per nasal cannula related to respiratory failure every shift. Review of Resident R64's current care plan failed to include care and management of the BiPAP machine as required. Observation on 7/21/26, at 10:31 a.m. Resident R64 was observed resting in bed. Resident failed to have a nasal cannula in their nose or a BiPAP mask on. Resident was breathing on room air only. Interview on 7/21/26, at 10:32 a.m. when Resident R64 was asked why she wasn't wearing her oxygen, she indicated staff took it off and did not put it back on. Interview and observation on 7/21/26, at 10:33 a.m. Licensed Practical Nurse (LPN) Employee E13 confirmed the oxygen was not in place as ordered. Interview on 7/21/26, at 10:45 a.m. Infection Preventionist Employee E7 confirmed Resident R64's plan of care failed to include care and management of the BiPAP. Review of the clinical record indicated Resident R85 was admitted to the facility on [DATE]. Review of Resident R85's MDS dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).Review of a physician order dated 1/5/26, indicated to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 3 mL inhale orally every 6 hours as needed for SOB (shortness of breath)/wheezing.During an observation on 7/20/26, at 9:27 a.m. Resident R85's nebulizer machine was observed on the resident's bedside table. No date was observed on the tubing, and the mouthpiece was stored on top of the machine, not in a bag while not in use. During an interview on 7/20/26, at 9:27 a.m. LPN Employee E1 confirmed the above observations and that the facility failed to provide appropriate respiratory care for Resident R85. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization for one of two residents (Resident R30).Findings include: Review of facility policy Trauma Informed Care and Culturally Competent Care dated 6/18/26, indicated trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident. Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE]. Review of Resident R30's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/17/26, indicated diagnoses of high blood pressure, depression, and anemia (low levels of healthy red blood cells in the blood). Review of a psychiatry progress note dated 5/13/26, stated, Patient is alert up to W/C (wheelchair) sitting quietly in his room having lunch. Cooperative with the interview. He would become tearful at times describing sx (symptoms) of depression and PTSD (Post Traumatic Stress Disorder - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions). Says, I don't know if the medicine is strong enough. PTSD Based Symptoms: Assessed and endorsed symptoms that include: avoidance of trauma reminder, flashbacks, re-experiencing, and dissociation. Review of Resident R30's comprehensive care plan did not include a plan of care developed with goals and interventions related to post-traumatic stress disorder and failed to identify any triggers and how to avoid them. During an interview on 7/23/26/26, at 1:59 p.m. Social Worker Employee E8 confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for a resident who was at risk for re-traumatization for Resident R30. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on observations, and staff interviews, it was determined that the facility failed to store medications and biologicals in a safe, secure, and orderly manner for one of three medication rooms (3 South Medication Room).Findings include: Observation on [DATE], at 8:59 a.m. of the 3 South Medication Room revealed the following expired items:-Eight culture swabs expired on [DATE].-Nine culture swabs expired on [DATE].-Ten culture swabs expired on [DATE].-Tuberculin vial labeled opened on [DATE].Interview on [DATE], at 9:03 a.m. Licensed Practical Nurse (LPN) Employee E14 confirmed the above items were expired as noted. 28 Pa. Code: 201(a) Responsibility of licensee.28 Pa. Code: 211.9(a)(1) Pharmacy services.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of resident records, resident business office documents and staff interview, it was determined that the facility failed to ensure that a resident right to manage their financial affairs was upheld by obtaining a signed authorization for one of three sampled resident records (Resident R37).Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2025, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairment Review of Resident R37's admitted to the facility on [DATE]. Review of Resident R37's admission signed documents dated 11/24/25, indicated a family member signed Resident R37 into the facility. Review of Resident R37's power of attorney (POA) financial document dated 2/10/26, indicated he signed over POA authorization to a relative. Review of Resident R37's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/30/26, indicated that he had diagnoses that included depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), lymphedema (a blockage in the lymphatic system causing swelling to legs or arms), gout (a form of arthritis involving severe pain), and anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry). Section C-0500 BIMS Summary Score indicated the Resident R37 scored a 11, moderately impaired. Review of Resident R37's care plan dated 3/30/26, indicated to actively involve the resident and resident's family in the plan of care. Review of Resident R37's resident fund authorization form (a form to open a resident fund account) indicated Resident R37's fund account was provided with a fax date of 4/16/26, and no signature date. The form was found signed by Resident R37. The section stating Anyone signing for the resident was left blank and without any additional information. Further review did not indicate that Resident R37's POA was involved in opening the fund account. Review of the facility trial balance (a balance showing current residents with a trust fund with the facility) dated 7/20/26, indicated Resident R37 account was still active. During an interview on 7/23/26, at 11:59 a.m. Licensed Practical nurse (LPN)/Business office staff Employee E15 was asked about Resident R37's fund authorization and signature and stated: I'm not sure who signed that. When Licensed Practical nurse (LPN)/Business office staff Employee E15 was asked about when Resident R37 fund account was opened she stated: i was able to get the start date and it shows open 4/16/26. During an interview on 7/23/26, at 2:28 p.m. information was disseminated to the Nursing Home Administrator (NHA) and Director of Nursing (DON) that the facility failed to ensure that Resident R37's right to manage his financial affairs was upheld by obtaining a signed authorization for a resident fund account as required. 28 Pa. Code 201.18(b)(2) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on review of clinical records and staff interview, it was determined that the facility failed to obtain a physician order to discharge for two of three residents (Resident R1, R2).Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included fracture of thoracic vertebra, urinary tract infection and muscle weakness. Review of Resident R1's admission MDS assessment (minimum data assessment)- periodic assessment of resident care needs) dated 12/11/25, indicated the diagnosis remained current. Review of facility provided documents indicated Resident R1 was discharged [DATE]. Review of Resident R1s most recent physician orders indicate no order for discharge. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular heart rhythm), diabetes mellitus and protein-calorie malnutrition. Review of Resident R2's 5-day MDS assessment (minimum data assessment)- periodic assessment of resident care needs) dated 3/2/26, indicated the diagnosis remained current. Review of facility provided documents indicated resident R2 was discharged [DATE]. Review of Resident R2s most recent physician orders indicate no order for discharge. During an interview on 3/18/26, at 1:45 p.m. Director of Nursing confirmed there was no physician order for discharges as required. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of four residents sampled with facility-initiated transfers (Resident R1, R2, and R3), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of four resident hospital transfers (Resident R1, R2, and R3).Findings include: Review of facility policy Transfer and Discharge Information dated 5/19/25, indicated when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Review of facility policy Bed Holds and Return dated 5/19/25, indicated all residents or representatives are provided written information regarding the facility bed hold policies well in advance of any transfer (in the admission packet) and at the time of transfer. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/26, indicated diagnoses of atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and dysphagia (difficult swallowing). Review of the clinical record indicated Resident R1 was transferred to the hospital on 2/20/26, and remains at the acute care hospital. Review of Resident R1's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R1's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 2/20/26. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], indicated high blood pressure, depression, and muscle weakness. Review of the clinical record indicated Resident R2 was transferred to the hospital on 1/26/26, and returned to the facility on 1/26/26. Review of Resident R2's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R2's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/26/26. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], indicated diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), high blood pressure, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).Review of the clinical record indicated Resident R3 was transferred to the hospital on 1/31/26, and returned to facility on 2/1/26. Review of Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility. Review of Resident R3's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/31/26. During an interview on 2/23/24, at 1:53 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of four residents sampled with facility-initiated transfers (Resident R1, R2, and R3), and failed to notify the resident or resident's representative of the facility bed-hold policy for three of four resident hospital transfers (Resident R1, R2, and R3). 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory results as ordered by the physician and failed to provide evidence that the physician or resident representative were notified of the results for two of three residents reviewed (Resident R3, and R4).Findings include: Review of facility policy Laboratory Services and Reporting dated 5/19/25, indicated the facility is responsible for the timeliness of the services and notifying the ordering physician of laboratory results that fall outside of the clinical reference range.Review of the facility policy Change in a Resident's Condition or Status dated 5/19/25, indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the residents' medical/mental condition and/or status.Review of the admission record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS -a periodic assessment of care needs) dated 1/12/26, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), hemiplegia (paralysis of one side of the body), and urinary tract infection.Review of Resident R3's physician order dated 2/18/26, indicated to acquire a CMP (complete metabolic panel - a blood test that measures various substances in your blood to assess your overall health. Includes tests for: kidney function, liver function, blood sugar levels, electrolyte and fluid balance) in the morning for monitoring.There was no documented evidence in Resident 3's clinical record that staff obtained the results of the bloodwork and there was no documented evidence that the physician or resident representative were notified of the results.During an interview on 2/23/26, at 11:05 a.m., Licensed Practical Nurse (LPN) Employee E1 indicated, the lab results were not in the clinical record, and she did not have access to the computer system for the lab results, only the supervisor has access.Review of the admission record indicated Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of anemia (the blood doesn't have enough healthy red blood cells), heart failure (heart doesn't pump blood as well as it should), and high blood pressure.Review of Resident R4's physician order dated 2/11/26, indicated to acquire a BMP (basic metabolic panel - a common blood test measuring eight key substances to assess kidney function, blood sugar, and electrolyte balance) one time only on 2/12/26.There was no documented evidence in Resident R4's clinical record that staff obtained the results of the bloodwork and there was no documented evidence that the physician or resident representative were notified of the results.During an interview on 2/23/26, at 10:30 a.m. with Resident R4's resident representative, it was indicated that Resident R4 had blood work a few weeks ago and nobody could tell the resident representative what the results were despite multiple inquiries made.During an interview on 2/23/26, at 11:05 a.m., LPN Employee E1 indicated, the lab results were not in the clinical record, and she did not have access to the computer system for the lab results, only the supervisor has access.During an interview on 2/23/26, at 3:00 p.m., the Director of Nursing confirmed that the facility failed to obtain laboratory results as ordered by the physician and failed to provide evidence that the physician or resident representative were notified of the results for two of three residents reviewed (Resident R3, and R4). 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, Resident Council meeting minutes, and staff interviews, it was determined the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (December 2025, January 2026, and February 2026).Findings include:Review of the facility policy Resident Council dated 5/19/25, indicated the purpose of the resident council is to provide a forum for discussions of concerns and suggestions for improvement. All feedback and requests communicated from the resident council to the facility are addressed in writing to the council.Review of facility provided Resident Council Meeting Minutes dated 12/2/25, indicated:-Discussion of old/unfinished business: call bells not being answered timely.-Systemic concerns residents are concerned about the call bell audits. As a group, they feel that the wait times are too long, agency staff turn off call bells and do not enter rooms for assistance, and agency staff provide poor care on the weekends (call bells not answered and being on their phones instead of giving care).-Follow up: this section of the form was blank and failed to provide any follow up to the residents' concerns.Review of facility provided Resident Council Meeting Minutes dated 1/6/26, indicated:-Discussion of old/unfinished business: call bells not being answered timely.-The remainder of the form was blank and failed to provide any follow up to the residents' concerns.Review of facility provided Resident Council Meeting Minutes dated 2/3/26, indicated:-Discussion of old/unfinished business: No old business to discuss.-Systemic concerns residents expressed medications not being delivered timely.-Follow up: this section of the form was blank and failed to provide any follow up to the residents' concerns.During an interview on 2/23/26, at 3:00 p.m. the Nursing Home Administrator confirmed the facility failed to consider the views of a resident and act promptly on concerns and recommendations concerning issues of resident care and life in the facility for three of three months (December 2025, January 2026, and February 2026).28 Pa. Code: 201.18(e)(4) Management28 Pa. Code: 201.29(i) Resident Rights

Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for four of 12 months (October 20, 2025, through January 8, 2026).Findings include: During an interview on 1/8/26, at 11:00 a.m. the Nursing Home Administrator stated Food Service Director (FSD) Employee E1 had been employed as the FSD since 10/20/25, and that she was not a Certified Dietary Manager. During an interview on 1/8/26, at 11:10 a.m. FSD Employee E1 indicated the Registered Dietitian normally comes to the facility once per week.During an interview on 1/8/26, at 11:30 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to provide documented evidence that FSD Employee E1 met the qualifications for the position of Food Service Director. Pa Code: 201.18(e)(6) Management.

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of four residents (Residents R1), which resulted in harm when Resident R1 rolled out of bed and sustained bilateral leg fractures. Findings include: Review of the facility policy Repositioning dated 3/4/25, reviewed 5/19/25, stated the purpose of the procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, and to promote comfort for all bed or chair bound residents. Review the resident's care plan to evaluate for any special needs of the resident. Review of the facility policy Safe Lifting and Movement of Residents dated 3/4/25, reviewed 5/19/25, stated in order to protect the safety and well-being of staff and residents, and to promote quality care, the facility uses appropriate techniques and devices to lift and move extremities. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document transferring and lifting needs in the care plan. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of the facility policy Falls-Clinical Protocol dated 3/4/25, last reviewed 5/19/25, indicated the staff, with the physician guidance, will follow up on any fall with associated injury until the resident is stable and related complications such as late fractures have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or days after a fall. Review of the facility policy Change in a Resident's Condition or Status dated 3/4/25, last reviewed 5/19/25, indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a discovery of injuries of unknown source, significant change in the resident's physical condition, and need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing interventions. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility.) Review of physician order dated 2/19/25, revealed Resident R1 transfers with a total assist of two persons via Hoyer lift, no ambulation. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of Residents R1's care plan dated 8/24/22, revealed the resident used side rails for increased independence and mobility due to impaired bed mobility. Resident R1's care plan failed to indicate the level of assistance the resident required for bed mobility or transfers. Review of Resident R1's progress note dated 4/14/25, indicated at 7:20 p.m. Licensed Practical Nurse (LPN), Employee E1 was called to Resident R1's room by Nurse Aide (NA), Employee E2. During care the resident rolled out of bed onto their knees while holding onto the bed rail. The resident was on their right side while care was being provided and NA, Employee E2 was unable to stop the resident from rolling. The resident was turned onto their back and a pillow was placed under their head. The supervisor was called to the room. The resident had a 2-centimeter (cm) x 1 cm abrasion to inner side of the right foot. Resident R1 was assisted back to bed with an assist of three people and a Hoyer lift. No redness at this time to knees. Review of Resident R1's progress note dated 4/14/25, at 7:47 p.m. revealed Registered Nurse (RN), Employee E3 was called to the unit by staff. Resident R1 was observed lying on the floor. The resident stated I slid out of bed and was on my knees with my legs underneath me. The resident denied any pain to bilateral lower extremities. The physician was notified. Review of Resident R1's late entry progress note dated 4/14/25, at 4:48 a.m. indicated Resident R1 was complaining of being sore from the fall. Review of Resident R1's physician order dated 4/15/25, indicated to complete a stat x-ray of the resident's right foot and ankle due to fall. Review of Resident R1's progress note dated 4/15/25, revealed the x-ray was completed at the resident's bedside at 6:30 p.m. of the right foot and ankle. Bruising to right shin present and left abdomen. There was no documentation of the size/measurement of brusing. Resident is on Coumadin. Further review failed to indicate the physician was notified of Resident R1's right shin and left abdomen bruising. Review of Resident R1's progress note dated 4/15/25, at 7:41 p.m. indicated Resident R1's x-rays were negative for fractures of the right foot and ankle. Review of Resident R1's progress notes had bruising, that was not measured, observed to the right shin on the following days with no evidence the physician was notified: -4/16/25 -4/17/25 -4/18/25 -4/21/25 -4/22/25 -4/23/25 -4/24/25 -4/25/25 -4/26/25 -4/29/25 Review of Resident R1's progress noted dated 5/5/25, revealed an assist of two staff members were used to reposition the resident. The resident asked for pain medication at the beginning of the shift. Resident R1 was provided 650 mg of Tylenol for 3/10 right knee pain (pain scale that grades pain levels from 0 (No pain), 1,2, and 3 (Mild), 4,5, and 6 (Moderate), 7,8, and 9 (Severe) to 10 (Worst Pain Possible)). It was indicated the resident had several bruises located on both legs. Review of a late entry progress note dated 5/7/25, at 11:33 a.m. entered by RN, Employee E4 stated a bruise was observed to Resident R1's left distal superior knee. Bruise was not observed during treatment on 5/5/25. Bruise was dark/purple in color, approximately 9 cm x 5 cm x 0 cm. Nurse Aide (unidentified) stated that resident began refusing care on 5/6/25, due to pain in left leg. Resident denied recent trauma to area, the supervisor was notified. Review of a late entry progress note dated 5/7/25, at 12:04 p.m.entered by RN, Employee E5 indicated the physician examined the resident at bedside and wanted the resident to go to the hospital. A purple bruise was observed near the left knee. Resident denies pain. Review of Resident R1's physician order dated 5/7/25, indicated to complete an x-ray of the resident's left knee due to pain and bruise to rule out fracture. Review of Resident R1's progress note dated 5/7/25, at 7:49 p.m. revealed the resident's left knee was fractured. The physician and family were notified, and the resident was transferred to the hospital for further evaluation. Review of progress note dated 5/8/25, revealed Resident R1 was admitted to the hospital. The resident's x-ray results show bilateral leg fractures. The resident's hemoglobin (red protein responsible for transporting oxygen in the blood, normal value in women is 11.6 to 15 grams per deciliter. A hemoglobin level less than 6.5 can be life threating) level was 5.1 and required a blood transfusion. Review of Resident R1's hospital records dated 5/8/25, stated the resident evidently had a fall on 4/14/25, when nursing staff inadvertently lost hold of the resident and the resident fell out of bed. The resident had extensive bruising to the right knee and is non-ambulatory and bed-bound at baseline. Tenderness along the left anterior knee diffusely associated with ecchymosis (medical term for a type of bruise that occurs when blood leaks out of blood vessels into the subcutaneous tissue beneath the skin, often caused by trauma), ecchymosis of the right knee and skin with some bruising of the right ankle was observed. The resident sustained a left distal femur fracture and a right tibial plateau fracture (a break of the upper part of the shinbone that involves the knee joint.) The resident's International Normalized Ratio (INR-a specific blood test used to measure the time it takes for blood to form a blood clot, normal value for someone taking anticoagulant is between 2 and 3.5) was 7.0 and hemoglobin was 5.1. The resident received two units of red blood cells. Review of information submitted to the Department of Health on 5/8/25, indicated on 5/6/25, Resident R1 complained of pain to the left leg. The physician ordered an x-ray of the left knee and it was confirmed the resident had a fracture. The resident was sent to the hospital for further evaluation. It was revealed the resident thinks the fractures occurred from being rolled out of bed with an assist of one person on 4/14/25. From 4/14/25, to 5/6/25, the resident had mild pain that was relieved by Tylenol. Abuse was ruled out and unsubstantiated. Prior to the incident bed mobility was not care planned for the resident. Review of a late entry progress note created on 5/18/25, effective 4/16/25, entered by Medical Director, Employee E11 indicated the resident was seen for follow up care. The resident had recent hospital admission for sepsis. There was no evidence Resident R1's fall or bruising to the right shin was addressed. During an interview on 5/28/25, at 9:12 a.m. the Nursing Home Administrator (NHA) stated what happened to Resident R1 was really a terrible accident. During an interview on 5/28/25, at 9:41 a.m. NA, Employee E6 stated if a resident is ordered to be transferred with an assist of two, then two people must assist the resident with bed mobility. Residents should be rolled towards the person rolling them. During an interview on 5/28/25, at 9:44 a.m. LPN, Employee E7 indicated physician orders should be entered for resident's transfer status and bed mobility. During an interview on 5/28/25, at 9:54 a.m. Occupational Therapist, Employee E8 stated when residents are admitted they are assessed by physical therapy within 48 hours. Nursing staff puts an order for an assist of two until evaluated by therapy. OT, Employee E8 stated every resident should have an order for bed mobility and transfer status. During an interview on 5/28/25, at 9:56 a.m. Physical Therapist, Employee E10 indicated typically bed mobility and transfers orders are not usually entered as separate orders unless necessary. During an interview on 5/28/25, at 11:41 a.m. [NAME] President (VP) of Rehab, Employee E9 stated once therapy evaluates a resident, therapy enters the order for the resident's transfer status. Typically bed mobility and transfer status orders are entered as one order, however if there are special requirements, separate orders for bed mobility and transfer status are entered. When asked what level of bed mobility Resident R1 required, VP of Rehab stated maximum to dependent. It is kind of confusing, therapy language is different than nursing. Review of the facility's investigation on 5/28/25, NA, Employee E2 indicated while changing Resident R1, NA, Employee E2 was putting a new lift sheet under the resident, and the resident kept rolling back over onto their back. NA, Employee E2 placed their hand on the resident's back to hold the resident on their side. The resident started moving their feet closer to the edge of the bed. NA, Employee E2 noticed the resident's feet going off the bed and the resident lowered themselves to the floor on their knees. During an interview on 5/28/25, at 12:07 p.m. NA Employee E2 indicated bed mobility and transfers status can be found in a resident's [NAME]. NA, Employee E2 stated If the bed mobility is not indicated on the [NAME], it depends on how much the resident can assist in the transfer for the level of assistance required. It depends on how much you pay attention to residents, if the resident is able to hold on to the rails or able to roll. When asked what occurred on 4/14/25, NA, Employee E2 stated Resident R1 does not want to do anything, wants to lay there, easier for [him/her] to have two people. NA, Employee E2 had been taking care of Resident R1 for a year. NA, Employee E2 stated Resident R1 was already mad that day, and the resident said I don't know why you can't get someone so I can roll over. NA, Employee E2 was putting a fresh sheet under the resident, and the resident kept flopping back over. NA, Employee E2 stated I told Resident R1 I only need two minutes. The resident then moved their feet closer to the edge of the bed and was hugging the rail. Resident R1 slid out of bed. During an interview on 5/28/25, at 2:03 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure the appropriate assistance for bed mobility was provided for one of four residents (Residents R1), which resulted in harm when Resident R1 rolled out of bed and sustained bilateral leg fractures. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide appropriate care and treatment for one of four residents (Residents R1), which resulted in harm, and Resident R1 required a blood transfusion. Findings include: Review of the facility policy Falls-Clinical Protocol dated 3/4/25, last reviewed 5/19/25, indicated the staff, with the physician guidance, will follow up on any fall with associated injury until the resident is stable. Review of the facility policy Change in a Resident's Condition or Status dated 3/4/25, last reviewed 5/19/25, indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a discovery of injuries of unknown source, significant change in the resident's physical condition, and need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing interventions. Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility.) Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses were current. Review of Residents R1's care plan dated 8/24/22, revealed the resident was at risk for bleeding secondary to anticoagulant (blood thinner) use. Interventions included to observe effectiveness of medication given and observe for adverse reactions, observe for signs and symptoms of bleeding such as skin bruising, and to check labs and notify physician of abnormal findings. Review of physician order dated 4/4/25, indicated to administer two tablets of 1 milligram (mg) of Warfarin (also known as Coumadin, a blood thinning medication that reduces formation of blood clots) at bedtime every Thursday, Friday, Saturday, and Sunday for atrial fibillation (abnormal heart rhythm). Review of Resident R1's progress note dated 4/14/25, indicated at 7:20 p.m. Licensed Practical Nurse (LPN), Employee E1 was called to Resident R1's room by Nurse Aide (NA), Employee E2. During care the resident rolled out of bed onto their knees while holding onto the bed rail. Resident R1 was assisted back to bed with an assist of three people and a Hoyer lift. No redness at this time to knees. Review of Resident R1's progress note dated 4/14/25, at 7:47 p.m. revealed Registered Nurse (RN), Employee E3 was called to the unit by staff. Resident R1 was observed lying on the floor. The resident stated I slid out of bed and was on my knees with my legs underneath me. The resident denied any pain to bilateral lower extremities. The physician was notified. Review of Resident R1's late entry progress note dated 4/14/25, at 4:48 a.m. indicated Resident R1 was complaining of being sore from the fall. The Director of Nursing advised Licesned Practical Nurse (LPN), Employee E12 to administer two tablets of 325 milligram (mg) Tylenol by mouth for pain. Medication was administered. Further review of clinical record failed to reveal a physician was notified of Resident R1's pain and an order for Tylenol was obtained. Review of Resident R1's progress note dated 4/15/25, at 1:26 p.m. revealed the resident requested to speak with the Director of Nursing and RN Supervisor. Resident R1 was requesting an as needed Tylenol order for pain. The order for Tylenol was pending approval. Review of Resident R1's physician order dated 4/15/25, indicated to administer two tablets of 325 mg Tylenol every four hours as needed for mild pain. The physician order failed to include a pain scale. Review of Resident R1's progress note dated 4/15/25, at 7:24 p.m. stated Bruising to right shin present and left abdomen. Resident is on Coumadin. Further review failed to indicate the physician was notified of Resident R1's right shin and left abdomen bruising. Review of clinical record revealed Resident R1 had bruising noted to the right shin on the following days with no evidence the physician was notified of the symptoms of bleeding: -4/16/25 -4/17/25 -4/18/25 -4/21/25 -4/22/25 -4/23/25 -4/24/25 -4/25/25 -4/26/25 -4/29/25 Review of physician order dated 4/25/25, indicated to obtain PT (Prothrombin time-the amount of time it takes for the blood to clot) and INR (International Normalized Ratio (INR-a specific blood test used to measure the time it takes for blood to form a blood clot, normal value for someone taking anticoagulant is between 2 and 3.5)) one time only for monitoring on 5/2/25. Review of Resident R1's lab results dated 5/2/25, revealed the resident's INR was critical at 7.2 A recommendation of an INR of 2.0 to 3.0 is made for all indications for oral anticoagulation except mechanical prosthetic heart valves and prevention of recurrent myocardial infarction for which an INR of 2.5 to 3.5 is recommended. It was indicated the lab notified Medical Director, Employee E11 on 5/2/25, at 9:08 a.m. of Resident R1's critical INR result. Review of physician order dated 4/4/25, to administer two tablets of 1 mg of Warfarin was discontinued on 5/2/25. Review of physician order dated 5/2/25, indicated to obtain PT/INR one time only for monitoring on 5/5/25. Review of Resident R1's progress note dated 5/5/25, revealed the resident had several bruises located on both legs. There was no evidence a physician was notified of signs and symptoms of abnormal bleeding such as bruising as the care plan indicated. Review of Resident R1's lab results dated 5/5/25, revealed the resident's INR was critical at 8.7. It was indicated the lab notified the Medical Director, Employee E11 on-call on 5/5/25, at 3:08 p.m. Review of Resident R1's clinical record from 5/5/25, to 5/7/25, failed to include evidence of the interventions that were implemented related to Resident R1's critical INR lab value, and failed to include evidence of the physicain repsonse related to Resident R1's critical INR lab value. Review of a late entry progress note dated 5/7/25, entered by RN, Employee E4 stated a bruise was observed to Resident R1's left distal superior knee. Bruise was dark/purple in color, approximately 9 cm x 5 cm x 0 cm. Nurse Aide stated that resident began refusing care on 5/6/25, due to pain in left leg. Resident denied recent trauma to area, the supervisor was notified. Review of Resident R1's physician order dated 5/7/25, indicated to complete an x-ray of the resident's left knee due to pain and bruise to rule out fracture. Review of a late entry progress note dated 5/7/25, at 12:04 p.m. entered by RN, Employee E5 indicated the physician saw the resident at bedside and wanted the resident to go to the hospital. Pro lab reported an INR 8.0. and Coumadin on hold. A purple bruise was observed near the left knee. The physician gave an order for Vitamin K 5 mg daily, for two days. The facility failed to timely address Resident R1's critical INR result. Review of Resident R1's progress note dated 5/7/25, at 7:49 p.m. revealed the resident's left knee was fractured. The physician and family were notified and the resident was transferred to the hospital for further evaluation. Review of progress note dated 5/8/25, revealed Resident R1 was admitted to the hospital. The resident's hemoglobin (a red protein responsible for transporting oxygen in the blood, normal value in women is 11.6 to 15 grams per deciliter. A hemoglobin level less than 6.5 can be life threatening) level was 5.1 and Resident R1 required a blood transfusion. Review of Resident R1's hospital records dated 5/8/25, stated the resident evidently had a fall on 4/14/25, when nursing staff inadvertently lost hold of the resident and the resident fell out of bed. Ecchymosis (medical term for a type of bruise that occurs when blood leaks out of blood vessels into the subcutaneous tissue beneath the skin, often caused by trauma) was observed to the resident's left anterior knee, right knee and skin with some bruising of the right ankle. The resident's INR was supratherapeutic for the past few days. Resident R1 INR was 7.0. The resident's hemoglobin was 5.1. The resident received two units of red blood cells. Review of a late entry progress note created on 5/18/25, effective 4/16/25, entered by Medical Director, Employee E11 indicated the resident was seen for follow up care. The resident had recent hospital admission for sepsis. There was no evidence Resident R1's bruising to the right shin was addressed. During an interview on 5/28/25, at 9:44 a.m. LPN, Employee E8 indicated if a resident has a change in condition the supervisor is made aware and the physician is notified. It was indicated any change in condition is documented in the clinical record with the physician response. During an interview on 5/28/25, at 2:03 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide appropriate care and treatment for one of four residents (Residents R1), which resulted in harm, and Resident R1 required a blood transfusion. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies.

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan to meet resident care needs for two of four residents (Resident R1 and R2), which resulted in harm, when a resident was rolled out of bed without the correct level of assistance and sustained bilateral leg fractures (Resident R1). Findings Include: Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the joints wears down over time, leading to pain, stiffness, and loss of mobility.) Review of physician order dated 2/19/25, revealed Resident R1 transfers with a total assist of two persons via Hoyer lift, no ambulation. Review of Residents R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses were current. Section GG- Functional Abilities revealed the resident was dependent with rolling left to right and required the assistance of two or more helpers. Review of Residents R1's care plan dated 8/24/22, revealed the resident used side rails for increased independence and mobility due to impaired bed mobility. Resident R1's care plan failed to indicate the level of assistance the resident required for bed mobility or transfers. Review of Resident R1's progress note dated 4/14/25, indicated at 7:20 p.m. Licensed Practical Nurse (LPN), Employee E1 was called to Resident R1's room by Nurse Aide (NA), Employee E2. During care the resident rolled out of bed onto their knees while holding onto the bed rail. The resident was on their right side while care was being provided and NA, Employee E2 was unable to stop the resident from rolling. Review of a late entry progress note dated 5/7/25, entered by RN, Employee E4 stated a bruise was observed to Resident R1's left distal superior knee. Bruise was dark/purple in color, approximately 9 cm x 5 cm x 0 cm. Resident denied recent trauma to area, the supervisor was notified. Review of a late entry progress note dated 5/7/25, at 12:04 p.m. entered by RN, Employee E5 indicated the physician saw the resident at bedside and wanted the resident to go to the hospital. A purple bruise was observed near the left knee. Resident denies pain. Review of Resident R1's physician order dated 5/7/25, indicated to complete an x-ray of the resident's left knee due to pain and bruise to rule out fracture. Review of Resident R1's progress note dated 5/7/25, at 7:49 p.m. revealed the resident's left knee was fractured. The physician and family were notified and the resident was transferred to the hospital for further evaluation. Review of progress note dated 5/8/25, at 3:00 a.m. revealed Resident R1 was admitted to the hospital. The resident's x-ray results shows bilateral leg fractures. The resident's hemoglobin (a red protein responsible for transporting oxygen in the blood, normal value in women is 11.6 to 15 grams per deciliter. A hemoglobin level less than 6.5 can be life threating) level was 5.1 and required a blood transfusion. During an interview on 5/28/25, at 9:56 a.m. Physical Therapist, Employee 10 confirmed the facility failed to ensure Resident R1's care plan had the level of assistance required for bed mobility on 4/14/25. Review of Resident R1's investigation on 5/28/25, at 10:45 a.m. revealed on 5/9/25, Resident R1 was interviewed. Resident R1 was asked Do you know what happened that caused the fractures to your legs? Resident R1 answered Yes, it happened when I rolled out of bed a few weeks ago. During an interview on 5/28/25, at 12:07 p.m. Nurse Aide (NA), Employee E2 conifrmed Resident R1's bed mobility was not available on the [NAME] (a documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan.) when Resident R1 rolled out of bed on 4/14/25. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of muscle weakness, ataxic gait (problem with coordinating muscle movements), and obesity. Review of Resident R2's physician orders dated 5/26/25, revealed the resident transfers with a total assist of two via Hoyer lift, no ambulation. Review of Resident R2's clinical record on 5/28/25, at 11:41 a.m. failed to include a care plan for the resident's transfer status. During an interview on 5/28/25, at 11:41 a.m. [NAME] President (VP) of Rehab, Employee E9 confirmed Resident R2 failed to have a care plan for transfer status or bed mobility. During an interview on 5/28/25, at 2:04 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to develop a comprehensive care plan to meet resident care needs for two of four residents (Resident R1 and R2), which resulted in harm, when a resident was rolled out of bed without the correct level of assistance and sustained bilateral leg fractures (Resident R1). 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policy, facility provided documentation, and staff interviews, it was determined that the facility failed to protect one of four residents (Resident R1) from sexual abuse, prevent psychosocial and/or physical harm, and physical discomfort that resulted in actual harm for Resident R1. Findings include: Review of facility policy Resident Rights dated 3/4/25, indicated residents have a right to be free from mental physical, sexual abuse, exploitation, neglect, and involuntary seclusion: no one may mistreat, threaten, or coerce a resident in anyway. Review of the facility policy Abuse and Neglect dated 3/4/25, indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any kind. Sexual abuse includes unwanted touching, sexual harassment, inappropriate comments or requests of a sexual nature, and all types of sexual assault or battery. Sexual assault or battery includes rape, sodomy, coerced nudity, and sexually explicit photographing. Sexual contact with any person incapable of giving consent is also considered sexual abuse. If residents are touched against their will or are incapable of stopping a person from touching them inappropriately it is considered sexual abuse. Review of the admission record indicated Resident R1 admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25, indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), multiple sclerosis (MS - immune system eats away at protective covering of nerve cells), anxiety disorder (a group of mental illnesses that cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness), and neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem). -Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) score of four. The distribution indicated zero to seven as severe cognitive impairment. -Section GG0130 Self Care indicated resident is dependent for eating, oral hygiene, toileting, lower body dressing, personal hygiene, transfers, and wheelchair propelling. Review of Resident R1's current care plan indicated the resident has impaired cognitive function and impaired thought processes related to dementia. Monitor, document, and report to physician any changes in cognitive function. Review of Resident R1's social services progress note dated 3/17/25, at 5:57 p.m. indicated social service was made aware that Confidential Employee (CE) E1 witnessed Resident R1's husband inappropriately touching the resident's genital area. Social Service (SS) Employee E2 and Director of Nursing (DON) asked Resident R1's husband to leave the facility. DON asked Resident R1 if her husband was touching her inappropriately. Resident responded, YES. DON asked resident if she wanted her husband's visitation to continue. Resident responded, No. SS Employee E2 repeated the series of questions with Resident R1 and received the same answers. The DON and SS Employee E2 later repeated the series of questions for a third time with Resident R1 and received the same answers. Review of facility provided document Sexual: Family to Resident dated 3/17/25, at 1:30 p.m. indicated CE Employee E1 reported to the DON and SS Employee E2 that she observed Resident R1's husband touching Resident R1 inappropriately in the vaginal area. Further review of the facility provided document Sexual: Family to Resident dated 3/17/25, at 1:30 p.m. indicated Resident Description: Unable to give description. When asked if the husband touched Resident R1 inappropriately, Resident R1 nodded her head Yes. Emotional support provided. No physical injuries were noted post episode. During an interview on 3/26/25, at 11:52 a.m. CE Employee E1 indicated on 3/17/25, in the morning a duty was to pass out the daily chronicle (a listing of activities/events) and Resident R1's husband was in the room. Later that afternoon, mail was being delivered to the resident rooms, approximate time was 1:30 p.m. as a scheduled activity was due at 2:00 p.m. CE Employee E1 entered Resident R1's room to deliver mail to Resident R2 who had the privacy curtain pulled due to using the bedside commode. CE Employee E1 turned away from the pulled privacy curtain towards Resident R1 and observed Resident R1's husband sitting in the chair, had Resident R1's blanket pulled up, and observed his fingers inside of Resident R1's vagina. The husband had a glove on one hand, and specifically had his middle and ring fingers inside Resident R1's vagina. Resident R1 was lying in bed like always and looked teary eyed. CE Employee E1 immediately told nursing what was observed. The husband told Nurse Aide (NA) Employee E3 he wanted to speak to CE Employee E1 personally but CE Employee E1 refused to speak with Resident R1's husband. CE Employee E1 indicated frequently hearing the nursing staff speak with Resident R1's husband telling him he can't touch his wife every 15 minutes with that glove on and the husband's response was always She's my wife, I can touch her if I want. CE Employee E1 was visibly shaken and pale during the interview and indicated being traumatized from what was observed and fearful of the husband. During an interview on 3/26/25, at 9:59 a.m. NA Employee E3 indicated being employed as a nurse aide for over five years and has cared for Resident R1 for a very long time. NA Employee E3 confirmed that CE Employee E1 reported to her and Licensed Practical Nurse (LPN) Employee E4 that Resident R1's husband was touching her vaginal area inappropriately. LPN Employee E4 and NA Employee E3 immediately went to Resident R1's room. Observed Resident R1's husband with one glove on the right hand, sitting in the chair at bedside. Observed Resident R1's brief was ripped and when NA Employee E3 changed the brief post episode, there was a significant amount of Resident R1's pubic hair in the brief that was not normally there. Staff notified the DON immediately. The facility failed to protect and ensure that Resident R1 was free from sexual abuse perpetrated by the husband. Review of the Centers for Medicare and Medicaid Services psychosocial outcome guide, application of the reasonable person concept, Resident R1 would have the expectation that she was safe in her home and treated with respect and dignity. When the reasonable person concept is applied, Resident R1 would have suffered psychosocial harm and humiliation due to being sexually abused by her husband. During an interview on 3/27/25, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to protect one resident (Resident R1) from sexual abuse and prevent psychosocial and/or physical harm and physical discomfort for Resident R1. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a)(c)Resident Rights. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of facility policy, clinical records, facility investigation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision, assistance, and proper equipment to prevent injuries during a transfer for one of four residents reviewed (Resident R47). This failure resulted in Resident R47 having pain, bruising, and was transferred to the hospital and diagnosed with a fractured rib, which were sustained during an improper transfer. The facility failed to maintain resident Kardexes (a snapshot of resident care needs) and care plans to reflect accurate mobility transfer statuses. This failure created an Immediate Jeopardy situation for nine of 17 residents reviewed (Residents R47, R7, R21, R29, R33, R37, R51, R68, and R75). Findings include: Review of facility policy Accidents and Incidents - Investigating and Reporting dated 8/24/23, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of facility policy Activities of Daily Living (ADLs), Supporting dated 8/24/23, indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication. Review of facility policy Safe Lifting and Movement of Residents dated 8/24/23, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE]. Review of Resident R47's MDS dated [DATE], indicated diagnoses of high blood pressure, atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and anemia (too little iron in the body causing fatigue). Section C0200 Brief Interview for Mental Status (BIMS) revealed Resident R47 scored a 15 indicating cognitively intact. Review of Resident R47's physician orders dated 5/21/24, indicated the resident transferred with an assist x 2, no ambulation. This order was discontinued on 6/4/24. Review of Facility Submitted documentation dated 5/24/24, stated, On 5/24/24 at 6:45 a.m., the Licensed Practical Nurse (LPN) on duty was called into Resident R47's room by the Nurse Aide (NA). NA reported some bruising on residents right and left breast and left abdominal areas, both lower and upper. When the LPN asked the resident what happened, she stated the following. NA Employee E1 and another large girl (NA Employee E2) were taking her out of the chair and transferring her to the bed when they grabbed both armpits and pulled her up. She then stated, Please stop you're hurting my arms! Resident stated both NAs said, You're almost to bed, you're fine. Resident stated that areas are painful. Resident was assessed by the Registered Nurse (RN) Supervisor. Upon assessment a 23 centimeter (cm) L (length) x 5 cm W (width) dark purple in color bruise is observed to her left lower breast area. The skin is intact, no swelling or redness present. Resident's right lower breast area observed with a 16 cm L x 6 cm W dark purple in color bruise. No swelling or redness present. Also a 9 cm L x 2 cm W red and purple in color bruise is present to the resident's right upper outer abdominal area and a 7 cm L x 1 cm W red and purple in color bruise is present directly below the first abdominal bruise. Current transfer order: Transfer with assist x 2, no ambulation. Resident was wearing proper footwear. Update: Resident was sent to the emergency department on 5/28/24. A CT (a computed tomography scan) of the chest was done with results showing a possible acute anterior (nearer the front) 3rd rib fracture in addition to multiple old right sided rib fractures. Review of a Nurse Practitioner (NP) Note dated 5/24/24, completed by NP Employee E11, stated, Patient seen for new onset chest bruising per request of nursing. She [Resident R47] reports that the evening prior to my assessment she was assisted back to bed with assistance. She was feeling very weak and needed the staff to help lift her up by her arms, which she thinks caused the bruising. Patient states the areas were tender but currently she has no pain. Review of a Skin/Wound Follow-Up Note dated 5/24/24, at 7:45 a.m. completed by RN Employee E10 stated, Resident was assessed by this writer this morning when charge nurse reported this resident had bruises to both of her breasts. On assessment a 23 cm L x 5 cm W dark purple in color bruise is observed to her left lower breast area. The skin is intact, No swelling or redness is present. Resident's right lower breast area is observed with a 16 cm L x 6 cm W dark purple in color bruise. No swelling or redness is present. Also a 9.0 cm L x 2 cm W red and purple in color bruise is present to resident's right upper outer abdominal area and a 7.0 cm L x 1.0 cm W red and purple in color bruise is present directly below the first abdominal bruise. Resident states areas are painful. Resident receives Eliquis (a medication administered to prevent blood clots) 2.5 milligrams BID (twice a day). Therapy to be consulted to evaluate transfer. Resident educated to inform staff when any situation occurs for resident's safety. Resident stated, I didn't tell my parents. I don't want trouble. Staff to monitor bruising and report any changes to MD (physician). MD notified by fax. Family to be notified this morning. Review of a Skin/Wound Note dated 5/24/24, at 6:46 a.m. completed by LPN Employee E9 stated, Was called in to residents room by NA. NA reports some bruising on residents right and left breast and left abdominal areas, both lower and upper. When asked resident what happened she stated the following, NA Employee E1 and another large girl [NA Employee E2] were taking her out of the chair and transferring her to the bed when they grabbed both armpits and pulled her up. She then stated, Please stop you're hurting breaking my arms! Resident stated both NAs said, You're almost to the bed, you're fine. Review of a Nursing Progress Note dated 5/28/24, at 11:03 a.m. completed by RN Employee E14 stated, Resident seen by CRNP (Certified Registered Nurse Practitioner), ordered to send to ER (emergency room ) for possible bilateral (both sides) lower extremity infection. 911 called to transport. Report given. Daughter aware and going to emergency room . Review of a Hospitalist History & Physical dated 5/28/24, completed by a Physician Assistant at the emergency department stated, Closed fracture of one rib of right side. CT of the chest abdomen and pelvis reveals possibly acute right anterior 3rd rib fracture in addition to multiple old right-sided rib fractures. Suspect secondary to trauma from being lifted by staff member at SNF (skilled nursing facility). Traumatic ecchymosis (bruising) of chest: patient noted to have ecchymosis to chest wall, bilateral breasts, upper abdomen, and bilateral flanks and has some tenderness to lower chest and bilateral rib cage. Ecchymosis is secondary to trauma from being manually lifted by staff at SNF to transfer patient from her wheelchair into bed. She states that she was experiencing pain while being lifted. Review of a witness statement dated 5/27/24, completed by NA Employee E1 stated, Resident R47 was complaining on Monday evening that the side of her breasts were hurting. I said you're leaning on the side of your wheelchair, so another NA and I help her into bed. When I helped Resident R47 put her gown on she had no bruising. The next time I was here was Wednesday. I had to get Resident R47's weight. I was helping Physical Therapy transfer Resident R47 into the wheelchair. She said before you put me into the chair, I'm very sore on my upper body. That night, NA Employee E2 and I put Resident R47 to bed. NA Employee E2 had her upper half under her arms an I had Resident R47's pants. Resident R47 was hanging on the side row and we put her into bed. Prior to that, Resident R47 was hanging on both side of her wheelchair with her arm down dangling over the metal part of the wheelchair. That when NA Employee E2 and I put her into bed she was going to fall out of the chair leaning on both side of the chair. Review of a witness statement dated 5/29/24, completed by NA Employee E2 stated, On Wednesday May 22, 2024 I worked the back section assignment on the third floor on the 3 p.m. to 11 p.m. shift. Resident R47 was not in my assignment however her NA for the night asked for assistance in changing her for last rounds before I had to go downstairs to assist another aide in last rounds because she was alone and had an admission come in. NA Employee E1 and I went into her [Resident R47] room, transferred her from her wheelchair by stand pivot to bed slowly, rolled her from side to side to clean her up for bed. NA Employee E1 finished up in Resident R47's room and I headed downstairs to the first floor. During an interview on 8/5/24, at 10:07 a.m. LPN Employee E3 stated, Resident transfer status is in the computer, the aides have it in their Kardex. During an interview on 8/5/24, at 10:13 a.m. NA Employee E4 stated, The transfer status is found in their chart, it's on our kiosk charting. If I saw a mobility status for assist x 2 no ambulation, I would say that means a hoyer with two people. During an interview on 8/5/24, at 10:17 a.m. NA Employee E1 stated, The transfer status is in the kiosk in the Kardex. I'm not sure what assist x 2 no ambulation means, it's a very confusing order. I always grab a second person, but it is very confusing. I don't know what it means. During an interview on 8/5/24, at 10:37 a.m. NA Employee E5 stated, The transfer status is in the computer, that's the only place. Assist x 2 no ambulation means two people to help transfer, I think it's with a lift. During an interview on 8/5/24, at 12:36 p.m. NA Employee E1 stated, On Monday morning she [Resident R47] was complaining under her breast near ribs it was hurting, she had therapy that day. I was just helping therapy transfer her and she was complaining of pain. I told one nurse and therapy knew. Resident R47 was also saying someone transferred her in bed on Tuesday. Wednesday night I asked NA Employee E2 can you please help me transfer her into bed. Before that she was just two assist, under arm then by pant leg. I put my foot in between to pivot. Each of us held on to her pants and both on each side, hooked our arms under her arm pits. During an interview on 8/5/24, at 1:23 p.m. the Director of Nursing (DON) stated, The transfer orders are in the Kardex. The aides can also ask the nurse, I do not think the transfer status would be anywhere else besides the Kardex. Review of Resident R47's physician orders dated 6/5/24, stated, Transfers total assist x 2 via hoyer (a mechanical lift designed to assist caregivers in safely transferring individuals with limited mobility), no ambulation. Review of Resident R47's clinical record on 8/5/24, revealed that the resident's transfer status was listed as the resident is able to transfer with assist x 1, may ambulate to/from bathroom with wheeled walker assist x 1 in both her care plan and Kardex. Additional clinical record reviews of Residents R7, R21, R29, R33, R37, R51, R68, and R75 revealed the following concerns: Review of the clinical record indicated Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression (a constant feeling of sadness and loss of interests). Review of a physician order dated 2/9/22 indicated resident transfers total assist x 2 via hoyer lift, no ambulation. Review of Resident R7's clinical record on 8/5/24, revealed that the transfer order was not included in her Kardex. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE]. Review of Resident R21's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia, and anxiety (a feeling of worry, nervousness, or unease). Review of a physician order dated 3/27/24 indicated resident transfers assist x 2, no ambulation. Review of Resident R21's clinical record on 8/5/24, revealed that the transfer order was not included in her care plan or in her Kardex. Review of the clinical record indicated Resident R29 was admitted to the facility on [DATE]. Review of Resident R29's MDS dated [DATE], indicated diagnoses of hyperlipidemia (high levels of fats in the blood), aphasia (language disorder that affects communication), and quadriplegia (paralysis of all four limbs). Review of a physician order dated 11/29/23, indicated the resident transfers with full body hoyer lift, assist x 2. Review of Resident R29's clinical record on 8/5/24, revealed that the transfer status was listed as full body hoyer lift x 2, walk in corridor and walk in room. Review of the clinical record revealed that Resident R33 was admitted to the facility on [DATE]. Review of Resident 33's MDS dated [DATE], indicated diagnoses of high blood pressure, dementia, and stroke. Review of the clinical record indicated Resident R33 had a physician's order dated 7/11/24, that stated, patient transfers assist x 1, no ambulation. Review of Resident R33's clinical record on 8/5/24, revealed that the transfer order was not included in her care plan or in her Kardex. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's MDS dated [DATE], indicated diagnoses of high blood pressure, muscle weakness, and hyperlipidemia. Review of a physician order dated 4/9/24, indicated the resident transfers total assist x 2 via hoyer, no ambulation. Review of Resident R37's clinical record on 8/5/24, revealed that the transfer order was not included in her care plan or in her Kardex. Review of the clinical record indicated Resident R51 was admitted to the facility on [DATE]. Review of Resident R51's MDS dated [DATE], indicated diagnoses of high blood pressure, septicemia (an infection that occurs when germs get into the bloodstream and spread), and muscle weakness. Review of a physician order dated 7/24/24, indicated the resident transfers with extensive assist x 1, no ambulation. Review of Resident R51's clinical record on 8/5/24, revealed that the transfer order was not included in her care plan or in her Kardex. Review of the clinical record revealed that Resident R68 was admitted to the facility on [DATE]. Review of Resident 68's MDS dated [DATE], indicated diagnoses of high blood pressure, diabetes (too much sugar in the blood), and weakness. Review of clinical record indicated Resident R68 had a physician's order dated 10/24/22, that stated, Transfer with a total lift with assist x 2. Review of Resident R68's clinical record on 8/5/24, revealed that the transfer order was not included in her care plan or in her Kardex. Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE]. Review of Resident R75's MDS dated [DATE], indicated diagnoses of anemia, high blood pressure, and hyperlipidemia. Review of a physician order dated 11/15/23, indicated the resident transfers with extensive assist x 1 with wheeled walker, may ambulate up to 50 feet with right platform wheeled walker assist x 1 and wheelchair follow. Review of Resident R75's clinical record on 8/5/24, revealed that the transfer order was not included in his care plan or in his Kardex. During an interview on 8/5/24, at 1:38 p.m. the DON was made aware than an Immediate Jeopardy (IJ) existed. The Nursing Home Administrator (NHA) was provided the IJ Template and at that time a corrective action plan was requested. During an interview on 8/5/24, at 1:49 p.m. the Director of Rehab Employee E6 stated, Resident R47's transfer order was entered incorrectly when the incident occurred on 5/22/24. It should have said assist x 2 or hoyer lift. Assist x 2 could mean a stand-pivot transfer with max assistance. On 8/5/24, at 5:30 p.m. an acceptable Corrective Action Plan was received, which included the following interventions: - Resident R47's transfer status will be verified with therapy and care plan and Kardex will be updated by the facility Director of Rehabilitation by 8/5/24. - All resident transfer statues and physician orders will be reviewed for accuracy and updated as needed by facility Director of Rehabilitation as of 8/5/24. - All resident's physician ordered transfer status will be reviewed for accuracy and updated as needed on the resident's care plan by the facility assessment office and Director of Rehabilitation by 8/5/24. - All resident physician ordered transfer status and corresponding resident's Kardex will be reviewed for accuracy by the facility assessment office and Director of Rehabilitation by 8/5/24. - The Safe Lifting and Resident Movement policy has been reviewed on 8/5/24 by the facility Administrator and Director of Nursing and accepted as written. - Education on the Safe Lifting and Resident Movement policy as well as finding the transfer orders and how to have the transfer orders properly reflected on the Kardex will be provided to facility rehabilitation and nursing staff, by the Director of Nursing, or designee(s) starting on 8/5/24 and will be completed by 8/6/24. All remaining nursing staff shall complete the education prior to duty. - Audits will be completed daily by the Director of Nursing, or designee, five days a week for eight weeks. The results of the audits will be communicated to the Quality Assurance and Performance Improvement Committee as needed. Review of medical records on 8/6/24, indicated that all 86 residents had physician transfer orders reviewed and updated for accuracy, and that all resident care plans and Kardexes had been updated to reflect current physician transfer orders. Review of facility documents on 8/6/24, revealed that the facility is auditing all resident transfer statuses and orders. Review of facility documents on 8/6/24, revealed that the facility had 107 nursing and rehabilitation employees and that 100% had received resident transfer status education. 36 of these employees received formal education on the Safe Lifting and Resident Movement policy and how to properly enter resident transfer orders and have the orders reflect in the Kardex and care plan. 71 of these employees had received this education via telephone as they had not been working in the building. One employee received this education via e-mail. Staff are to sign that they received this education when they are in the building before the start of their next shift. During staff interviews conducted on 8/6/24, between 9:45 a.m. and 11:15 a.m. 22 nursing and rehabilitation employees confirmed that they received education on how to enter and locate resident transfer orders and the Safe Lifting and Resident Movement policy. 12 of these employees had received education in person and 10 of these employees had received education over the telephone and signed the training sheet prior to the start of their shift. The Immediate Jeopardy was lifted on 8/6/24, at 12:39 p.m. when the action plan implementation was verified. During an interview on 8/6/24, at 1:22 p.m. the NHA confirmed that the facility failed to provide adequate supervision, assistance, and proper equipment to prevent injuries during a transfer, which resulted in Resident R47 having pain and bruising. While at the hospital for an evaluation of a lower extremity infection, Resident R47 was diagnosed with a fractured rib, which was sustained during the improper transfer. During this interview, the NHA confirmed that the facility failed to maintain resident Kardexes and care plans to reflect accurate mobility transfer statuses and that this failure created an Immediate Jeopardy situation for nine of 17 residents reviewed. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(e)(1) Management.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, facility documents, clinical records, and resident and staff interviews, it was determined that the facility failed to make certain residents were free from verbal abuse resulting in mental anguish for one of three residents (Resident R1). Findings include: The facility policy entitled Abuse of Residents dated 8/1/22, indicated that abuse definitions include intimidation resulting in physical harm, pain, or mental anguish Verbal abuse is defined as oral, written or gestured language that willfully includes disparaging and derogatory terms, to the resident or their families, to describe resident, regardless of age, ability to comprehend or disability. Review of admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS- periodic assessment of care needs), dated 8/31/22 , indicated the diagnoses of diabetes, high blood pressure, and depression. Review of Section C: Cognitive Patterns a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Resident R1's BIMS score was 14 - cognitively intact. Review of the Care Plan dated 9/24/22, indicated that Resident R1 had a problem identified related to depression and was to have mood and behavior monitored for changes and report to the physician ongoing signs and symptoms of depression sad, irritable, anger, crying, shame and worthlessness. Review of facility documentation dated 11/4/22, at 11:00 a.m. indicated Resident R1 told the facility that two aides were changing her roommate, Resident R2, and she overheard them making fun of her (Resident R1) being blind and shitting herself. When it was her turn to be changed she told them she didn't want them to change her. Nursing Assistant (NA) Employee E1 responded yes I am going to change you. Resident R1 stated she had her hands holding her blankets up to her chin and NA Employee E1 ripped them out of her hands, ripped open her brief and stated who do you think is going to change your shitty ass. She then threw me from one side to the other really rough I thought I was going to roll right off the bed. Resident stated she was crying and very upset after the event. During an interview on 11/17/22, at 2:30 p.m Resident R1 confirmed she called her son crying, stated she overheard two aides taking care of her roommate, the one female aide especially making fun of her (being blind and shitting herself) while they were taking care of the roommate. She could hear them and when it was her turn she told them she didn't want them to change her. Resident R1 said the female aide forced her blanket down, forced/ripped her diaper open and said who do you think is going to change your shitty ass. Victim stated she was too rough and she asked her to stop but she (female aide) didn't and threw her from side to side so that she almost rolled off the bed. During an interview on 11/17/22, at 2:40 p.m. with Resident R2 confirmed the aide making fun of Resident R1 and that she heard Resident R1 tell NA Employee E1 that she didn't want to be changed and that NA Employee E1 changed her anyway and Resident R1 was crying when it was over. During an interview on 11/17/22, at 3:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed that they had been notified of the incident involving Resident R1 and NA Employee E1 on 11/3/22, and confirmed that the NA Employee E1 engaged in verbal and physical abuse toward Resident R1, resulting in harm causing mental anguish during the incident on 11/3/22. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(1)2)(3) Nursing Services.

Based on review of clinical records, resident interview, and staff interviews, it was determined that the facility failed to make certain that proper pain management was provided for one of 18 residents reviewed (Resident R1), resulting in harm when the resident suffered severe pain without effective relief. Findings include: Review of policy, Medication Dispensing: Back Up Medications created February 2009, and revised July 2016, revealed the pharmacy will provide a supply of oral medications for use in emergency situation at the facility. If medication is not located and or has not been delivered, licensed nurse is to check on availability of medication from the EMS machine (electronic medication storage system) in the second floor medication room, notify clinical manager/wellness manager or nursing supervisor immediately, call the pharmacy to ensure they received a valid prescription, and document in the resident's electronic medical record if medication has not been delivered and medication has either been pulled from the EMS machine or not administered and provider was notified. Review of the clinical record for Resident R1 revealed resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set assessment (MDS - a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 4/21/22, indicated that the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed Resident R1 was at risk for pain and nursing staff will monitor/record/report to the nurse, resident complaints of pain or requests for pain treatment. Care plan also states to administer pain medication as ordered by physician. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for 4/20/22, through 4/23/22, until 1:00 p.m. revealed that Resident R1 received the scheduled [MEDICATION(S)]/acetaminophen doses at, 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m, and on 4/23/22, at 1:00 p.m. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .m, no pain assessment was completed and scheduled [MEDICATION(S)]/acetaminophen dose was not administrated. Review of the MAR for 4/26/22, through 4/27/22, indicated that [MEDICATION(S)]/acetaminophen was not administered and the pain assessments were not completed for all three shifts in the time frame. Review of nursing progress notes on 4/27/22, 11:42 a.m. entry indicated that the medication was not available. Review of nursing progress notes on 4/27/22, 2:39 p.m. entry indicated that the medication was not available. Review of nursing progress notes on 4/27/22, 4:12 p.m. entry indicated that the medication was not available and awaiting on pharmacy. During an interview on 5/20/22, at 10:00 a.m. Resident R1 stated that she remembers that day and was in pain all day, rating pain as 7/10 (on a pain scale with 10 being the worst pain she could imagine, and 0 being no pain at all) in the right hip and radiating down her leg. Resident R1 stated that pain is frequent and happens daily. Resident R1 stated that when the nurse was told about the pain, they stated she had run out of medication and did not bring anything for the pain. During an interview on 5/20/22, at 2:45 p.m. Licenced Practical Nurse (LPN) Employee E1, confirmed Resident R1 is ordered [MEDICATION(S)]/acetaminophen for pain. LPN Employee E1 stated knew Resident R1 was out of the meds and did not check the EMS Machine to see if medication was on hand in the facility. During an interview on 5/20/22, at 3:15 p.m. the NHA (Nursing Home Administrator) and DON (Director of Nursing) confirmed the Resident R1 did not receive her scheduled doses of [MEDICATION(S)]/ Acetaminophen on 4/27/22, and was determined that the facility failed to make certain that proper pain management was provided for Resident R1, resulting in harm when the resident suffered severe pain without effective relief. The NHA and DON also confirmed the medication was available in the EMS Machine on 4/27/22. During an phone interview on 5/20/22, at 4:30 p.m. LPN Employee E2, confirmed that Resident R1 had complained of pain on more than one occasion and stated she knew the Resident R1 was out of pain meds and did not check the EMS Machine. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited: 9/10/21 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 201.20(a)(b)(c)(d) Staff development. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code 211.5(f) Clinical records. Previously cited: 9/10/21 28 Pa. Code 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services. Previous cited: 1/16/20 and 9/10/21