Every finding on record at Edenbrook on Second Ave

Based on observations and staff interviews, it was determined the facility failed to provide a safe, clean, and homelike environment for residents on four out of 5 nursing units (B Hall, C Hall, D Hall, and TCU).Findings include: An observation on June 25, 2026, at 8:20 AM in the B Hall resident lounge revealed cobwebs in the courtyard-side window, debris, food crumbs, and wrappers along the edge of the floor on the hallway-side wall, peeling and torn wallpaper on three walls, brown liquid stains on walls, and orange food debris near the lounge entrance. An observation on June 25, 2026, at 8:27 AM in the D Hall resident lounge revealed brown and black food debris and yellow food pieces on the floor, torn and peeling wallpaper on three walls, and brown liquid stains on the courtyard-side wall. An observation on June 25, 2026, at 8:32 AM in the resident's main dining room revealed red and yellow food pieces and a smear near the center of the room and a small orange pill with 013 embossed on it. on the floor. During an interview on June 25, 2026, at 8:43 AM, the assistant director of nursing identified the small orange pill as Aspirin 81 mg (an antiplatelet medication that prevents blood cells from clumping together). An observation on June 25, 2026, at 8:45 AM in the C Hall shower room revealed a toilet chair with multiple long black hairs on the seat cover, a white floor with grey discoloration stains, dirt, dust, and debris on the shower floor, and a blue plastic shaving razor in the shower-wall soap holder. An observation on June 25, 2026, at 8:49 AM in the TCU long hall outside of resident room [ROOM NUMBER] revealed a grey floor discoloration and stain measuring 12 inches by 2 inches. An observation on June 25, 2026, at 8:52 AM in the TCU long hall shower area (room [ROOM NUMBER]) revealed plastic medical tape with red and brown-stained gauze on the floor. An observation on June 25, 2026, at 11:59 AM revealed three used glucose testing strips (part of a medical device that stores a small amount of blood to determine blood sugar levels) on the floor in the D Hall. An observation on June 25, 2026, at 12:07 AM revealed a small round orange pill on the floor outside of resident room C2. During an interview at 12:13 PM, Employee 1, LPN, identified the round orange pill as Dulcolax 5 mg (a stimulant laxative medication). During an interview on June 25, 2026, at 2:00 PM, the above findings were reviewed with the nursing home administrator (NHA). The facility failed to provide a safe and clean environment for residents. Refer F867 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident Rights.

Based on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement committee failed to implement and maintain an effective corrective action plan to prevent the recurrence of deficiencies related to providing residents with a safe, clean, comfortable, and homelike environment.Findings include: During the survey ending May 8, 2026, the facility was cited for failing to provide and maintain a clean, comfortable, and homelike environment for residents.In response, the facility submitted a Plan of Correction that included immediate cleaning of identified resident rooms, shower rooms, and common areas. Shower rooms located on A Hall, B Hall, and C Hall were deep cleaned. Black buildup was removed from the grout (the material that fills the spaces between floor tiles), damaged grout was repaired, chipped floor tiles were replaced, and ceiling vents were cleaned to remove accumulated dust.The Plan of Correction further indicated the Maintenance Director and Housekeeping Supervisor would conduct facility-wide environmental audits of resident rooms, bathrooms, and shower and tub rooms to ensure floors were free of sticky residue, bathrooms were clean and free of visible dust, toilet bases were properly sealed, shower rooms remained clean, and floor tiles were maintained in good condition. Housekeeping staff were assigned weekly deep-cleaning schedules that included shower and tub rooms, ceiling vent inspections, and floor inspections. Grout and tile inspections were to be completed monthly.The facility also provided education to housekeeping, maintenance, and nursing staff regarding environmental cleaning standards and procedures for reporting environmental concerns.The Plan of Correction further required the Nursing Home Administrator, or designee, to conduct environmental rounds three times each week for four weeks, weekly for an additional four weeks, and monthly thereafter. Audit results were to be reviewed during monthly QAPI (Quality Assurance and Performance Improvement) meetings to evaluate the effectiveness of the corrective actions and ensure the improvements were maintained.The facility indicated all corrective actions would be implemented by June 23, 2026.However, during the revisit survey ending June 25, 2026, the facility again failed to maintain a clean, comfortable, and homelike environment for residents under the same regulatory requirement.The recurrence of the deficient practice demonstrated the facility's QAPI monitoring process did not effectively identify that the corrective actions had not been sustained and failed to prevent the recurrence of the previously cited environmental deficiencies.Cross Ref. F584 28 Pa. Code 211.12 (d)(1)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1) Management

Based on observations, clinical record review, select facility policy review, and staff interview, it was determined the facility failed to consistently ensure the provision of respiratory care and supplemental oxygen in accordance with physician orders and facility policy for three residents out of 28 residents reviewed. (Residents 3, 4, and 128).Findings include: Review of the facility's policy titled Oxygen Administration and Storage last reviewed by the facility on April 9, 2026, revealed that oxygen is to be administered at the prescribed amount. During an initial facility tour of the facility on April 5, 2026, at 11:10 AM, and again at 11:35 AM, Resident 3 was observed seated in a wheelchair in the dining room with an oxygen tank attached to the back of the wheelchair. The oxygen tank gauge indicated the tank was empty. This observation was confirmed by Employee 1 (Licensed Practical Nurse). Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses including chronic cor pulmonal (a form of right-sided heart failure caused by long-term high blood pressure in the lungs stemming from chronic lung disease) and pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). A review of Resident 3's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 6, 2026, revealed that Resident 3 was severely cognitively impaired and was not able to complete the BIMS assessment (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information). A physician's order dated February 6, 2026, specified oxygen at 2 liters per minute via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen), to be administered continuously. Review of Resident 3's comprehensive care plan, in effect at the time of survey, failed to include the resident's pulmonary diagnoses, physician orders for continuous oxygen therapy, interventions related to oxygen administration and monitoring, or staff responsibilities for ensuring oxygen equipment was functioning and available for use as ordered. During an interview on April 7, 2026, at 2:26 PM, the Director of Nursing (DON) stated the facility was unable to provide documentation identifying the frequency of monitoring oxygen tanks. The DON acknowledged the facility failed to ensure Resident 3 received oxygen therapy as ordered. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnosis of recent brain surgery and a tracheostomy (a surgical opening in the neck used to place a tube in the throat as an alternate airway). A review of Resident 4's admission MDS dated [DATE], revealed that Resident 4 was cognitively intact with a BIMS score of 14 (a score of 13 through 15 indicates intact cognition). Review of May 2026 physician orders revealed Resident 4 was to receive 28 percent oxygen through a tracheostomy humidification system. The physician order specified the system required oxygen to flow at 4 liters per minute from an external oxygen source to maintain delivery of 28 percent oxygen to the tracheostomy site. Room air contains approximately 21 percent oxygen. Observation of Resident 4's oxygen delivery system on May 5, 2026, at 11:30 AM, and again on May 6, 2026, at 2:30 PM, revealed the oxygen delivery system was set to deliver 35 percent oxygen with oxygen flowing at 3 liters per minute. Observation of the equipment revealed the system in use could not deliver oxygen concentrations lower than 35 percent. Therefore, the physician-ordered oxygen concentration of 28 percent could not be administered using the equipment provided by the facility. Clinical record review revealed that Resident 128 was admitted to the facility on [DATE], with diagnosis of respiratory failure and a tracheostomy (a surgical opening in the neck used to place a tube in the throat as an alternate airway). A review of Resident 128's admission MDS dated [DATE], revealed that Resident 128 was severely cognitively impaired and was not able to complete the BIMS assessment. Review of May 2026 physician orders revealed Resident 128 was to receive 28 percent to 30 percent oxygen through a tracheostomy humidification system. The physician order specified the system required oxygen to flow at 6 liters per minute from an external oxygen source to maintain delivery of 28 percent to 30 percent oxygen to the tracheostomy site. Observation of Resident 128's oxygen delivery system on May 5, 2026, at 11:30 AM, and again on May 6, 2026, at 2:30 PM, revealed the oxygen delivery system was set to deliver 40 percent oxygen with oxygen flowing at 7 liters per minute. Observation of the equipment revealed the system in use could not deliver oxygen concentrations lower than 35 percent. Therefore, the physician-ordered oxygen concentration of 28 percent to 30 percent could not be administered using the equipment provided by the facility. During an interview on May 7, 2026, at 10:30 AM, the Nursing Home Administrator confirmed the oxygen delivery systems for Residents 4 and 128 were not set according to physician orders at the time of the survey observations. The Nursing Home Administrator stated the oxygen settings were corrected after the surveyor identified the concerns and notified facility staff. 28 Pa. Code 211.10 (c) Resident care policies.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing service.

Based on observations and resident and staff interviews, it was determined the facility failed to provide and maintain a clean, comfortable, and homelike environment for residents on two of three nursing units.Findings include: Observation of Station B on May 5, 2026, at 11:38 AM revealed the floor surface in resident room D2, Bed A, was sticky to the touch. Observation of Station B on May 5, 2026, at 11:40 AM revealed the floor surface in resident room D5, Bed B, was sticky to the touch. Observation of Station A on May 5, 2026, at 8:30 AM revealed the floor surface in resident room B5, Bed B, was sticky to the touch. A review of Resident 108's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 10, 2026, revealed that Resident 108 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). During an interview conducted on May 6, 2026, at 1:30 PM, Resident 108 expressed concerns regarding the cleanliness of the bathroom shared with another resident. Resident 108 stated feces was frequently left on the floor and on the toilet rim by the roommate. Resident 108 also expressed concern regarding the cleanliness of the shower room. Observation of Resident 108's bathroom at this time revealed that the floor surrounding the toilet was stained with a brown colored substance. The rim of the toilet bowl was visibly soiled. The bar surrounding the toilet was worn and discolored. The flooring surrounding the base of the toilet was heavily worn and unsealed. The wall vent located behind the toilet contained a thick accumulation of dust. Observation of the shower room located on A Hall of Station A Nursing Unit on May 6, 2026, at 1:45 PM revealed the shower stall next to the tub area was visibly soiled. The bottom two rows of wall grout were missing grout material and contained a buildup of a black-colored substance. Hair accumulation was present in the drain. The grout on the shower floor was visibly worn and discolored. The ceiling vent located in the center of the shower room contained a thick accumulation of dust. Observation of the shower room on the B Hall of Station A Nursing Unit on May 8, 2026, at 11:20 AM revealed the wall and floor grout in shower stall next to the toilet area was visibly soiled with a black colored substance. The surface of the toilet seat on the toilet in the shower room was worn with a two inch area of paint which was peeled from the surface of the toilet seat. Observation of the shower room located on C Hall of Station B Nursing Unit on May 8, 2026, at 11:35 AM revealed the ceiling vent near the tub area contained a thick accumulation of dust. A floor tile measuring two inches by one inch was chipped near the drain in the middle shower stall. The floor grout in the middle shower stall was visibly soiled with a black-colored substance. The above findings were reviewed with the Nursing Home Administrator on May 8, 2026, at 12:00 PM. 28 Pa Code 201.18(e)(1)(2.1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on observation, review of facility planned menus, select facility policy review, and resident and staff interviews, it was determined the facility failed to honor resident food preferences and ensure residents received meal items and condiments as identified on meal tray tickets, to the extent possible, for 2 of 28 residents reviewed for food services (Residents 10 and 55), and residents participating in a Resident Council group interview (Residents 5, 112, 46, 88, 51, 13, 10, 83, 8, 12, 120, 108, and 92).Findings include: Review of the facility policy titled Resident Food and Meal Preferences, last reviewed by the facility on April 9, 2026, revealed the facility will make reasonable efforts to provide each resident with a nourishing, palatable, well-balanced diet that meets nutritional and special dietary needs while considering resident preferences and input from residents and resident groups. During an interview conducted on April 5, 2026, at 12:12 PM, Resident 55 stated she does not always receive the food items identified on her meal tray ticket or foods she requested. Resident 55 stated she did not receive yogurt, prune juice, or creamers with breakfast that morning. Review of Resident 55's lunch meal tray ticket on April 5, 2026, at 12:35 PM revealed the resident was to receive sugar substitute packets and creamers. Observation of the lunch meal tray revealed the sugar substitute packets and creamers were not provided. Review of Resident 55's breakfast meal tray ticket on April 7, 2026, at 9:00 AM revealed the resident was to receive two cream cheese packets with a toasted bagel. Observation of the breakfast meal tray revealed no cream cheese packets were provided. During an interview conducted on April 7, 2026, at 9:05 AM, the Food Services Director confirmed cream cheese was unavailable in the kitchen despite being listed on Resident 55's meal tray ticket. Review of Resident 10's lunch meal tray ticket on April 5, 2026, at 12:27 PM revealed the resident was to receive gravy. Observation of the lunch meal tray revealed gravy was not provided. During an interview at the time of observation, Resident 10 stated the kitchen frequently forgets to provide ordered items or condiments on meal trays. During a Resident Council group interview conducted on April 6, 2026, at 10:00 AM, Residents 5, 112, 46, 88, 51, 13, 10, 83, 8, 12, 120, 108, and 92 reported meal trays frequently arrived without ordered food items, beverages, or condiments. Residents stated they often had to wait for nursing staff to obtain missing items from the kitchen, causing meals and beverages to become cold before they could eat or drink them. During an interview conducted on April 7, 2026, at 1:35 PM, the Nursing Home Administrator confirmed residents' meal tray tickets should have been followed to ensure residents received food items and condiments according to their identified needs and preferences. 28 Pa. Code 211.6 (a) Dietary Services. 28 Pa. Code 211.10 (c) Resident Care Policies.

Based on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement committee failed to implement and maintain an effective corrective action plan to prevent the recurrence of deficiencies related to providing residents with a safe, clean, comfortable, and homelike environment.Findings include: During the survey ending May 8, 2026, the facility was cited for failing to provide and maintain a clean, comfortable, and homelike environment for residents.In response, the facility submitted a Plan of Correction that included immediate cleaning of identified resident rooms, shower rooms, and common areas. Shower rooms located on A Hall, B Hall, and C Hall were deep cleaned. Black buildup was removed from the grout (the material that fills the spaces between floor tiles), damaged grout was repaired, chipped floor tiles were replaced, and ceiling vents were cleaned to remove accumulated dust.The Plan of Correction further indicated the Maintenance Director and Housekeeping Supervisor would conduct facility-wide environmental audits of resident rooms, bathrooms, and shower and tub rooms to ensure floors were free of sticky residue, bathrooms were clean and free of visible dust, toilet bases were properly sealed, shower rooms remained clean, and floor tiles were maintained in good condition. Housekeeping staff were assigned weekly deep-cleaning schedules that included shower and tub rooms, ceiling vent inspections, and floor inspections. Grout and tile inspections were to be completed monthly.The facility also provided education to housekeeping, maintenance, and nursing staff regarding environmental cleaning standards and procedures for reporting environmental concerns.The Plan of Correction further required the Nursing Home Administrator, or designee, to conduct environmental rounds three times each week for four weeks, weekly for an additional four weeks, and monthly thereafter. Audit results were to be reviewed during monthly QAPI (Quality Assurance and Performance Improvement) meetings to evaluate the effectiveness of the corrective actions and ensure the improvements were maintained.The facility indicated all corrective actions would be implemented by June 23, 2026.However, during the revisit survey ending June 25, 2026, the facility again failed to maintain a clean, comfortable, and homelike environment for residents under the same regulatory requirement.The recurrence of the deficient practice demonstrated the facility's QAPI monitoring process did not effectively identify that the corrective actions had not been sustained and failed to prevent the recurrence of the previously cited environmental deficiencies.Cross Ref. F584 28 Pa. Code 211.12 (d)(1)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1) Management

Based on clinical record review, facility policy review, observations, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to address aggressive behavior interventions and the care, monitoring, and maintenance needs associated with a central line for one of 28 residents reviewed (Resident 58).Findings include: A review of the policy titled Care Plans, Baseline, and Comprehensive, last reviewed by the facility on April 9, 2026, revealed it is the policy of the facility to ensure that each resident receives care individualized to the resident and that goals and approaches for care are communicated to all parties, including caregivers, the resident, and the resident's representative. The interdisciplinary team will develop an individualized, comprehensive care plan for each resident based on their medical condition, medical history, assessments from different members of the interdisciplinary team, lifestyle, and current resident goals. Clinical record review revealed Resident 58 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of sugar in the blood and urine). A review of facility-provided investigative documentation dated February 2, 2026, revealed Resident 58 was involved in a resident-to-resident altercation with their roommate, Resident 40. The documentation revealed Resident 58 admitted to hitting the roommate following an argument regarding the window curtain being closed. The investigative documentation further revealed the facility identified interventions that included redirecting the resident to discuss their dog and redirecting the resident to the lounge/dayroom area to look out the windows. Review of Resident 58's comprehensive care plan, initiated April 15, 2025, revealed the facility failed to develop care plan interventions addressing the resident's aggressive behavior history, including identified interventions for redirection following the resident-to-resident altercation. A review of a physician's order dated April 16, 2026, documented a central line to the right chest (a thin, flexible tube that is inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream) 18 French single lumen catheter (a catheter size and single internal channel used to administer fluids or medications). The physician's order directed staff to change the dressing every Thursday evening shift and as needed, maintain an emergency kit at bedside containing gloves, hemostats (a medical instrument used to clamp blood vessels), tape, abdominal pads, and a dressing change kit, and flush the line every shift with 10 milliliters of sodium chloride (a sterile saltwater solution used to maintain the line and prevent blockage) before and after medication administration. Observation of Resident 58 on May 5, 2026, at 11:00 AM revealed a central line present in the resident's right upper chest. Review of Resident 58's comprehensive care plan revealed the facility failed to develop care plan interventions addressing the resident's central line, including monitoring of the insertion site, dressing changes, flushing requirements, infection prevention measures, and ordered maintenance interventions associated with the device. An interview was conducted with the Director of Nursing on May 7, 2026, at 11:30 AM. The above findings were reviewed regarding the facility's failure to develop and implement a comprehensive person-centered care plan to address Resident 58's aggressive behavior interventions and central line care needs. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, facility policy review, and staff interviews, it was determined the facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for one of 28 residents reviewed (Resident 5) with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Findings include: A review of the facility policy titled Trauma-Informed Care, last reviewed by the facility on April 9, 2026, revealed it is the policy of the facility to ensure that residents who are trauma (deeply distressing or disturbing experience)survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Residents will be screened and assessed upon admission in order to identify any history of trauma and/or post-traumatic stress disorder (PTSD). The interdisciplinary team will ensure that an individualized resident-centered care plan is developed for the resident that has experienced a traumatic event. A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event). A review of Resident 5's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 4, 2026, revealed that Resident 5 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). The MDS further revealed the resident was assessed as yes to having a PTSD diagnosis. A review of Resident 5's current comprehensive care plan, in effect at the time of review on May 5, 2026, failed to identify the resident's PTSD diagnosis, trauma-related symptoms, known triggers, resident preferences, or individualized interventions to minimize emotional distress and prevent re-traumatization. Review of the clinical record failed to reveal evidence the interdisciplinary team developed or implemented resident-specific approaches to provide trauma-informed care, despite the resident's documented diagnosis of PTSD. The facility failed to develop and implement an individualized person-centered plan to address this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety. Interview with the Nursing Home Administrator and Director of Nursing on May 6, at 1:00 PM, confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for the resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. 28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa Code 211.12 (d)(3)(5) Nursing services.

Based on clinical record review, observation, staff and resident interview, and incident investigation, it was determined that the facility failed to maintain a fully functional call light system for one semi-private room, affecting two of 28 sampled residents (Residents 74 and 127).Findings include: Clinical record review revealed Resident 74 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus (a chronic condition affecting blood sugar regulation) and kidney failure (loss of kidney function). A review of Resident 74's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 21, 2026, revealed that Resident 74 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information a score of 13-15 indicates intact cognition). In addition, it was also noted that the resident had severely impaired vision. An interview conducted with Resident 74 on May 5, 2026, at 10:00 AM revealed the visual call light notification located outside the resident room did not illuminate when the call system was activated so staff could quickly identify that he or his roommate needed assistance from outside of the room. Resident 74 stated the malfunction existed since the time of admission and staff were aware the system was not functioning properly. The resident wanted a different room where the call light system was functioning properly but was not given another choice at the time of admission. Resident 74 indicated due to visual impairment he periodically required staff assistance and stated staff were unable to readily identify when assistance was needed unless staff were physically present at the nurses' station to observe the main call light board. Resident 74 stated he at times experienced delayed staff response and had to go into the hallway and verbally call for assistance and had recently done so because his roommate (Resident 127) had fallen attempting to get back into bed. Observation on May 5, 2026, revealed activation of the call light system for Resident 74's room did not illuminate the visual notification light located outside the resident room. Resident 127 was admitted to the facility on [DATE], with a diagnosis of diabetes and chronic kidney disease. A BIMS assessment score of 15 dated April 29, 2026 indicated the resident was cognitively intact. An interview with Resident 127 on May 5, 2026, at 10:30 AM revealed the resident was aware the visual call light notification located outside the resident room did not illuminate when the call light system was activated and therefore did not alert staff that assistance was needed in the room. Resident 127 stated the malfunction had existed since the time of admission. Resident 127 stated that on May 4, 2026, at approximately 2:00 PM, he was sitting in his wheelchair and wanted assistance returning to bed. The resident stated he pushed his call light button; however, no staff responded. Resident 127 indicated that after waiting for assistance, he attempted to transfer himself from the wheelchair back into bed without staff assistance and subsequently slid from the wheelchair to the floor. Review of facility-provided investigative documentation dated May 4, 2026, at 2:05 PM confirmed Resident 127 was found on the floor after attempting to transfer from the wheelchair into bed without staff assistance. Observation of Residents 74 and 127's room on May 5, 2026, revealed no alternative method was implemented to allow residents to summon staff assistance in place of the malfunctioning visual call light notification system. During an interview conducted on May 5, 2026, at 1:00 PM, the Nursing Home Administrator was unable to provide evidence that the facility timely repaired the malfunctioning visual call light notification system or implemented an alternative method for Residents 74 and 127 to effectively summon staff assistance. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility documentation, and resident and staff interviews, it was determined the facility failed to develop and implement discharge planning consistent with a resident's expressed discharge goals and demonstrated self-care abilities for one of 28 residents reviewed (Resident 7).Findings included: A review of in-service documentation provided by the facility, dated December 2, 2025, revealed that discharge planning is a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. Clinical record review revealed Resident 7 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease affecting the body's ability to regulate blood sugar levels) and hemiplegia and hemiparesis following cerebral infarction (weakness or paralysis on one side of the body resulting from brain damage caused by interrupted blood flow to the brain). A review of Resident 7's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 10, 2026, revealed that Resident 7 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). A clinical record review revealed that Resident 7 served as their own responsible party. A care plan indicating Resident 7 was a short-term care resident and would return to the community was initiated on February 5, 2026. Interventions implemented to ensure Resident 7 would have a safe transition back to the community included discussing discharge options with the resident and family and having a discharge care conference to be held closer to discharge. A review of documentation titled Notice of Medicare Non-Coverage (NOMNC) dated February 24, 2026, revealed Resident 7 was notified that Medicare, a federal health insurance program, would no longer cover skilled nursing facility services after February 26, 2026. A review of documentation titled Immediate Notification of Medicare Beneficiary Appeal Request dated February 24, 2026, revealed Resident 7 appealed the termination of Medicare coverage for the skilled nursing facility stay. Review of the appeal documentation revealed the appeal was denied and Medicare coverage for skilled nursing facility services ended. A review of a social worker progress note dated March 20, 2026, at 10:30 AM, revealed the resident requested to set up discharge planning as he felt ready to return home. A review of a social services progress note dated March 24, 2026, at 10:53 AM revealed the social worker discussed discharge planning with Resident 7 and the resident's daughter. The note revealed Resident 7 requested discharge to home. The resident's daughter stated she did not believe the resident was ready for discharge at that time. The note further revealed the resident already possessed a wheelchair and cane at home. The social worker documented that the resident would require diabetic education prior to discharge due to the resident's history of cerebral infarction. A review of a social services progress note dated April 21, 2026, at 9:52 AM, revealed one identified barrier to discharge included insulin administration and blood glucose monitoring (the process of measuring sugar in the blood) education. The note revealed the social worker planned to obtain a physician order for diabetic teaching. A review of a physician's order dated April 21, 2026, at 2:49 PM, revealed an order for diabetic education each shift with documentation of the education provided. A review of a nurse progress note dated April 23, 2026, at 10:30 AM, revealed Resident 7 demonstrated understanding of diabetic education and was doing well with instruction. A review of the resident's Treatment Administration Record (TAR a clinical record used to document treatments and services provided to residents)) for April 2026 and May 2026 revealed nursing staff documented diabetic education each shift as ordered by the physician. During an interview on May 5, 2026, at 12:00 PM, Resident 7 indicated that he was frustrated and upset that he was still in the nursing facility and not discharged home as planned. Resident 7 indicated that the facility was not actively working with him on discharge planning. Resident 7 indicated that he was told that once he was educated on insulin (a medication used to manage diabetes that is injected into the skin) administration and on performing self-blood glucose monitoring that he would be able to be discharged from the facility. Resident 7 indicated that he independently performed insulin injections and blood glucose monitoring prior to being admitted and even provided the facility with one of his own insulin pens from home to be used for education. Resident 7 stated he routinely left the faciity on leave of absence (LOA, approved temporary leave away from the facility) during daytime hours without incident.A review of Resident 7's LOA documentation for April 2026 and May 2026 confirmed the resident frequently left the facility independently during daytime hours without documented incident. Review of the clinical record revealed no documented follow-up regarding Resident 7's repeated requests for discharge home, reassessment of discharge readiness, physician notification regarding the resident's demonstrated self-care abilities, or updated discharge planning after April 23, 2026, until it was brought to the attention of the facility on May 5, 2026. Clinical record review revealed no documented determination that discharge to the community was unsafe or not feasible and no documentation identifying who made such a determination. During an interview on May 5, 2026, at 1:35 PM, the Social Services Director confirmed Resident 7, and the resident's family expressed a desire for discharge to home. The Social Services Director stated discharge was pending diabetic education and physician approval but could not explain why discharge planning efforts did not progress after the resident completed diabetic education. Following surveyor inquiry, the facility conducted a care conference for Resident 7 on May 7, 2026, at 11:00 AM, with the resident, social worker, and the resident's daughter to discuss discharge planning. The facility failed to facilitate discharge planning consistent with Resident 7's expressed discharge goals, demonstrated ability to perform diabetic self-care tasks, and repeated requests for discharge to the community. This failure delayed progression of discharge planning for Resident 7 consistent with the resident's expressed goals. During an interview on May 7, 2026, at 1:00 PM, the Nursing Home Administrator and Director of Nursing confirmed there was no documented evidence reflecting reassessment of the resident's discharge readiness or an updated discharge planning process for Resident 7 prior to surveyor inquiry. 28 Pa. Code 201.18 (b)(2) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on review of clinical records, facility initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for four out of 28 residents reviewed (Residents 1, 2, 14, and 118).Findings include: A review of the clinical record revealed that Resident 1 was transferred to the hospital on January 16, 2026, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 2 was transferred to the hospital on February 18, 2026, and was readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 14 was transferred to the hospital on August 6, 2025, and was readmitted to the facility on [DATE]. Resident 14 was also transferred to the hospital on September 27, 2025, and was readmitted to the facility on [DATE]. Resident 14 was also transferred to the hospital on January 29, 2026, and was readmitted to the facility on [DATE]. Resident 14 was also transferred to the hospital on February 21, 2026, and readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 118 was transferred to the hospital on November 30, 2025, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfer, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the nursing home administrator on May 8, 2026, at 9:30 AM confirmed there was no documented evidence that copies of facility initiated transfer notices for Residents 1, 2, 14, and 118 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The nursing home administrator also confirmed there was no evidence that copies were sent consistently for resident transfers to a representative of the Office of the State Long-Term Care Ombudsman from May 2025 through April 2026. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on a review of facility policies, employee personnel records, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to implement its established abuse prevention and response policies following an allegation of abuse for one resident (Resident 1) out of 9 residents reviewed and failed to follow required employee screening procedures for one of three employees reviewed (Employee 1) Findings include:A review of the facility's Abuse and Neglect Prevention Policy defined serious bodily injury to include sexual acts involving a resident who is unable to consent or understand the nature of the act. The policy directed that in the event of suspected maltreatment (abuse, neglect, or exploitation), the resident must be assessed for injuries and trauma. The policy also directed staff to preserve evidence by not bathing or cleaning the resident, not washing or discarding clothing or linens, and not destroying documentation. The policy further directed that if maltreatment may involve a crime, the facility must immediately notify the police and report the allegation to the State agency no later than two hours after the allegation is made.A review of the facility's Abuse and Neglect Prevention Policy defined serious bodily injury as sexual intercourse with a resident by force or when the resident is incapacitated (unable to resist or protect themselves due to physical or mental condition). The policy further defined serious bodily injury to include sexual intercourse with a resident who is unable to refuse participation or who lacks the ability to understand the nature of the sexual act. The policy directed that when maltreatment (abuse, neglect, or exploitation) is suspected, the resident must be assessed for changes in physical appearance, skin injuries, bruising, and signs of trauma (physical or emotional injury caused by an event). The policy instructed staff to follow applicable state and local laws related to preserving evidence (protecting items or information that may be used in an investigation). The policy further directed staff not to interfere with potential evidence by washing clothing or bed linens, destroying records, bathing or cleaning the resident before the resident is examined, or failing to transfer the resident to the emergency department for medical examination, including a rape kit (a medical and forensic examination used to evaluate injuries and collect physical evidence after a suspected sexual assault). The policy directed that if suspected maltreatment may involve a crime, the facility must immediately notify the police. The policy further directed that the facility must report the allegation to the State agency immediately, but no later than two hours after the allegation is made. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with a diagnosis of dementia (a condition involving decline in memory, reasoning, and the ability to understand or make decisions). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 19, 2025, revealed that Resident 1 was severely impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). A clinical record review revealed Resident 2 was admitted on [DATE], with diagnoses including depression (a mood disorder that affects how a person feels, thinks, and acts). A review of a quarterly MDS dated [DATE], revealed Resident 2 was cognitively intact with a BIMS score of 14, (a score of 13-15 indicates intact cognition). A review of Resident 2's care plan dated December 29, 2025, revealed the resident was identified as being at risk for behavioral and emotional episodes related to mental health symptoms. The care plan indicated Resident 2 experienced visual hallucinations (seeing people, objects, or things that are not actually present), which were described as distressing to the resident and others. The care plan also indicated Resident 2 experienced auditory hallucinations (hearing voices or sounds that are not actually present), which were also distressing to the resident and others.The care plan further documented that Resident 2 made verbal complaints (spoken statements) of feeling down, depressed, and hopeless, as well as feelings of anxiety (persistent worry or nervousness). The care plan also documented complaints of feeling nervous and having an inability to obtain restful sleep (difficulty sleeping through the night), which impaired the resident's quality of life (overall comfort, well-being, and ability to function day to day). The care plan also identified that Resident 2 had the potential for ineffective coping (difficulty managing stress or emotional responses in a healthy way) related to a traumatic event (a highly distressing or disturbing experience), specifically as a survivor of a domestic incident (violence or abuse that occurred in a personal relationship). A review of a progress note dated January 19, 2026, at 1:00 PM revealed Resident 1's roommate (Resident 2) reported to staff that Resident 1 was possibly the victim of sexual assault by a male caregiver (Employee 1, Nurse Aide). The note documented Resident 2 reported Employee 1 put on gloves and told Resident 1, you're going to have the time of your life. The note further documented that a body audit (a visual skin and body check for injuries) was completed, and no visible injuries were observed. A review of facility investigative documentation revealed Resident 2 reported an allegation of possible sexual assault to the Activity Director at approximately 11:15 AM on January 19, 2026. At that time, Resident 2 stated Employee 1 sexually assaulted Resident 1 at approximately 5:00 AM. A review of a witness statement from Resident 2 revealed Resident 2 reported hearing noises from Resident 1 and Employee 1. The statement documented Resident 2 heard Employee 1 tell Resident 1, we are going to get it right this time, I am not going to hurt you, I promise I will be gentle. The statement further documented Resident 2 reported she did not observe any sexual contact but heard Resident 1 say to Employee 1, you're nothing but a freak. Resident 2 stated she believed Employee 1 raped Resident 1 based on the manner in which Employee 1 spoke to Resident 1. The statement further documented Resident 2 asked Resident 1 if Employee 1 had ever made her feel uncomfortable, and Resident 1 responded no .A review of a witness statement dated January 19, 2026, revealed Social Services asked Resident 1 whether any staff member had touched her inappropriately, whether anyone had entered her room at night and touched her private areas, whether she had pain on her body, and whether she had pain, burning, or redness in her private areas. Resident 1 answered no to each question. A review of a witness statement from Employee 3 (Licensed Practical Nurse) dated January 19, 2026, revealed Resident 1 was observed wandering the facility throughout the night and frequently at the nurse's station. Employee 3 documented Resident 1 appeared to be in no distress.A review of a witness statement from Employee 1 revealed Resident 1 had a bowel movement while wandering in a hallway. Employee 1 documented that he took Resident 1 into a bathroom to clean and change her. Employee 1 documented Resident 1 was resistant, stated she did not need to use the bathroom, and yelled at him. Employee 1 documented Resident 1 was resistant to sitting on the toilet while being cleaned. Employee 1 documented he cleaned the resident, dressed her in clean clothing, transferred her back to her wheelchair, and escorted her back into the hallway. Employee 1 documented Resident 2 was upset about being awakened during this care. A review of a witness statement from Employee 4 (Nurse Aide) dated January 19, 2026, revealed she observed Resident 1 in a bathroom on the opposite side of the building with bowel movement on her clothing and wheelchair. Employee 4 documented Employee 1 offered to clean Resident 1 so Employee 4 could complete another assigned task. Employee 4 documented she observed Resident 1 multiple times after Employee 1 cleaned her and that Resident 1 showed no signs of distress.An interview with the Activity Director on January 21, 2026, at 12:35 PM revealed Resident 2 approached her in the hallway and stated she believed Resident 1 was possibly raped. The Activity Director stated she immediately escorted Resident 2 to the Nursing Home Administrator (NHA) to report the allegation. An interview with the NHA on January 21, 2026, at 1:00 PM revealed Resident 2 was brought to her office at approximately 11:00 AM on January 19, 2026, and an allegation of possible rape was reported. The NHA stated she began an investigation at that time. When asked why Resident 1 was not transferred to the emergency department for medical evaluation, including a rape kit (a forensic medical examination used to collect and preserve evidence after a sexual assault), until approximately ten hours later, the NHA stated she offered emergency room evaluation to the resident's responsible party at approximately 1:00 PM and the family declined, despite facility policy requiring preservation of evidence and hospital evaluation. The NHA stated it was not until a later conversation at approximately 7:00 PM that the family agreed to send the resident to the hospital. An interview with Resident 1's responsible party on January 21, 2026, at 1:30 PM revealed she was informed of a possible rape when she arrived at the facility at approximately 1:00 PM on January 19, 2026. The responsible party stated she was not offered the option to send Resident 1 to the emergency department during her visit and was repeatedly told by staff that the incident did not occur. An interview with Resident 2 on January 21, 2026, at 9:45 AM revealed that on the morning of January 19, 2026, at approximately 5:00 AM, she observed Employee 1 enter the shared room. She stated she heard Employee 1 tell Resident 1 it would be okay and that he would be gentle. Resident 2 stated Resident 1 did not want to go into the bathroom and was calling Employee 1 names. Resident 2 stated she heard Employee 1 instruct Resident 1 to stand and hold onto grab bars, then to sit on the toilet, then to stand again and hold onto the bars. Resident 2 stated Employee 1 exited the bathroom, retrieved a brief and clothing from Resident 1's closet, and returned to the bathroom. Resident 2 was questioned about whether she heard any sounds of distress, moaning, or statements such as stop from Resident 1. Resident 2 stated she did not hear Resident 1 express distress. Resident 2 stated she asked Resident 1 if Employee 1 had ever made her feel uncomfortable, and Resident 1 responded no. When asked why she believed Resident 1 was assaulted, Resident 2 stated Employee 1 called Resident 1 baby. Resident 2 further stated that whenever Employee 1 entered the room, Resident 1 would raise her hands to her face. Resident 2 stated she believed Resident 1 was raped based on Employee 1's manner of speaking and Resident 1's reactions when Employee 1 was present. An interview attempt with Employee 1 on January 21, 2026, was unsuccessful. A second attempt on January 22, 2026, resulted in Employee 1 stating that due to the escalation of the situation, he would not provide a statement. An interview with Employee 2 (Nurse Aide) on January 21, 2026, at 12:47 PM revealed she showered Resident 1 on the morning of January 21, 2026, at approximately 10:15 AM after again finding Resident 1 with bowel movement on her clothing and wheelchair. Employee 2 stated she was unaware of any sexual abuse allegation prior to bathing the resident. Employee 2 stated she cleaned the resident's private area to remove fecal matter. An interview with a police department clerk on January 21, 2026, at 11:30 AM revealed the facility notified law enforcement at 3:21 PM on January 19, 2026, approximately four and one-half hours after the allegation was reported to the NHA, despite facility policy directing immediate police notification when sexual abuse is suspected. The above findings demonstrated the facility failed to implement its Abuse and Neglect Prevention Policy by not securing the scene, not preserving potential evidence, not ensuring timely transfer of the resident for a sexual assault examination, and not immediately notifying law enforcement when the facility became aware of a possible sexual assault allegation. The above findings were reviewed with the Nursing Home Administrator on January 21, 2026, at 2:45 PM, including the facility's failure to implement its abuse policies and procedures.A review of the facility's Policy and Procedure for Vulnerable Adult Abuse and Neglect Prevention, last reviewed by the facility on March 25, 2025, revealed the facility is responsible for screening potential employees for any history of abuse, neglect, exploitation, or mistreatment. The policy required reasonable efforts to obtain information from previous employers and/or current employers, and to verify information through appropriate licensing boards and registries, as applicable. A review of the facility's Policy and Procedure for Employment Screenings for Potential Hires last reviewed by the facility on March 25, 2025, revealed that prior to employment, the hiring manager should ensure all candidates are properly interviewed and that employment verification is completed. The policy required attempts to obtain references from previous employers, including verification of dates of employment, position held, and salary or hourly wage rate. When prior employment is not available, references may be obtained from schools, churches, or personal associations. Review of employee personnel records revealed that Employee 1 (Nurse Aide) was hired June 17, 2025, and listed two previous employers on the employment application. However, there was no documented evidence that reference checks or verification of employment from either previous employer were obtained prior to the employee's start date. An interview with the Director of Human Resources on January 21, 2026, at 2:34 PM confirmed the facility could not provide documentation showing reasonable efforts were made to contact Employee 1's previous employers in accordance with the facility's screening procedures. 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(1)(2) Nursing services.

Based on observation and staff interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and three of five resident pantry areas (Nursing Units Medbridge Hall, A Hall, and B Hall). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean, and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness, according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations on September 25, 2025, at 8:28 AM revealed the kitchen floor with dirt, discolorations, dust, and food pieces along the kitchen floor perimeter. Observations on September 25, 2025, at 8:36 revealed the A Hall pantry with an opened, undated chocolate instant pudding mix; cabinets with dust and discolorations; a refrigerator with substance stains and discolorations; and a microwave with used brown napkins and substance stains inside and around the exterior of the appliance. Observations on September 25, 2025, at 8:43 AM revealed the B Hall pantry with an opened plastic bag containing white crackers, a microwave with food substance stains and pieces of food, and a refrigerator with a soiled brown paper towel. Observations of September 25, 2025, at 10:12 AM revealed the Medbridge Hall pantry with an undated plastic bowl containing a tan food in the refrigerator. The refrigerator had brown-red substance stains along the bottom shelf and an undated frozen liquid drink in the freezer. The microwave was observed with food pieces and a substance stain on the interior of the appliance. An interview with the nursing home administrator on September 25, 2025, at 10:45 AM confirmed the food and nutrition services department and resident pantry areas were to be maintained in a sanitary manner and confirmed food items were to be dated to ensure quality and food safety to prevent opportunities for foodborne illness. 28 Pa Code 211.6(f) Dietary services. 28 Pa Code 210.18 (e) (2.1) Management.

Based on observations, a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for four out of five nursing units (Units Medbridge Hall, A Hall, B Hall, and D Hall), including experiences reported by two out of three residents interviewed (Residents 1 and 2). Findings include:A review of resident council meeting minutes dated August 4, 2025, revealed residents in attendance expressed concerns regarding the housekeeping services. Residents reported that only garbage is emptied, and floors are occasionally mopped. Additional concerns included housekeepers using dirty water to mop floors, particularly in hallways and dining areas; lack of top dusting; dusty surfaces; spider webs; over-bed tables not being cleaned; and bathroom floors uncleaned. Observations on September 25, 2025, at 8:26 AM revealed a black mat with multiple pieces of white debris, a wet paper towel, and black-gray discolorations in front of the ice machine in the Medbridge Nursing Unit dining area.Observations on September 25, 2025, at 8:44 AM revealed a clump of hair measuring 2 inches by 1 inch and multiple pieces of dirt and debris in the Nursing A Hall.Observations on September 25, 2025, at 8:51 AM revealed missing and stained tiles, saturated paper, and hair in the B Hall shower room drain. A resident bathtub in the B Hall shower room was also observed with several pieces of hair and debris inside the tub. The shower room floor had multiple areas with discolorations, a discarded plastic glove, stains, and pieces of debris.Observations on September 25, 2025, at 8:55 AM revealed dirt, debris, and stains on the floor around the A Hall nursing station. The running board adjacent to the Nursing A Hall nursing station was observed with a brown-red substance stain and buildup.A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a chronic mental health condition characterized by a combination of symptoms, such as flat affect, hallucinations, and/or impairments with cognitive functioning, that significantly impact a person's thoughts, emotions, and behaviors).A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2025, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment).During an interview on September 25, 2025, at 8:57 AM, Resident 1 stated that his room is never cleaned. He explained that he saw staff cleaning today because the surveyors were here. An observation of Resident 1's room revealed the resident's floor with a substance splattered near his bed measuring 5 inches by 10 inches, small white pieces of paper, dirt, and debris.Observations on September 25, 2025, at 8:58 AM revealed the Resident B Hall hallway with dirt, debris, and a substance buildup on the edges of the floor near the baseboard. The dirt and substance buildup extended several feet along the B Hall walls on both sides.Observation on September 25, 2025, at 9:35 AM revealed Resident D Hall's shower room with a floor with dirt, debris, and discolorations; a bathtub with brown substance stains; a shower chair with brown substance stains on the seat opening; and a drain with clumps of hair.Observations on September 25, 2025, at 9:45 AM revealed the Resident B Hall lounge with two overlapping trays. Both trays had multiple substance stains on the base of the trays. A green rocking chair was observed with a red substance buildup near the armrest measuring 2 inches by 4 inches. The floor of the B Hall lounge was observed with pink and red stains.A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).A review of a quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 2 was cognitively intact with a BIMS score of 15; a score of 13-15 indicates cognition is intact.During an interview on September 25, 2025, at 9:55 AM, Resident 2 explained the facility staff do not clean every day, and it has been this way for a while. Resident 2 pointed out a buildup of dirt, dust, discolorations, and debris that ran along the wall of her room near her closet.An observation on September 25, 2025, at 10:04 AM revealed the Medbridge Hall hallway adjacent to the nursing station with brown liquid stains on the wall and dirt, debris, and dust on the floor near the floorboards.An observation on September 25, 2025, at 10:07 AM revealed resident room [ROOM NUMBER]'s window side wall with brown-gray liquid stains and dirt, debris, cobwebs, and a leaf near the tall armoire. The resident bathroom was observed with brown substance stains on the floor and a brown substance smear near the shower drain.An observation on September 25, 2025, at 10:10 AM revealed the Medbridge Hall hallway outside of resident room [ROOM NUMBER] with paper, plastic pieces, and red stains.An observation on September 25, 2025, at 10:16 AM revealed the Medbridge Hall shower room with a clump of brown substance near the shower drain and brown substance smears on the floor. There was dirt, debris, stains, and dust in multiple areas of the shower room floor.During an interview on September 25, 2025, at 10:45 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents living at the facility. 28 Pa. Code 201.18 (e)(1) (2.1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to properly store resident personal care equipment on one of five nursing units (A wing) and failed to store a urinary catheter drainage bag in a manner to limit the potential for infection for one of three sampled residents (Resident 29). Findings include: A review of the facility Infection Control Program Policy last reviewed May 5, 2025, indicated the infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. An observation on June 3, 2025, at 11:58 AM in the bathroom of resident room A 05 revealed a grey bedpan on the floor under the sink, wedged between the garbage can and the wall. The bedpan was not enclosed in a plastic bag and was in direct contact with the floor, wall, and garbage can. A pink wash basin was also observed on the floor in the corner of the bathroom, similarly, unbagged and in direct contact with the floor and wall. Two urinals containing a small amount of yellow liquid were hanging on the grab bar. The urinals were not labeled with a resident name to indicate resident ownership. A second observation of the same bathroom on June 4, 2025, at 2:09 PM revealed the same grey bedpan unbagged and, on the floor, and two unlabeled urinals containing a small amount of yellow liquid still on the grab bar. An additional observation on June 3, 2025, at 12:15 PM of the bathroom in resident room A 09 revealed a grey bedpan on the floor under the sink with a dry washcloth draped over the side of the bedpan. The bedpan was unbagged and in direct contact with the floor. Further observation revealed four wash basins (3 pink and 1 grey) stacked on top of the toilet tank. The basins were not labeled with a resident name or bed number to identify which basin belonged to each resident. There was a bag of unlabeled supplied inside the top basin. An interview conducted on June 5, 2025, at 11:30 AM with the Director of Nursing confirmed that facility procedure requires bedpans and basins to be cleaned after use, bagged, and stored on the bottom shelf of each resident's nightstand. The Director acknowledged that these items should not be stored on the floor or on top of toilet tanks and confirmed the observed practices did not align with facility protocol. A clinical record review revealed Resident 29 was admitted to the facility on [DATE], with diagnoses which include spastic quadriplegic cerebral palsy (brain damage that affects both sides of the brain leading to muscle stiffness and difficulty controlling movement in all four limbs). A physician's order dated April 14, 2025, indicated a suprapubic catheter (18 French/30 cc balloon) to be maintained on a closed drainage system for neuromuscular dysfunction, with monitoring every shift. A physician order dated April 14, 2025, noted an order for a Suprapubic catheter (a type of urinary catheter that is inserted directly into the bladder through a small incision in the lower abdomen, rather than through the urethra) 18 French (catheter's outer diameter)/30 cc balloon (balloon's capacity for holding fluid) to closed drainage system for a diagnosis of neuromuscular dysfunction (disease which affects the motor and sensory nerves that connect the brain and spinal cord to the rest of the body) to be maintained with monitoring the catheter/dignity drainage bag every shift. An observation on June 3, 2025, at 1:50 PM revealed Resident 29's catheter drainage bag, though covered for privacy, was resting directly on the floor. An interview at the time with Employee 3 (Registered Nurse) confirmed the observation and stated that catheter drainage bags are required to be positioned to avoid contact with the floor. An interview on June 5, 2025, at 1:00 PM with the facility's Infection Preventionist confirmed that infection control protocols require catheter drainage bags to be positioned so that they do not touch the floor, to reduce the risk of environmental contamination and infection transmission. The facility failed to ensure personal care equipment and urinary drainage systems were stored and maintained according to infection prevention best practices. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa code 211.12 (d)(1)(5) Nursing services.

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for one residents out of 29 sampled residents (Resident 3) and failed to provide nursing care consistent with professional standards of practice in accordance with physician orders for one resident out of 29 sampled residents (Resident 93). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome, right below the knee amputation, and Type 2 diabetes (body has trouble controlling blood sugar and using it for energy). A review of Resident 3's hospital records dated June 21, 2024, documented the resident previously underwent a spinal cord stimulator stage I implantation of lead and generator (refers to the initial trial phase of spinal cord stimulation therapy. It involves temporary placement of leads (electrodes) in the spinal epidural space to evaluate whether electrical stimulation can effectively relieve a patient's chronic pain before permanent implantation) performed on November 26, 2019. A review of Resident 3's Admission assessment dated [DATE], failed to document the presence of the spinal cord stimulator implant. Physician orders for Resident 3 did not reflect the presence of, or any required care or precautions related to, the spinal cord stimulator. Additionally, review of the resident's plan of care, current as of the survey ending June 6, 2025, failed to address the spinal cord stimulator despite identifying multiple comorbidities including chronic pain from phantom limb syndrome and osteoarthritis. An interview with the Director of Nursing (DON) on June 5, 2025, at 11:35 AM, confirmed the facility failed to perform a comprehensive assessment related to the spinal cord stimulator, failed to obtain relevant physician orders, and failed to include the device in the resident's plan of care to meet the resident's medical and treatment needs. A review of the facility policy titled Physician Orders, last reviewed by the facility on May 5, 2025, revealed that it is the policy of the facility to provide guidance to ensure physicians orders are transcribed and implemented in accordance with professional standards. The licensed nurse is required to record the order accurately in the medical record and is required to record the order on the appropriate administration record of the MAR/TAR (Medication Administration Record/Treatment Administration Record). A review of the facility policy titled Administering Medications, last reviewed by the facility on May 5, 2025, revealed that it is the policy of the facility that the individuals administering medications shall sign the residents MAR for the specific time and date the medication was administered, and if it is discovered the person administering the medications has forgotten to sign in the e-Mar, the supervisor or designee shall notify that person to investigate if the medication or treatment has been administered or performed. If the response indicates the medication or treatment was administered, the staff member shall return to the facility to complete appropriate documentation, and a late entry note will be documented indicating the administration of the medication. A review of the clinical record revealed that Resident 93 was admitted to the facility on [DATE], with diagnoses to include epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures, which include uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2025, revealed that Resident 93 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). Physician orders dated April 9, 2025, directed the resident receive Levetiracetam 750 mg (an anti-seizure medication used in those with epilepsy, and it is crucial to follow the prescribed dosage and to not stop taking it suddenly, as this can increase seizure frequency) by mouth daily for idiopathic epilepsy. Further review of the clinical record revealed a physician's order dated April 21, 2025, for the night shift to give 9:00 AM meds at 7:00 AM due to Resident 93 having an appointment and leaving at 7:15 AM, and the appointment location was an hour away from the facility. A nurse's progress note dated April 22, 2025, at 7:15 AM, confirmed that the resident was transferred to the appointment accompanied by a Certified Nursing Assistant (CNA). A later progress note at 9:54 AM documented that the facility received a call from the CNA reporting the resident became unresponsive during the appointment and was transported to the emergency department. Resident 93's representative was present at the appointment and aware of the incident. A 2:22 PM note on the same day indicated the resident was diagnosed with a possible seizure and treated with appropriate medications as per telephone contact by the emergency department. A clinical review of an outside report from an emergency room , dated April 22, 2025, for Resident 93 revealed that she came in after an unresponsive episode at her appointment, and there were concerns that she had experienced a focal seizure. Resident 93 was then treated with the appropriate medications and became she became responsive after. Review of the facility's Medication Administration Record (MAR) for April 2025 showed that Levetiracetam 750 mg was documented as administered at 10:21 AM by Employee 5, LPN. However, the resident was not present in the facility at that time. There was no documentation of a late entry or clinical progress note to justify this late recording. The facility's internal investigative documentation dated April 24, 2025, stated that the nurse administered the medication prior to the resident's departure but failed to document it due to a shift change. The investigation noted the nurse was re-educated but did not provide statements from the resident, her representative (who was present at the appointment), or the accompanying CNA. The facility also failed to explain why the night shift did not administer the medication as ordered. During an interview on June 3, 2025, at 11:25 AM, Resident 93 stated she had not received her seizure medication prior to leaving for her appointment despite requesting it several times and voiced concern over leaving the facility without taking her prescribed anti-seizure medication. Resident 93 stated that they did not give her a reason as to why her medications could not be given prior to leaving and stated she questioned why she was leaving the facility prior to taking her seizure medication, with no answer She stated that she experienced a seizure during the appointment and required emergency treatment as a result. During an interview with the DON on June 7, 2025, at approximately 9:00 AM, the DON acknowledged the facility failed to document the medication administration at the time of actual administration and failed to follow established policy for documenting late entries. The DON confirmed that nursing staff failed to comply with physician orders and standards of nursing documentation. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(i)(iii)(iv) Medical records.

Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 29 residents sampled (Residents 2, 3, and 5) and four out of five residents interviewed during a resident group interview (Residents 4, 61, 77, and 112). Findings include: During a resident council meeting on June 4, 2025, at 10:00 AM, Residents 4, 61, 77, and 112 voiced concerns about the timeliness of staff response to activated call bell lights. Resident 112 stated he rang his call bell for assistance the night before but did not receive help for over one hour. He needed assistance with toileting. He reported that he has waited at least 30 minutes anytime he utilized the call bell. Resident 4 stated that he frequently waited over an hour for staff to answer his call bell. He stated that staff often enter his room, turn off his call bell light, and leave without providing care. He said they tell him they will be right back, but they never come back He recalled an incident where he soiled his incontinence brief and waited two hours for care after his call bell was silenced. He expressed that delays are more frequent during the evening shift. Resident 77 stated that she frequently waited one to two hours at night for staff assistance after she had activated her call bell. She expressed frustration that staff enter her room, turn off her call bell light, say they will return, but never return or only return after she re-activated the call bell light a second time. Resident 61 stated she rarely used her call bell, but when she did, it typically took over 30 minutes for staff to respond. A clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe) and type 2 diabetes (body has trouble controlling blood sugar and using it for energy). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 30, 2025, revealed that Resident 5 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates intact cognitive responses). During an interview on June 3, 2025, at 11:20 AM, the resident stated she waited up to an hour for care during the day shift and was concerned about the delays. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included below the knee amputation of the right lower extremity (leg), blindness of the left eye, and low vision of the right eye. A review of an annual MDS dated [DATE], revealed that Resident 3 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates intact cognition). During an interview on June 3, 2025, at 11:30 AM Resident 3, reported excessive wait times for staff assistance. He stated staff often responded to his call bell, said they needed to find another staff member (due to his two-person assist needs), and then did not return. He also reported difficulty locating the call bell when seated in his wheelchair due to his vision impairment. At the time of the interview, observation revealed the call bell was on the floor near the head of the bed and out of his reach. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes and chronic obstructive pulmonary disease. A review of a quarterly MDS dated [DATE], revealed that Resident 2 is cognitively intact with a BIMS score of 15. During an interview on June 3, 2025, at 11:55 AM, Resident 2 indicated she experiences long wait times for care. She indicated she often waits 30 minutes or longer before receiving assistance after activating her call bell. During an interview on June 5, 2025, at approximately 10:30 AM, the Nursing Home Administrator (NHA) acknowledged that all residents should be treated with dignity and respect and receive care in a timely manner that promotes quality of life. The NHA was unable to explain why multiple residents reported consistent delays in staff response to call bells. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the discharge status of one resident out of 29 sampled (Resident 180). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section A0310F: Entry/Discharge Reporting indicates to review the medical record for entry/type of discharge (return anticipated versus return not anticipated). A review of Resident 180's clinical record revealed the resident was admitted to the facility on [DATE], and discharged to the hospital on May 18, 2025. Further review of the resident's payor status indicated the resident was private pay and did not elect to continue private payment for his room while hospitalized , a key indicator that the return was not anticipated. However, the Discharge Return Anticipated MDS assessment dated [DATE], documented in Section A0310F Entry/Discharge Reporting the resident was discharged with return anticipated, contrary to the resident's payor status and discharge planning information. During an interview conducted on June 5, 2025, at 11:00 AM, Employee 4 (Registered Nurse Assessment Coordinator) acknowledged that the MDS assessment for Resident 180 was inaccurate and confirmed that Section A0310F should have indicated a discharge with return not anticipated based on the circumstances of the resident's hospitalization and decision not to pay privately to hold the bed. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to conduct a care plan conference and failed to ensure that the resident was invited to participate in the care planning process for one of 29 residents reviewed (Resident 112). Findings include: A clinical record review revealed Resident 112 was admitted to the facility on [DATE], with diagnosis to include a below the knee amputation of the left lower extremity (leg), and end stage renal disease (final, permanent stage of chronic kidney disease, where the kidneys can no longer function on their own). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 12, 2025, revealed that Resident 112 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognitively intact). During an interview on June 3, 2025, at 12:05 PM, Resident 112 stated he has not been invited to participate in the care planning process for development of his comprehensive person-centered care plan or attend any care plan meetings. A further review of the clinical record revealed no documented evidence that a care plan conference had been conducted for Resident 112 or that the resident had been invited to participate in the development or review of his comprehensive care plan. During an interview with the Director of Nursing (DON) and the Admission's Director on June 5, 2025, at 11:20 AM, both confirmed there was no documentation to show that a care plan conference had been held for Resident 112 or that the resident had been invited to participate in the care planning process. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records, facility investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement a planned intervention to prevent intrusive wandering by a cognitively impaired resident (Resident 103) which resulted in a resident-to-resident altercation for two of 29 sampled residents (Residents 91 and 103). Findings include: A clinical record review revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and hypertension (blood pressure that is higher than normal). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 4, 2025, revealed that Resident 91 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of Resident 91's comprehensive care plan, initiated on July 5, 2023, indicated the resident had the potential to be verbally aggressive and/or loud with outbursts toward others, using vulgar or foul language, secondary to ineffective coping skills and poor impulse control. An intervention initiated on September 24, 2024, directed the placement of a stop sign at Resident 91's doorway to deter wandering residents from entering. A clinical record review for Resident 103 revealed an admitted [DATE], with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time). A quarterly MDS of Resident 103, dated April 23, 2025, revealed the resident was severely cognitively impaired. A quarterly MDS dated [DATE], documented that Resident 103 was severely cognitively impaired. The comprehensive care plan, initiated on November 5, 2024, identified the resident as an elopement risk and a wanderer due to dementia. A nurse progress note dated April 29, 2025, at 5:00 PM documented that a Certified Nurse Aide (CNA) observed Resident 91 backing his wheelchair into Resident 103 and then striking him with his arm. At that time, the planned intervention of a stop sign on Resident 91's door had not been implemented. The stop sign was only applied after the altercation had occurred. A subsequent nurse progress note dated April 29, 2025, at 6:26 PM revealed that Resident 103 was redirected out of Resident 91's room after a verbal outburst from Resident 91, Get out of my room. Shortly afterward, Resident 103 again passed by Resident 91, at which time Resident 91 attempted to roll backward toward Resident 103 and then physically struck the resident's arm. The incident was reported to the nurse supervisor, and a full assessment of Resident 103 found no injury or pain. Notifications were made to the resident representative, local police, and the Department of Aging. A review of a facility investigation report dated April 30, 2025, revealed that Resident 103 was attempting to enter Resident 91's room, and Resident 91 was sitting in his doorway and was yelling, Get out of my room, and Resident 103 self-propelled past Resident 91, and a CNA witnessed Resident 91 attempt to roll backwards into Resident 103 and was not successful, so Resident 91 shoved and hit Resident 103's right arm with his elbow. A body audit was completed, and no injuries were noted on Resident 103. Immediate interventions included separation of Resident 91 and Resident 103, and a stop sign was placed in front of Resident 91's doorway to deter Resident 103 from re-entering his room. Further review of this investigation revealed the conclusion was Resident 91 became physically aggressive towards Resident 103 due to the resident's wandering behaviors. During an interview conducted on June 7, 2025, at 9:00 AM, Resident 91 confirmed there had been no stop sign at his door at the time of the incident on April 29, 2025. Observations conducted on June 7, 2025, at 9:00 AM revealed the absence of a stop sign at Resident 91's doorway, contrary to the intervention outlined in his care plan. This was confirmed with Employee 1, Registered Nurse. In an interview conducted on June 7, 2025, at approximately 12:30 PM, the Director of Nursing confirmed the facility's failure to implement the planned intervention of a stop sign at Resident 91's doorway, acknowledging this may have contributed to Resident 103's entry into the room and the resulting physical altercation. The Director of Nursing further confirmed that it is the facility's responsibility to implement appropriate safety measures to prevent resident-to-resident altercations and potential abuse. 28 Pa. Code 201.18 (b)(1)(e)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records and select incident reports and staff and resident interviews it was determined that the facility failed to provide necessary staff assistance and assistance devices as planned for performing resident transfers resulting in a fractured arm for one resident (Resident 7) and failed to ensure safe technique was used during transfers causing a fractured finger for one resident (Resident 49) out of three sampled residents. Findings include: A review of the clinical record revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses, which included diabetes, chronic kidney disease, and fracture of the upper end of the right humerus. A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 28, 2023, revealed that Resident 7 was severely cognitively impaired with a BIMS score of 3 (the Brief Interview for Mental Status a tool that assesses cognition) and required extensive assistance with transferring. A review of the resident's care plan, initiated June 21, 2021, for the resident's activity of daily living (ADL) self-care performance deficit revealed that the resident had problems with activity intolerance, fatigue, impaired balance. A planned intervention for this problem of performance deficit was to use of a mechanical lift (Hoyer) to transfer the resident, with a large lift sling, initiated June 21, 2021. A review of the facility's Kardex Report (a communication tool for staff compiling the resident's care needs and current status) dated July 2, 2023, indicated that Resident 7 is to be transferred using a mechanical lift with a large sling. Nurses notes dated July 2, 2023, at 10:39 AM revealed that Resident 7 complained of increased right shoulder pain following transfer that morning and the CRNP was notified and pain medication and an x-ray were ordered. Nursing noted on July 2, 2023, at 2:52 PM that an x-ray of the resident's arm/shoulder that was obtained that date, in response to the resident's shoulder pain, revealed an acute (develops suddenly, immediate), spiral (twisting or torque) fracture of the right humerus (long bone of the arm). New orders were received to send the resident to hospital ER for evaluation. A hospital Radiology Results Report dated July 2, 2023, indicated that Resident 7 had a right shoulder X-ray completed for the purpose of pain, and that the impression was: 1. Acute spiral fracture of the proximal humeral diaphysis with approximately 2.3 cm lateral displacement and approximately 30 - degree lateral angulation of the distal humeral fracture. 2. Old ununited horizontal fracture through the proximal right humeral metaphysis, with approximately 2.4 cm medial displacement of the distal fracture. Nursing notes dated July 3, 2023, at 8:57 AM revealed that the resident returned from hospital with a diagnosis of an acute closed fracture of the upper right arm and sling was in place. A nurses note, dated July 6, 2023, at 1:55 PM, revealed that nursing spoke with Dr. this date after reviewing records, Dr. feels that X-ray from July 2, 2023, is a new fracture of the humeral shaft in comparison with previous chronic fracture of humeral neck (May 2023). The facility incident investigation into the resident's fracture dated July 2, 2023, revealed that the resident was complaining of increased pain to her right shoulder area. STAT X-rays revealed acute spiral fracture through the proximal humeral diaphysis. An employee witness statement dated July 3, 2023, revealed that Employee 1, a nurse aide, indicated that she and Employee 2, an LPN, transferred Resident 7 from bed to the wheelchair without using a mechanical lift. Employee 1 reported that after the resident's transfer she heard the resident's shoulder pop. An employee witness statement dated July 3, 2023, from Employee 2, LPN, however, revealed that Employee 2 denied assisting Employee 1 with Resident 7's transfer on July 2, 2023, and denied providing any care for Resident 7 that day. Employee 2 denied transferring, boosting or assisting Resident 7 with bed mobility. Employee 2's statement noted that when she returned to the resident's room, the resident was already transferred and complaining of increased shoulder pain. On July 3, 2023, at the conclusion of the facility's investigation, Employee 1 was suspended for not transferring Resident 7 as care planned. Employee 1 acknowledged not looking at Resident 7's Kardex before transferring the resident. Employee 2 was also suspended. During an interview on July 6, 2023, at approximately 10:58 AM, the Nursing Home Administrator (NHA) confirmed that Employee 1, and possibly Employee 2 as well, did not follow the resident's care plan and Kardex for transfers. The mechanical lift was not used for transferring the resident from the bed to wheelchair and Resident 7 sustained a serious injury and experienced pain. A review of the clinical record revealed that Resident 49 had diagnoses, which included cerebral infarction (stroke caused by a blockage in a blood vessel in the brain) and hemiplegia (paralysis/weakness of one side of the body) of the left non-dominant side. A quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14 and required extensive assistance with transferring. A review of the resident's care plan for activity of daily living (ADL) self-care performance deficit related to residual deficits from CVA (stroke) and hemiplegia with a date-initiated June 20, 2021, and revised November 25, 2022, included the intervention that for resident transfers (how resident moves between surfaces including from bed to chair) the resident required the assistance of one staff to transfer. A nurses note dated July 3, 2023, at 8:27 AM revealed that the resident stated that while a staff member was transferring her out of bed this morning, the resident's left finger fifth finger (pinky or little finger) was pinched on her wheelchair. The resident's left fifth finger was swollen at the base with no redness or bruising noted. The resident stated that she was experiencing pain and a new order was received for STAT (immediate) x-ray of left fifth finger and ice. A nurses note dated July 3, 2023, at 11:00 AM revealed that the resident was transferred to the emergency room . Review of Resident 49's Radiology Results Report dated July 3, 2023, indicated that the resident had sustained a minimally displaced and intra-articular fracture (a fracture that crosses a joint surface) at the base of the fifth proximal phalanx. A nurses note dated July 3, 2023 at 3:49 PM indicated that the resident returned to the facility with a left finger splint in place for fractured finger. Review of a facility Incident Investigation dated July 3, 2023, indicated that the resident sat on her hand while being placed in the wheelchair by staff. The resident was educated on transferring into wheelchair and to use both hands securely and slowly transfer into the chair. The resident's care plan was updated for staff to check placement of the resident's hands before sitting resident down in her wheelchair. The facility's incident investigation did not include staff education or interview/observation of staff regarding technique used during transfer. Interview with Resident 49 on July 6, 2023 at 11:15 AM revealed that the resident stated that when Employee 3, a nurse aide, was transferring her out of bed into the wheelchair, Employee 3 (nurse aide) quickly seated the resident in the wheelchair before the resident had a chance to move her hand, which resulted in her pinky finger getting injured. Resident 49 described the incident as an accident, but stated that nursing staff needs to be more careful when moving her to and from her wheelchair and not so rushed. During interview on July 6, 2023 at approximately 1:30 PM the director of nursing confirmed that the facility did not evaluate staff transfer technique or educate staff and failed to provide documented evidence that the facility had assured that staff used safe technique during Resident 49's transfer resulting in a fractured finger. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of clinical records and facility investigation reports and staff interview, it was determined that the facility failed to implement necessary individualized safety measures and staff supervision of resident identified with poor safety awareness and a history of falls to prevent a fall with serious injury, a hip fracture, for one of 29 sampled residents (Resident 76). Findings include: Clinical record review revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses to include dementia and a history of falls. A review of an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 15, 2023, revealed that Resident 76 was severely cognitively impaired, exhibited physically aggressive behaviors towards others, required assistance with activities of daily living, had a history of falling and exhibited behaviors to include wandering in the facility. The resident's care plan, initiated October 3, 2019, indicated that Resident 76 is at risk for falls due to weakness, poor safety awareness and cognitive impairment. Interventions planned were to assist the resident out of bed to broda chair (wheelchair that provides tilt-in-space positioning) when restless. The resident's care plan to address the resident's wandering behavior, dated October 6, 2022, included planned interventions to distract the resident with pleasant diversions, structured activities to accomodate the resident's cognitive communication ability, and TV room to be kept clear of overbed tables due to the resident's history of using tables to stand and attempt to ambulate using the overbed table as an assistance device. A review of a facility investigation report dated March 5, 2023, at 11:15 P.M. revealed that nursing staff found Resident 76 on the floor of the A hall main dining room, lying on her right side in front of her broda chair, near a dining table. The resident was awake and alert with confusion at the resident's baseline. The resident was unable to state what had occurred. No obvious signs of injury or non verbal signs of pain were identified at that time. The resident moved all extremities as per baseline. Two staff assisted the resident to the chair and then transported the resident back to the resident's room and back to bed. A body audit revealed no injuries or trauma. The resident was in the dining room unsupervised at the time of the resident's fall. A review of a facility investigation note dated March 5, 2023, no time noted, revealed that Resident 76 self propels throughout the facility in her broda chair, was restless and found trying to get out of bed. It was noted that nursing staff followed the resident's care kardex and had assisted the resident out of bed to the broda chair due to the restless and unassisted attempts to get out of bed on the night of the resident's fall. A review of an employee witness statement dated March 5, 2023, no time, revealed that Employee 6, a nurse aide, stated as I was leaving to go home (after 3 PM to 11 PM shift), Resident 76 was attempting to get out of bed at the end of the shift, approximately 10:45 PM-11 PM. Employee 7, a nurse aide, and I got her out of bed into her (broda) chair. A review of an employee witness statement dated March 5, 2023, no time, revealed that Employee 10, RN supervisor, stated that Resident 76 was last observed at 11 PM self propelling in her chair, as per her norm. Employee 10 stated that he and Employee 9, RN supervisor, were walking in the hallway by the main A hall dining room and found Resident 76 on the floor, laying on her right side. A review of an employee witness statement dated March 5, 2023, no time, revealed that Employee 8, nurse aide, stated I checked on Resident 76 every hour on the 11 PM to 7 AM shift. She slept the entire shift. Employee 8's statement was not consistent with the resident's activities that night as other staff noted that the resident was restless and attempting to get out of bed and was assisted out of bed and observed self-propelling in her chair at approximately 11 PM. The resident fell while unsupervised in the dining room at 11:15 PM. A review of nursing documentation dated March 6, 2023, at 1:05 PM revealed that the resident complained of of pain in right leg. Nursing noted that the resident was crying out if her leg is touched. Nursing called the physician and the physician ordered a STAT (immediate) x-ray from toes to hips. Nursing documentation dated March 6, 2023, at 4:46 PM revealed that Resident 76 was sent to the emergency room due to fall overnight and an x-ray done was positive for a hip fracture. A review of nursing documentation dated March 6, 2023 at 9:16 PM. revealed that nursing called the hospital for an update and was informed that Resident 76 was being admitted with the diagnosis of a fractured right hip. A review of hospital documentation dated March 6, 2023, at 7:09 PM revealed that Resident 76 fell at the facility March 5, 2023, and an X ray completed as an outpatient revealed a right hip fracture. A CT scan (diagnostic imaging study) of the resident's pelvis was completed on March 6, 2023, at 7:54 PM revealed an impacted fracture of the right femoral neck (Impacted femoral neck fractures are hip injuries which occur just below the femoral head, or the ball-and-socket hip joint, where the broken ends of the bone are jammed together by the force of the injury. This area of the thigh bone, or femur, is known as the femoral neck). The resident was admitted to the hospital and had hip surgery to repair the fracture. Nurses notes dated March 10, 2023, at 1:57 P.M. revealed that the resident was readmitted to the facility with 30 staples intact right hip area without drainage. The facility was aware that Resident 76 had a history of falls and poor safety awareness. On the night of the resident's fall the resident was restless and displaying unsafe behaviors of trying to get out of bed unassisted. Nursing staff assisted the resident out of bed into the broda chair in response to the resident's behavior, but failed to consistently supervise the resident to prevent this fall with serious injury. The resident was found on the floor of an unsupervised dining room by nursing staff passing by the room. The facility failed to demonstrate the resident was sufficiently supervised while wandering/self-propelling in the facility. There was no evidence that the facility had provided the resident with diversional activities to occupy the resident's attention as noted on the resident's plan of care after assisting the resident out of bed into the broda chair on the night of the resident's fall. Interview with the director of nursing on March 8, 2023, at 1 PM failed to provide evidence that Resident 76 was adequately supervised or that necessary individualized fall prevention interventions had been implemented to prevent the resident's fall with serious injury. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services 28 Pa. Code 211.11 (d) Resident care plan

Based on a review the facility's abuse prohibition policy, clinical records and select facility investigative reports and staff interviews it was determined that the facility failed to ensure that one resident out of 18 sampled was free from sexual abuse, which caused severe bruising, pain and emotional upset (Resident 2). Findings include: Review of the facility's abuse policy dated as reviewed June 2021, indicated that the purpose of the document was to keep residents free from abuse, neglect and corporal punishment of any kind by any purpose. The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property and exploitation. This includes freedom from verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion, and physical or chemical restraint not required to treat the residents medical symptoms. This protection extends to abuse by staff, consultants, contractors, volunteers, students and visitors (collectively staff). The definition of abuse to include; The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse or mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse to include, non-consensual sexual contact of any type with a resident who appears to want the contact to occur, but lacks the cognitive ability to consent or a resident who does not want the contact to occur. A review of the clinical record of Resident 2 revealed admission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's admission MDS assessment (Minimum Data Set - a federally mandated standardized assessment process to plan resident care) dated November 26, 2021 revealed Resident 2 was severely, cognitively impaired with a BIMS score of 3 (BIMS score is a measure of a resident's cognition), required staff assistance for activities of daily living and was slight of stature, 62 inches tall and weighed 116 pounds. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment dated [DATE] revealed that Resident CR1 was cognitively intact with a BIMS score of 15, required limited staff assistance with activities of daily living. The resident's height was 67 inches tall and the resident weighed 162 pounds. The resident required the extensive assistance of one person for ambulating in the room at that time. A review of nursing documentation dated November 23, 2021, at 1:45 AM revealed Resident CR1 combative with staff. He was attempting to get into the medication cart located in the hallway next to the nurses station. A review of nursing documentation dated November 23, 2021 at 5 AM revealed Resident CR1 had been seated in the dining room with a sharps (a container for used for disposing of used needles and sharps instruments) container next to him on the floor. He was observed to urinate in the container before facility staff took it away from him During an interview December 21, 2021 at approximately 2 PM, the DON (director of nursing) stated that Resident CR1 was experiencing behaviors, which were not included in his person-centered care plan when reviewed during the survey of December 21, 2021. A review of Resident CR1's care plan dated November 17, 2021 revealed no behaviors were noted. There was no documented evidence that the facility had developed and implemented approaches to addresss and/or attempt to manage Resident CR1's unsafe and socially inappropriate behaviors. A review of a facility investigation report dated December 15, 2021, revealed that on December 15, 2021, at 1:45 AM Employee 1 (a nurse aide employed by a staffing agency) entered the room shared by Residents' 2 and CR1. Employee 1 witnessed Residents 2 and CR1 in the same bed together (Resident 2's bed). Resident CR1 was observed on top of Resident 2. Both residents were naked from the waist down. Resident 2 was positioned buttocks up and face down on the bed. Resident CR1 had his right leg on top of Resident 2. Resident CR1 was observed touching Resident 2's buttocks with his penis. Employee 1 immediately separated the residents by pushing Resident CR1 off Resident 2 and sought help from licensed nursing staff. A review of nursing documentation dated December 15, 2021 at 1:45 AM, revealed that Employee 1 reported that something really bad is happening now, you need to come to resident's room you need to see this. Employee 1 was very nervous, trembling and nearly crying. Employee 2 (RN) and Employee 3 (LPN charge nurse) noted we both ran to resident's room. When I (Employee 2), this writer entered the room, immediately noted that Resident 2 was in very compromising position. His head was toward the foot of the bed, he was in fetal position on his right side and he was naked from waist down his bottom was all exposed and slightly tilted to the side. Noted extreme bruising from left hip area all the way across his both buttocks and almost to the right hip area. Resident 2 does not have any notes re; potential fall in the last few days. Bruising is very dark blue especially over the buttocks that appeared in that darker room. According to this documentation Employee 2 initially thought that Resident 2 had been incontinent of stool and only had bruising over right hip, but with closer examination was able to definitely determine that, this dark area was in fact extremely dark fresh looking bruise not a bowel movement. Employee 2 noted that Resident CR1 was in bed at the time that I (Employee 2 RN) entered the room, Resident CR1 was lying in supine position with his paints down to his ankles, his underwear was off, to his knees and his penis was covered with his left hand. Curtain was pulled close and Resident 2 was covered and taken out of the room. Resident 2 was brought to the nurses station for initial observation and then placed in room a different resident room. Resident 2 was upset and stating I can't take him (Resident CR1), need to find a nurse for me and I go home. Nursing assessment of Resident 2 revealed no visible rectal bleeding, but Resident 2 presented with a large amount of purple/blue bruising extending from his left hip area all the way across his both buttocks and almost to the right hip area. Extreme bruising noted from left hip on to across both buttocks and to right hip. Director of Nursing (DON) was made aware. Resident 2 was sent to the emergency room for evaluation on December 15, 2021. Local police were notified along with the Resident 2's physician and Responsible Party. A review of an employee witness statement dated December 15, 2021, no time noted, revealed that Employee 1 (agency nurse aide) stated I was doing my rounds and walked into {Residents' CR1 and 2's} room when I saw {Resident CR1} on top of {Resident 2} (in Resident 2's bed). They were both naked from the waist down. {Resident 2} was bottom up and face down and {Resident CR1} had his right leg on top of Resident 2. Resident CR1 was touching Resident 2's butt with his penis. I immediately moved Resident CR1 to his own side of the room and I ran for help. {Resident 2} told me he was tired of {Resident CR1} and wanted his own room. I ran for help. Employee 2 (RN) and 3 (LPN) helped me get Resident 2 dressed and out of that room. Resident 2 had bruises on his bottom and I helped to care for him on December 14, 2021, and he did not have those bruises at that time. A review of a witness statement dated December 15, 2021, no time, indicated Employee 3 (LPN) stated Called into {Resident CR1 and Resident 2's} room by Employee 1. {Resident CR1} was lying across his bed (the window bed) on his right side with his pants/brief down around his ankles. Resident 2 was lying in his bed, on his right side, with his right leg tucked back and his left leg out. He was naked from the waist down. He was in the fetal position with his buttocks exposed and tilted toward the ceiling. Bruising noted to both buttocks, dark purple in color. A statement from Resident CR1 dated December 15, 2021 (no time indicated) revealed that {Resident CR1} was questioned by the Director of Nursing (DON). Resident CR1 denied any contact with Resident 2, stating that he had not been out of bed since his admission to the facility. He also stated that he cannot walk without assistance. He stated that the girl Employee 1) saw something, but misunderstood. In response to staff informing Resident CR1 that he was observed naked from the waist down and on top of Resident 2, Resident CR1 stated that she (Employee 1) must be hallucinating and this is the most ridiculous thing he ever heard. Resident CR1 continued to state that he was unable to walk, alleging that there was no way he could have gotten out of bed and screwed his roommate and got back into bed. Resident CR1 again expressed that the whole thing is ridiculous. Someone else must have come in and screwed his roommate. The facility placed Resident CR1 on one to one staff supervision until the resident's discharge from the facility on December 17, 2021. Interview with physical therapy staff on December 21, 2021, revealed that the Resident CR1 had received specialized rehab services during this stay. PT staff stated that Resident CR1, reached his maximum potential in physical therapy and was ambulating independently without staff assistance at the time of the sexual assault of Resident 2. Resident CR1 was discharged to home without services, on December 17, 2021, following his sexual abuse of Resident 2. A review of Resident 2's hospital emergency room discharge documentation dated December 15, 2021 at 9:09 AM revealed a discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of nursing documentation dated December 16, 2021 2:53 PM revealed Resident 2 complained of pain. Tylenol (non narcotic pain medication) 325 mg, 1 tab, by mouth was given to Resident 2. The CRNP (Certified Registered Nurse Practioner) was contacted and ordered a stat (immediate) Lumbar Spine X-ray in response to resident complaints of pain. A review of a mobile x-ray report dated December 17, 2021 at 7:38 PM revealed the xray of the lumbar spine (lower spine) was completed in response to complaints of pain. The impression was noted as severe compression fracture (occurs when one or more bones in the spine weaken and crumple) superior end plate ( complete burst fracture involves both endplates, the superior {upper} one as well as the inferior {lower}one). During an interview December 21, 2021 at approximately 3 PM the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that Resident 2 was free from sexual abuse perpetrated by Resident CR1. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 7/7/21, 5/14/21, 1/8/21 28 Pa. Code 201.18 (e)(1) Management Previously cited 11/17/21, 8/17/21, 7/7/21, 5/14/21, 1/8/21 28 Pa. Code 201.29(a) Resident rights Previously cited 11/17/21, 8/17/21, 7/7/21, 5/14/21, 1/8/21 28 Pa. Code 201.29(c) Resident rights Previously cited 7/7/21, 5/14/21 28 Pa. Code 201.29(d) Resident rights Previously cited 7/7/21

Based on review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses timely and consistently evaluated the resident's condition and provided necessary care for one resident out of eight residents reviewed (Resident CR1) displaying a change, and continued decline, in condition, delaying the resident's transfer to the hospital, and subsequent admission to the intensive care unit and below the knee amputation, which compromised the resident's clinical condition and ability to maintain and/or reach his highest practicable physical well-being and delayed the provision of necessary care and treatment to prevent further decline in physical condition. Findings included: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: · Assessments · Clinical problems · Communications with other health care professionals regarding the patient · Communication with and education of the patient, family, and the patient 's designated support person and other third parties. According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. A review of the clinical record revealed that Resident CR1, was most recently admitted to the facility on [DATE], with diagnoses, which included, dementia (a group of thinking and social symptoms that interferes with daily function; not a specific disease , dementia is a group of conditions characterized by impairment of at least two brain functions, such as memory and loss of judgement), chronic kidney disease, diabetes type 2, and peripheral vascular disease (a circulatory problem in which narrowed arteries reduce blood flow to your limbs). A review of a Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 8, 2021, revealed that the resident was moderately impaired with a BIMS score of 11 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 8-12 indicates moderate impairment). The resident required limited assistance of one staff member for bed mobility and extensive assistance of one staff member for transfers, dressing, toileting and personal hygiene. Nursing progress notes dated August 13, 2021, at 3:51 PM, indicated that the resident had a change in condition, the resident required extra help in standing and a mechanical lift for transfer. Nursing noted that the physician was notified and had ordered lab work including, A CBC (a group of tests that evaluate the cells that circulate in blood), CMP (a test that measures 14 different substances in your blood), UA (urinalysis - a test of your urine used to detect and manage a wide range of disorders) and C&S (culture and sensitivity - laboratory techniques that allow a disease-causing microorganism to be identified, and that determine which antibiotics are sensitive to) and KUB (an X-ray study that allows your doctor to assess the organs of your urinary and gastrointestinal systems). Review of the clinical record revealed a progress note, an administration note, dated August 15, 2021, at 5:58 AM, noting that the resident was complaining of leg pain and was provided Tylenol (a non-narcotic pain reliever). A nursing progress note dated August 16, 2021, at 4:59 AM, revealed that the resident had been more tired the last few days. Nursing noted that the resident had [CONDITION(S)] (swelling) to the left leg. A nursing progress note dated August 16, 2021, at 10:50 AM, indicated that the physician had examined the resident and ordered x-rays of her left hip, pelvis, knee and a venous doppler (a diagnostic test used to check the circulation in the large veins in the legs) of the left lower extremity. A nursing progress note dated August 16, 2021, at 10:52 AM, indicated that the resident had recent confusion, lack of appetite and decreased mobility with complaints of lower extremity discomfort and was provided Tylenol. A nursing progress note dated August 16, 2021, at 2:34 PM, indicated that the resident was unable to walk because of weakness. A nursing progress note dated August 17, 2021, at 5:33 AM, indicated that Resident CR1 was lethargic (tired), resting in bed, [CONDITION(S)] (superficial reddening of the skin) to the left leg, cooler to touch than the right leg, with [CONDITION(S)]. A nursing note dated August 17, 2021, at 9:31 AM, indicated that the venous doppler was positive for a DVT ([CONDITION(S)] - a blood clot which forms in one or more of the deep veins in your body, usually in your legs). The physician was notified, and new orders were obtained to start [MEDICATION(S)] (anticoagulant medication used to treat and prevent blood clots and to prevent stroke) BID (twice a day). The results of the diagnostic doppler study dated August 17, 2021, revealed the presence of a [CONDITION(S)] involving the left mid to distal femoral vein. A nursing progress note dated August 19, 2021, at 4:53 PM, indicated that the resident had complained of right lower extremity pain, the physician was notified and ordered a venous doppler of the right lower extremity. A nursing progress note dated August 20, 2021, at 7:43 AM, indicated that the resident had been alert and oriented at the beginning of the shift, but at 1:00 AM displayed confusion, speaking of being at the movie theater. The resident's left leg continued to display [CONDITION(S)], and was cool to the touch in comparison with the right leg. A nursing progress note dated August 21, 2021, at 7:32 AM, indicated that the resident's left leg was red, purple and cool to touch. Review of the clinical record revealed a progress note, an administration note, on August 21, 2021, at 4:35 PM, indicating that the resident was complaining of left leg pain and was provided Tylenol. A nursing progress note dated August 21, 2021, at 5:57 PM, indicated that at the family's request, the resident had been sent to the ER for evaluation related to the positive DVT in the left leg. A further review of the progress notes revealed that the physician was not notified of the identified change in Resident CR1 left leg presentation as being red/purple as documented on August 21, 2021, at 7:32 AM, and leg pain on August 21, 2021, at 4:35 PM until the resident was transferred to the hospital per family request on August 21, 2021, at 5:57 PM. A nursing note dated August 22, 2021, at 8:24 PM, indicated that Resident CR1 was admitted to the ICU (Intensive Care Unit). A nursing progress note dated August 23, 2021, at 9:43 PM, indicated that the resident was scheduled for a left leg amputation on August 24, 2021. A review of Hospital documentation, ED provider notes, dated August 21, 2021, indicated that Resident CR1 was seen in the ED (emergency department) for evaluation of [CONDITION(S)], no palpable pulses on the left lower extremity, and left leg pain. The ED documentation further indicated that the physician examination in ER identified that the resident's left lower extremity was cold inferior (below) the knee with color changes. The cardiovascular examination involving pulses of the left femoral (blood vessel in the thigh), left popliteal (hollow area back of the knee), left dorsalis pedis (blood vessel of the lower limb that carries to the surface of the foot), and left posterior tibial (posterior aspect of the lower leg) was zero (0). A further review of Hospital documentation, entitled Operative Report, dated August 24, 2021, indicated that Resident CR1 had received vascular surgery, for a non-salvageable left leg. It further indicated a left above knee amputation was performed. Interview with Employee 1, (RN), on September 8, 2021, at approximately 12:35 PM, revealed that the facility's expectation is continual monitoring and or assessment of Resident CR1's change in condition and known positive doppler (DVT). Employee 1 further confirmed that the facility had no documented evidence to demonstrate that licensed and professional nursing had performed ongoing monitoring and timely assessment of the resident's left lower extremity for approximately three days and had consulted with the physician regarding the continued decline in condition of the resident's lower leg, including discoloration, swelling and leg pain. The resident's family requested that the resident be transferred to the hospital because of the appearance of the resident's toes, pain and known DVT, where the resident was admitted to ICU and required a left above the knee amputation. Interview with the Nursing Home Administrator (NHA) on September 8, 2021, at approximately 1:20 PM confirmed there was no documented evidence in the resident's clinical record, at the time of the survey ending September 8, 2021, that the facility's professional nursing staff had continually monitored and assessed Resident CR1's change in condition, DVT, and signs and symptoms of a continued decline in condition and had timely consulted with the physician to ensure that the resident received timely and necessary medical care, at the level required, based on the resident's current clinical condition. 483.25 Quality of Care Previously cited 1/8/21, 5/14/21, 7/7/21, 8/17/21 28 Pa. Code 211.5 (f)(g)(h) Clinical Records Previously cited 1/8/21, 5/14/21, 7/7/21, 8/17/21 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services Previously cited 1/8/21, 5/14/21, 7/7/21, 8/17/21

Based on a review of clinical records and staff interview it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the physician ordered bowel protocol indicated that both Residents A1 and A2, were prescribed Milk of Magnesia Suspension 1200 MG/15 ML ([MEDICATION(S)], a [MEDICATION(S)]) Give 1 Tbsp by mouth as needed for constipation on second shift of day 3 no BM, [MEDICATION(S)] Suppository 10 MG, Insert 1 suppository rectally as needed for constipation given on 1st shift of day 4 no BM and Fleet Enema Enema 7-19 GM/118 ML ([MEDICATION(S)]), Insert 1 application rectally as needed for constipation give on 1st shift on day 5 of no BM. A review of the clinical record revealed that Resident A1 was admitted to the facility on July, 2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident A1's report of bowel activity from August 10, 2021, to August 15, 2021, revealed that the resident did not have a bowel movement during that time period. Review of Resident A1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident A2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident A2's report of bowel activity from August 10, 2021, to August 13, 2021, revealed that the resident did not have a bowel movement during this time period. Review of Resident A1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the assistant Director of Nursing on August 17, 2021 at p.m. confirmed that there was no documented evidence that physician ordered bowel protocol was followed for the above residents. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(g)(h) Clinical records.

Based on a review of clinical records and staff interview it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the physician ordered bowel protocol indicated that Residents A1, A2, B1, B2, B3, were prescribed [MEDICATION(S)] 10 GM/15 ML, Give 30 ml by mouth, as needed, for constipation; give after 3 day of no BM (bowel movement); [MEDICATION(S)] Powder ([MEDICATION(S)]) Give 17 gram by mouth, as needed, for constipation give after 4 days of no BM - mix with 6 oz of fluid and a Fleet Enema Enema 7-19 GM/118 ML ([MEDICATION(S)]) Insert 1 application rectally as needed for constipation give after 5 days of no BM. A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident A1's report of bowel activity from June 29, 2021 to July 7, 2021, revealed that the resident did not have a bowel movement from June 29, 2021 to July 3, 2021. Review of Resident A1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident A2 was most recently admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident A2 ' s report of bowel activity from July 1, 2021 to July 7, 2021, revealed that the resident did not have a bowel movement from June 2, 2021 to July 6, 2021. Review of Resident A1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the clinical record revealed that Resident B1 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident B1's bowel activity from June 29, 2021 to July 7, 2021 revealed that the resident did not have a bowel movement from June 29, 2021 to July 3, 2021. Review of Resident B1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident B2 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident B2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident B3 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident B3's bowel activity from June 28, 2021 to July 7, 2021 revealed that the resident did not have a bowel movement from June 28, 2021 to July 3, 2021, and no bowel movement from July 3, 2021 to July 7, 2021. Review of Resident B3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that Resident B4 was admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident B4's bowel activity from June 29, 2021 to July 7, 2021 revealed that the resident did not have a bowel movement from July 1, 2021 to July 6, 2021. Review of Resident B4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator on July 7, 2021 at 11:30 a.m. confirmed that there was no documented evidence that physician ordered bowel protocol was followed. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(g)(h) Clinical records. 28 Pa. Code 211.10 (c)(d) Resident care policies

Based on a review of clinical records and staff interview it was determined that the facility failed to ensure that a resident received care in accordance with professional standards of practice by failing to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician ordered bowel protocol dated April 10, 2021, revealed that [MEDICATION(S)] (a [MEDICATION(S)] and [MEDICATION(S)] reducer) 30 ml was to be given by mouth for constipation after three days of no bowel movement. [MEDICATION(S)] powder ([MEDICATION(S)]) 17 grams mixed with six ounces juice or water was to be given by mouth after four days of no bowel movement. Fleet Enema insert one applicator rectally after five days of no bowel movement. Review of Resident 57's report of bowel activity from May 5, 2021, to May 9, 2021 (five days), revealed that the resident did not have a bowel movement. A small hard bowel movement was noted on May 10, 2021. Review of Resident 57's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the director of nursing on May 14, 2021, at 11:45 AM failed to provide documented evidence in the clinical record that the physician ordered bowel protocol was followed as ordered by the physician. 28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(g)(h) Clinical records.

Based on review of clinical records and select facility investigative reports and staff and resident interviews, it was determined that the facility failed to utilize planned assistance devices and safe technique necessary to safely transfer a resident resulting in pain and serious injury, a fractured femur, for one resident out of six sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 had diagnoses of [CONDITION(S)] (bone growth disorder where cartilage doesn't convert to bone causing dwarfism) spinal stenosis (spinal column narrows and compresses spinal cord) and [CONDITION(S)] (unspecified paralysis of legs and lower body.) The resident's Quarterly MDS ( minimum data set -a mandated assessment tool completed at various intervals to assess resident needs and plan care) dated October 12, 2020, revealed that the resident had a BIMS (brief interview for mental status-cognitive assessment portion of the MDS) of 15 ( intact cognition) The resident required the assistance of two staff members for mobility and turning and repositioning in bed and two persons for transfer. According to review of the resident's comprehensive plan of care, initiated on March 17, 2020, staff was to transfer the resident, utilizing the mechanical lift with a blue (small sized) sling. A review of the resident's clinical record revealed an interdisciplinary progress note dated October 31, 2020, at 11:42 AM. The entry indicated that the resident was complaining of pain to the back, neck and left leg. The resident's attending physician was contacted and an X-RAY was ordered. According to review of a facility investigation into an incident, on October 31, 2020, the resident complained to the nursing supervisor that two staff members had transferred her without using the mechanical lift. When questioned about technique, the resident stated that both staff members stood to the right of the resident; one took her arm and the other her legs and transferred her into the wheelchair. A review of the resident's statement revealed that the resident said she felt a pop in her neck and upper back. She complained her arm, armpits and left knee were also hurting. A review of the x-ray results revealed that the resident had a moderate displaced (pulled out of normal alignment) angulated (position of the bone is tilted) fracture of the left femur (thigh bone) According to a statement completed by the staff member assigned to the resident (Employee 1, agency nurse aide) this was her first time caring for Resident 1. She stated she asked Employee 2 (agency nurse aide) to assist her with the resident's transfer. Employee 1 alleged that the transfer status of the resident, was not included on her assignment/care sheet. A review of Employee 2's statement, revealed that Employee 1 had asked her to assist with the Resident 1's transfer. She stated she had only worked at the facility for a few shifts and was not familiar with the resident. She alleged that she had no access to the computer kiosk to access the resident's Kardex (care cards used by the staff to provide resident care according to assessed needs) to view the resident's transfer status. There was no evidence that the facility had ascertained if Employees 1 and 2 had attempted to assess the resident's care Kardex through the computer kiosk or had asked other staff for assistance in doing so. There was no indication that the facility had determined if supervisory nursing staff were aware of any issues accessing resident Kardex information (including logging into the facility computer kiosk) to accurately provide resident care. A review of Employee 3's (Agency RN) statement revealed she was the registered nurse on duty at the time of the incident. Employee 3 stated that she had not been provided an orientation to the facility's protocols and/or policies. She stated that she did not know the transfer status of residents, but had the capability to access the Kardex via the kiosk. A statement from Employee 6, RN, alleged that she was aware that some of the nursing assistants did not have the capability to access the facility computer kiosk system to obtain resident care details. According to review of Employee 4, a nurse aide on a 30 day contract from a staffing agency, she did not receive any orientation from the facility. She estimated that she began working at the facility on October 15, 2020. In her statement she said the agency staff relied on other staff members to document the care needs of the residents for them on a piece of paper. She stated that Employee 2 had only been at the facility for her third shift and had no way to get into the facility computer Kiosk system. A review of the statement completed by Employee 8, LPN, revealed that she had noticed that most of the agency staff did not have access to the computer kiosk, to directly obtain resident care information. She stated that this situation had worsened when the facility's administrative personnel had been quarantining at home due to exposure to COVID 19. Interview with Employee 5, nurse aide, who was present and assigned to Resident 1's unit on the day of the survey was completed on November 15, 2020 at 2:45 p.m. Employee 5 stated she had been the one who was responsible for documenting resident care needs on Employee 1's assignment sheet. She stated that this duty usually fell to the nurses, but sometimes the nursing assistants completed it instead, due to their knowledge of resident care needs. She alleged she had clearly written on the assignment sheet that Resident 1 required the assistance of two people and the Hoyer lift for transfer. She said she was familiar with some agency staff members alleging they could not access the computer kiosk. Employee 7, nurse aide, was interviewed on November 15, 2020 at 10:45 a.m. Employee 7 stated that she was aware that some of the agency staff members were alleging they were not able to get into the computer kiosk system. She stated that staff are given a sheet of paper with the resident names and room numbers on their assignment so they could document pertinent information to use while documenting resident care in the computer kiosk. She alleged, in some instances the transfer status or care needs are written in by other staff members. Interview with Employee 9, nurse aide, was completed on November 15, 2020. She stated that she was also aware that some agency staff members had been alleging they were unable to access the computer kiosk system. She also confirmed that transfer status and care needs were often communicated by documentation on assignment sheets or verbal communication. Resident 1 was interviewed on November 15, 2020 at 11:49 a.m., regarding the incident. She stated that Employees 1 and 2 entered her room to perform the transfer. She stated that Employee 2 was not assigned to her, but Employee 1 had asked Employee 2 to assist her. Resident 1 stated that Employee 1 had been rude to her the previous shift and had an attitude. She stated that the two caregivers came into her room and told her they were going to transfer her using the old- fashioned way. She stated at the time, it was not clear what that statement implied. Resident 1 explained that one staff member then took her arm and the other took her leg. She believed they also used a sheet during the transfer, but was not 100 % certain about the use of the sheet. She stated that she felt a pop and initially thought it was her neck, but then began to experience pain in her arm and leg. When interviewed on November 15, 2020, at 2:30 p.m., the interim Director of Nursing Services confirmed that issues had been identified after the incident, that select agency staff members had been experiencing difficulty accessing the facility computer kiosk, for various reasons. It was confirmed that these caregivers were providing care without accessing the facility computer kiosk, but instead were relying on the guidance/knowledge of peers or other staff members, either verbally or written on assignment sheets. Select professional nursing staff, both licensed practical and registered nurses directly supervising the nurese aides were aware that some agency staff members did not have access to resident care Kardex's and resident care needs were being communicated via other means, but there was no indication that this practice was communicated to the facility's administration. The facility's administration failed to ensure agency staff members were appropriately oriented to the facility and its practices and protocols and provided with a consistent means of communication of resident care plans and needs. Employees 1 and 2 failed to utilize safe transfer technique and the planned assistance device (mechanical lift) resulting in Resident 1's fractured femur. 483.25 (d)(1)(2) Free of Accident Hazards/Supervisor/devices Previosuly cited 1/15/20, 4/16/19, 6/14/19, 11/19/18 28 Pa. Code 201.18(e)(1) Management Previously cited 10/30/20, 1/15/20, 4/16/19, 2/9/19, 11/19 28 Pa. Code 201.18(e)(3) Management Previosuly cited 4/16/19 28 Pa. Code 201.20(b) Staff Development 28 Pa. Code 211.11(d) Resident care plan Previously cited 1/15/20, 2/9/19 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services. Previously cited 10/30/20, 10/2/20, 6/16/20, 1/15/20, 3/5/20, 8/6/19, 4/16/19, 6/14/19 28 Pa. Code 211.12 (d)(1) Nursing Services. Previsously cited 10/30/20, 10/2/20, 1/15/20, 3/5/20, 8/6/19, 4/16/19, 6/14/19

Based on a review of clinical records, select incident and accident and information submitted by the facility and staff interviews, it was determined that the facility failed to provide necessary supervision with activities of daily living, consistently implement identified and individualized safety measures and maintain an environment free of potential accident hazards to prevent falls and accidents for two residents out of 25 sampled residents (Residents [AGE] and 28). Findings include: A review of the clinical record revealed that Resident [AGE] was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 14, 2019, revealed that the resident was severely cognitively impaired (no BIMS (brief interview for mental status) score), required minimal assistance of one person for bed mobility, transfers between surfaces, toileting, dressing, hygiene and required supervision of one staff member for ambulation on the unit. Review of the resident's care plan, initiated November 6, 2018, revealed that the resident was at risk for falls due to impaired balance/poor coordination and at risk for falls due to impaired balance/poor coordination. The identified goal was to minimize the resident's risk for falls and associated injury. Approaches planned were to encourage the resident to transfer and change positions slowly; to ensure that her shoe laces are tied, have commonly used items within reach, encourage rest periods between activities. A review of a facility incident report investigation dated July 6, 2019, at 2:54 PM revealed that another resident yelled that Resident [AGE] just fell in the doorway of that resident's room. The report noted that Resident [AGE] was found lying on her right side, on another resident unit, in the doorway of Room C6. It was noted that Resident [AGE]'s shoe lace was observed to be untied and the other resident reported, that caused Resident [AGE] to fall. The investigation indicated that Resident [AGE] had been in her bed taking a nap from 1:30 PM to 2:50 PM, got up, ambulated to room C6 and tripped on her shoelace. The planned intervention implemented in response to this fall, to prevent future falls, was to speak to the resident's sister to bring in shoes with Velcro or zipper closures for Resident [AGE]. A review of a facility incident report investigation dated July 19, 2019, at 9:15 AM revealed that Resident [AGE] was reaching to the ground outside resident room C1 and lost her balance. The resident fell and landed head first on the left side of her head sustaining a 0.1 cm x 3 cm laceration above her left eye with [MEDICAL CONDITION] and bruising. The physician was notified and the resident was treated with ice and neurochecks. The facility's investigation noted that Resident [AGE] was ambulating the facility hallways after breakfast, as per her norm when the fall occurred. There were no additional interventions initiated at that time to deter future falls. A review of a facility incident report investigation dated August 17, 2019, at 2:38 PM revealed that Resident [AGE] was found on her back, on the floor near nursing station A. Resident [AGE] was noted to have a large hematoma ( a large fluid, blood filled area, usually caused by [MEDICATION NAME] trauma) above her right eye. The resident was wearing non-skid socks at the time of the fall. Nursing assessed the resident, the physician was called and neuro checks were implemented. The resident's care plan for falls was updated at that time to include interventions to, encourage more frequent snack times to help the resident to remain energized and to encourage more rest periods between activities to prevent falling. A review of a facility incident report investigation dated October 2, 2019, at 9:30 AM revealed that nursing staff heard Resident [AGE] yell. Staff found the resident on her right side on the floor at the end of the C hallway, past the shower room. No injuries were noted with this fall. The resident was wearing non-skid socks at the time of the fall. The investigation indicated that Resident [AGE] had received AM care at 7:30 AM; ate breakfast at 8:10 AM and then ambulated in the hallways of the facility and fell . The planned intervention to prevent future falls was to offer Resident [AGE] a nap after breakfast and lunch. A review of a facility incident report investigation dated October 12, 2019, at 1:30 AM revealed that Resident [AGE] was found sitting on the floor next to her bed. No injuries were noted. The facility's investigation noted that Resident [AGE] was seen by staff ambulating in the hallways at 1:20 AM just prior to her fall. The planned intervention was to offer toileting around 1 AM. The facility updated the resident's care plan on October 12, 2019, with the approach that the resident wear non-skid socks when not wearing shoes. The resident had incurred two falls while wearing the non-skid socks (August 17, 2019 and October 2, 2019), but the facility failed to re-evaluate the effectiveness of this intervention in preventing falls. The facility had assessed the resident to require supervision with ambulation on the unit, but this approach was not included on the resident's plan of care for safety/fall prevention. A review of a facility incident report investigation dated November 14, 2019, at 3:48 PM revealed that a family member of Resident [AGE]'s roommate's witnessed Resident [AGE] get out of bed, attempt to get a drink of water and fall to the floor. No injuries were noted at that time. The facility investigation concluded that Resident [AGE]'s gait is unsteady at times. The resident's care plan was revised on November 14, 2019, adding the approach to provide the resident assistance to transfer and ambulate, as needed, and to reinforce need to call for assistance. A review of a facility incident report investigation and information dated January 14, 2020, at 7:45 AM revealed that Resident [AGE] is a self ambulator with decreased safety awareness. Current BIM's score shows cognitive impairment. Resident [AGE] was self ambulating throughout unit as per normal routine. CNA (nurse aide) in hallway A was delivering breakfast tray when she caught site of the resident lifting her arm in the air and falling to the floor striking her head. Resident was immediately assessed by RN. At time of assessment unable to determine if resident had injury aside from hematoma on of back of head. Resident was transferred to chair and returned to bed for full assessment. Upon assessment resident noted to have increased pain in Lt. hip area with noted facial grimacing and attempting to grab at Lt. side of leg. It was noted that resident had on anti-skid socks, floor was clean of debris, no tripping hazards noted on floor. However, upon further assessment it was found that resident's cuff of pants extended beyond heel. The incident report noted that a licensed nurse assessed the resident revealing that the resident had increased pain in the left hip area with noted facial grimacing and attempting to grab at her left leg. The physician was contacted and an x-ray was ordered. A review of an x-ray report of the resident's hip dated January 14, 2020, revealed an acute fracture involving the left femoral neck ([MEDICAL CONDITION]) with displacement (the bone snaps into two or more parts and moves so that the two ends are not lined up straight). The resident was transported to the hospital for evaluation and treatment of [REDACTED]. Incident Report indicated that Resident [AGE] did have non-skid socks on at the time of the fall, but the cuff on the resident's pants extended beyond her heel. The resident's pants were too long, leading to unsteadiness and subsequent fall. The report indicated that Resident [AGE] had not yet received AM care at the time of the fall. She was awake and began to wander about the building. The facility's report noted that Resident [AGE] self ambulates and walks about the building every day, independently. There was no evidence at the time of the survey that Resident [AGE] was provided adequate staff supervision with ambulation and dressing and the necessary safety measures to prevent repeated falls and subsequent serious injury. The facility was aware of the resident's risk factors for falls, including lack of safety awareness, wandering habits and unsteady gait and had identified the resident's need for supervision when ambulating on the unit. However, the facility failed to demonstrate that the resident's ambulation activity and attire (shoes, clothing) did not create accident hazards and increase the resident's risk for falls and injury. An interview with Director of Nursing (DON) on January 15, 2020, at approximately 11:30 AM confirmed that the staff failed to provide needed assistance to the resident to prevent falls. A review of the clinical record revealed that Resident 28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 8, 2019, revealed that the resident required extensive assistance with one person for bed mobility, transfers between surfaces, toileting and hygiene. Review of the resident's care plan revealed that the resident was at risk for falls due to weakness. An intervention initiated on August 22, 2019, directed staff that the resident was not to be unattended in the restroom. The intervention was cancelled on October 22, 2019. Review of a resident incident report dated October 20, 2019, at 1:48 AM revealed that the resident was found lying on the floor face down on the bathroom floor after attempting to self-transfer from the toilet to her chair. Employee 4 (nurse aide) and Employee 5 had helped the resident to the bathroom,but then the employees left the resident alone in the bathroom. A review of a statement from Employee 4 dated October 20, 2019, indicated that Employee 4 entered the resident's room at 1:10 AM with Employee 5. Employee 4 and Employee 5 assisted the resident from the bed to the wheelchair and then to the toilet. Employee 4 exited the resident's room. At 1:20 AM the nurse came to get the employee to help get the resident off the floor. A review of a statement from Employee 5 dated October 20, 2019, indicated that Employee 5 entered the resident's room at 1:10 AM with Employee 4. Employee 4 and Employee 5 assisted the resident from the bed to the wheelchair and then to the toilet. Employee 5 exited the resident's room with Employee 4. At 1:20 AM the nurse came to get the employee to help get the resident off the floor. The incident report dated October 21, 2019 at 5:13 PM revealed that the resident had a bruise to her chin as a result of the fall that occurred on October 20, 2019. An interview with Director of Nursing (DON) on January 14, 2019, at approximately 11:30 AM confirmed that the staff failed to provide sufficient assistance and supervision with transfers and toileting, as planned for the resident, to prevent a fall. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a) Nursing services Previously cited 11/19/18, 2/9/19, 4/16/19, 6/14/19, 8/6/19 28 Pa. Code 211.12(c) Nursing services Previously cited 11/19/18, 2/9/19, 4/16/19, 6/14/19, 8/6/19 28 Pa. Code 211.12(d)(1) Nursing services Previously cited 11/19/18, 2/9/19, 4/16/19, 6/14/19, 8/6/19 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 11/19/18, 2/9/19, 6/14/19, 8/6/19 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/19/18, 2/9/19, 4/16/19, 6/14/19, 8/6/19

Based on observations, clinical record review and staff and resident interviews, it was determined that the facility failed to provide care consistent with professional standards of practice to accurately assess and identify skin impairments and implement measures to prevent the development of pressure sores, promote healing of existing pressure sores and prevent new pressure sores from developing for two residents (Resident 56 and 54) out of five sampled with pressure sores. Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record of Resident 56 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 56's admission skin evaluation dated November 27, 2019, revealed that the resident had two areas of impaired skin integrity at the time of admission to the facility. An area was noted on the resident's chest (related to a pacemaker) left chest wall and right flank area 3 cm x 3 cm. No additional details were documented related to either area of skin impairment. An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 2, 2019, indicated the resident had a BIMS score of 15 (brief interview for mental status, a tool to assess cognitive function ; a score of 13-15 indicates cognition is intact), was dependent on staff for activities of daily living and required extensive assisstance with bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS indicated that the resident had an indwelling urinary foley catheter (a thin, sterile tube inserted into your bladder to drain urine) and was frequently incontinent of bowel. The resident had no pressure sores at the time of admission according to the MDS Assessment. During an interview conducted on January 12, 2020, at 9:22 AM, the resident stated that she has skin issues and motioned to her backside. The resident stated that she believed they (staff) put some kind of cream on her backside. The resident stated that she didn't have any skin issues prior to coming to the facility. A review of the clinical record revealed a nursing progress note dated December 25, 2019, at 2:46 PM noting the resident has a reddened area on left and right buttock, no complaints of pain or discomfort noted at this time. MD (medical doctor) and RP (responsible party) aware. At the time of the survey ending January 15, 2020, the facility failed to provide documented evidence of the preventative measures in place for the resident to prevent skin breakdown at the time of the reddened areas were identified on the resident's buttocks on December 25, 2019. Nursing noted on December 26, 2019, at 5:59 PM Resident has MASD (inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus, or saliva) with one superficial open area to RT. (right) buttock. Areas is Blanchable (Skin blanches with pressure. Color returns immediately with release). Open area on Rt. buttock 2 centimeters (cm) x .5 cm. Pink superficial area measures 25 cm (centimeter). Wound cleansed with NSS (normal saline solution), pat dry and Z-guard (skin protectant) applied. Denies pain, no c/o's. No odor or drainage noted. MD and RP aware. Will continue to monitor. The facility did not revise the resident's care plan on December 25, 2019, upon identification of the redness on the buttocks, which subsequently developed into open areas the next day, on December 26, 2019. A review of a form titled: SKIN ALTERATION RECORD DO NOT USE FOR PRESSURE ULCERS provided by the facility dated December 25, 2019, December 30, 2019 and January 8, 2020, revealed that the alteration in the skin was identified as other and written in was Abrasion (open wound that's caused by the skin rubbing against a rough surface. It may be called a scrape or a graze) MASD. The form was initially dated December 25, 2019, and described the alteration as dark pink/red tissue, without drainage, and skin surrounding alteration was reddened. The form did not provide any measurements. Documentation on the form dated December 30, 2019, the skin alteration was the documented as same as December 25, 2019. Documentation on the form dated January 8, 2020, noted that the measurements of the skin impairment were 3 cm x 1 cm x 0 cm. without documentation of the location of the skin impairment, and continued to describe the alteration as dark pink/red tissue, without drainage, and surrounding skin described as reddened. The form reflected that on all three dates noted above the resident had no pain at the site. A nursing progress note dated January 2, 2020 at 7:48 PM noted CNA's providing care on resident reported superficial skin alterations on inner thigh that appear purple in color. Two areas noted on right inner thigh; the one on the right most inner thigh measures 3 cm x 1 cm and the other one measures 10 cm x 1 cm. On the left inner thigh it measures 12 cm x 1 cm. Nursing noted that the physician was made aware and a new order was received to cleanse the area (inner thigh) with normal saline solution and apply a light coat of Z guard (skin protectant) to areas two times a day in the morning and in the evening. The resident developed additional pressure sores, identified on January 2, 2020, but the facility was unable to provide evidence of the measures that had been implemented to prevent the existing pressure sore on the buttocks from worsening and the development of additional pressure areas on the resident's thighs. A review of a form titled: SKIN ALTERATION RECORD DO NOT USE FOR PRESSURE ULCERS provided by the facility dated January 2, 2020, revealed that the alteration in the skin was other and written in was excoriation. The form was dated January 2, 2020, and January 8, 2020. On January 2, 2020, the measurements were noted as 12 cm x 1 cm; the depth was left blank. The description of the alteration was intact skin, dark pink/red tissue. No drainage was noted and skin surrounding alteration was described as normal appearance. The documentation of the resident's thigh area dated January 8, 2020, reflected the identical information as the documentation of Janaury 2, 2020. A review of Resident 56's current plan of care after finding to new skin alteration on January 2, 2020, only identified the treatment prescribed with no identified approaches to deter further skin breakdown noted. physician progress notes [REDACTED]. A nursing progress note dated January 8, 2020 at 2:30 PM, noted that the resident has an open area to posterior Rt. thigh. 3 cm x 1 cm. Wound bed beefy red and surroundings tissue is normal. Scant amt of serous clear drainage. Denies pain, no c/o's. Skin sheet complete. Collagen and comfort foam in place. Will continue to monitor. There was no documented evidence of the interventions being implemented to prevent the development of additional skin breakdown or worsening of the identified pressure areas, other than the prescribed treatments. A review of a form titled: SKIN ALTERATION RECORD DO NOT USE FOR PRESSURE ULCERS provided by the facility dated January 8, 2020, indicated that the alteration in the skin was other and written in was abrasion. On January 8, 2020, the measurements were noted as 3 cm x 1 cm x 0 cm. The 3 SKIN ALTERATION RECORDS provided dated January 15, 2020, at 8:30 AM indicated that there were three areas being monitored: abrasion MASD on buttocks; excoriation left leg and abrasion left posterior thigh. However, the descriptions of the resident's skin damage noted on the skin alteration records, were not consistent with the descriptions noted in nursing progress notes, which described the areas with depth, significant discoloration (beefy redness, purple) and drainage. A review of the Resident 56's January Treatment Administration Record revealed a physician order [REDACTED]. buttock wound with NSS, par dry, apply Z-guard BID everyday and evening shift for wound care and timed for 7:15 A & 3:15 P and was reddened/purplish area inner thighs with NSS apply Z guard lightly over areas bid inner thighs day and evening shift everyday and evening shift for skin alteration times for 7:15 A & 3:15 P. At the time of the survey ending January 15, 2020, the facility did not identify Resident 56 has having any pressure sores. An observation of the resident's wounds was conducted on January 15, 2020, at approximately 9:30 AM accompanied by the DON and Employee 10, RN. Observations, which were confirmed by the Director of Nursing at the time, revealed that the wounds were not consistent with the description in nursing progress notes or the skin alteration sheets. Observations revealed that the pressure areas were deep tissue injuries (a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise) and were unstageable due to slough (dead white blood cells, [MEDICATION NAME], cellular debris and liquefied devitalized tissue) present in the wound beds. The Director of Nursing and Employee 10, RN Unit Manager, conducted skin assessments at this time in order to accurately document the measurements and description of the pressure areas observed. Review of PRESSURE ULCER HEALING CHART (used by the facility to monitor trends in PUSH {tool used to measure the status of pressure wounds over time} score over time provided by the facility after the pressure areas were measured by the DON and Employee 10 on January 15, 2020, revealed that the resident had nine (9) individual pressure areas. The following areas, description, and measurements were obtained on January 15, 2020 at 9:30 AM were as follows: open area noted on sacrum 3.5 cm x 2 cm with slough noted in wound bed; left posterior lower thigh open area noted 1.3 cm x 1.4 cm; left upper posterior thigh open area 4.5 cm x 0.5 cm; right thigh upper front pressure like area 3 cm x 0.5 cm; left mid buttock DTI 4 cm x 2.5 cm; lateral sacrum DTI 4 cm x 2.5 cm; MASD right buttock #1 1cm x 0.5 cm x 0.1 cm; MASD Right buttock #2- 2.5 cm x 1 cm 0.1 cm; MASD right buttock #3 1 cm 0.5 cm 0.1 cm. Interview with Employee 8, nurse aide, on January 15, 2020 at 10:00 AM revealed that the facility had been aware of the appearance of Resident 56's pressure sores, but did not accurately document their appearance in the clinical record and skin alteration records and also did not identify them as pressure sores, but other forms of skin damage such as abrasions. Interview with Employee 9, a Licensed Practical Nurse, at 12:00 PM on January 15, 2020, revealed that Resident 56's wounds were similar in appearance today (Janaury 15, 2020) as when she had observed them on January 9, 2020. Employee 9 stated she was not aware the wounds had worsened because Resident 56's wounds looked as the same today as the first time she saw them on January 9, 2020. Interview with the Director of Nursing on January 15, 2020 at approximately 2:00 PM confirmed that the measurements and description of the resident's wounds observed that morning were not consistent with the facility's skin alteration records. The DON verified that the facility was unable to demonstrate the implementation of necessary measures to prevent the development and worsening of multiple pressure areas. A review of the clinical record revealed that Resident 54 was readmitted to the facility on [DATE], with diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and adult failure to thrive. A review of the resident's Quarterly MDS assessment dated [DATE], revealed that the resident was moderately cognitively impaired, required two person assistance for bed mobility (how you move from the lying position and turning side to side) and was at risk for developing pressure sores. A review of a facility Admission/Readmission screen dated November 16, 2019, indicated that the resident has a reddened non-blanchable (skin remains red at all times when pushed on) area on the sacrum (area on lower back situated between the two hipbones of the pelvis) measuring 5 cm x 6 cm. The resident's skin remained intact with no depth to the area. A review of the resident's care plan dated November 16, 2019, revealed that the resident was at risk for altered skin integrity related to impaired immobility and incontinence with planned interventions initiated on November 16, 2019, for the application of a barrier cream to the buttocks and repositioning the resident. Nursing progress notes dated November 20, 2019, at 7:30 AM revealed that the resident's pressure sore had worsened. The resident now had a left buttock pressure area, which measured 2 cm x 0.5 cm x 0.1 cm and a right buttock pressure area, which measured 0.5 cm x 0.5 cm x 0.1 cm. The pressure areas were noted as Stage III (involves the full thickness of the skin and may extend into the subcutaneous tissue layer). An observation on January 12, 2020, at 10:00 AM revealed that the resident was lying on his back in bed (the site of the resident's pressure sores). An observation on January 12, 2020, at 12:00 PM revealed that the resident remained in bed and lying on his back. An observation of Resident 54 on January 15, 2020, at 9:53 AM revealed that the resident lying on his back in bed. Employee 14, LPN, confirmed that the resident was lying on his back when observed on January 15, 2020, at 9:53 AM. Employee 14 rolled the resident onto his side and Employee 14 measured the resident's pressure areas. The resident now had three pressure areas on his buttock. The left buttock pressure sore measured 0.5 cm x 0.5 cm x 0.1 cm. The right buttock pressure sore measured 1 cm x 0.5 cm x 0.1 cm. An area on the coccyx region (base of the spinal column) measured 1 cm x 2 cm and slough was covering the wound. The facility identified these these areas as Stage III pressure sores. The resident was readmitted to the facility on [DATE], with a reddened area on the sacrum and no open areas. Four days later on November 20, 2019, the facility identified that the resident had two Stage III pressure sores on the buttocks. At the time of the survey ending January 15, 2020, the resident had three Stage III pressure areas on the buttocks and coccyx area was observed repeatedly positioned on his backside, the site of the skin breakdown. An interview with the DON on January 15, 2020, revealed that the facility was unable to demonstrate the consistent implementation of measures to prevent worsening and promote healing of pressure sores. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services previously cited: 11/19/18, 2/9/19, 6/14/19, 4/16/19, 8/6/19 28 Pa. Code 211.11(d) Resident care plan previously cited: 11/19/18, 2/9/19

Based on observations, review of clinical records and facility investigations into incidents and interviews with residents and staff, it was determined that the facility failed to maintain the environment free of accident hazards, provide timely supervision and appropriate safety interventions, based on each resident's clinical condition and individual preferences, to prevent accidents. The facility further failed to fully evaluate the circumstances surrounding resident incidents, to effectively plan preventative measures necessary to promote resident safety as evidenced by two (Residents 8 and 13 ) out of 11 residents sampled. Findings include: Observations conducted during the day of the survey, (MONTH) 16, 2019, revealed that Resident 8 was seated in the hallway in front of his room, positioned next to the handrails. He was seated in a reclined Broda chair with a cushion to the seat. The resident was observed to continually slide down in the chair or bend at the waist as if to stand up, while verbalizing he was sliding/falling. Staff members were observed to reposition or seat the resident down back down in the chair throughout the day, with the resident continuing this behavior repeatedly. A review of the resident's comprehensive plan of care dated/last revised by the facility (MONTH) 8, (YEAR), revealed that he was to use a Broda chair with bilateral leg rests. During observations conducted on (MONTH) 16, 2019, at 12:30 p.m., the resident was observed lying on his back on the floor, in front of the Broda chair in the hallway. Staff members remarked to the nurse assessing the resident, that he had been displaying these behaviors for awhile. Subsequent to this incident, the resident was observed in the hallway in the reclined Broda chair continuing similar behavior throughout the afternoon of (MONTH) 16, 2019. A review of documentation in the resident's clinical record from (MONTH) 2019 through (MONTH) 16, 2019, revealed that staff repeatedly documented that the resident was sliding himself down in his chair. It was documented that this was determined to be intentional behavior. A review of a Therapy Discharge Communication dated (MONTH) 26, (YEAR), revealed that the resident required a Broda chair for seating, but did not specify the position, of a reclined chair. The resident's continued to display behaviors of sliding, but there was no indication the resident's seating position had been assessed to ascertain its continued appropriateness and safety. Resident 6 approached the surveyor at 2:40 PM on (MONTH) 16, 2019, to complain that she had sustained a fall in the shower due to what she felt was the unsafe use of a shower chair, which did not safely support the resident. The resident alleged that the shower chair was too high and when she went to step down the floor was slippery and she fell . Resident 6 stated that administration was aware of her concerns regarding the height of the chair. A review of the resident most recent MDS assessment dated (MONTH) 4, 2019, revealed that the resident's cognition was intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognition, a score of 13-15 indicates intact cognition). A review of a facility investigation into Resident 6's fall revealed that the staff member providing the resident's shower on (MONTH) 9, 2019, stated that the floor had appeared oily and she used a towel to dry the floor, but the condition did not improve. The resident reached for her cane and the staff member reached for the resident's wheelchair and the resident slipped. Following the incident the facility determined that the resident's slippers were worn on the bottom. There was no indication that the facility had evaluated the size/height of the shower chair during its investigation. The facility failed to demonstrate that all hazards were eliminated to assure the resident's safety and prevent falls. Observations completed on the D hall at 12:05 p.m. on (MONTH) 16, 2019, revealed that a blister packet of [MEDICATION NAME] 400 mg (used to treat certain types of serious (possibly fatal) irregular heartbeat (such as persistent ventricular fibrillation/[MEDICAL CONDITION]. It is used to restore normal heart rhythm and maintain a regular, steady heartbeat) was on top of the medication cart along with a hemostat (a surgical tool used in many surgical procedures to control bleeding). There was no staff supervision observed in the area at this time and wandering residents were observed in the area of these accident hazards 28 Pa. Code 211.12(a) Nursing services Previously cited. 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18 28 Pa. Code 211.12(c) Nursing services Previously cited. 2/9/19,11/19/19,7/9/18,4/17/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited. 2/9/19,11/19/18,7/9/18,4/17/18. 28 Pa. Code: 211.12(d)(3)(5) Nursing Services Previously cited: 2/9/19, 7/9/19/, 4/17/18.

Based on review of clinical records, observations and staff interviews it was revealed that the facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) by one of one resident reviewed (Resident 134). Findings include: A review of the clinical record revealed that Resident 134 was admitted to the facility on (MONTH) 13, 2019, with [DIAGNOSES REDACTED]. At the time of admission, the facility assessed the resident to have two pressure ulcers (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction). One pressure area was located on her sacrum (area on bottom of the spine and lies above the tailbone) measuring 1cm (centimeter) x 1cm and a second pressure area was located on the resident's left buttock measuring 0.5cm x 1 cm. The facility identified that the resident was at high risk for development of skin breakdown. A review of an Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 20, 2019, revealed that Resident 134 was at risk for developing pressure sores and required maximum assistance of 2 staff for activities of daily living, including bed mobility, transfers and toileting. A review of clinical documentation dated (MONTH) 25, 2019, at 6:02 PM revealed wound rounds were completed on (MONTH) 24, 2019. The resident was noted to have the two open areas as seen on admission. Further review of documentation indicated that the open areas measured 2.1 cm x 1 cm x 0. 2 cm on the sacrum and 1 cm x 0.7 cm x 0.1 cm on the left buttock. A review of the resident's treatment record for (MONTH) 2019, revealed that staff were to complete a body audit weekly for observation of the resident's skin. In addition, to skin checks the resident was to receive a treatment to the open areas, which included cleansing with normal saline solution and application of protective ointment until healed. On (MONTH) 24, 2019, a new physician order [REDACTED].>Further review of the (MONTH) 2019 treatment record revealed no documentation was entered that the treatment was done as ordered by the physician on (MONTH) 27, 2019. A review of facility documentation dated (MONTH) 1, 2019, at 4:43 PM. revealed the resident was seen on wound rounds. During assessment of the resident it was identified that the resident's two pressures sores had become one large butterfly shaped pressure area, purple in color measuring 7.8 cm x 9.8 cm with an open area in the middle measuring 4.5 cm x 2.6 cm x 0.2 cm with a moderate amount of bloody drainage. A review on Resident 134's current care plan in place at that time revealed interventions, which included that staff were to encourage the resident to reposition as needed and observe skin condition with ADL (activities of daily living) and report abnormalities. The facility was unable to demonstrate that the resident had been turned and repositioned as needed to prevent worsening of the resident's pressure sores. There was no documented evidence that nursing staff had identified decline in the condition and/or changes in the appearance of the resident's pressures sores from (MONTH) 25, 2019, until on (MONTH) 1, 2019, when the wound was found to have worsened. Review of nursing documentation dated (MONTH) 3, 2019, at 12:51 PM revealed that the resident had a decline in health and the physician wanted the resident transferred to the hospital. Further review of documentation on this date revealed that the resident was admitted to the hospital due to infection, failure to thrive and a pressure ulcer. Review of nursing documentation on (MONTH) 9, 2019, at 4:32 PM indicated the resident was readmitted to the facility and the physician would like the resident to be turned every two hours due to the resident's pressure ulcer. Observation on (MONTH) 14, 2019, at 9:52 AM revealed the resident was lying in her bed, on her back. The resident's Broda chair (a chair to correct positioning to provide improved independence and quality of life) was against the wall with no pressure relieving device on the chair. An observation on (MONTH) 14, 2019, at approximately 1:00 PM revealed the resident remained in bed positioned on her back as observed at 9:52 AM. No pressure relieving device was seen in the room for her Broda chair. An interview with Employee 2, Registered Nurse Quality Consultant, on (MONTH) 14, 2019, at approximately 1:30 PM revealed that the facility does not document repositioning of residents. Therefore the facility was unable to demonstrate that the resident was turned and repositioned at the frequency required to prevent worsening of the pressure sore and that the resident was turned and repositioned every two hours as directed by the physician on (MONTH) 9, 2019. Employee 2 stated that you can see the resident is being moved when she is toileted. An observation on (MONTH) 14, 2019, at 2:05 PM revealed that the resident was lying on her right side in bed. An interview with Employee 1 LPN (license practical nurse) confirmed there was no pressure relieving device in the room for her the resident's Broda chair. Employee 1 stated that he did not know if she gets it anymore. Employ 1 further stated that the resident only gets out of bed for meals that she needs assistance. The facility was unable to demonstrate that they had timely identified declines in skin integrity and had implemented prompt and adequate measures to prevent the worsening of a pressure sore on the resident's sacrum and left buttock for a resident identified as a high risk for pressure sore development upon admission to the facility on (MONTH) 13, 2019. 28 Pa. Code 211.5(f)(g)(h) Clinical records. Previously cited 2/19/19, 11/19/18, 10/16/18, 4/17/18, 3/9/18 28 Pa. Code 211.12(a) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18 28 Pa. Code 211.12(c) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/19,7/9/18,4/17/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/18,7/9/18,4/17/18. 28 Pa. Code: 211.12(d)(3)(5) Nursing Services Previously cited: 4/16/19, 2/9/19, 7/9/19/, 4/17/18.

Based on review of clinical records, observations and staff interviews it was revealed that the facility failed to timely identify and address declines in skin integrity to prevent the development and/or worsening of a pressure sore (injury to skin and underlying tissue resulting from prolonged pressure or friction on the skin) by one of one resident reviewed (Resident 134). Findings include: A review of the clinical record revealed that Resident 134 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. At the time of admission, the facility assessed the resident to have two pressure ulcers (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction). One pressure area was located on her sacrum (area on bottom of the spine and lies above the tailbone) measuring 1cm (centimeter) x 1cm and a second pressure area was located on the resident's left buttock measuring 0.5cm x 1 cm. The facility identified that the resident was at high risk for development of skin breakdown. A review of an Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 20, 2019, revealed that Resident 134 was at risk for developing pressure sores and required maximum assistance of 2 staff for activities of daily living, including bed mobility, transfers and toileting. A review of clinical documentation dated April 25, 2019, at 6:02 PM revealed wound rounds were completed on April 24, 2019. The resident was noted to have the two open areas as seen on admission. Further review of documentation indicated that the open areas measured 2.1 cm x 1 cm x 0. 2 cm on the sacrum and 1 cm x 0.7 cm x 0.1 cm on the left buttock. A review of the resident's treatment record for April 2019, revealed that staff were to complete a body audit weekly for observation of the resident's skin. In addition, to skin checks the resident was to receive a treatment to the open areas, which included cleansing with normal saline solution and application of protective ointment until healed. On April 24, 2019, a new physician order [REDACTED].>Further review of the April 2019 treatment record revealed no documentation was entered that the treatment was done as ordered by the physician on April 27, 2019. A review of facility documentation dated May 1, 2019, at 4:43 PM. revealed the resident was seen on wound rounds. During assessment of the resident it was identified that the resident's two pressures sores had become one large butterfly shaped pressure area, purple in color measuring 7.8 cm x 9.8 cm with an open area in the middle measuring 4.5 cm x 2.6 cm x 0.2 cm with a moderate amount of bloody drainage. A review on Resident 134's current care plan in place at that time revealed interventions, which included that staff were to encourage the resident to reposition as needed and observe skin condition with ADL (activities of daily living) and report abnormalities. The facility was unable to demonstrate that the resident had been turned and repositioned as needed to prevent worsening of the resident's pressure sores. There was no documented evidence that nursing staff had identified decline in the condition and/or changes in the appearance of the resident's pressures sores from April 25, 2019, until on May 1, 2019, when the wound was found to have worsened. Review of nursing documentation dated May 3, 2019, at 12:51 PM revealed that the resident had a decline in health and the physician wanted the resident transferred to the hospital. Further review of documentation on this date revealed that the resident was admitted to the hospital due to infection, failure to thrive and a pressure ulcer. Review of nursing documentation on May 9, 2019, at 4:32 PM indicated the resident was readmitted to the facility and the physician would like the resident to be turned every two hours due to the resident's pressure ulcer. Observation on June 14, 2019, at 9:52 AM revealed the resident was lying in her bed, on her back. The resident's Broda chair (a chair to correct positioning to provide improved independence and quality of life) was against the wall with no pressure relieving device on the chair. An observation on June 14, 2019, at approximately 1:00 PM revealed the resident remained in bed positioned on her back as observed at 9:52 AM. No pressure relieving device was seen in the room for her Broda chair. An interview with Employee 2, Registered Nurse Quality Consultant, on June 14, 2019, at approximately 1:30 PM revealed that the facility does not document repositioning of residents. Therefore the facility was unable to demonstrate that the resident was turned and repositioned at the frequency required to prevent worsening of the pressure sore and that the resident was turned and repositioned every two hours as directed by the physician on May 9, 2019. Employee 2 stated that you can see the resident is being moved when she is toileted. An observation on June 14, 2019, at 2:05 PM revealed that the resident was lying on her right side in bed. An interview with Employee 1 LPN (license practical nurse) confirmed there was no pressure relieving device in the room for her the resident's Broda chair. Employee 1 stated that he did not know if she gets it anymore. Employ 1 further stated that the resident only gets out of bed for meals that she needs assistance. The facility was unable to demonstrate that they had timely identified declines in skin integrity and had implemented prompt and adequate measures to prevent the worsening of a pressure sore on the resident's sacrum and left buttock for a resident identified as a high risk for pressure sore development upon admission to the facility on [DATE]. 28 Pa. Code 211.5(f)(g)(h) Clinical records. Previously cited 2/19/19, 11/19/18, 10/16/18, 4/17/18, 3/9/18 28 Pa. Code 211.12(a) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/18,10/16/18,7/9/18,4/17/18 28 Pa. Code 211.12(c) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/19,7/9/18,4/17/18 28 Pa. Code 211.12(d)(1) Nursing services Previously cited. 4/16/19, 2/9/19,11/19/18,7/9/18,4/17/18. 28 Pa. Code: 211.12(d)(3)(5) Nursing Services Previously cited: 4/16/19, 2/9/19, 7/9/19/, 4/17/18.

Based on observation, review of clinical records, facility documentation and the facility's abuse prohibition policy and procedure and interviews with staff and residents, it was determined the facility failed to protect one resident (CR1) from physical abuse, which resulted in significant bruising, fractured ribs and transfer to emergency room for one out of nine clinical records reviewed. Findings include: A review of the facility's practice guide entitled Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention dated (MONTH) (YEAR) indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment (causing physical pain), involuntary seclusion and any physical or chemical restraint not required to treat a medical condition. As per this practice guide, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching and kicking. It also an injury involving: extreme physical pain, substantial risk of death; protracted loss or impairment of the function of a body member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. A review of the clinical record of Resident CR1 revealed that the resident was admitted to the facility on (MONTH) 26, 2019, from the hospital. The resident's hospital stay was from (MONTH) 23, 2019, as the result of a fall to her knees at home on Janaury 22, 2019, until the resident's admission to the facility on (MONTH) 26, 2019. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated (MONTH) 2, 2019, indicated that the resident required extensive assistance with two persons for toileting such as using the bedpan. An admission nursing assessment dated (MONTH) 26, 2019, indicated that the resident had clear speech was understood by others and able to communicate her needs. Nursing noted that the resident had several tiny scabs on her abdomen, a fading bruise on her right front knee and a wound on her plantar (bottom) area of her right foot and no complaints of pain. Documentation provided by the facility indicated that in the early morning of (MONTH) 30, 2019, at approximately 1:00 AM, Employees 1 and 2 were placing the resident on the bedpan. Employee 2 had been sent from another unit to assist Employee 1 who was assigned to the resident's care during that shift. Employee 1 was on the resident's right side and Employee 2 was on the resident's left side, when Employee 1 went to roll the resident towards Employee 2, Employee 2 grabbed the resident's hip and right arm and yanked her over. Employee 1 placed the bedpan under the resident. When both nurse aides went to take the resident off the bedpan Employee 2 pushed the resident on her hip so hard she {the resident} almost fell off the bed. Employee 1 stated that she had to put all her weight against the resident so she would not fall out of the bed. Employee 1 reported Employee 2's rough care of Resident CR1 to Employee 3, the LPN (licensed practical nurse). Employee 1 reported that Employee 3 replied that Employee 2 was acting like that because she actually had to work and not sleep. A review of a statement from Employee 1 dated (MONTH) 4, 2019, revealed that she stated she had asked Employee 2 to help her with Resident CR1 (on (MONTH) 30, 2019, 11 PM to 7 AM shift). Employee 1 stated that Employee 2 was rough with all the residents she helped her with that night, and in particular Resident CR1. Employee 1 stated Employee 2 pulled Resident CR1 by her arm and pulled her towards her; she then rolled Resident CR1 so hard that she had to put her knees on the side of the bed and her arms behind the resident so she wouldn't roll off the bed. Employee 1 stated that Resident CR1 sustained a bruise at the location where Employee 2 had pushed the resident. Employee 2's statement dated (MONTH) 5, 2019, revealed that Employee 2 stated that this was not her hall. Employee 2 stated that she went to help another aide for a few people only. Employee 2 stated that she went with Employee 1 into every single room. She stated I do not remember. If I see them (the residents) then maybe I remember. I don't remember. A review of Employee 3's statement confirmed that Employee 1 told her that Employee 2 was rushed with care. Employee 3 stated she that was busy and was unaware it was specifically regarding Resident CR1. Employee 3 stated that she just thought it was a general statement. A statement was obtained from Resident CR1's roommate, Resident 1. Resident 1 stated that she was in the room while Employees 1 and 2 were providing care to Resident CR1 on that night. Resident 1 stated she didn't actually see anything (the privacy curtain was between them), but she heard Resident CR1 calling out because she was in fear of falling. Resident 1 was interviewed on (MONTH) 9, 2019, at 9:40 AM and she confirmed she didn't actually see anything the night in question, but she heard the resident moaning and yelling. Resident 1 also stated she heard Employee 1, with whom she is very familiar, saying to Employee 2 you have to be careful you are turning her too hard! Resident 1 also stated Employee 4, an RN (registered nurse), told her to keep her mouth shut regarding her account of the incident. On (MONTH) 31, 2019, at 12:37 PM nursing documentation indicated that Resident CR1 presented with an ecchymotic (bruised) area in her left axilla (armpit). The resident stated it was sore, but did not confirm how it happened. The resident had been receiving the blood thinning medication, [MEDICATION NAME], due to her [DIAGNOSES REDACTED]. However, the [MEDICATION NAME] had been on hold since (MONTH) 28, 2019, due to abnormal blood levels. The facility began an investigation into the resident's bruising on (MONTH) 31, 2019. As of the date of the survey, (MONTH) 9, 2019, the facility indicated that the resident had bruising because she was on the blood thinner [MEDICATION NAME]. The facility's investigation indicated that the resident's daughter called Employee 5, an LPN, to her mother's room on (MONTH) 3, 2019, to inform the Employee 5 that her mother had bruising to her left armpit region and she is bruised badly. Employee 6, RN, assessed the resident on (MONTH) 4, 2019, at 11:35 AM, which revealed that the resident's bruise under her left armpit now encompassed the resident's left breast and was painful with movement of the arm or repositioning the left breast. The resident also had bruising on her left hip. The resident was admitted to the hospital with [REDACTED]. A review of the hospital records dated (MONTH) 4, 2019, indicated that resident was admitted to the hospital with [REDACTED]. The hospital records indicated that the injury was caused by a direct blow. X-ray results revealed a [MEDICAL CONDITION] ninth and tenth ribs. This X-ray was compared to the (MONTH) 23, 2019, hospital evaluation and no rib fractures were identified during that stay. The resident's family requested that the resident not be readmitted to the facility. Interview with the Nursing Home Administrator (NHA) on (MONTH) 9, 2019, at 3:00 PM revealed that the facility concluded that the cause of the resident's bruising was from the resident receiving the blood thinner, [MEDICATION NAME]. The NHA stated that the facility could not substantiate abuse, but did suspend Employee 2 and were awaiting her return to work. The facility failed to ensure residents were free from injury as the result of nursing staff mistreating the resident while assisting the resident on a bedpan, resulting in physical harm to Resident CR1, which included extensive bruising, fractured ribs and transfer to the hospital. 483.12(a)(1) Free from Abuse Previously cited 7/9/18 28 Pa. Code 201.18(e)(1) Management Previously cited 11/19/18, 10/16/18, 7/9/18, 4/17/18 28 Pa. Code 201.29(a)(c) Resident rights Previously cited 11/19/18, 7/9/18 28 Pa. Code 211.12 (a) Nursing services. Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17 28 Pa. Code 211.12(c) Nursing services. Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17

Based on a review of clinical records and interview with resident family members and staff, it was determined that the facility failed to timely provide the necessary care, treatment and services to a resident from the time of admission to meet the resident's clinical needs and prevent clinical complications, which compromised the resident's condition requiring acute care medical intervention for one out of nine residents reviewed (Resident CRB3). Findings included: A review of Resident CRB3's clinical record revealed that the resident was admitted to the facility from the hospital on February 17, 2017. The resident's [DIAGNOSES REDACTED]. place a healthy kidney from a live or deceased donor into a person whose kidneys no longer function properly) and [MEDICAL CONDITION] (bacterial infection causing extreme diarrhea.) A review of the resident's BIMS (Brief Interview for Mental Status -a tool to assess cognitive function) revealed that the resident was cognitively intact with a score of 15 out of 15 on February 19, 2017, according to Social Service progress notes dated February 23, 2017. A review of the hospital form, Most Recent after Visit Summary, (instructions the hospital provided to the nursing care facility upon the resident's discharge from the hospital) revealed that the resident had received these hospital discharge instructions on February 17, 2017, at 1:53 p.m. The instructions included the resident's use of [MEDICATION NAME] (insulin [MEDICATION NAME], a fast acting insulin) insulin (a hormone that lowers the level of glucose (sugar) in the blood used to treat diabetes) 100 units/ml (milliliter), which was to be administered in conjunction with a yet to be specified sliding scale (the dose of insulin administered is based on your blood sugar level before your meal. The higher your blood sugar, the more insulin you are given), [MEDICATION NAME] Immediate Release (IR) 5 mg (a narcotic pain medication) every six hours as needed for moderate to severe stump pain, [MEDICATION NAME] 1 mg twice daily (a drug to prevent organ rejection after a transplant), [MEDICATION NAME] 100 mg/ml 1.25 ml daily by mouth for four days (an antibiotic) and [MEDICATION NAME] 0.4 mg, give 0.4 mg daily (a [MEDICAL CONDITION] medication.) A review of the resident's hospital medication administration records revealed no indication that the resident had received any of these medications after these discharge instructions had been provided to the resident and prior to transferring the resident to the nursing care facility on February 17, 2017. Along with the above medications noted on the hospital's, Most Recent After Visit Summary, the hospital also provided the nursing care facility with multiple paper prescriptions and physician's orders [REDACTED]. A review of these paper prescriptions revealed that these orders were also dated February 17, 2017, and included, [MEDICATION NAME] 5 mg (an anticoagulant medication that thins the blood to treat and prevent blood clots) one tablet every evening, [MEDICATION NAME] (a long acting insulin) 100 units/ml, subcutaneous injection (applied under the skin) 26 units at bedtime, [MEDICATION NAME] EX lotion (a moisturizing skin lotion) apply to affected area of resident's stump twice daily, [MEDICATION NAME] (antibiotic) in D5W (a solution of [MEDICATION NAME] (sugar) and normal saline (salt/water)) 2 gm/100 ml. 2 grams intravenously (through or within a vein) every eight hours. A review of the resident's, Order Summary Report, (physician's orders [REDACTED]. These medication orders included, insulin [MEDICATION NAME] injection ([MEDICATION NAME], a fast acting insulin) 100 unit/ml following sliding scale special instructions (which were not specified in these orders) [MEDICATION NAME] Solution (a long acting insulin) 100 units/ml 26 units at bedtime for diabetes, [MEDICATION NAME] 2.5 mg every Saturday (a medication that treats high blood pressure and fluid retention ([MEDICAL CONDITION])), [MEDICATION NAME] Extended Release (ER) 100 mg daily for hypertension (high blood pressure), [MEDICATION NAME] 1 mg twice daily (an anti-rejection medication for kidney transplant,) [MEDICATION NAME] HCL solution, 125 mg by mouth once daily for [MEDICAL CONDITION] and [MEDICATION NAME] Sodium 5 mg by mouth at bedtime for [MEDICAL CONDITION] ([MEDICAL CONDITION] fib - an irregular and rapid heart rate that can increase your risk of stroke, heart failure and other heart related complications) The resident also had orders for a 2 gm sodium, 1800 cc (cubic centimeters) fluid restricted diet. A review of the resident's clinical record revealed no interdisciplinary progress notes following the resident's admission to the facility on [DATE], until a nursing note was completed on February 18, 2017 at 7:06 a.m., the morning after the resident's admission to the facility. The entry stated that the pharmacy had been contacted to submit the (medication) orders, confirm medications and request a shipment of the resident's prescribed medications. This entry was the first indication that any of the above referenced medications were ordered from the facility's pharmacy for administration to the resident. There was no documented evidence that the facility's nursing staff had clarified the resident's sliding scale with the resident's physician upon the resident's admission since the specific scale was not included with the hospital discharge instructions. According to a nursing progress note dated February 18, 2017, at 8:50 a.m. the resident's attending physician was contacted to clarify an order for [REDACTED]. A review of a social service progress note dated February 18, 2017, at 9:43 a.m. revealed that the resident was visited for a supportive visit, with much support offered. The resident was assured at that time, that his physician would be in early that day to examine him. A review of nursing progress notes dated February 18, 2017, at 11:38 a.m. revealed that the resident's admission assessment was completed. The resident was assessed to have a right [MEDICATION NAME] (relating to or denoting an artery or vein that serves the neck and arm on the left or right side of the body) single PICC line (A PICC (Peripherally Inserted Central Catheter) line is a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck. The tip of the catheter is positioned in a large vein that carries blood into the heart. The PICC line is used for long-term intravenous (IV) antibiotics, nutrition or medications, and for blood draws), a left upper arm AV fistula (the connection of a vein and an artery, usually in the forearm, to allow access to the vascular system, for [MEDICAL TREATMENT] a procedure that performs the functions of the kidneys in people whose kidneys have failed. Connecting the vein and artery is a surgical procedure. The fistula develops over a period of months after the surgery) and a left thoracentesis wound (a procedure used to drain the fluid within the chest cavity surrounding the lungs). At the time of this admission assessment on February 18, 2017, at 11:38 a.m., the resident was noted to have + 3 [MEDICAL CONDITION] (swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area. If the pressing causes an indentation that persists for some time after the release of the pressure this is measured by the depth of the indentation and minutes it lasts. + 3 deep indention [MEDICATION NAME] more than one minute) The areas of the [MEDICAL CONDITION] involved were the resident's left arm and scrotal [MEDICAL CONDITION]. There was no indication prior to this nursing entry of an initial nursing assessment of the resident completed upon this resident's admission to the facility on [DATE], to promptly evaluate the resident's condition at the time of admission and to identify and immediately address the resident's needs and initiate necessary care and services in a timely manner. On February 18, 2017, at 2:34 p.m. nursing documented that the resident's physician's orders [REDACTED]. According to a physician's progress note, the resident was examined on February 18, 2017, and orders for [MEDICATION NAME] 40 mg (a diuretic medication to remove excess fluid from the body) twice daily for [MEDICAL CONDITION] were given. The physician documented that the resident had extensive [MEDICAL CONDITION] when examined (on that date). The physician also ordered [MEDICATION NAME] Insulin 100 unit/ml on a sliding scale after meals and at bedtime. A review of the resident's Medication Administration Records for February 2017, revealed that the resident did not receive any medications on the day of his admission to the facility on [DATE], which included the lack of administration of any insulin, antibiotics or anticoagulant therapy for the resident's [MEDICAL CONDITION] fib ([MEDICATION NAME]) on the day of admission. The resident did not receive the first dose of the IV antibiotic [MEDICATION NAME] until 8 p.m. on February 18, 2017. The resident did not receive the dose scheduled for administration at 10 p.m. on February 17, 2017, or the 6:00 a.m. and 1:00 p.m. doses on February 18, 2017. The resident's blood sugar was assessed at 2:00 p.m. on February 18, 2017, and noted to be 400 (before-meal normal sugars are ,[DATE] mg/dl (deciliter) two hours after meals should be less than 140 mg/dl.) Eight (8) units of [MEDICATION NAME]were administered, according to the sliding scale, for a blood glucose range of ,[DATE]. Blood sugars over 400 required contact with the physician. This was the first documented evidence that the resident's blood sugar was obtained following admission, although the facility had received transfer orders upon admission on February 17, 2017. Further review of the physician's orders [REDACTED]. Nursing documentation indicated that at 7:00 p.m. on February 18, 2017, the resident's blood sugar was obtained and registered HI (too high to register on the testing device) three times. The resident's attending physician was contacted and ordered 15 units of [MEDICATION NAME]with blood sugar testing again in one hour. The resident's blood sugar was tested again an hour later and again registered HI at two attempts. The resident's attending physician was contacted and the resident received 15 additional units of [MEDICATION NAME] insulin. A review of the resident's February 2017 Medication Administration Record [REDACTED] After the physician examined the resident at the facility on February 18, 2017, additional orders were noted to administer one time doses of [MEDICATION NAME] 80 mg and [MEDICATION NAME] 2.5 mg. [MEDICATION NAME] 2.5 mg was scheduled to be administered on Saturday February 18, 2017, at 6:00 a.m. according to the initial transfer orders, but had not been administered to the resident. Both of these medications were prescribed as treatment for [REDACTED]. Nursing documented that both these diuretic medications were provided to the resident at 1:34 p.m. on February 18, 2017. an order for [REDACTED].>A review of the interdisciplinary progress notes dated February 19, 2017, at 1:22 a.m. revealed that arrangements were made for the resident to have a chest X-ray, electrocardiogram (EKG -a test that checks for problems with the electrical activity of your heart) and laboratory services. There was no documentation of the clinical reason these diagnostic studies were ordered. Progress notes revealed that on February 19, 2017, at 8:17 a.m. the resident was assessed by nursing as having +4 [MEDICAL CONDITION] (an increase since the prior +3 [MEDICAL CONDITION] noted on February 18, 2017) of both of his hands and lung congestion (an accumulation of fluids or mucus in the lungs). The resident's attending physician was contacted and ordered the resident to be transfered to the hospital where he was admitted . An interview with the resident's daughter via telephone on [DATE], at 11:52 a.m. revealed that the daughter stated that her father arrived at the facility on Friday February 17, 2017, during the late afternoon hours into early evening hours. She stated that according to her father, the facility had not provided any medications to him on the day of his admission. The resident also stated that the facility did not provide him a dinner meal tray on the day of his admission. The resident's daughter stated that she brought food in for the resident's evening meal on the day of his admission. The resident's daughter stated that the resident's attending physcian was not aware of his admission to the facility until the next day. According to the resident's daughter, the resident's attending physician was, very upset and insisted on seeing the resident prior to verifying any orders due to the resident's medical history and the facility's failure to administer any medications to the resident on the evening of his admission. The resident had relayed to his daughter that the first medication administration the resident received following his admission to the facility occurred only after the physician visited the resident on the afternoon of February 18, 2017. The resident's daughter stated that her father was still at the hospital at the time of this interview on [DATE]. On [DATE], at 1:15 p.m. Employee 1 (Licensed Practical Nurse) was interviewed and confirmed that her nursing documentation in the resident's clinical record reflected the first entry made by the staff following the resident's admission on February 17, 2017. Employee 1's entry was made on February 18, 2017, at 7:06 a.m. noting the resident's admission to the facility and that the pharmacy was contacted to confirm the medication orders and initiate shipment of the medications to the facility. The Director of Nursing Services was interviewed on [DATE], at 2:30 p.m. regarding the absence of any documentation of the resident's admission to the facility on [DATE], and lack of documented evidence of timely nursing admission assessments, prompt notification to the resident's attending physician of the resident's transfer and admission to the facility and medication order confirmation, procurement and administration of medications necessary for immediate administration, treatments and care. The Director of Nursing Services stated that the resident had been admitted to the facility, very late in the evening as the explanation. Refer F425 483.24 Provide Care and Services for Increased Well Being. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.10(a)(c) Resident Care Policies. Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.12(a)(d)(1) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on a review of clinical records, facility processes, a resident incident report and facility documentation and staff interview, it was determined that the facility failed to implement or revise individualized planned safety interventions to prevent a fall with injury for one sampled resident (Resident 89) and failed to provide consistent supervision of one resident (Resident 116) to promote the resident's safety out of 24 sampled residents. Findings include: A review of Resident 89's clinical record revealed that the resident was [AGE] years old and had diagnoses, which included Schizophrenia (a disabling brain disorder which affects how a person thinks, feels, and acts), anxiety, muscle weakness, and gait abnormality. Review of a resident Incident Report dated November 26, 2014, at 11:10 p.m., noted that a nurse aide found the resident on the bathroom floor. Reddened areas to the resident's left elbow and right knee were noted. The facility's conclusion regarding the occurrence of this fall was not completed and no actions were identified as taken to prevent a future fall. Review of the resident's Safety Care Card dated November 28, 2014, (two days after the above fall), indicated that safety interventions included to discourage the resident's use of the resident's pink jelly shoes due to increased fall risk. Staff were to encourage, and assist the resident as needed to wear proper non-slip footwear. A review of facility correspondence submitted to the State Survey Agency dated January 15, 2015, revealed that Resident 89, who was severely cognitively impaired and independent in ambulation, lost her balance and fell after standing from the bed to ambulate to the bathroom on January 14, 2015 at 8:20 p.m. The facility noted that the resident was at risk for falls and prior planned interventions included the resident wearing slipper socks or shoes. At the time of this fall the facility noted that the resident was wearing non-skid shoes (no further description of the shoes). A nurses noted dated January 14, 2015 at 10:21 p.m., noted that the resident was observed sitting on the floor near the wall in front of her bed, awake and alert. A nurse aide stated that the resident was sitting on her bed, got up to use the bathroom, lost balance, near the wall, bumped her head, and fell to the floor. The registered nurse assessed the resident and noted that the resident's pink rubber shoes were intact and ill fitting. According to nursing documentation the resident was known to refuse to wear non-skid socks or alternate footwear. However, there was no documented evidence of the facility's efforts to obtain, and encourage the resident to wear, appropriate fitting similar (pink) footwear, in an effort to promote this cognitively impaired resident's acceptance of the safer footwear. A nurses note dated January 14, 2015 at 11:30 p.m., noted that the resident was complaining of left hip pain. The resident's left leg was observed to be shorter than the right leg. The resident was sent to the hospital for an evaluation and admitted to the hospital with [REDACTED]. Further review of the clinical record prior to the resident's fall on January 14, 2015, revealed no documented evidence that the facility attempted to acquire alternate properly fitting footwear for the resident to decrease the resident's fall risk. There was no indication that the facility had increased supervision of the resident based on their knowledge of the resident's ill-fitting footwear and the resident's risk for falls. Interview with the Director of Nursing on October 30, 2015 at 9:00 a.m., failed to provide documented evidence that the facility had developed and implemented effective safety interventions and provided adequate staff supervision to prevent the fall with injury for the resident who was identified to be at risk for falls. A review of a facility process for when a resident goes on an appointment reviewed by the facility January 2015, revealed that if a resident is alert and oriented and are their own guardian they can go to the appointment alone (without staff). The facility will arrange for the transport service to pick up the resident at the facility and check them in with the receptionist at the office at the appointment location. When the appointment is completed the facility's expectation is that the receptionist at the office of the appointment location calls the transport service to return and pick up the resident and take the resident back to the facility. For residents with cognitive deficits and are incapable of understanding, the same process applies, however, a facility staff member accompanies the resident throughout the entire process. A review of the clinical record revealed that Resident 116 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 16, 2015, revealed that she was moderately cognitively impaired and required staff assistance for transfers, mobility and toilet use. A review of a physical therapy evaluation dated July 10, 2015, revealed that Resident 116 was non-weight bearing on her right foot and had poor safety awareness with unsteady balance and was at an increased risk for falls. A review of nursing documentation dated from admission to July 31, 2015, revealed multiple entries, which indicated that the resident had poor judgement including instances of the resident independently ambulating to other units in the facility despite staff education having been provided to the resident. A review of a resident incident report and nursing documentation dated July 31, 2015, at 6 p.m., revealed that Resident 116 left the facility for an appointment at 1 p.m., with the transportation company. According to the report the resident left the physician's office at 5 p.m., on July 31, 2015, and there was no transport ambulance waiting for her in the parking lot of the physician's office. The physician's office was then locked and the resident walked to a convenience store several blocks away from that office. The report noted that a man picked her up in his car and drove her to another nursing facility in the area. The unidentified man then called the police. The police picked the resident up at the other nursing facility and returned her to this skilled nursing facility on July 31, 2015, at 6 p.m. The facility failed to ensure that this resident, with impaired judgement, was provided with sufficient supervision to maintain the resident's safety. 28 Pa. Code: 211.12 (a)(c) Nursing services. Previously cited 2/24/15, 1/29/15, 11/7/14 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 2/24/15, 11/7/14

Based on a review of clinical records and facility practice guide, observation and resident and staff interview, it was determined that the facility failed to consistently implement timely and sufficient interventions to deter development of pressure sores and promote healing for one of 25 sampled residents (Resident 126). Findings include: A review of the clinical record revealed that Resident 126, a cognitively intact resident, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].{a collection of pus (infected material) between the outer covering of the brain and spinal cord and the bones of the skull or spine} [MEDICAL CONDITION] (due to a bacterial infection) resulting in the temporary inability to move her lower body by herself. The resident was frequently incontinent of bladder and bowel and was identified by the facility as being at risk for pressure sores. Due to the resident's inability to move her lower body at the time of admission, she was dependent on staff for toileting and continence care. The resident wore adult briefs for incontinence management. A review of an admission Minimum Data Set assessment {The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes.} dated May 21, 2014, revealed Resident 126 was cognitively aware and required maximum assistance of two for bed mobility, transfers and toileting, was frequently incontinent of bowel and bladder and was at risk for pressure ulcers. The facility's "Skin Practice Guideline," reviewed by the facility January 2014, revealed that preventative measures included frequently repositioning residents in bed and chair and managing continence with toileting programs for all residents at risk for developing presure sores. The guide further indicated that if moisture (such as urine from incontinency) on the skin is an issue for the resident, utilize an incontinence management program and appropriate skin protection products. A review of a nursing admission assessment form dated May 14, 2014, revealed that Resident 126 displayed both urinary and fecal incontinence and had no noted skin issues on the lower body upon admission. The resident skin was noted to be exposed to moisture; she spent the majority of the day in a chair or bed and had limited mobility according to the admission assessment. A three day admission bladder diary (a record of the resident's bladder activity identifying continence or incontinence and the time the resident voided) was completed between May 15, 2014, through May 17, 2014. The facility did not conduct the corresponding bladder assessment using the results of the bladder diary and develop and implement bladder management interventions for the resident until after Resident 126 developed skin breakdown in the form of an open sacral pressure area that was discovered by the facility on May 28, 2014. A review of toileting records dated May 14, 2014, through May 28, 2014, revealed that Resident 126 was both continent and incontinent of urine and there was no pattern as to the frequency she was assisted with bladder needs by staff. An initial care plan dated May 14, 2014, revealed a problem of alteration in skin integrity related to impaired mobility and incontinence with interventions to include: use of a barrier cream to peri area/buttocks as needed, encourage the resident to reposition as needed, and to observe the resident's skin condition with ADL care daily. Planned incontinence care included the staff providing assistance with toileting and incontinence care as needed. The nursing documentation at this time revealed that this resident required assistance to turn and reposition herself. There was no documented evidence at the time of the survey that Resident 126 was consistently turned and repositioned prior to the development of the sacral open area on May 28, 2014. A review of a skin alteration record dated May 29, 2014, revealed that Resident 126 had an open area measuring 8 cm (centimeter) x 7 cm x <0.1 cm on the resident's sacrum and described as dark pink/red tissue, with a scant amount of serous-clear drainage. The area was identified as incontinence [MEDICAL CONDITION] and the surrounding skin noted as maceration (Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected.) The facility did not identify this wound as a pressure sore according to their skin alteration record and an interview with the Director of Nursing on November 7, 2014, at 1 PM. The following day, May 30, 2014, the description of the pressure area now included yellow striations. The skin alteration form included weekly measurements and assessments with very little change in this pressure sore. On July 1, 2014, the area was documented as "healed." The next week, July 8, 2014, the pressure area measured 5 cm x 8 cm x <0.1 cm, and was described as dark pink/red, serosanguineous (bloody) drainage and the surrounding skin had a "normal" appearance. The physician was notified and an order to send the resident to a wound care physician was noted at that time. On July 9, 2014, the resident was sent to a wound care clinic and diagnosed with [REDACTED]. On July 10, 2014, the facility's wound documentation noted that the pressure area was Stage II {partial thickness tissue loss, present as a shiny or dry shallow ulcer with no slough (dead skin separating)} measuring 5 cm x 8 cm x <0.1 cm with maceration of the surrounding skin. On July 17, 2014, the pressure area measured 2.3 cm x 3.3 cm x < 0.1 cm and the surrounding skin was macerated. The resident had a hospital stay from July 18, 2014 through July 24, 2014. Upon readmission, the resident's sacral pressure area was noted to be a Stage III (full thickness tissue loss, slough may be present) measuring 8 cm x 10 cm x 0.2 cm with macerated surrounding skin. A review of facility wound documentation revealed that the pressure sore continued to deteriorate from July 24, 2014, until August 11, 2014, with increased depth and slough in the area. A review of a wound clinic note dated August 11, 2014, revealed, "Resident 126 is out of bed seven (7) or more hours a day in a wheelchair, not on a ROHO (a speciality cushion for pressure relief), but on a foam cushion only." The note indicated that the wound was debrided (surgically cleaned of dead tissue). The wound note continued noting, "Stage III pressure ulcer has some necrotic tissue indicative of new pressure since my last exam. She would benefit from better offloading"(relieving pressure). On October 5, 2014, the resident had another hospital stay and a [MEDICAL CONDITION] (the colon is cut in half and one end is brought through the wall of the abdomen and attached to the skin. A bag is attached to the skin with adhesive to collect feces.) and a Foley catheter was inserted to assist with wound healing of the now Stage IV sacral pressure area (full thickness tissue loss with exposed bone, tendon or muscle. Slough {dead skin separating} or eschar {thick scab-like material} may be present on some parts of the wound bed. Often includes undermining and tunneling). An observation of the wound on November 7, 2014, at 11:30AM, revealed that Resident 126's sacral pressure area measured 7 cm x 5.2 cm x 5 cm depth at 12 o'clock and 12 cm at 6 o'clock. The wound was beefy red with an area of slough 3.9 cm x 3.4 cm in the center and an area of slough 3 cm x 0.5 cm at the top of the wound. The skin surrounding the wound was pink. Drainage could not be determined as the wound was packed with a wet dressing prior to observation. During an interview on November 7, 2014, at 12 PM, Resident 126 stated that when she was first admitted to the facility she could not reposition or toilet herself. She stated that there was no consistency in her toileting schedule or turning and repositioning prior to the development of the sacral area. She stated that, "some staff were better than others," in meeting her needs for toileting and repositioning. During an interview on November 7, 2014, at 1 PM, the Director of Nursing (DON) stated that the facility does not explore causative factors for residents' pressure sore development. She was unable to explain why the facility had determined that Resident 126's sacral area was not a pressure sore when first identified. The DON was also unable to provide evidence that facility staff had consistently provided Resident 126 timely and adequate services to prevent pressure sores and promote healing. cross refer F315 28 Pa. Code 211.10 (a)(d) Resident care policies. Previously cited 10/8/13, 8/27/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 10/8/13, 8/27/14

Based on a review of clinical records, resident/accident reports, facility event reports and a facility report for an investigation of alleged resident abuse, it was determined that the facility failed to implement or revise planned interventions to prevent an accident with injuries for one out of ten residents sampled (Resident A1). Findings include: A review of an event report submitted to the State Licensing Agency revealed that on July 17, 2014, Resident A1 was identified with a fracture of the right distal femur. Review of the facility's investigation report of alleged abuse (PB#22) revealed that on July 17, 2014, the resident started to complain of right knee pain, was taking Tylenol frequently for complaints of right knee pain starting on that same date of July 17, 2014 and then on a continuing daily basis. When the resident was questioned on July 21, 2014 regarding the new onset of knee pain and frequent use of Tylenol for the knee pain, the resident reported that a nurse had fallen on top of her in the shower room and hurt her knee on July 17, 2014. A review of the investigation report for alleged abuse revealed that Employee 2, a licensed nurse and Employee 3, a nurse aide, attempted to transfer the resident into a geri-chair. Employee 1 slipped and fell into the ger-chair and Resident A1 fell on top of the nurse. The resident reported that the right knee "hurt." Employee 2 reported that the resident "bumped" the knee of Employee 2 during the slip and fall into the geri-chair. Prior to July 21, 2014, there was no evidence that the slip and fall into the geri-chair had occurred or was reported by nursing staff until the resident was questioned regarding the continued knee pain and self reported the incident. A review of the resident's annual Minimum Data Set assessment dated [DATE] (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care), and a quarterly MDS assessment dated [DATE] revealed that the resident required the assist of two persons plus physical assistance for transfers. The resident did not ambulate and utilized a wheelchair for locomotion. The resident was also identified with a BIMS of 14 (brief interview for mental status, orientation and ability to register and recall new information, a score of 14-15 equates to being cognitively intact). The resident's care plan revised on January 3, 2014, revealed that the resident did have a self-care deficit as evidenced by increased weakness related to physical limitations and staff would provide assistance as necessary to meet the resident's needs. An intervention included in the resident's plan of care was that a full lift for transfers (full body sling and resident is passive during transfer) would be used that corresponded with the MDS assessments indicating that the resident required 2 persons and physical assistance for transfers. A review of an occupational therapy evaluation completed on March 28, 2014, also identified that the resident required maximum assistance from two persons along with the full body lift. The occupational therapy evaluation also noted that the resident does not like to use the lift. A review of the facility's investigation form into the alleged resident abuse/neglect (not using the lift as a necessary device planned for safe transfers for the resident) revealed a statement from Employee 3 obtained on July 22, 2014, that revealed that the nurse aide reported that all staff have been using only 2 persons for transfers and not the lift. An interview conducted with Resident A1 on August 27, 2014 at 2 PM verified that the full body lift was not used by nursing staff although it was planned for the resident's use. The resident stated that she was afraid of the lift and instructs the staff not to use it for her transfers. There was no evidence that the interdisciplinary care team responsible for planning the resident's care was aware that the planned intervention of the full body lift for safe transfers was not being used in order to plan alternatives that would provide safe transfers for the resident. The resident relayed that since the incident the resident continues with the right leg immobilizer (keeps the right lower leg in good alignment) all the time and continues to take Tylenol daily for pain as of this date August 27, 2014. The facility failed to implement and/or revise the resident's transfer status for the resident, which resulted in a fracture and continued complaints of pain. An interview conducted with the facility's Administrator and Director of Nursing Services on August 29, 2014 at 2:15 PM revealed that these administrative staff members were not aware that nursing staff had not been using the full body lift as planned for assuring safe transfers for this resident. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 10/8/2013

Based on a review of clinical records, hospital emergency room record, select facility policy and procedures and staff statements and interview with the Director of Nursing Services it was determined that the facility failed to implement the facility's established policy and procedures designed to clear an obstructed airway that resulted in acute respiratory distress and hospitalization for one resident (Resident A1) and failed to ensure that one resident with known risk factors for constipation received the necessary services to maintain adequate bowel elimination (Resident CRB1) out of 10 sampled residents. Findings include: A review of the clinical record revealed that Resident A1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to a Speech/Language Evaluation completed on July 30, 2014, the resident attempts to communicate needs through gestures and caregivers anticipate the resident's wants and needs accordingly. The resident had no difficulty in swallowing and was able to eat regular consistency food items and thin consistency liquids. A Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) completed on July 30, 2014, revealed that the resident required supervision (oversight, encouragement and cueing) for eating and set-up help with the meal. During an interview with the Director of Nursing Services (DON) on August 27, 2014, at 2:15 PM, the DON relayed that the resident required regular consistency food such as meat and solids to be prepared for eating by cutting food into bite size pieces due to resident's impaired mobility of the right arm. Nursing documentation dated July 31, 2014 at 1:34 PM, revealed that the resident was eating veal parmesan when he started coughing. He became cyanotic around his lips(bluish discoloration of the skin and mucous membranes (such as membranes covering the inside of the mouth and trachea (wind-pipe) and due to lack of oxygen in the blood) so "I started suctioning the resident, applied oxygen via non-rebreather mask and started vitals, 911 called. The resident was transferred to the hospital." A review of the staff statements obtained by the facility after the above resident incident revealed that a statement (not dated) from Employee 1, a licensed practical nurse, revealed that the resident was eating a regular consistency lunch and started to cough after taking a bite of veal. The resident had an unproductive cough and the licensed nurse had asked another employee if speech therapy had evaluated him for swallowing. Employee 1 noted that she immediately ordered a pureed consistency diet for the resident. The resident had gagged several times and was unsuccessful at dislodging the food. A pulse oximetry reading indicated that the resident's oxygen saturation level had decreased to 78% (normal blood oxygen levels are 95% -100%). She then began suctioning the resident when she observed cyanosis (bluish discoloration of the skin due to lack of oxygen in the blood) around the resident's lips. She took vital signs (blood pressure, respiration rate and pulse rate) and applied oxygen at 10 liters per minute via rebreather mask (an oxygen delivery device) and continued suctioning the resident until the resident was taken by ambulance to the emergency room . A review of the facility investigative report timeline of events revealed that at 11:40 AM the resident was being fed in dining room by Employee 1, LPN, and began coughing with partial airway occlusion. The resident became cyanotic around the mouth. The resident's airway was suctioned and O2 (oxygen) was applied via rebreather at 10 liters per minute and that resident's the pulse oximetry reading was 78%. There was no evidence that the facility had identified in the review of the timeline of events that the nurse had observed the resident gagging several times and that he was unable to dislodge the food. Employee 1's statement noted that she was not aware if the resident had eaten anything prior to the piece of food (veal) that she was providing the resident, although the resident required oversight, cueing and encouragement during the meal. A review of the facility's nursing procedures (no date of review or revision) for 'Obstructed Airway Management' revealed that if a resident has an obstructed airway with a foreign body; abdominal thrusts are to be performed on a conscious patient. According to the American Red Cross, universal signs of choking on a foreign body include difficulty breathing or noisy breathing, inability to cough forcefully, skin, lips and nails turning blue or dusky. If choking is occurring, the American Red Cross recommends 5 back blows and if ineffective followed by 5 abdominal thrusts and alternate. There was no direction in either the facility's procedures or the American Red Cross procedures that oral suctioning was a procedure utilized when an individual is choking. A review of the hospital emergency record revealed that Resident A1 arrived at the hospital emergency room at 12:10 PM with difficulty breathing, elevated blood pressure, rapid heart heart rate and rapid respirations. The resident was in severe respiratory distress and had cyanosis, drooling from the mouth. The resident was intubated (insertion of a tube into the throat) and a large piece of meat along with noodles were removed from the resident's trachea. The resident remained intubated and was admitted to the hospital with [REDACTED]. The facility failed to assure that the resident received oversight, cueing and encouragement during the meal and was unaware what the resident had been eating prior to being fed a piece of meat by the Employee 1. The facility failed to implement its nursing procedures for an obstructed airway. The resident was admitted to the hospital with [REDACTED]. Resident CRB1 was admitted to the facility on [DATE], with a history of constipation along with current physician orders [REDACTED]. These medications included [MEDICATION NAME] 5 mg one tablet daily ( a muscle relaxant that blocks nerve impulses), [MEDICATION NAME] (an opioid narcotic pain medication) 40 mg once daily and [MEDICATION NAME] 80 mg twice daily. Additionally, the resident had physician orders [REDACTED]. A review of the resident's medication administration records revealed that the resident utilized this medication on a consistent basis. In response to the resident's history of constipation, routine physician's orders [REDACTED]. A review of the resident's bowel elimination records revealed that the resident had a small bowel movement on May 20, 2014, with the prior(medium) on May 15, 2014. On May 24, 2014, the resident was given Milk of Magnesia since he had not moved his bowels since May 20, 2014. After the resident did not move his bowels, he was offered alternate interventions of a suppository or Fleets enema. The resident refused these interventions. On May 26, 2014, the resident again was given Milk of Magnesia and was noted to have a "small" bowel movement. A review of the resident' s clinical record revealed that the resident was given another dose of Milk of Magnesia on May 27, 2014. According to the resident ' s bowel elimination records his next bowel movement (large) did not occur until June 8, 2014 (13 days from May 26, 2014.) Nursing progress notes however revealed that the resident had a "small " amount of bowel movement on June 6, 2014 (11 days from May 26, 2014.) On May 28, 2014 the resident's attending physician came into the facility to examine the resident. She discontinued the Fleets enema and ordered Senna (plant laxative) two tablets twice daily and "Day four of no BM " administer [MEDICATION NAME] 17 grams in 4 oz. of liquids twice daily. According to review of the resident's medication administration records, the resident received the [MEDICATION NAME] (laxative) on May 28, 2014 and then again on June 1, 2 and twice on June 3, 2014. There was no indication that the resident had received this medication on May 29, 30, or 31, 2014, despite the resident's continued lack of a bowel movement. A review of the resident's clinical record, revealed that on June 3, 2014, a communication form was sent to the attending physician to notify her that it had been seven days since the resident's last bowel movement (small). The resident's abdomen was described as slightly distended with hyperactive bowel sounds. The resident's attending physician ordered [MEDICATION NAME] 17 grams twice daily and [MEDICATION NAME] (laxative) 10 mg three times daily until the resident had a bowel movement. The instructions were to contact the physician if this combination of medications was not effective. On June 5, 2014, additional physician orders [REDACTED]. A review of the resident's medication administration records revealed no indication that the resident had received the Magnesium [MEDICATION NAME] as ordered on June 5, 2014. When interviewed on August 27, 2014 at 3:15 p.m., the Director of Nursing Services was unable to find documented evidence that the medication had been administered as ordered. On June 8, 2014, the resident was noted to have a large bowel movement, according to bowl elimination records. Subsequently bowel movements were documented on June 10, 2014 (large) and June 11, 2014 ( large) 2014. A review of the resident ' s Medication Administration records revealed that although the resident had documented bowel movements on June 8th, 10th and 11th 2014, the facility continued to provide the combination of [MEDICATION NAME] and [MEDICATION NAME] daily until June 13, 2014, which was to be given only until the resident had a bowel movement. Cross refer F312 483.25 Quality of Care Previously cited 10/8/2013 28 Pa. Code 211.10 (a)(c)(d) Resident care policies Previously cited 10/8/2013 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 10/8/2013

Based on clinical record review and staff interview, it was determined that the facility failed to assure that a resident having pressures sores receives the necessary treatment and services to promote healing and prevent new sores from developing as evidenced for one of two residents sampled (CRA1). Findings include: Resident CRA1 was admitted to the facility on [DATE], for rehabilitation services after hospitalization and continuing outside [MEDICAL TREATMENT] services until a planned discharge to another nursing care facility closer to the resident's home could be arranged. A nursing assessment completed on December 23, 2010, revealed that the resident was admitted to the facility with a pressure sore on the coccyx area described as Stage 2, measuring .5 centimeters (cm) by .5 centimeters (cm) and showing granulation tissue (tissue that is healing). A second pressure sore was identified on the left buttock area described as Stage 2, measuring 3 cm by 2 cm and also revealed granulation occurring. The nursing assessment completed on December 23, 2010, also identified that the resident was at risk for pressure sores due to immobility evidenced by the resident's inability to position self in bed without staff assistance. The assessment also identified that the resident was at risk for friction and shearing due to limited immobility and the potential for sliding on the sheets with transfers or sliding from a seated position in a chair. The resident did utilize a wheelchair for seating. Physician orders [REDACTED]. An APM (alternating pressure mattress) was ordered and provided. These measures were identified in the resident's initial plan of care developed on December 23, 2010. Prescribed topical treatment and dressings were ordered to be administered two times every day. A nursing assessment completed of the coccyx pressure sore on December 28, 2010 revealed that the pressure sore increased in size to 3 cm by 3 cm, had sero-sanguinous drainage (thin, bloody). The left buttock pressure sore remained the same in size except for drainage a scant amount of sero-sanguinous drainage. Documentation on the assessment revealed that the pressure sores would be difficult to heal due to the resident attending [MEDICAL TREATMENT] services three times a week and lying on the litter at the [MEDICAL TREATMENT] center for hours and not being turned and position due to the fear of disconnecting the resident from the [MEDICAL TREATMENT] machine. The assessment also identified that the resident was at further risk for non-healing due to sliding in bed and immobility while in bed, requiring staff assistance for positioning in bed. A nursing assessment completed on January 4, 2011, revealed that the pressure sore on the coccyx increased to 4 cm x 4 cm and the left buttock pressure sore remained unchanged. A nursing assessment dated [DATE], revealed that the pressure sores on both the coccyx and left buttock remain unchanged. Documentation on the nursing assessment again identified that it was taking longer than usual to heal due to the resident laying on a litter three times a week for [MEDICAL TREATMENT] and the resident states that at [MEDICAL TREATMENT] the resident is not positioned for fear of disconnecting the resident from the [MEDICAL TREATMENT] machine. The physician changed the topical treatment and prescribed a topical [MEDICATION NAME] treatment and dressing changes (cleans/removes dead tissue) to be provided twice a day. There was no evidence that any additional or alternative therapeutic nursing approaches (such as more frequent turning, alternative mattress or pressure relieving devices) were evaluated and provided to promote and aid in healing the pressure sores. A physical therapy assessment completed on February 3, 2011, for the previous five days of therapy, revealed that the resident had been reporting pain 100% of the time when in bed and in the wheelchair and that the therapist spoke to nursing regarding a mattress change. There was no evidence that nursing had acknowledged the physical therapist's communication regarding the change in mattress. A nursing assessment dated [DATE], revealed that the coccyx and left buttock pressure ulcers had developed into one pressure ulcer and extended into the right buttock area. The pressure ulcer measured 15 cm by 15 cm and had a butterfly shape with stringy yellow-type tissue and gray colored necrosis (dead tissue). The physician was notified the further decline in the pressure sores of February 6, 2011. A consult with the Wound Center was requested along with the continuation of the prescribed topical treatment. There was no evidence that any other therapeutic approaches were designed or developed to promote healing and prevent further decline. There was no evidence that despite the non-healing and worsening pressure sores that were identified on February 6, 2001 that the facility had assessed the resident for adequacy of nutritional support that would aid in healing the pressure sores. On February 28, 2011, the physician prescribed the use of a Clinitron bed (air-fluidized bed) to relieve pressure from the buttocks and promote healing. A Minimum Data Set Assessment (MDS) dated [DATE], revealed that while at the facility, the pressure sores that the resident had upon admission had worsened from two ulcers described as Stage 2 to one pressure ulcer described as Stage 4. The resident was transferred as planned to another nursing care facility on March 3, 2011. The facility failed to promptly identify, develop and implement timely and adequate pressure relieving approaches and interventions along with nutritional support to assure that the resident was provided with the necessary services to promote healing and prevent decline. 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 11/4/2010, 4/5/2011

Based on review of clinical records and select facility event reports and staff interviews, it was determined that facility failed to provide sufficient staff assistance planned for safety to prevent accidents resulting in serious injury and failed to develop and implement appropriate and effective safety interventions to prevent accidents for three residents out of five residents sampled (A1, A2 and CRA5). Findings include: A review of a physician order [REDACTED]. A physical therapy evaluation completed on April 1, 2009 also revealed that two persons are required for assisting the resident with transfers. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was not steady and only able to transfer with human assistance from the bed to the chair and when getting on and off the toilet. The MDS assessment revealed that support from two persons were required for all transfers and toileting needs. A review of the resident's plan of care identified that on April 22, 2009, the need for two persons to assist the resident with safe transfers and toileting was added as an intervention to prevent falls/accidents from occurring. A review of the resident's daily activities report from February 1, 2011, through February 28, 2011, revealed, however, that only one person assisted the resident at different hours during the above time frame (February 2011) for both toileting and transferring. A review of a facility event report dated February 28, 2011 at 2 PM revealed that the resident was being assisted to the toilet by Employee 1, and when transferring to the toilet Employee 1 lowered the resident to the floor. The resident sustained [REDACTED]. During an interview with Employee 1 (nurse aide) on April 5, 2011 at 10:45 AM, the employee relayed that although the resident's plan of care had identified that the resident required two persons for transfers and toileting, employees have been transferring and toileting the resident with one person on most occasions throughout the past months, and prior to that accident, and it was assumed that professional staff were are that the staff were doing so. Employee 1 also stated that the resident's roommate's plan of care (Resident A2) had identified that the resident required two persons for transferring and toileting, but nursing staff were only providing a one person assist on most occasions prior to the fall that Resident A1 had experienced on February 28, 2011. Interview conducted with Employee 2 (nurse aide) at approximately 11 AM on April 5, 2011 verified that the resident was being provided with the assistance of one person on frequent occasions, because the resident was able to do it, but also received the assistance of two persons when needed. The employee stated that one person assistance was documented when it was provided on the activities of daily living forms and it was assumed that professional nursing staff were aware what was being provided for the resident. The employee also relayed that the care plan for the resident's roommate (Resident A2) had directed that two persons provide assistance for transfers and toileting, but on occasions only one person was provided and it was documented as being provided by only one person. Interview with Employee 3 (nurse aide) at approximately 11:15 AM on April 5, 2011 verified the same information provided by both Employee 1 and Employee 2. A review of an annual Minimum Data Assessment completed for Resident A2 on August 5, 2010, revealed that the resident requires extensive assistance from 2 staff persons for transfers and toileting. A review of the resident's plan of care revealed that since November 26, 2008 the intervention of assuring that two persons were utilized for transferring the resident remained current in the resident's plan of care. A review of the resident's toileting assistance from April 1, 2011 through April 4, 2011 revealed that there frequent occasions that the resident was provided with assistance from one person, rather than the two persons identified for the resident's transfer and toileting needs. A review of Resident A5's clinical record revealed that the resident was admitted to the facility on [DATE], for two days of respite care (short term stay at facility in order to provide relief for the at home provider of full-time care). A review of the Interview/Assessment Form completed on the resident's admission in order to determine the resident's care and services that were required for the short-term stay revealed that the resident had a history of [REDACTED]." The Interview/Assessment form also revealed that the resident required maximum assistance for all transfers and toileting needs. A review of the resident's plan of care initiated on February 25, 2011, revealed that the resident required the assistance of two persons for all transfers (bed, chair, and toilet) due to the physical limitations of the resident. A review of the activities of daily living forms for February 25, 2011 and February 26, 2011, however, revealed that out of nine transfers that were provided during the resident's stay, only one person provided that assistance on four of those transfers. A review of a facility accident report completed for the resident on February 26, 2011 revealed that at 3:30 PM, the resident had fallen from the toilet when left alone in the bathroom sitting on the toilet. The accident report revealed that only one person had provided transfer assistance to the toilet and despite identifying on admission that the resident slides from seated positions was left alone while seated on the toilet. An interview conducted with the Director of Nursing Services on April 5, 2011 at approximately 2 PM confirmed that two persons were identified on the resident's plan of care to provide transfer assistance and that the resident should not have been left unattended in the bathroom. 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 11/4/2010 28 Pa Code 211.11 (d) Resident care plan