Every finding on record at Edgehill Nursing and Rehab Cen

Based on review of facility documents, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal system for one of one quarter reviewed (Quarter 2). Findings Included:Review of the Payroll-Based Journal staffing data reports revealed that the facility failed to submit data for Quarter 2 (January 1, 2026, thru March 31, 2026).Interview with Administer E1 on July 23, 206 at 02:00 p.m. confirmed no further documented evidence of submission.28Pa Code 201.14(a) Responsibility of licensee

Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process. Finding Included:Review of the facility's facility assessment, dated April 23, 2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members.Interview with Director of Nursing E2, on July 24, 2026, at approximately 11:00 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management.

Based on staff interviews and a review of employee personnel file, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employee E10).Findings include: Interview on August 11, 2025, at 12:24 p.m. with the Nursing Home Administrator, Employee E1, revealed the Registered Dietitian was employed by the facility part-time. Review of Food Service Directors, Employee E10, personnel file revealed the employee held the position of Director of Dining Services with a start date of October 3, 2024. Job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Review of the Food Service Directors, Employee E10, personnel file revealed Employee E10 obtained his/her ServSafe Certification on November 20, 2025. Continued review of Food Service Directors, Employee E10, personnel file revealed the employee was not a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution. Interview on August 12, 2025, at 12:06 p.m. with [NAME] President of Culinary & Nutrition Services, Employee E16, confirmed the Food Service Director, Employee E10, only had a ServSafe certification. Review of the specifications for ServSafe certification revealed this certification covers topics and education pertaining to food safety, not inclusive of food service management. Review of Food Service Directors, Employee E10's, credentials indicated that Employee E10 did not meet the statutory qualifications of a director of food and nutrition services. 201.14 (a) Responsibility of licensee.

Based on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include:Review of facility policy Refrigerator and Frozen Food Storage undated, and facility policy Dry Storage, undated, revealed all food items should be labeled, dated, and sealed.A tour of the main kitchen was conducted on August 11, 2025, at 9:27 a.m. with the Assistant Food Service Director, Employee E11, which revealed the following:Observations inside the reach in refrigerator revealed two opened containers of thickened juices that had no open date. Per the specifications on the boxes, the juices should be consumed within seven days of opening. Further observations inside the reach in refrigerator revealed two black serving trays being used to store milk. The trays were observed to have a significant build up of milk that was sticky to touch.Observations in the dry storage area revealed cereal that was taken out of its original packaging and stored in facility bowls/lids with no open or use by dates. 201.14 (a) Responsibility of licensee.

Based on review of facility documentation, review of facility policy and interview with resident, it was determined that facility did not ensure to report the results of all investigations within 5 working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency) for one of one resident reviewed. (Resident R38)Findings include:Review of facility policy 'Resident Abuse & Neglect Prevention Program,' initiated on May 1st, 2023, under section 2. Identification and investigation of suspected abuse/neglect/misappropriation, indicates that the director of nursing services, administrator or social services designee will keep the resident and/or his/her representative informed of the progress of the investigation.Further review of policy, under section 3. Regulatory Reporting, indicates that the facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies and/or local authorities per federal and state requirements.Review of facility reported event to the State Agency dated May 22, 2025, revealed and event type misappropriation of patient/resident property The facility reported Resident R38 missing money in the amount of $50.00 on May 21, 2025. Further review of the reportable event revealed that the event will be updated when investigation is completed. Interview with Resident R38 on August 12, 2025, at 1:20 pm, revealed that he received $50.00 from the facility on August 12, 2025.Review of facility reported events for month of May 2025, revealed the event related to Resident E38 misappropriation of property was rejected by the State agency on May 30, 2025, and was not re-submitted by the facility until August 12, 2025. 28 Pa Code 201.14(a) Responsibility of licensee

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for two of three hospitalizations reviewed (Resident R9 and R5). Findings Include: Review of Resident R9's clinical record revealed a nursing progress note dated April 25, 2025, that indicated the resident was experiencing weight loss and dysphagia (difficulty swallowing) and was subsequently transferred to the local hospital for evaluation.Review of Resident R5's clinical record revealed a nursing progress note dated June 17, 2025, that indicated the resident had abnormal lab results was transferred to the local hospital for evaluation.Review of Resident R9's and R5's clinical record revealed no documented evidence that the Office of the State Long Term Care Ombudsman was made aware of unplanned hospital transfers.Interview on August 14, 2025, at 12:36 p.m. with Nursing Home Administrator, Employee E1, confirmed the ombudsman was not made aware of Resident R9's and R5's unplanned hospital transfers.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(2) Management

Based on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to develop and implement a person-centered comprehensive care plan for two of 24 residents reviewed related to activities of daily living and pressure ulcers (Resident R4 and R15).Findings include:Review of Resident R4's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 3, 2025, revealed the resident had moderate cognitive impairment and was frequently incontinent (loss of bowel or bladder control) of urine and always incontinent of bowel. Resident R4 had diagnoses of hemiplegia (paralysis of one side of the body) or hemiparesis (muscle weakness of one side of the body), anxiety (intense, excessive, persistent worry or fear), depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things), and rheumatoid arthritis (autoimmune disease typically affecting the joints causing pain, swelling, and stiffness).Review of Resident R4's comprehensive care plan revised August 1, 2025, revealed the resident required assistance for bathing, grooming, and personal hygiene. Interventions dated July 17, 2025, included to monitor for pain and medicate as appropriate prior to activity or rehabilitation.Review of documentation submitted by the facility to the State Survey Agency on July 1, 2025, revealed on July 1, 2025, Resident R4 reported that the nurse aide, Employee E6, tossed him/her around like a piece of meat.Continued review of facility documentation submitted to the State Survey agency on July 1, 2025, revealed upon facility investigation it was revealed that while nurse aide, Employee E6, attempted to provide incontinence care for Resident R4 the resident expressed that the aide was being rough, and the nurse aide continued to provide incontinence care without addressing patients concerns.Review of facility documentation revealed a statement by nurse aide, Employee E6, dated July 1, 2025, which revealed the employees recall of the incident reported by Resident R4.Review of nurse aide, Employee E6, statement dated July 1, 2025, revealed the nurse aide went into the room to change Resident R4 and had no knowledge of any of her condition and started to change her. Nurse aide, Employee E6, described Resident R4 as very fussy.Further review of facility documentation submitted to the State Survey agency on July 1, 2025, revealed Nurse aide, Employee E6, was further educated concerning resident rights and how to address resident pain.Interview on August 14, 2025, at 10:00 a.m. with nurse aide, Employee E5, revealed Resident R4 does tend to have discomfort during incontinence care. Nurse aide, Employee E5, reported being familiar with Resident R4 and knows how to approach/handle the resident. Nurse aide, Employee E5, reported if Resident R4 complains of pain during care to stop and further alert the nurse.Interview on August 14, 2025, at 11:20 a.m. with the Director of Nursing, Employee E2, confirmed there was no care plan developed to address Resident R4's pain during incontinence care prior to the incident with the resident and Nurse aide, Employee E6.Review of facility policy 'Comprehensive Person-Centered Care,' reviewed March 2025, indicated that care plan will include focus, issues, problems, needs ( . physical .prevention of decline in condition) identified through resident involvement, direct observation, coordination, coordination of discipline observations and assessment. As each issue, problem or need is added to the care plan; a date will be recorded with the issue to document the specific time when the issue was identified.Review of R15's clinical record on Tuesday, June 12, 2025, at 2:00 pm, revealed Resident R15 was admitted with medical history of congestive heart failure, muscle weakness, stage three - chronic kidney disease, abnormal results of liver function studies, chronic atrial fibrillation, high blood pressure.Further review of Resident R15's clinical record revealed a nursing note, completed on June 12, 2025, at 10:45 pm, by licensed nurse Employee E14, stating resident has a Stage III (ulcer involving thickness of skin loss, exposing tissue) pressure ulcer noted to sacrum.Resident heels are boggy. Review of a Nurse Practitioner's note dated June 12, 2025, at 8:00 pm, indicated Resident R15 had medical history of lymphedema (tissue swelling cause by tissue swelling) with recommendations for compression stockings and feet elevation.Further review of a Nurse Practitioner's note dated June 18, 2025, at 2:28 pm, revealed recommendation for heel boots when in bed.Further review of Nurse Practitioner's note dated July 2, 2025, at 2:32 pm, revealed preventative measures to float heels while in bed with use of pillows.Review of Resident R15's wound assessment, completed on June 18, 2025, by Nurse Practitioner, Employee E15, revealed a 3.10cm (centimeters) length, 5.40 cm width pressure ulcer/injury of right heel, noting that it was not acquired in house. Continued review of Employee E15 note revealed The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit.Review of Resident R15's care plan initiated on June 12, 2025, revealed the resident had actual impairment to skin integrity, and has potential for pressure ulcer development related to limitations in mobility. There was no evidence of facility developed and implementing interventions for recommended preventative measures of heel boots and float heels to prevent pressure injury in the resident's care plan. Interview with the Directo of Nursing on August 12, 2025, approximately 10:00 a.m. confirmed that the interventions of heel boots and for the resident's heels to be floated while in bed were not the resident's care plan. 28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of clinical records and staff and resident interviews it was determined that the facility failed to ensure care was provided in accordance with physician orders related to ACE wraps and cholecystostomy care for two of 24 residents reviewed (Resident R8 and R61). Findings Include:Review of Resident R8's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 3, 2025, revealed the resident was admitted to the facility on [DATE], was deemed cognitively intact, and had a diagnosis of heart failure.Review of Resident R8's comprehensive care plan revised July 17, 2025, revealed the resident was on diuretic (helps the body get rid of excess fluid) therapy for lower extremity edema (fluid retention).Review of Resident R8's clinical record revealed a skin and wound note dated July 2, 2025, that indicated due to comorbidities Resident R8 is at an increased risk of skin breakdown. Recommendations included to apply ACE wraps to lower extremities, from toes to below knees with instructions to apply in the morning and remove at night.Review of Resident R8's clinical record revealed a physician order dated July 4, 2025, which indicated to apply ACE wraps, in the morning, to lower extremities for edema.Continued review of Resident R8's clinical record revealed order administration notes dated July 8, July 9, July 10, July 15, July 16, July 17, July 18, July 19, July 22, and July 23, 2025, that Resident R8's ACE wraps were unavailable.Interview on August 11, 2025, at 12:45 p.m. with Resident R8 revealed staff could not find the ACE wraps and subsequently they were not being applied.Review of Resident R61's comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and had a diagnosis of acute cholecystitis (inflammation of the gallbladder).Review of Resident R61's comprehensive care plan dated August 13, 2025, revealed the resident was at risk for infection post-surgical cholecystostomy (minimally invasive procedure used to drain fluid from the gallbladder) tube placement. Interventions included to monitor for signs/symptoms of infection.Review of Resident R61's clinical record revealed a physician order dated July 29, 2025, to call the physician if the cholecystostomy drainage bag output is less than 25 cc/day.Review of Resident R61's treatment administration record revealed on August 1, August 5, August 7, August 8, and August 9, 2025, nursing staff documented less than 25 cc output of the cholecystostomy drainage bag.Review of Resident R61's clinical record revealed no documented evidence that the physician was made aware when the cholecystostomy drainage bag output was less than 25 cc/day for the above dates. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R2, and R29).Findings include: Review of physician orders for Resident R2, indicated an order dated, [DATE], for the following: Tylenol Oral Tablet 325 MG (Acetaminophen), give 2 tablet by mouth three times a day for Pain.On [DATE], at 8:43 a.m., observed that Employee E12, a Licensed Nurse, decanted Acetaminophen 325 MG (milligrams) two tablets, with expiration date [DATE], among other medications as ordered, and was initiating to administer it. Employee E12 was prevented from administering the Acetaminophen 325 MG two tablets to R2, as those medications were expired by date.At the time of the observation, interview with Licensed nurse, Employee E12, confirmed the above finding.On [DATE], at 9:24 a.m., review of physician orders for Resident R29, indicated order dated [DATE], for the following: Sitagliptin Phosphate Oral Tablet 100 MG, give 1 tablet by mouth, one time a day for DMII (Diabetes Mellitus Type II, also known as type 2 diabetes. It's a metabolic disorder where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels).On [DATE], at 9:28 a.m., observed that Employee E13, a Licensed Nurse, searched for the medication Sitagliptin Phosphate Oral Tablet 100 MG, (Brand Name: Januvia), for Resident R29, but could not find it in the medication cart. Employee E13 requested the supervisor to look for the medication Sitagliptin Phosphate Oral Tablet 100 MG for Resident R29 in the medication Pyxis, (Pyxis is an automated medication dispensing system used in healthcare facilities to improve medication safety and efficiency). But the nursing staff could not find the medication, Sitagliptin Phosphate Oral Tablet 100 MG for Resident R29. Eventually, Sitagliptin Phosphate Oral Tablet 100 MG, was not administered to Resident R29.At the time of the observation, interview with Employee E13, confirmed the above findings.The facility incurred a medication error rate of 6.9%. 28 Pa Code 211.12(d)(1)(2)(5) Nursing Services

Based on observation, review of policies, procedures, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with the cleaning techniques for medical equipment on two of two residents observed during Medication Administration review (Resident R51 and Resident 29).Findings include:Review of facility policy on Preparing for Medication Administration, undated, indicated; Prior to beginning medication administration pass, ensure that the medication cart is well stocked with the required supplies; vital sign equipment is cleansed before and after each resident use.On August 12, 2025, at 9:08 a.m., during medication administration to Resident R51, a Licensed Practical Nurse (LPN), Employee E12, used the Sphygmomanometer (an instrument for measuring Blood Pressure), without disinfecting it, before and after checking the Blood Pressure of R51. On August 12, 2025, at 9:14 a.m., E12 confirmed the findings.On August 12, 2025, at 9:28 a.m., during medication administration to Resident R29, a Licensed Practical Nurse (LPN), Employee E13, used the Sphygmomanometer, without disinfecting it, before and after checking the Blood Pressure of R29. Also, on August 12, 2025, at 9:55 a.m., during medication administration to Resident R42, Employee E13, used the Sphygmomanometer, without disinfecting it, before and after checking the Blood Pressure of R42. On August 12, 2025, at 9:59 a.m., E13 confirmed the findings.28 Pa Code 211.12 (d)(1)(5) Nursing services

Based upon observations, interviews and review of clinical records and facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of Multidrug-resistant organism (MDRO) transmission for one residents with indwelling medical devices (Resident R51) and two residents with wounds (Resident R32 and R39) of 14 residents records reviewed. Findings include: Review of the facility 's policy Infection Control Enhanced Barrier Precautions dated in March 2024, revealed that This facility strives to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by utilizing the least restrictive precautions or isolation for the resident under certain circumstances. Enhanced barrier precautions (EBPs), in addition to Standard Precautions, are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. I.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 2.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of [NAME] colonization or infection status. a. Wounds are those that are chronic or longer healing. Shorter lasting wounds such as skin tears or breaks in skin that are covered with an adhesive bandage such as a band-aid do not require EBP. t. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. b. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. i. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Signs are posted on the door or wall outside the resident room indicating the high-contact resident care activities that require the use of gown and gloves. Review of the Resident R51's physician order dated July 24, 2024 revealed an order for Enhanced Barrier Precaution. Further review of the physician order dated April 24, 2024 revealed an order for indwelling foley catheter for the diagnosis (no diagnosis listed in the order) Observations on October 7, 2024, at 1:16 p.m. revealed that Resident R51's had a foley catheter. Further observation revealed no evidence of any enhanced barrier precautions supplies were available or no signs were posted outside the room to alert the staff and visitors about enhanced barrier precautions. Review of wound care providers documentation for Resident R39 dated September 12, 2024, revealed that the resident had open wounds to sacrum and heels ulcer with etiology of pressure injury/ulcer and peripheral vascular disease. Review of active physician orders for Resident R39 dated October 1, 2024, revealed that the resident was currently receiving treatment for pressure ulcer to the sacrum. Observations on October 7, 2024, at 10:28 a.m. revealed that Resident R39 was in the room. Further observation revealed no evidence of any enhanced barrier precautions supplies were available or no signs were posted outside the room to alert the staff and visitors about enhanced barrier precautions. Review of wound care providers documentation for Resident R32 dated September 5, 2024, revealed that the resident had open wounds to right heel with etiology of pressure injury. Review of active physician orders for Resident R32 dated September 30, 2024, revealed that the resident was currently receiving treatment for pressure ulcer to the right heel. Observations on October 7, 2024, at 9:48 a.m. revealed that Resident R32 was in the room. Further observation revealed no evidence of any enhanced barrier precautions supplies were available or no signs were posted outside the room to alert the staff and visitors about enhanced barrier precautions. Interview with Employee E3, Regional Nurse on October 8. 2024 at 12:00 p.m. stated facility did not implement enhanced barrier precautions and confirmed that residents with catheter and open wounds should be placed on enhanced barrier precautions. 28 Pa Code 211.12 (d)(1)(5) Nursing services 28 Pa Code 201.14(a) Responsibility of licensee

Based on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024 and September 2024). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.2 The Centers for Disease Control and Prevention (CDC) recommends that all acute care hospitals implement an antibiotic stewardship program (ASP) and outlined the seven core elements which are necessary for implementing successful ASPs.2 CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Integrate the dispensing and consultant pharmacists into the clinical care team as key partners in supporting antibiotic stewardship in nursing homes. Pharmacists can provide assistance in ensuring antibiotics are ordered appropriately, reviewing culture data, and developing antibiotic monitoring and infection management guidance in collaboration with nursing and clinical leaders. Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use. Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Some antibiotic use measures (e.g., prevalence surveys) provide a snap-shot of information; while others, like nursing home initiated antibiotic starts and days of therapy (DOT) are calculated and tracked on an ongoing basis. Selecting which antibiotic use measure to track should be based on the type of practice intervention being implemented. Interventions designed to shorten the duration of antibiotic courses, or discontinue antibiotics based on post-prescription review (i.e., antibiotic time-out), may not necessarily change the rate of antibiotic starts, but would decrease the antibiotic DOT. Review of facility antibiotic stewardship/surveillance data provided by the facility during the survey revealed that the facility was required to review each antibiotic order with the following information, Name of the resident, Location admitted Type of infection(origin) Name of antibiotic ordered. Start Date and End Date Days of therapy Indication Indication in detain(symptoms) Drug class Labs/Xray Infection Criteria-(McGees criteria Yes/No) Review of facility documentation from the month of January 2024 revealed that the facility had a total of 11 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 3 antibiotic orders. Review of facility documentation from the month of February 2024 revealed that the facility had a total of 33 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 33 antibiotic orders. Review of facility documentation from the month of March 2024 revealed that the facility had a total of 10 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 10 antibiotic orders. Review of facility documentation from the month of April 2024 revealed that the facility had a total of 11 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 11 antibiotic orders. Review of facility documentation from the month of May 2024 revealed that the facility had a total of 15 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 15 antibiotic orders. Review of facility documentation from the month of June 2024 revealed that the facility had a total of 5 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 5 antibiotic orders. Review of facility documentation from the month of July 2024 revealed that the facility had a total of 12 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 12 antibiotic orders. Review of facility documentation from the month of August 2024 revealed that the facility had a total of 10 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 10 antibiotic orders. Review of facility documentation from the month of September 2024 revealed that the facility had a total of 19 infections which were treated with antibiotic orders. It was revealed that the surveillance tool did not contain symptoms, any test ordered or a review to determine the appropriateness of the antibiotic orders for 19 antibiotic orders. Interview with Employee E3, Regional Nurse, on October 8, 2024, at 12:00 p.m., confirmed that the facility antibiotic stewardship program did not include use protocols for antibiotics, review of facility antibiotic orders to determine the appropriateness of the antibiotics and a system to effectively monitor antibiotic usage and a tracking of symptoms. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides received their at least 12 hours of continued education per year as required for three of four personnel files reviewed. (Employee E10, E12, E13) Findings Include: Review of four nurse aide records revealed the facility did not ensure nurse aides completed their required twelve hours of training for the calendar year of 2023-2024. Nurse aide Employee E10's chart revealed the nurse aide was hired at the facility on November 7, 2022. Review of Employee E10's training records revealed only 10 hours of training was completed from October 10, 2023 to the current date. No other trainings were completed between March 1, 2024 to the current date. The nurse aide is short two hours of trainings for the calendar year 2023-2024 Nurse aide Employee E12 chart revealed the nurse aide was hired at the facility on October 8, 1999. Review of Employee E12's training records revealed only 10 hours of training was completed from October 10, 2023 to current to the current date. No other trainings were completed in the year of 2024. The nurse aide is short two hours of trainings for the calendar year 2023-2024. Nurse aide Employee E13 chart revealed the nurse aide was hired at the facility on March 5, 2009. Review of Employee E13's training records revealed only 7.5 hours completed on from October 10, 2023, to the current date. Interview with Employee E9 from Human Resources on October 9, 2024 at 11:13 a.m. confirmed that the above nurse aides did not receive the twelve hours of required trainings for the calendar year of 2023-2024. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(d) Staff development

Based on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers for two of two residents reviewed for pressure ulcer. (Resident R39 and R32) Findings Include: Review of facility policy titled Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, And Monitoring dated October 2021, revealed that Goal-Residents admitted with pressure ulcers receive the care and services necessary to promote healing. Interventions are multi-factorial. In the context of the resident's choices, clinical condition, and physician input, the resident's treatment and support plan should establish relevant goals and approaches to stabilize or improve underlying conditions. Interventions may include: Redistribute pressure (such as repositioning, protecting heels, etc.); Provide appropriate pressure-redistributing, support surfaces; Review of clinical record for Resident R39 revealed that the resident was admitted to the facility with diagnosis including dementia (a decline in mental abilities that affects a person's daily life) and Parkinson's disease (a brain disorder that causes movement problems, and can also affect mental health, sleep, and pain). Review of wound care providers documentation for Resident R39 dated September 12, 2024, revealed that the resident had open wounds to sacrum and heels ulcer with etiology of pressure injury/ulcer and peripheral vascular disease. Review of active physician orders for Resident R39 dated October 1, 2024, revealed that the resident was currently receiving treatment for pressure ulcer to the sacrum and heel. Review of physician order for Resident R39 dated September 12, 2024 revealed an order for heel suspension device to right and left foot while in bed and chair for DTI (deep tissue injury- a type of pressure ulcer) Review of care plan for Resident R39 dated August 29, 2024 revealed that the resident was skin impairment related to impaired cognition and incontinence: sacrum unstageable pressure ulcer; DTI to bilateral heels with interventions including, off load/float heels while in bed with heel suspension device. Observation of Resident R39 on October 7, 2024, at 10:28 a.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. Observation of Resident R39 on October 7, 2024, at 12:40 p.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. There were no heel boots/heel suspension devices available in resident's room. Observation of Resident R39 on October 8, 2024, at 10:45 a.m. revealed that the resident was sitting in the dining room a special wheelchair with footrest. Resident's heels were touching against the footrest without any offloading measures. Observation of Resident R39 on October 8, 2024, at 11:31 a.m. revealed that the resident was sitting in his room in a special wheelchair with footrest. Resident's heels were touching against the footrest without any offloading measures. Interview with Employee E16, Licensed Practical Nurse, on October 8, 2024, at 11:31 a.m. confirmed that resident's heel was pressing against the foot of the chair and there was no heel suspension device available in resident's room. Review of clinical record for Resident R32 revealed that the resident was admitted to the facility with diagnosis including dementia and chronic obstructive pulmonary disease(a common lung disease that makes it difficult to breath). Review of wound care providers documentation for Resident R32 dated September 5, 2024, revealed that the resident had open wounds to right heel with etiology of pressure injury. Review of active physician orders for Resident R32 dated September 30, 2024, revealed that the resident was currently receiving treatment for pressure ulcer to the right heel. Review of physician order for Resident R32 dated May 30, 2024, revealed an order for heel suspension device to right foot while in bed for DTI. Observation of Resident R32 on October 7, 2024, at 9:48 a.m. revealed that the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. There was one heel boot/heel suspension device next to resident's dresser. Observation of Resident R32 on October 9, 2024, at 12:30 p.m. revealed that the resident was the resident was lying in the bed. Resident's heels were touching against the mattress without any offloading measures. Interview with Employee E16, at the time of the observation confirmed that resident's heel was pressing against the mattress without any offloading measures. Employee also confirmed that there was no heel boot/heel suspension device in resident's room. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.

Based on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with resident needs to maintain acceptable parameters of nutritional status for three of five residents reviewed for nutrition (Resident R2, R12, R39). Findings Include: Review of undated facility policy Weighing of Residents revealed the facility must monitor the resident's weight to detect significant weight loss or gain to ensure that the resident maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate intervention, when there is a nutritional problem. Per the facility policy, residents should be weighed monthly and subsequently should be documented in the medical record. Review of care plan for Resident R12 dated October 19, 2021, revealed that the resident was at nutritional risk related to inconsistent intake and potential for weight loss related to holding food in her mouth, shoveling food in her mouth with potential for choking and behaviors that interfere. Care plan interventions included, weigh per schedule and alert dietitian and physician to any significant loss or gain. Report changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. Review of weight documentation for Resident R12 revealed that on July 10, 2024, the resident weighed 96.5 lbs. On August 1, 2024, the resident weighed 87.8 pounds which is a -9.02 % loss. Review of dietary assessment dated [DATE], revealed that the dietician documented the reason for undesired weight loss as recent hospitalization . The BIM was less than 18.5, which indicated that the resident was under weight. It was revealed that no new dietary interventions were initiated from this assessment, and it was documented that the care plan was revised. Review of clinical record revealed that the weight loss of Resident R12 was from August 1, 2024, and the resident did not have any documented hospitalization in 2024 prior to the weight loss. Further review of the assessment revealed no documented evidence that the physician was notified and completed an assessment for the weight loss. Interview with Employee E3, Regional Nurse, on October 9, 2024, at 11:36 a.m. confirmed that the weight loss was not related to the hospitalization and the weight loss occurred while the resident was in the facility prior to the hospitalization . Review of weight documentation for Resident R39 revealed that on August 29, 2024, the resident weighed 130.2 lbs. On September 11, 2024, the resident weighed 117.2 lbs. which is a -9.98 % loss in a month. Review of care plan for Resident R39 dated October 19, 2021, revealed that Resident R39 is at nutrition risk related to involuntary weight loss >/=5% with in past month related to hospital admission and suspected inadequate intake. Care plan interventions included, weekly weight for 4 weeks, and alert dietitian and physician to any significant loss or gain. Review of dietary assessment dated [DATE], revealed that the resident was documented for significant weight loss of 5% or more in last 30 days, 7.5% or more in last 90 days and 10% or more in last 180 days and the resident was not on a weight loss regimen. Nutritional interventions included, provide 8oz lactose free nectar thick milk with meals, requested nursing to notify physician for new order for multivitamin with minerals supplement. Further review of the nutritional assessment revealed that the care plan was revised. Review of weight documentation for Resident R39 revealed that the weekly weight for Resident R39 was not completed. Review of Resident R2's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 2, 2024, revealed the resident was cognitively impaired and had a diagnosis of dementia (loss of cognitive functioning that interferes with daily life). Review of Resident R2's clinical record revealed a care plan meeting was held with Social Services and Registered nurse on April 10, 2024. Review of the care plan meeting note indicated that Resident R2 was taken off hospice services (specialized care that mainly aims to provide comfort and dignity to the patients) on March 13, 2024. Further review of the care plan meeting note revealed the Registered Dietitian was not apart of the care plan meeting. Review of Resident R2's clinical record revealed a comprehensive nutrition assessment dated [DATE], by Registered Dietitian, Employee E4, revealed Resident R2 was on hospice so monthly weights were not required to be completed. Further review of the assessment revealed no additional oral supplements were warranted at that time. Goals for Resident R2 included comfort measures due to hospice. Interview on October 9, 2024, at 9:45 a.m. with Social Services, Employee E15, confirmed Resident R2 was taken off hospice on March 13, 2024. Review of Resident R2's weight history revealed no documented monthly weight for May, July, September, or October 2024. Review of psychiatry progress note dated September 13, 2024, revealed Resident R2 has been eating poorly per the roommate's observations. Interview on October 9, 2024, at 10:30 a.m. with Registered Nurse, Employee E8, confirmed Resident R2 is not a big eater but does enjoy supplements and will consume 100%. Since Resident R2 was no longer on hospice services at the time of the nutrition assessment on July 31, 2024, the Registered Dietitian failed to accurately and consistently assess a resident's nutritional status based on current needs. Interview on October 9, 2024, at 10:20 a.m. with Registered Dietitian, Employee E5, confirmed Resident R2's nutrition assessment would determine different goals and interventions if Resident R2 was no longer on hospice services. 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for one of one resident reviewed (Resident R54). Findings Include: Review of facility policy Central Vascular Access Device (CVAD) Dressing Change revised January 15, 2004, revealed a CVAD includes peripherally inserted central catheter (PICC). The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Assessment of the vascular access site is performed upon admission and during dressing changes, at least once every shift when not in use, and routinely for signs and symptoms of infusion related complications. The length of the external catheter is obtained upon admission and during dressing changes. Review of Resident R54's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 20, 2024, revealed the resident was admitted to the facility on [DATE], and had a diagnosis of urinary tract infection. Further review of Resident R54's admission MDS dated [DATE], revealed the resident was taking an antibiotic and intravenous (IV - administered into a vein) medications. Review of Resident R54's clinical record revealed a physician order with a start date of September 15, 2024, and discontinue date of September 20, 2024, for Ertapenem Sodium Solution Reconstituted (antibiotic used to prevent and treat a variety of bacterial infections) to be administered intravenously one time a day for UTI. Review of Resident R54's care plan revised September 28, 2024, revealed the resident had a peripherally inserted central line IV (PICC - a tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) due to UTI and antibiotic therapy. Interviews included to flush IV and sterile dressing changes per policy and as needed. Review of Resident R54's medication and treatment administration record revealed that there were no orders or documentation of any IV line care or maintenance, such as dressing changes, or assessments. Review of progress notes revealed that there was no indication that the IV line was assessed or monitored each shift and/or with each infusion. Further review of Resident R54's entire clinical record revealed no documented evidence that the length of the external catheter was obtained upon admission. Interview on October 9, 2024, at 10:51 a.m. with Regional Nurse confirmed Resident R54 had a PICC line on admission. Further interview confirmed Resident R54 did not have orders for the care and management of the PICC line and that the external catheter length was not measured on admission. 28 Pa Code 211.12(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for two of five residents reviewed for nutritional risk (Resident R12 and Resident R39). Findings include: Review of facility policy Weighing of Residents undated, revealed If the weight change falls into the significant category-5% in one month or 10% in 6 months, the RD completes an assessment to investigate the cause of the weight change. Examples of interventions are noted in this policy #6-10. The charge nurse will notify the RD, Doctor, Family, and RNAC of significant weight changes. The nurse will document the weight loss and notification of responsible party/MD, in the resident medical record. Review of care plan for Resident R12 dated October 19, 2021, revealed that the resident was at nutritional risk related to inconsistent intake and potential for weight loss related to holding food in her mouth, shoveling food in her mouth with potential for choking and behaviors that interfere. Care plan interventions included, weigh per schedule and alert dietitian and physician to any significant loss or gain. Report changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. Review of weight documentation for Resident R12 revealed that on July 10, 2024, the resident weighed 96.5 lbs. On August 1, 2024, the resident weighed 87.8 pounds which is a -9.02 % loss. Review of dietary assessment dated [DATE], revealed that the dietician documented the reason for undesired weight loss as recent hospitalization . The BMI (Body Mass Index) was less than 18.5, which indicated that the resident was under weight. It was revealed that no new dietary interventions were initiated from this assessment, and it was documented that the care plan was revised. Review of the clinical record for Resident R12 revealed no documented evidence that the physician was notified and completed an assessment for the weight loss. Review of weight documentation for Resident R39 revealed that on August 29, 2024, the resident weighed 130.2 lbs. On September 11, 2024, the resident weighed 117.2 lbs. which is a -9.98 % loss in a month. Review of dietary assessment dated [DATE], revealed that the resident was documented for significant weight loss of 5% or more in last 30 days, 7.5% or more in last 90 days and 10% or more in last 180 days and the resident was not on a weight loss regimen. Review of care plan for Resident R39 dated October 19, 2021, revealed that Resident R39 is at nutrition risk related to involuntary weight loss >/=5% with in past month related to hospital admission and suspected inadequate intake. Care plan interventions included, weekly weight for 4 weeks, and alert dietitian and physician to any significant loss or gain. Review of the clinical record for Resident R12 revealed no documented evidence that the physician was notified and completed an assessment for the weight loss. Interview with Employee E3, Regional Nurse, on October 9, 2024, at 11:36 a.m. confirmed that there was no evidence that the physician was notified of Resident R12's and R39's weight loss according to the care plan and facility policy. 28 Pa. Code:211.12(d)(5) Nursing services. 28 Pa. Code:211.2(a) Physician services. 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and interview with staff, it was determined that the facility failed to ensure required yearly performance reviews for two out of the four nurse aides reviewed. (Employee E10 and E13). nurse aides. Findings Include: Review of facility records revealed nurse aide Employee E10 was hired on November 7, 2022 and did not have a yearly review completed in the year 2023. Review of facility records revealed nurse aide Employee E13 was hired on hire date March 5, 2009 and did not have a yearly review completed in the year 2023 or 2024. Interview held with Employee E9 from Human Resources on October 9, 2024 at 10:35 a.m. confirmed that two out of the four staff did not have yearly reviews. She stated they have been through several Director of Nursing which may be why she cannot find them. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for one of five residents reviewed (Resident R32). Findings Include: Review of Resident R117's Consultant Pharmacist review report dated August 1, 2024, by consultant pharmacist, revealed a recommendation to increase resident's medication order Clindamycin (It can treat various types of infections, including skin and vaginal infections.) dose to increase 300 mg every 6 hours due to resident's . Further review of the consult revealed that the recommendation was approved by the physician. Review of Resident R32's medication administration record (MAR) revealed that the resident was ordered for Clindamycin 300 mg tablet three times daily on July 25, 2024, for 10 days. Further review of the MAR revealed that the dosage was not increased as recommended by the consultant pharmacist. Continued review of Resident R32's MAR revealed that the resident was ordered for Clindamycin 300 mg tablet three times daily on August 8, 2024, for 21 days. Further review of the MAR revealed that the dosage was not increased as recommended by the consultant pharmacist. Resident continued to receive clindamycin three times a day. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.12 (d)(5) Nursing Services.

Based on staff interviews and a review of employee personnel file, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employee E6). Findings include: An interview on October 7, 2024, at approximately 9:45 a.m. with Food Service Director, Employee E6, revealed that job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview revealed the Registered Dietitian only works part time at the building. Review of Food Service Directors, Employee E6, personnel file revealed the employee held the position of Director of Dining Services with a start date of October 3, 2024. Review of the Food Service Directors, Employee E6, personnel file confirmed the employee was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution. Interview on October 8, 2024, at approximately 1:00 p.m. with the Registered Dietitian Consultant, Employee E7, confirmed the Registered Dietitian only worked at the facility part time. Review of Food Service Directors, Employee E6's, credentials indicated that Employee E6 did not meet the statutory qualifications of a director of food and nutrition services. 201.14 (a) Responsibility of licensee.

Based on review of clinical and hospital records, review of professional standards of practice, review of facility documentation and interviews with staff, it was determined that a registered nurse failed to meet professional standards of practice related to medication administration for one of four residents reviewed (Resident R1). This failure resulted in actual harm to one resident (Resident R1) who did not receive anticoagulant medication as ordered by the physician for eleven consecutive days, was subsequently transferred to the hospital via emergency services and admitted to the hospital with shortness of breath, [CONDITION(S)] (decreased oxygen level in the bloodstream) and worsening pulmonary emboli.(Resident R1). Findings include: Review of Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing Chapter 21, Subchapter A, 21.11 (a) states the registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: Carries out nursing care actions which promote, maintain and restore the well-being of individuals. Section 21.14 (a) states A licensed registered nurse may administer a drug ordered for a patient in the dosage and manner prescribed. Review of the clinical record for Resident R1 revealed that the resident was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's Significant Change Minimum Data Set (MDS- assessment of resident's care needs) dated August 19, 2020, revealed that the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's August 2020 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Employee E3, registered nurse, on January 6, 2020, at 10:02 a.m. confirmed that the employee had discontinued the physican's order to give [MEDICATION(S)] 5 mg, one tablet by mouth every 12 hours for bilateral pulmonary emboli, start date August 20, 2020; because she thought that there were two orders for [MEDICATION(S)], and to avoid overdose, she discontinued it. Review of a witness statement completed by Employee E3, dated January 6, 2021, confirmed that the employee had not contacted or consulted Resident R1's physician prior to discontinuing the resident's anticoagulant medication, [MEDICATION(S)]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the August 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation indicated Resident readmitted with two [MEDICATION(S)] orders, a treatment dose for five days, then a maintenance dose ongoing after that. A charge nurse noticed the two orders for the same medication, and erroneously discontinued the maintenance dose order, mistaking them for duplicate orders. The resident was hospitalized two weeks later and had a recurrence of pulmonary embolism. The physician noted that anticoagulation had been stopped at the nursing home, and we were notified by her primary physician. Review of nursing notes dated August 30, 2020, 7:33 p.m. revealed received a call from care nurse stated resident is having difficulty breathing. Upon arriving found resident in acute resp (respiratory) distress . Pox (oxygen saturation level): 88 (normal level 95%-100%) on 4L(liters) of oxygen. Charge used rebreather mask to increase resident Pox but still not going up. Pox: 87% to 88%. Resident using her chest muscle compensate her breathing. Resident then stated nurse can you please help me. VS (vital signs): 100/59, 80, 97.8, 24, Pox: 88%. Called place to 911 (Emergency Medical Services), resident was transport to [local] hospital. Review of Resident R1's hospital records dated August 30, 2020, revealed that the resident had been hospitalized from August 10-14, 2020, for shortness of breath, [CONDITION(S)] (deficiency in the amount of oxygen reaching the tissues), . and . At the same time, she was diagnosed with pulmonary embolism (blood clot in the lung). She was treated with [MEDICATION(S)], and bridged to [MEDICATION(S)] . Now (August 30, 2020), again presenting with SOB with increased work of breathing. Staff at the residence reported pulse ox of 68% on room air earlier today and transient blood pressure of 90/70. There has been no fevers or chills. She denies any cough, chest pain, abdominal pain, back pain, or discomfort. Further review of hospital record stated, Patient was found to have bilateral pulmonary embolism to which her respiratory failure was attributed to. She was restarted on [MEDICATION(S)]. Review of chest radiology results dated August 30, 2020, revealed: Increasing bilateral pleural effusions. Cat Scan dated August 31, 2020, CT Chest/thorax PE (physical exam) comparison August 10, 2020, impression indicated as follows: Extensive pulmonary emboli. Large clot burden was also present on August 2020, exam. However, configuration has changed and there is increased clot within main pulmonary arteries and bilateral upper lobes. Additional findings include: Moderate right pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), stable cardiomegaly (abnormal enlargement of the heart), emphysematous disease (lung disease), mild pulmonary [CONDITION(S)], basilar atelectasis (partial or complete collapse of the lung). Continued review of Resident R1's hospital records dated August 30, 2020, revealed a physician History and Physical (H&P) dated August 31, 2020, which indicated that the resident had developed worsening dyspnea and [CONDITION(S)] (low blood pressure), and [CONDITION(S)], brought to emergency room , repeat CT scan showed worsening P.E. (Pulmonary Embolism). Patient was admitted to Intensive Care Unit (ICU) because of persistent [CONDITION(S)] and hypoxemia. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management

Based on review of closed clinical record, facility policy, and interviews with facility staff, it was determined that the facility failed to ensure that Resident R1 was free of neglect during a transfer via mechanical lift resulting in actual harm to Resident R1, sustaining a laceration to the right side of the scalp, requiring 18 staples for one of two resident reviewed (Resident R1). Findings include: Review of the facility's policy, Safe Resident Handling/Transfer Equipment, revised 11/1/19, revealed that two persons are required to operate a total lift (a mechanical lift that uses a cloth sling to move a resident from one area to another). Review of Resident R1's January 2020, physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of the quaterly Minimum Data Set (MDS-assessment of resident care needs) dated December 31, 2019, revealed that the resident was identified with cognitive impairment, requiring the physical assistance of two persons for transfers and personal hygiene. The resident had no ambulation capabilities. Review of Resident R1's care plan last revised January 22, 2020, identified the resident at risk for falls related to the resident's [DIAGNOSES REDACTED]. An intervention developed on January 19, 2017, specified that the resident was to be transfer using a total lift (mechanical device utilized to transfer a resident from one surface to another) with the assist of 2 staff persons. Review of nursing documentation dated January 15, 2020, at 8:17 a.m. revealed Resident R1 was being transferred from bed to wheelchair via total lift and her head was banged on the side of lift causing wound with excessive bleeding. She was lethargic in state. The nurse practitioner was notified and an order was obtained for the resident to be transfer to the emergency room for evaluation via 9-1-1 (Emergency Medical Services). Review of the hospital admission history dated January 15, 2020, revealed that Resident R1 had a right parietal scalp (on the side of the head) hematoma (a localized collection of blood outside the blood vessel due to disease or trauma) and laceration requiring 18 staples. Review of the facility documentation title, Event Summary Report completed on January 15, 2020, revealed that the resident was being transferred from the bed to wheelchair by her nursing assistant, using the lift without the assistance of another nursing assistant or nurse. The resident sustained [REDACTED]. The facility concluded that the nursing assistant did not follow the facility policy and the resident's plan of care. Review of the facility's investigation of this incident revealed a statement by Employee E6, a nursing assistant, that indicated that she dressed the resident after giving her a bed bath and then went and get the hoyer lift to transfer resident from bed to wheelchair, while transfering resident hoyer lift, I turned resident toward the wheelchair to lower her in the wheelchair resident head hit the edge of the hoyer lift. and I notify supervisor about the incident. Resident was transferred without assistance. Review of the interview conducted by the facility dated January 15, 2020, revealed that when nursing assistant, Employee E6 was asked why did you do alone? Employee E6 indicated I transfer her with the hoyer lift alone, I know I am not supposed to but I thought I could do it by myself. Review of facility documentation revealed a statement by Employee E9, a licensed nurse, dated January 16, 2020, indicating that when she was informed of the resident's injury, she went to the resident's room and the resident was in the wheelchair bleeding from the occipital part of her head. In an interview with Employee E10, a licensed nurse, on January 31, 2010, at 3:15 p.m., revealed that she entered Resident R1's room approximately 2 to 3 minutes after Employee E9 and observed that Resident R1 was bleeding from her head. Employee E10 held gauze on the back of Resident Rl's head. Review of a statement obtained from the Maintenace Director dated January 15, 2020, revealed that a full inspection was conducted of the lift utilized to transfer Resident R1 and there was no malfunction or mechanic defects identified. Review of nursing assistance Employee 6's personnel file confirmed that Employee E6 was aware of how to utilize the mechanical lift. Review of facility documentation titled Grievance/Concern Form dated January 15, 2020, revealed that Employee E6 was terminated from employment following the incident. The facility failed to ensure that Resident R1 was free of neglect during a transfer via mechanical lift resulting in actual harm to Resident R1, sustaining a laceration to the right side of the scalp, requiring 18 staples. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.27(c) Resident rights 28 Pa Code 201.27(j) Resident rights 28 Pa Code 211.10(d) Resident Care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services