Every finding on record at Elan Skilled Nursing and Rehab, A Jewish Senior Li

Based on a review of clinical records, select facility policy, facility investigative documentation, and staff and resident interviews, it was determined the facility failed to implement adequate accident prevention measures when staff transported a resident identified as being at risk for falls through the hallway in a shower chair, for one out of 8 residents sampled (Resident 1) resulting in actual harm including a frontal scalp hematoma. This deficiency is cited as past noncompliance. Findings include: A review of the facility policy titled Personal Hygiene, last reviewed by the facility in June 2026, revealed it is the facility's policy that residents should not be transported to the shower room in the shower chair. A review of a medical guideline titled Falls and Fall Prevention in the Post-Acute and Long-Term Care Setting Clinical Practice Guideline developed by the Post-Acute and Long-Term Care Medical Association (PALTmed) and published February 2, 2026 revealed that In the PALTC setting, patients taking anticoagulants who experience a fall should be sent for imaging if a reliable patient or witness reports evidence of head trauma or a credible history of trauma. Clinical record review for Resident 1 revealed the resident was admitted to the facility on [DATE], with diagnoses including paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs that is usually due to injury or disease of the spinal cord in the thoracic or lumbar region). An Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 5, 2026, indicated the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and required extensive staff assistance with activities of daily living (basic self-care tasks such as bathing, dressing, toileting, transferring, and moving about).A review of Resident 1's individualized care plan revealed the resident had an activities of daily living (ADLs, basic self-care tasks such as bathing, dressing, toileting, transferring, and moving about) self-care deficit related to muscle spasms and activity intolerance (reduced ability to tolerate physical activity), initiated on May 5, 2022. The care plan directed staff to provide extensive assistance with transfers using two staff members and a Hoyer lift (a mechanical lifting device used to safely transfer individuals who cannot independently stand or bear weight). The care plan also identified Resident 1 as being at risk for falls related to impaired mobility and balance, with interventions intended to reduce the likelihood of injury during transfers and movement throughout the facility. Despite these identified risks and planned interventions, staff transported Resident 1 through the hallway while the resident remained seated in a shower chair, contrary to facility policy. Review of the clinical record revealed a physician's order initiated May 5, 2022, for Apixaban (Eliquis), an anticoagulant (blood thinner that reduces blood clotting and increases the risk of bleeding following an injury), to be administered 5 milligrams by mouth every morning and every evening. A nurses' progress note dated June 17, 2026, at 9:20 PM documented Resident 1 experienced a witnessed fall from a shower chair. The note indicated staff found the resident lying face down in the hallway near the fire doors. Resident 1 reported head pain rated three on a zero to 10 pain scale. Nursing documentation indicated neurological assessments performed after the fall did not identify changes in the resident's level of consciousness, orientation, or neurological status. The note further documented the resident was receiving Eliquis. The physician was notified, and recommended transfer to the Emergency Department. Resident 1 refused transfer at that time. Facility investigative documentation dated June 17, 2026, revealed Employee 1 (Nurse Aide) and Employee 2 (Nurse Aide) transported Resident 1 from her room to the shower room while the resident remained seated in a shower chair. When the shower chair transitioned from the carpet to the laminate flooring, Resident 1 fell from the chair and struck the left side of her face on the floor. Staff assessed the resident and identified a hematoma (collection of blood underneath the skin) on the left side of the forehead. Resident 1 required a mechanical lift and assistance from three staff members to be lifted safely from the floor. The physician was notified and recommended emergency department evaluation; however, the resident declined transfer. Review of the investigation revealed the shower chair was used to transport the resident through the hallway contrary to facility policy. As part of the investigation, Employee 1 and Employee 2 were reeducated that transporting residents to the shower room in shower chairs is not an acceptable practice. A written witness statement dated June 17, 2026, completed by Employee 1 acknowledged Resident 1 was transported in the shower chair despite facility policy because the resident requested transportation in the shower chair to avoid multiple transfers with a mechanical lift.A written witness statement dated June 17, 2026, completed by Employee 2 likewise acknowledged Resident 1 was transferred into the shower chair in the resident's room despite facility policy because the resident requested this method of transport. These statements confirmed that staff transported Resident 1 in the shower chair despite acknowledging the practice was contrary to the facility policy. Although Resident 1 requested transportation in the shower chair, staff remained responsible for implementing safe transportation practices consistent with the residents assessed fall risk and the facility's established policy. Facility investigative documentation revealed Resident 1 complained of wrist pain at approximately 8:30 AM on June 18, 2026. Staff again discussed emergency evaluation with the resident, who agreed to transfer to the Emergency Department at 9:00 AM. Hospital records dated June 18, 2026, revealed Resident 1 had X-rays of the wrist, chest, and pelvis, which identified no fractures. Computed tomography (CT, a specialized X-ray examination that produces detailed internal images) of the brain and cervical spine was completed because of the resident's head injury and anticoagulant therapy. The CT scan identified a frontal scalp hematoma without evidence of an acute intracranial hemorrhage (bleeding inside the skull) or spinal injury. Interview on June 24, 2026, at 10:30 AM, revealed that Resident 1 was observed with purple and yellow bruising on the left side of the face, purple and yellow bruising beneath both eyes, and a healing yellow scabbed area on the left forehead. When asked how the injuries occurred, Resident 1 stated that on June 17, 2026, staff transported her from her room to the shower room while she remained seated in a shower chair. Resident 1 explained she has paraplegia (paralysis affecting both legs) and requires a Hoyer lift for transfers. Resident 1 stated she preferred transportation in the shower chair because it reduced the number of mechanical lift transfers required during showering. She stated that while staff were transporting her through the hallway, the shower chair struck the transition between carpet and hard flooring, causing her to fall forward onto the floor, striking her face. Resident 1 stated she initially refused transfer to the hospital; however, staff encouraged her to seek evaluation, and she agreed to go the following morning. Resident 1 stated she was thankful nothing was broken, reported minimal pain other than itching from the healing hematoma, and stated she was mostly embarrassed by the situation. This deficient practice resulted in actual harm. Resident 1 sustained a frontal scalp hematoma with extensive facial bruising requiring emergency department evaluation, diagnostic imaging, and ongoing clinical monitoring. This deficiency is cited as past noncompliance. The findings were reviewed with the Assistant Nursing Home Administrator and the Director of Nursing on June 24, 2026, at approximately 2:00 PM. Corrective actions implemented by the facility included: Following the incident, Resident 1 was immediately assessed by nursing staff. After initially refusing emergency department evaluation, the resident agreed to transfer the following morning for diagnostic testing. Nursing staff received reeducation regarding the facility's Personal Hygiene policy prohibiting transportation of residents to the shower room while seated in shower chairs. Laminated reminder signs were placed in shower rooms instructing staff not to use shower chairs for resident transportation. Nursing administration implemented random transportation safety audits conducted daily for five consecutive days, weekly for three weeks, and monthly for two months. Audit results were reviewed through the facility's Quality Assurance and Performance Improvement (QAPI) Committee to evaluate ongoing compliance and identify any additional corrective measures. The facility achieved substantial compliance with this deficient practice on June 19, 2026. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on observation, review of select facility policy, and staff interviews, it was determined the facility failed to ensure the kitchen was maintained in a manner that ensured food was prepared, distributed, and served under sanitary conditions and free of pest infestation. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms. This failure created an increased potential for foodborne illness and placed 135 of 135 residents in a situation of Immediate Jeopardy to their health and safety.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). The Food and Drug Administration (FDA, the federal agency responsible for regulating food safety and establishing sanitation requirements for food service operations) requires commercial food service establishments to clean and sanitize all equipment and utensils that come into contact with food using an effective two-step process: cleaning (removal of debris) and sanitizing (elimination of microorganisms). According to Ecolab Inc., a global company specializing in water hygiene and infection prevention solutions for industries that require strict safety and sanitation standards such as health care, long term care, food service, food processing, hospitality and manufacturing indicate that cockroaches are known vectors for disease-causing organisms including: Salmonella (bacteria that can contaminate food, water, and surfaces and cause salmonellosis, resulting in diarrhea, fever, and abdominal cramps when ingested. E. coli (Escherichia coli bacteria commonly found in the intestines of humans and animals; some strains produce toxins that can cause severe gastrointestinal illness, including diarrhea and, in some cases, kidney complications). Staphylococcus (bacteria often found on human skin and in nasal passages; certain strains, such as Staphylococcus aureus, can cause food poisoning, skin infections, or more serious illnesses when introduced into the body, which can lead to serious foodborne illnesses in residents). Cockroaches acquire these organisms on their bodies and legs while traveling through contaminated areas and transfer them to food, utensils, and preparation surfaces, creating a significant risk for the spread of disease. A review of the facility's Pest Control Policy last updated on December 11, 2025, indicated the facility will maintain an on-going pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Contracted outside pest control services are provided. Only approved FDA and EPA (Environmental Protective Agency federal agency responsible for regulating and approving pesticides and chemicals to ensure their use does not pose an unreasonable risk to human health or the environment) insecticides (chemical agents used to kill or control insects and must be approved for use and applied in a manner that prevents contamination of food, equipment, and food-contact surfaces) and rodenticides (chemical agents used to kill or control rodents and must be approved for use and applied in a manner that prevents exposure to residents and contamination of food and food preparation areas) are permitted in the facility, and all such supplies are stored away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services. A tour of the kitchen on January 22, 2026, at 12:30 PM revealed the following unsanitary conditions with the potential to contaminate food and increase the risk of foodborne illness. Observation of the dishwashing area revealed the floor contained debris and rodent droppings. The perimeter floors throughout the kitchen had a buildup of dirt, debris, and rodent droppings. The floor area under the dishwasher was soiled and contained used latex gloves, garbage, bottle caps, a fork, and rodent droppings. Observation of the food preparation and tray line service area revealed seven sticky traps (colored cardboard or plastic strips coated with a sticky substance that capture insects by adhering them to the trap) placed on the floor. One sticky trap located under the left side of the food preparation area had five cockroaches present, three of which were alive and moving. Another sticky trap located on the right side of the kitchen had five cockroaches present, with two observed alive and moving. A third sticky trap contained four cockroaches, two of which were alive and moving. An interview with the Director of Dietary Services on January 22, 2026, at 12:30 PM indicated the outside pest control company had been treating the kitchen for rodents since December 2025; however, the area was not currently being treated to prevent cockroaches. An interview with Employee 1 (dietary worker) on January 22, 2026, at 12:45 PM revealed he had not seen live mice in one week. The employee stated he frequently opens the kitchen in the morning and usually doesn't see any cockroaches. The employee stated he had not seen many cockroaches recently but had visualized them in the past. An interview with the Nursing Home Administrator (NHA) on January 22, 2026, at 1:00 PM confirmed the facility had a contract with a pest management company and that on December 5, 2025, in response to a rodent infestation, the facility requested pest control services. The inspection recommended remediation services twice weekly. Review of pest control inspection reports revealed that on January 5, 2026, the pest management provider conducted an inspection of the first floor. The inspection identified cockroaches at the coffee station located in the main lobby, 50 feet away from the kitchen entrance. The report also identified two potential rodent entry points, including one located in the dishwasher room, and recommended plugging the opening with steel wool after dishwasher cycles. Review of ongoing pest control monitoring documented visits on January 6, 8, 12, 13, 15, and 20, 2026. None of the documentation indicated that cockroach-specific treatment was initiated. An interview with the pest control provider on January 22, 2026, at 3:00 PM revealed the company provided routine pest control services consisting of spraying the internal and external perimeter of the building. No targeted cockroach treatment areas had been identified. The provider confirmed observing cockroach activity at the coffee station on January 5, 2026. The provider identified the species as a German cockroach (small 0.3-0.6 inches, light brown insects with two dark stripes behind the head, known for rapid reproduction. As the most common household pest worldwide, they are nocturnal, flightless, and thrive in warm, humid indoor environments like kitchens and bathrooms.) Other than increased visit frequency, there was no documented evidence the facility addressed cockroach presence in the kitchen, increased sanitation, or evaluated food distribution practices between pest control visits. The facility failed to provide documented evidence that staff were monitoring for cockroaches in the kitchen or that increased sanitation measures or environmental controls (such as sealing gaps, repairing cracks, or ensuring doors were closed) were implemented to ensure food was stored, prepared, distributed, and served under sanitary conditions and free of pest infestation. Immediate Jeopardy was identified and called on January 22, 2026, at 1:50 PM due to the facility's failure to maintain the kitchen in a sanitary condition. The Immediate Jeopardy Template was provided to the NHA at 1:53 PM. The presence of live and dead cockroaches in food preparation and storage areas created a high risk of contamination of food, utensils, and food-contact surfaces with disease-causing organisms, resulting in failure to maintain sanitary food service conditions and placing all residents at risk for foodborne illness Evaluation of the facility's records determined that Immediate Jeopardy was initially identified on January 5, 2026, when the pest control company documented the need for pest control treatment in lobby and kitchen. In response, the facility submitted an immediate corrective action plan at 6:45 PM on January 22, 2026. The plan directed disposal of exposed food items, cessation of food preparation, and transition of dietary services to an outside vendor until pest mitigation was completed. Pest control services were activated for immediate treatment of source areas, including clean-out treatment, aerosol application, and gel treatments. The kitchen was placed under continuous monitoring by the Director of Dietary Services and the Nursing Home Administrator. Audits were scheduled for each meal, daily for seven days. On January 22, 2026, at 4:20 PM a licensed pest control inspector conducted a comprehensive inspection of the kitchen and identified cockroach activity around walls and behind appliances throughout the kitchen. Recommendations included aerosol treatment for immediate control and gel application for prevention. Dietary staff received education on the facility's Pest Control and Kitchen Sanitation Policies and Protocols. All residents were reviewed for signs and symptoms of foodborne illness. The facility initiated daily audits of pest control logs and environmental monitoring and implemented weekly inspection and monitoring by the pest control provider. The Immediate Jeopardy was lifted on January 23, 2026, at 10:00 AM after verification the facility had implemented a comprehensive corrective action plan that immediately addressed the risk of serious harm to residents. Cross Refer F925 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(2.1)(3) Management 28 Pa. Code 211.6 (f) Dietary services 28 Pa Code 211.10 (a)(d) Resident care policies

Based on observations, a review of facility policy, facility-provided documentation, and interviews with residents and staff, it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of pests, and rodents on two out of four resident nursing units (Nursing Units 3 and 4) and in the kitchen of the facility.Findings include: According to the Centers for Disease Control (CDC), in Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. A review of the facility policy titled Preventative Maintenance Program, last reviewed by the facility on December 11, 2025, revealed it is the facility policy to maintain an effective pest control program. The policy indicated the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. A review of facility-provided documentation revealed that on December 8, 2025, the facility contracted with a licensed pest control company to perform remediation services twice weekly until pest activity was resolved. The remediation plan initiated December 8, 2025, included mass trapping and baiting of all rooms located on floors 3, 4, and 5, with continued monitoring of floors 1 and 2. The remediation plan recommended that any food in resident rooms be placed in plastic containers to prevent access by mice. A review of pest control service documentation revealed: A visit dated December 15, 2025, documented inspection and treatment along the interior perimeter of the facility, including common areas, bathrooms, and hallways. The documentation indicated no pest concerns were noted. A visit dated December 19, 2025, documented that no new mice had been caught since the prior visit and that new glue boards were provided for resident rooms. A visit dated December 29, 2025, documented the same inspection and treatment activities as the December 15, 2025, visit, including treatment of interior perimeter areas, common areas, bathrooms, and hallways. A visit dated January 2, 2026, documented treatment of the interior perimeter on the first floor, including common areas, bathrooms, and hallways, and inspection of the third floor for flies. A visit dated January 5, 2026, documented inspection of the first floor and treatment for roaches in the coffee station. The documentation also confirmed signs of rodent droppings on the fourth floor. Review of pest control documentation dated January 6, January 8, January 12, January 13, January 15, and January 20, 2026, revealed no documentation addressing concerns or documenting targeted treatment to the kitchen area following the identification of roaches and rodent droppings. Observations conducted on January 22, 2026, at approximately 9:00 AM revealed a dead cockroach located behind a resident's bed in room [ROOM NUMBER]. Observations of the third-floor kitchenette revealed rodent droppings present in drawers, with a significant amount of food debris and crumbs observed throughout the area. During an interview conducted on January 22, 2026, at 3:15 PM the outside pest control provider indicated awareness of roaches since January 5, 2026, and stated that no additional targeted treatment had been provided since that date. The provider indicated that targeted treatment was focused on mice activity on the fourth and fifth floors, with general treatment provided on other floors. During an interview conducted on January 22, 2026, at 4:00 PM, the Director of Maintenance stated that construction on the first floor may have contributed to movement of cockroaches toward the kitchen area. The Director of Maintenance further stated the facility was not implementing preventative measures specific to cockroach control in the kitchen. The above findings were reviewed with the Director of Nursing and the Nursing Home Administrator on January 22, 2026, at 3:00 PM. The facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents on Nursing Units 3 and 4 and in the kitchen of the facility.28 Pa. Code 201.18 (e)(1) (2.1) Management. 28 Pa Code 211.20 (a)(b)(c)(d) Resident care policies.

Based on observations, a review of facility policy, facility-provided documentation, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of insects, pests, and rodents on two out of four resident nursing units (Nursing Units 3 and 5).Findings include: According to the Centers for Disease Control (CDC), in Controlling Wild Rodent Infestations, rodents can carry many diseases that can spread directly or indirectly to people, including through contact with rodent droppings, urine, or saliva. Signs of rodents include droppings (feces) and gnaw marks. The CDC indicates that to determine if the activity is current, regular cleaning and disinfecting are required. When droppings are identified following cleaning, it can confirm the presence of rodents. A review of the facility policy titled Pest Control, last reviewed by the facility on January 20, 2025, revealed that it is the facility policy to maintain an effective pest control program. The policy indicated the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. A review of a facility-provided document dated September 28, 2025, indicated a work order was entered into the facility's maintenance system regarding fruit flies on Nursing Unit 3. Further review of the document revealed that the work order was completed on September 29, 2025. A review of a facility-provided document dated October 24, 2025, indicated a work order was entered into the facility's maintenance system regarding fruit flies on Nursing Unit 3 going on residents' food, and to please take care of this issue. Further review of the document revealed the work order was completed on October 24, 2025. A review of contractor pest management records from September 2025 through November 2025 revealed no documented evidence that the facility made the company aware of fruit fly issues at the facility. Observations on November 19, 2025, at 12:20 PM revealed four small black flying insects on the ceiling in the Unit 3 resident dining area. Two small black flying insects were observed on the backsplash of the sink in the Unit 3 resident dining area. During a phone interview on November 20, 2025, at 12:50 PM, the pest management contractor confirmed he did not treat for fruit flies or drain flies in the past few months. The pest management contractor indicated the facility did not inform him of any issues regarding fruit flies, nor did he identify any issues during observations. During an interview on November 20, 2025, at 12:55 PM, the Director of Maintenance indicated that the facility has been utilizing a drain maintainer cleaning agent to sanitize drains on the nursing units. He also indicated that the maintenance and custodial department staff spray areas throughout the facility with an indoor-outdoor pesticide and insecticide designed to target fruit flies and flying insects. A clinical record review revealed Resident 68 was admitted to the facility on [DATE], with diagnoses that include paraplegia (a condition characterized by the loss or impairment of motor and sensory functions in the lower half of the body). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 8, 2025, revealed that Resident 68 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). During an interview on November 19, 2025, at 2:10 PM, Resident 68 indicated that she has been seeing mice in her room for over a month. Resident 68 explained that she is upset because she found a candy bar that was partially eaten by a mouse. She explained that the candy was a gift from a family member. An observation on November 19, 2025, at 2:15 PM in Resident 68's room revealed a drawer with 1.0 millimeter x 1.0 millimeter pieces of candy bar wrapper. Amongst the small shreds of paper were small pieces of chocolate and one mouse-like dropping (a small, long, black pellet that is tapered at the ends, resembling a black grain of rice). Further observation revealed multiple mouse-like droppings around the perimeter of Resident 68's room. An observation on November 20, 2025, at 11:44 AM in resident room [ROOM NUMBER] revealed mouse-like droppings behind the window-side dresser and reclining chair. An observation on November 20, 2025, at 11:51 AM in resident room [ROOM NUMBER] revealed several mouse-like droppings behind the door-side reclining chair and in both resident closets. A review of pest management records from September 2025 through November 2025 revealed no documented evidence that the pest management contractor identified any mouse activity (mouse droppings or gnaw marks) until inquiries were made during the survey ending on November 21, 2025. The above findings were reviewed with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on November 21, 2025, at 11:30 AM. The facility failed to maintain an effective pest control program to ensure the facility was free of insects, pests, and rodents on two nursing units. 28 Pa. Code 201.18 (e)(2.1) Management.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included individualized interventions for maintaining skin integrity for two out of 30 residents sampled (Residents 4 and 42).Findings include: A review of the facility policy titled Comprehensive Person-Centered Care Planning Comprehensive Care Plan Policy, last reviewed by the facility on January 20, 2025, revealed it is the facility's policy that the completion and implementation of a comprehensive person-centered care plan is intended to address the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The Comprehensive Care Plan will be reviewed after each assessment as required by Federal and/or State Regulations and will be revised based on the resident's changing goals, preferences, and needs and in response to current interventions. A clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included polyneuropathy (a disorder that damages multiple nerves in the peripheral nervous system, causing symptoms like numbness, tingling, pain, and weakness in the hands and feet) and end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of a significant change in status Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 28, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A physician's order dated October 23, 2025, indicated Resident 4 was to wear a right palm protector (a medical device designed to prevent hand contractures and protect the skin by preventing the fingers from curling into the palm) during AM care, remove during PM care, and remove every two hours for skin checks. An occupational therapy Discharge summary dated [DATE], documented discharge from therapy services and recommended continuation of the palm protector as part of a restorative program (ongoing nursing directed interventions provided after therapy services have ended that are intended to maintain or improve functional ability). A care plan initiated August 27, 2025, identified risk for impaired skin integrity, pressure and non-pressure injuries related to fragile skin, immobility and moderate malnutrition with interventions including the wearing and monitoring of a right palm protector. However, during an observation and interview on November 18, 2025, at 10:48 AM, Resident 4 was observed in bed without the palm protector in place and confirmed he was not wearing it During an interview and observation on November 18, 2025, at 10:50 AM, Employee 1, Licensed Practical Nurse (LPN), confirmed Resident 4 was not wearing his palm protector. She confirmed that Resident 4 had a physician's order for the right palm protector and explained that nurse aides were tasked with ensuring the palm protector was applied to the resident's hand. A clinical record review revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 42's care plan identified risk for impaired skin integrity due to immobility, with interventions including redirecting the resident to prevent scratching revealed she has the potential of impairment to skin integrity related to immobility, initiated on March 21, 2022. Interventions in place to ensure Resident 42 will be free from further injury included redirecting the resident in an effort to prevent scratching of the elbows and forearms. A review of a significant change MDS dated [DATE], revealed Resident 42 was severely cognitively impaired with a BIMS score of 07 (a score of 00 to 07 indicates severe cognitive impairment). An occupational therapy discharge record dated October 10, 2025, documented discharge from therapy and recommended a restorative program including the use of a palm protector during AM care with skin checks every two hours. A Certified Registered Nurse Practitioner (CRNP) progress note dated October 14, 2025, revealed the resident was observed picking and eating her skin and recommended use of Geri sleeves (protective arm coverings designed to prevent skin tears caused by friction or scratching). A Certified Registered Nurse Practitioner (CRNP) progress note dated October 14, 2025, revealed the resident was observed picking and eating her skin and recommended use of Geri sleeves (protective arm coverings designed to prevent skin tears caused by friction or scratching). The resident's skin was examined, and the resident did not have any rash but had several areas within reach that were excoriated (scratched, abraded, or stripped of skin). A review of the clinical record revealed no evidence that Geri sleeves were developed or implemented in the care plan. A review of the medical record revealed no evidence that Geri sleeves were developed or implemented in the care [NAME] progress note dated October 20, 2025, documented continued recommendation for the palm protector during AM care and off during PM care to decrease the risk of contracture with skin checks every two hours to maintain skin integrity. The note documented the resident was meeting goals with encouragement. A Psychiatric-Mental Health Nurse Practitioner progress note dated November 13, 2025, revealed Resident 42 was seen sitting up in a wheelchair in the dayroom. She was seen with some skin picking and hair twirling periodically, but no visible skin markings.During an observation on November 18, 2025, at 11:15 AM, Resident 42 was observed in the dayroom with her right hand clenched in a fist, without a palm protector or Geri sleeves in place. A red abrasion measuring 1.0 cm by 1.0 cm was observed on the dorsal side of her forearm. During an interview at 11:20 AM, Employee 2, LPN, confirmed the resident was not wearing the devices and acknowledged reddened indentation on the resident's palm from fingernail pressure. Employee 2, LPN, confirmed the skin on Resident 42's right palm surface was intact. During an interview on November 21, 2025, at 9:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to implement palm protectors for Residents 4 and 42 as ordered by the physician. The DON and NHA were unable to provide evidence that care plan interventions were developed or implemented for Geri sleeves for Resident 42 following recommendations made by the CRNP on October 14, 2025. The DON and NHA further confirmed the facility failed to develop and implement care plan interventions for palm protectors for Residents 4 and 42 following recommendations made by occupational therapy as part of restorative programming.28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, and staff interviews, it was determined that the facility failed to complete an accurate Minimum Data Set for three of 30 residents sampled (Resident 11, 43, and 133).Findings include: The Long-Term Care Facility RAI User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS,a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 2025, requires the assessment accurately reflects the resident's status, a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals, and the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. A clinical records review revealed Resident 11 was admitted to the facility on [DATE] with diagnoses including Borderline Personality Disorder (a serious mental illness that involves difficulty regulating emotions, leading to impulsivity) and Post Traumatic Stress Disorder (mental health condition that's caused by an extremely stressful or terrifying event and may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). A review of the quarterly MDS dated [DATE], section M (section addressing skin conditions such as pressure injury, surgical ulcers, and diabetic ulcers) documented Resident 11 experienced no skin conditions during the assessment reference period. Further review of Resident 11's clinical records, specifically the document titled, Wound Evaluation & Management Summary, Specialty Physician, dated May 27, 2025, documented a surgical wound of the left neck area, measuring 0.8 cm (length) x 0.8 (width) x 0.5 cm (depth). An interview with the Registered Nurse Assessment Coordinator (RNAC) on November 20, 2025, at 8:54 AM acknowledged the quarterly June 3, 2025, MDS for Resident 11 did not accurately reflect the presence of the left neck surgical wound. The RNAC entered a subsequent correction for the MDS to accurately document the skin condition for Resident 11. According to the clinical record, Resident 133 was admitted to the facility on [DATE], with diagnoses to include fracture of an unspecified part of the right clavicle (broken collar bone) and cellulitis (skin infection) of the right upper limb (arm). The quarterly MDS dated [DATE], section J (section addressing falls) documented that Resident 133 experienced no falls since admission/readmission or prior assessment. Upon clinical review, Resident 133 experienced a fall on March 6, 2025. The March 6, 2025, fall experienced by Resident 133 was not accurately documented in the quarterly, April 22, 2025, MDS. An interview with the RNAC on November 20, 2025, at 8:54 AM acknowledged the quarterly MDS for Resident 133 did not accurately document the fall history and entered a subsequent correction for the MDS. A clinical record review documented Resident 43 was admitted to the facility on [DATE], with diagnosis to include right artificial shoulder joint (device used to replace a joint). The annual MDS dated [DATE], section J (section addressing falls) indicated Resident 43 experienced no falls since admission/ readmission or prior assessment. Upon further review of Resident 43's clinical records, three falls occurred within the assessment reference period for the May 2, 2025, MDS. Resident 43 experienced a fall on February 15, 2025, which resulted in injury. Specifically, the fall on February 15, 2025, resulted in a left forehead hematoma (blood collects outside the blood vessel). According to the clinical records, Resident 43 experienced a fall on April 1, 2025 (no injury) and on April 22, 2025 (no injury). An interview with the RNAC on November 20, 2025, at 1:54 PM acknowledged the annual MDS for Resident 43 did not accurately reflect the fall history and the three falls were not present on the annual MDS. The RNAC entered a subsequent correction for the MDS. 28 Pa. Code 211.5(f)(iii) Medical records28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to the provider's parameters for two out of 30 sampled residents (Resident 125 & Resident 72). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to 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 facility policy, Medication Administration, last reviewed on January 20, 2025, revealed the purpose of the policy is to guide licensed nursing in medication administration. The policy further revealed that licensed nurses will accept orders for the residents from their primary physician and follow the Rights of Medication Administration including right drug, right resident, right time, right dose, right route, right dosage form, right reason, and documentation. Documentation for medication administration will be completed in the electronic medication administration record according to the policy. A clinical record review revealed Resident 125 was admitted to the facility on [DATE]. 2025, with diagnoses which included chronic kidney disease (long-term condition where the kidneys are damaged and lose their ability to filter waste from the blood) and benign prostatic hyperplasia (BPH, enlarged prostate). A physician order, initially dated February 17, 2025, was noted for Midodrine (medication to treat low blood pressure) 10 mg one tablet by mouth three times a day for hypotension (low blood pressure) with instructions to hold the medication if the resident's systolic blood pressure (measures pressure inside the arteries and is the top number of a blood pressure reading) is greater than 110 mm/Hg. Review of Resident 125's October 2025 Medication Administration Record revealed that on the following dates Midodrine 10 mg was administered when the resident's systolic blood pressure was greater than 110 mm/Hg: October 10, 2025, at 9:30 AM administered when the resident's systolic blood pressure was 122 mm/HgOctober 10, 2025, at 1:30 PM administered when the resident's systolic blood pressure was 126 mm/HgOctober 10, 2025, at 5:30 PM administered when the resident's systolic blood pressure was 142 mm/HgOctober 11, 2025, at 9:30 AM administered when the resident's systolic blood pressure was 132 mm/HgOctober 11, 2025, at 1:30 PM administered when the resident's systolic blood pressure was 132 mm/HgOctober 11, 2025, at 5:30 PM administered when the resident's systolic blood pressure was 130 mm/HgOctober 12, 2025, at 9:30 AM administered when the resident's systolic blood pressure was 126 mm/HgOctober 15, 2025, at 1:30 PM administered when the resident's systolic blood pressure was 112 mm/HgOctober 18, 2025, at 9:30 AM administered when the resident's systolic blood pressure was 130 mm/HgOctober 18, 2025, at 1:30 PM administered when the resident's systolic blood pressure was 130 mm/HgOctober 19, 2025, at 9:30 AM administered when the resident's systolic blood pressure was 145 mm/Hg. During an interview on November 19, 2025, at 1:00 PM, the Director of Nursing confirmed the medication was improperly administered, contrary to the physician's orders. A review of the clinical record revealed resident 72 was admitted to the facility on [DATE], with a diagnosis of encounter for surgical aftercare following surgery of the circulatory system (required care after surgery on the heart and blood vessels). A review of a comprehensive, annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 31, 2025, revealed that Resident 72 had moderately impaired cognition with a BIMS score of 9 (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 cognition is moderately impaired). A clinical record review for Resident 72 revealed physician orders, dated July 23, 2025, for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG, give 1 tablet by mouth one time a day and Hold for SBP less than110 mm/Hg or heart rate is less than 60 beats per minute related to essential hypertension (high blood pressure). Review of the July 2025 and August 2025 electronic medication administration records (EMARs) revealed Resident 72 received Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG every day from July 23, 2025, to August 31, 2025. The medication was administered for a total of 40 days. The MAR and clinical record did not include documentation of the blood pressure or pulse assessment at the time of medication administration as the order indicated. During an interview with the Director of Nursing on November 21, 2025, at 10:52 AM the aforementioned information regarding the administration of Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG in the absence of documented blood pressure and pulse was reviewed. The facility failed to adhere to professional standards of nursing care by not ensuring prescribed medications were administered according to the specific physician-ordered parameters for two residents. 28 Pa. Code 211.5 (f) (ix) Medical Records. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to demonstrate that a resident's discharge from the facility was appropriate and necessary for one of 30 sampled residents (Resident 94).Findings include:A review of the clinical record revealed Resident 94 was admitted to the facility on [DATE], with diagnoses that included diverticulosis of the large intestine without perforation or abscess without bleeding (presence of one or more balloon-like sacs in the colon) and generalized anxiety disorder (a disorder characterized by excessive worry that interferes with daily functioning). Review of the admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 31, 2025, revealed that Resident 94 had a Brief Interview for Mental Status (BIMS), a cognitive assessment tool used in long-term care settings to evaluate cognitive function within the Cognitive Section of the MDS, with a score of 00. A BIMS score of 00 indicates severe cognitive impairment and suggests the resident required significant support for decision making during care planning and discharge planning. A review of the facility policy, Discharge Planning Procedure, last reviewed January 20, 2025, revealed that social services are to establish a discharge plan upon admission and include the resident's goal for discharge as well as the resident representative's goal for discharge. The policy further revealed specific documentation regarding referrals made and services necessary for a successful discharge will be delineated in the Social Service Progress notes and/or the Social Service Discharge Referral Form. The policy noted that if discharge to the community is not feasible, the social worker will document who made the determination and why. Review of the clinical record revealed Resident 94 was transferred to an acute care facility on October 28, 2025, due to a change in medical condition, specifically increased heart rate and difficulty breathing. Review of clinical records from both the facility and the acute care hospital revealed the change in condition was related to a medication error in the facility involving the duplicate administration of a vaccine. During hospitalization, all psychiatric medications were discontinued to address the acute medical condition. Resident 94 returned to the facility on October 31, 2025, once stabilized.Further review of the clinical record revealed Resident 94 was transferred again to an acute care facility on November 6, 2025, due to a change in mental status and increased physical aggression, including punching staff. Review of the clinical record revealed a Bed Hold Agreement acknowledged by the resident's representative (brother) on November 6, 2025. A Bed Hold Agreement is a document informing the resident or resident representative that the resident's bed will be held during a temporary hospital transfer so the resident may return to the same bed. When a Bed Hold Agreement is acknowledged, it indicates understanding and agreement that the resident intends to return to the facility and that the bed will be held.However, the medical record also revealed that a Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS), a federally mandated standardized assessment used to plan resident care, was completed on November 6, 2025. Completion of a DRNA MDS indicated the resident was not expected to return to the facility. The completion of a DRNA MDS directly conflicted with the acknowledged Bed Hold Agreement and demonstrated that the facility did not clearly determine, document, or communicate whether Resident 94 was being temporarily transferred or permanently discharged .At the time of the survey, review of the clinical record lacked documentation of a discharge planning process including required information communicated to the receiving healthcare organization or provider, the resident's specific needs that could not be met at the facility, the services available at the receiving facility to address those needs, or documentation by the medical provider when discharge occurred. The record further lacked evidence that the discharge planning process addressed the resident's discharge goals and needs, including involvement of the resident representative and the interdisciplinary team.An interview with the Director of Nursing (DON) on November 21, 2025, at 9:39 AM revealed that Resident 94 was discharged on November 6, 2025, due to safety concerns for staff and other residents and stated the resident posed a risk to others in the care environment. The DON acknowledged that the clinical record lacked documentation reflecting adequate discharge planning, including documentation from the facility medical provider and interdisciplinary team.An interview with the Director of Social Work on November 21, 2025, at 10:42 AM confirmed concerns regarding safety and stated she could not provide a reason why the Bed Hold Agreement was acknowledged by the resident representative when the resident was discharged upon transfer to the acute care facility. 28 Pa. Code 201.29(h) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on a review of clinical records, facility provided investigative documentation, and staff interview, it was determined the facility failed to implement an effective, individualized, person centered care plan to address a resident's dementia related combative behavior for one of three residents reviewed (Resident 91).Findings include: A review of the clinical record revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). A significant change Minimum Data Set (MDS an assessment completed periodically to plan resident care) dated August 11, 2025, indicated that Resident 91 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and the ability to register and recall new information, a score of 0-7 equates to severe cognitive impairment) and was dependent on staff to transfer from bed to chair. The resident's current care plan for cognitive impairment related to dementia initially dated November 15, 2023, and last revised March 7, 2025, identified that the resident was resistive to care, refused medications, and was combative with care related to dementia. Planned interventions to address the resident's combative behavior included if the resident resists with activities of daily living, reassure the resident, leave and return later to try again. Review of facility investigative documentation dated October 26, 2025, at 8:45 AM revealed that Resident 91 became combative during care and during transfer to the resident's wheelchair by Employee 12 (agency nurse aide) and Employee 13 (nurse aide) the resident hit her leg on the metal part of the wheelchair which caused a skin tear to the resident's left lower extremity. To prevent recurrence staff were educated to ensure that the resident was not having behaviors or being combative. Staff were to provide space and pace (staff give the resident physical space and slow down their approach for care) before transferring if behaviors were noted. During interview with Employee 12 (agency nurse aide) on November 21, 2025, at 11:50 AM Employee 12 (agency nurse aide) confirmed that despite Resident 91 being resistive to care she and Employee 13 (nurse aide) continued to transfer the resident from the resident's bed to the resident's wheelchair when the resident hit her leg on the wheelchair which caused a skin tear. Employee 12 (agency nurse aide) revealed that following the incident she was educated to not provide care when the resident is being resistive to care. An interview with the Director of Nursing (DON) on November 21, 2025, at 1:00 PM, confirmed that staff failed to effectively implement Resident 91's dementia related person centered care plan to ensure the resident's safety when exhibiting combative behavior to the extent possible. Cross Refer F94928 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of resident clinical records, select facility policy, staff, and staff interview, it was determined the facility failed to ensure that one of the 30 residents sampled was free of a significant medication error (Resident 94).Findings include:A review of the clinical record revealed Resident 94 was admitted to the facility on [DATE], with a diagnosis of diverticulosis of large intestine without perforation or abscess without bleeding (presence of one or more balloon-like sacs in the colon) and generalized anxiety disorder (a condition characterized by excessive worry and worry that interferes with daily functioning). A review of the admission, comprehensive Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care)) revealed that Resident 94 had a Brief Interview for Mental Status (BIMS, 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) of 00. A BIMs of 00 indicates severe cognitive impairment, suggesting Resident 94 required significant support for making decisions. A review of the facility policy titled Vaccination of Residents reviewed on January 20, 2025, indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. The policy further stated that if a resident receives a vaccine, the following will be documented in the medical record: site and date of administration, vaccine lot number and expiration date, and the name of the individual administering the vaccine. A review of the facility policy, Medication Errors reviewed on January 20, 2025, indicated there will be ongoing surveillance of medication errors and processes to minimize errors. Among the procedural steps noted in the policy included that the Clinical Director or Nursing Supervisor will review staff involved in the error to improve/ review processes to minimize the re-occurrence of error.A review of physician orders, dated October 27, 2025, for Resident 94's immunizations included:Arexvy 120 micrograms in 0.5 milliliters to be given as one intramuscular injection for RSV immunization. Arexvy is a vaccine that helps protect against Respiratory Syncytial Virus (RSV), which is a virus that can cause serious lung infections. An intramuscular injection is a medication or vaccine that is administered directly into a muscle.Pneumococcal 20-Valent Conjugate Vaccine 0.5 milliliters to be given as one intramuscular injection for protection against pneumococcal disease. This vaccine protects against 20 types of pneumococcal bacteria that can cause pneumonia, bloodstream infections, and meningitis. A conjugate vaccine is a vaccine in which proteins are joined to parts of the bacteria to help the body develop a stronger immune response. Fluzone High-Dose Influenza Vaccine 0.5 milliliters to be given as one intramuscular injection for influenza immunization. This high-dose flu vaccine is designed for older adults to produce a stronger immune response. Immunization refers to giving a vaccine to help the body build protection against an infection. Moderna COVID-19 mRNA Vaccine to be given as one full syringe intramuscularly for COVID-19 immunization. This vaccine helps the body build protection against the virus that causes COVID-19. An mRNA vaccine uses a small piece of genetic material that teaches the body to recognize and fight the virus. A review of the electronic medication record revealed, Resident 94 received the following immunizations between October 27, 2025, and October 28, 2025:On October 27, 2025, at 7:17 PM, Resident 94 received the Fluzone High-Dose vaccine (flu shot)On October 28, 2025, at 7:38 AM, Resident 94 received the COVID-19 mRNA vaccine (COVID vaccine)On October 28, 2025, at 6:19 PM, Resident 94 received the Arexvy Intramuscular (RSV) vaccine A review of the clinical record revealed documentation dated October 28, 2025, by Employee 9, a Licensed Practical Nurse (LPN), which indicated that approximately 30 minutes after receiving an RSV vaccine at 6:19 PM, Resident 94 stated, my heart is racing from that shot. The resident's pulse (heartbeat) was recorded at 130 beats per minute and the oxygen saturation level in his blood was 90 percent. Oxygen saturation refers to the percentage of oxygen carried by red blood cells. The documentation further described the resident as gasping with increased anxiety. The physician was contacted, and the resident was transferred to an acute care facility (hospital) for further evaluation. A review of the hospital medical record indicated Resident 94 was admitted on [DATE], for evaluation of sustained wide complex tachycardia after RSV shot. Wide complex tachycardia refers to a fast heart rhythm with an abnormal electrical pattern. The resident remained hospitalized for monitoring and treatment and was discharged back to the facility on October 31, 2025. Further review of facility documentation, specifically a Medication Error Report, revealed that the RSV vaccine had been administered twice on October 28, 2025. The report showed the RSV vaccine was first administered at 7:38 AM by Employee 10, a Registered Nurse (RN), and later administered again at 6:19 PM by Employee 9 LPN. The Medication Error Report indicated the first administration at 7:38 AM had not been documented in the electronic medication record, which is the electronic system where nursing staff record medications and vaccines given. Because the first administration was not entered into the electronic medication record, the second administration occurred.The Medication Error Report also documented that once the duplicate administration was recognized, the physician and the hospital were notified. The report further documented a counseling session between the Director of Nursing (DON) and Employee 10 RN, which included a review of the protocol for proper documentation in the electronic medical record. During an interview with the DON on November 21, 2025, at 9:39 AM, the DON confirmed the clinical record and Medication Error Report reflected that the first administration of the RSV vaccine on October 28, 2025, at 7:38 AM had not been documented, and that a second administration later that day occurred. The DON confirmed the documentation reflected that Resident 94 experienced a change in condition after the second administration and was transferred to the hospital for further evaluation. The DON reported that the facility reviewed the process for immunization administration and documentation and identified revisions to recording vaccine administration. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services.

Based on observations, a review of clinical records, select facility policy, and staff interviews, it was determined that the facility failed to accommodate resident food allergies or intolerances for one of 30 sampled residents (Resident 82). Findings include: A review of the facility policy titled Departmental Food Service Policies- Gluten-Free/Restricted Diet, last reviewed by the facility on January 20, 2025, revealed the purpose of the policy was to promote healing of the small intestine and allow normal nutrient digestion and absorption. To decrease symptoms caused by sensitivity to gluten and gluten-containing products, such as classic symptoms of distention, flatulence, diarrhea, steatorrhea, and weight loss, and atypical symptoms such as growth retardation, chronic fatigue, pain, and anemia. The policy indicated that the guidelines for individuals with gluten-related disorders (celiac disease or non-celiac gluten sensitivity) stated that they must avoid gluten for health reasons. Gluten is the generic name for certain types of proteins found in the common cereal grains wheat, barley, rye, and their derivatives. When individuals with celiac disease ingest gluten, an immune response occurs, which damages the lining of the small intestine. Even tiny amounts of gluten can cause problems, and this is true whether or not obvious symptoms are present. In case of non-celiac gluten sensitivity, it is not believed that damage to the small intestine occurs, but gluten must still be avoided. The following grains and ingredients derived from these gluten-containing grains must be removed from the diet: wheat, barley, rye, and triticale (a crossbreed of wheat and rye). Choose naturally gluten-free grains and flours, including rice, corn, soy, potato, tapioca, beans, sorghum, quinoa, [NAME], buckwheat, cassava, coconut, arrowroot, amaranth, [NAME], flax, chia, yucca, and nut flours. A clinical record review revealed Resident 82 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 17, 2025, revealed that Resident 82 was severely cognitively impaired with a BIMS score of 07 (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 to 07 indicates cognition is severely impaired). A care plan review revealed Resident 82 has the potential for altered nutritional status related to celiac disease initiated on July 15, 2025. Interventions included providing diet as ordered. A physician's order for Resident 82 to be provided a regular diet, a mechanically soft texture, and nectar-like liquid consistency with directions that the diet be gluten-free was initiated on July 14, 2025. A review of the clinical record revealed Resident 82 has a gluten allergy initiated on July 14, 2025. A physician's order indicated a Licensed Practical Nurse (LPN) to check Resident 82's meal trays at breakfast, lunch, and dinner to assure there are no breaded items on the meal trays. If there are, please remove the items containing bread and call the kitchen to replace the item with a vegetable or meat item initiated on August 11, 2025. An observation on November 19, 2025, at 12:19 PM revealed Resident 82 was in the dining room. Facility staff provided the resident a tray of food with a clear plastic bag containing two cookies. Resident 82 was observed eating a cookie. During an interview on November 19, 2025, at 12:23 PM, Employee 3, Registered Dietician (RD), confirmed that Resident 82 was eating a sugar cookie. Employee 3, RD, removed the cookie from the resident and confirmed it was the same cookie that other residents were served. A review of Resident 82's meal ticket (a facility document that indicates the specific foods that the resident will receive) dated November 19, 2025, did not include sugar cookies. The meal ticket indicated Gluten Free and Supervisor to check meal. A review of the manufacturer's ingredients list revealed the sugar cookie is made with enriched wheat flour (wheat, barley, niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid), sugar, palm oil, eggs, natural vanilla flavor, baking soda, and salt. The manufacturer's label indicates that the product contains eggs, soy, and wheat. During an interview on November 19, 2025, at 1:30 PM, the above findings were reviewed with the Director of Nursing (DON). The facility failed to accommodate Resident 82's gluten allergy or intolerances and failed to check his tray prior to serving him food containing gluten on November 19, 2025.28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility did not follow physician-ordered diagnostic evaluation for suspected scabies for one resident (Resident 75), to possibly prevent and mitigate the spread of scabies in the facility and that an additional resident of 30 residents sampled (Resident 52) was identified with scabies on microscopic exam resulting in multiple residents in the facility being treatment for exposure, creating a potential for transmission among residents on impacted units.Findings include: A review of the facility policy entitled Scabies Information, Treatment, and Environmental Cleaning, last reviewed on October 7, 2025, indicated it is the policy of the facility to treat residents infected with and sensitized to Sarcoptes scabiei (scabies) and to prevent the spread of scabies to other residents and staff. Scabies is an itching irritation caused by the microscopic human itch mite, which burrows into the skin's layers and eventually causes itching, tiny irregular red lines just above the skin, and an allergic rash. Secondary bacterial skin infections may result from untreated scabies. Scabies are spread by skin-to-skin contact with the infected area or through contact with bedding, clothing, privacy curtains, and some furniture. Further review indicated the diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites can cause multiple lesions. Often a diagnosis is made from signs and symptoms, and treatment follows without scraping, although scrapings are preferred. Affected residents should remain in contact precautions (an infection control measure used to prevent the spread of germs through direct and indirect contact by wearing gowns and gloves) until twenty-four (24) hours after treatment. During a scabies outbreak among residents or staff, the infection preventionist or committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. A review of Resident 75's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include 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 major depressive disorder (a mental health disorder characterized by a persistently low or depressed mood, decreased interest in pleasurable activities, feelings of worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts). A review of Resident 75's quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated November 7, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 00 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment).A clinical record review revealed a Certified Registered Nurse Practitioner (CRNP) progress note dated August 19, 2025, that documented Resident 75 was evaluated for a raised papular rash consisting of small, raised bumps that can be red and itchy located on the back, abdomen, and chest wall. The note documented that the rash did not appear fungal and was treated as an allergic-type rash. The note further documented that a dermatology consultation was requested and that an in-house wound practitioner consultation for a skin scraping (top layer of skin is scraped to be placed under a microscope to look for mites) or biopsy (small piece of skin removed and sent to the laboratory to determine the cause of the skin problem) was indicated. A clinical record review revealed a physician's order dated August 19, 2025, at 2:39 PM, directing the facility to obtain a dermatology appointment for a skin biopsy and scraping for the rash. Additional physician's orders for Resident 75 included an August 19, 2025, order at 3:41 PM for fexofenadine 180 milligrams once daily (an antihistamine used for allergies), and an August 19, 2025, order at 4:42 PM for hydrocortisone cream 1% to be applied topically twice daily to the trunk area for rash. The clinical record review revealed no documentation that dermatology evaluated Resident 75 and no documentation of a skin scraping or biopsy being completed as ordered on August 19, 2025. A CRNP progress note dated September 10, 2025, documented increased swelling to the face, scratches to the arms, flaking to the scalp, and intermittent itching. The note documented treatment including prednisone (a steroid medication) and ketoconazole shampoo (an antifungal shampoo used for scalp dermatitis defined as flaky, red, and itchy patches). A physician's order dated September 10, 2025, at 4:00 PM directed ketoconazole shampoo to be applied on Mondays and Thursdays, and an additional physician's order dated September 10, 2025, at 4:04 PM directed prednisone 20 mg daily for three days due to facial swelling. A CRNP progress note dated September 25, 2025, documented worsening scalp rash with multiple raised papular areas and continuous scratching. Physician's orders dated September 25, 2025, at 2:19 PM and 2:22 PM directed the application of tacrolimus ointment 0.03 % (a prescription non-steroid ointment used to treat dermatitis) twice daily for seven days and washing the hair with Selsun Blue shampoo (an over-the-counter dandruff shampoo that helps control flaking and itching) for seven days. A CRNP progress note dated October 6, 2025, documented scratches to the arms and numerous red papular lesions to the scalp with evidence of scratching. A physician's order dated October 7, 2025, at 2:23 PM directed consultation with the wound physician. A wound physician consultation note dated October 7, 2025, documented that the rash was consistent with a mite reaction on microscopic bedside examination. Physician's orders dated October 7, 2025, at 3:32 PM directed application of Elimite (Permethrin) 5 percent external cream, a topical medication used to treat scabies, from head to the soles of feet one time only and removal after 8 to 14 hours, and an order dated October 7, 2025, at 4:41 PM directed implementation of contact precautions requiring gown and gloves before entry and removal before exit due to scabies. A Medication Administration Record for October 2025 documented that Resident 75 received Elimite cream on October 7, 2025, at 10:54 PM as ordered. An observation of Resident 75 on November 18, 2025, at 11:00 AM, revealed no rash on the resident's arms, chest, or scalp and no visible scratching. During an interview with the Infection Preventionist conducted on November 19, 2025, at 11:00 AM, it was confirmed that no scraping, biopsy, or dermatology evaluation was completed when ordered for Resident 75 on August 19, 2025. The Infection Preventionist also confirmed that a total of thirty-six residents received Elimite treatment, including all third-floor residents, two residents on the second floor, and one resident on the fifth floor, and that one additional resident (Resident 52) tested positive for scabies on microscopic exam. During an interview with the Director of Nursing conducted on November 19, 2025, at 11:00 AM, it was confirmed that the facility did not obtain a skin scraping or biopsy for Resident 75 for further evaluation, which possibly could have prevented spread and earlier mitigation of scabies in the facility.28 Pa Code 211.10 (c)(d) Resident Care Policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1)(e)(1) Management

Based on review of clinical records, select facility policy, facility provided investigative information, facility education records, and staff interview it was determined that the facility failed to provide dementia and behavior related training to one employee out of two employee education records reviewed (Agency Employee 12). Findings include: A review of the facility Dementia Programming Policy (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) last reviewed by the facility on January 20, 2025, revealed the facility will provide a comprehensive dementia program to the residents, staff, and families which include caregiving strategies, ongoing education, and support families in a collaborative approach to care for residents with dementia. A review of Employee 12's (agency nurse aide) Agency Personnel Orientation checklist, with a documented start date of September 20, 2025, revealed no evidence that the facility provided the required training on the facility's dementia care program. A review of the clinical record revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses including dementia (a progressive condition involving cognitive decline, memory loss, and changes in personality and behavior) and anxiety (a mental health condition characterized by persistent worry or fear that interferes with daily functioning). Review of facility investigative documentation dated October 26, 2025, at 8:45 AM revealed that Resident 91 became combative during care and during transfer to the resident's wheelchair by Employee 12 (agency nurse aide) and Employee 13 (nurse aide) the resident hit her leg on the metal part of the wheelchair which caused a skin tear to the resident's left lower extremity. To prevent recurrence staff were educated to ensure that the resident is not having behaviors or being combative. Provide space and pace (staff give the resident physical space and slow down their approach for care) before transferring if behaviors are noted. Interview with Employee 12 (agency nurse aide) on November 21, 2025, at 11:50 AM confirmed that the facility did not provide dementia or behavioral training related to challenges when dealing with residents who have dementia prior to the incident which occurred with Resident 91 on October 26, 2025. During an interview conducted on November 21, 2025, at 1:00 PM, the Director of Nursing (DON) confirmed that there was no documentation verifying Employee 12 (agency nurse aide) received the required training on the facility's dementia care program and behavior challenges and procedures either prior to beginning assigned duties or thereafter. Refer F744 28 Pa Code 201.18 (e)(1) Management. 28 Pa. Code 201.20(b) Staff development. 28 Pa Code 211.10 (d) Resident Care Policies.

Based on clinical record review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis and failed to ensure the physician orders were followed for one resident (Resident 136) of 30 residents reviewed. Findings include: A review of the facility policy, titled Pain Management last reviewed on January 20, 2025, indicated that in an effort to help a resident attain or maintain the highest practicable level of well-being and to manage pain, the facility, to the extent possible will recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated; evaluate the existing pain and the cause(s); and manage pain consistent with the comprehensive assessment and plan of care, current clinical standards of practice and the resident's goals and preferences. The policy further revealed pain documentation will include both administration of pharmacological (treatment that involve the use of medications) and non-pharmacological interventions (treatments or strategies used to prevent, reduce, or manage symptoms without using medications such as repositioning, exercise, relaxation techniques use of heat or cold and modification of the environment). A review of the clinical record revealed that Resident 136 was admitted to the facility on [DATE], with diagnoses to include Fractures and Other Multiple Trauma (broken bones and injuries). Additional clinical record review indicated Resident 136 had a physician order dated September 30, 2025, and again on October 13, 2025, for Tramadol HCL (a controlled substance/ narcotic used to treat pain) oral tablet 50 mg. Give 50 mg, one tablet by mouth every 12 hours as needed for pain. A review of Resident 136's October medication administration record (MAR) revealed staff administered Tramadol 50mg on: October 1, 2025, for a pain level of 5 (a pain scale is a method to rate pain 0 being least amount of pain and 10 being the worst amount of pain)October 23, 2025, for a pain level of 7Clinical record review revealed Resident 136 had a provider order dated October 6, 2025, and on October 13, 2025, for Tramadol HCL oral tablet 25 mg. Give one tablet by mouth every 6 hours as needed for moderate to severe (6-10) pain. A review of Resident 136's October 2025 medication administration record (MAR) revealed staff administered Tramadol 25 mg on October 12, 2025, for a pain level of 6October 17, 2025, for a pain level of 8October 19, 2025, for a pain level of 7October 23, 2025, for a pain level of 10 October 23, 2025, for a pain level of 8 October 24, 2025, for a pain level of 5October 24, 2025, for a pain level of 8 Further clinical record review revealed Resident 136 had a provider order dated November 1, 2025, for Percocet Oral Tablet 5-325 mg (Oxycodone with Acetaminophen) (a controlled substance, narcotic used for pain). Give one tablet by mouth every 6 hours as needed for pain 7 out of 10. A review of Resident 136 November 2025 MAR revealed staff administered Percocet 5-325 mg on the following dates:November 1, 2025, for a pain level of 6November 2, 2025, for a pain level of 7November 3, 2025, for a pain level of 7Clinical record review revealed Resident 136 had a provider order dated November 3, 2025, for Percocet Oral Tablet 5-325 mg (Oxycodone with Acetaminophen). Give one tablet by mouth every 6 hours as needed for pain 4-10. A review of Resident 136 November 2025 MAR revealed staff administered Percocet Oral Tablet 5-325 mg on the following dates:November 3, 2025, for a pain level of 6November 5, 2025, for a pain level of 8November 5, 2025, for a pain level of 5November 6, 2025, for a pain level of 8November 6, 2025, for a pain level of 5November 7, 2025, for a pain level of 7November 7, 2025, for a pain level of 7November 7, 2025, for a pain level of 7November 8, 2025, for a pain level of 6November 8, 2025, for a pain level of 5November 9, 2025, for a pain level of 6November 9, 2025, for a pain level of 5November 10, 2025, for a pain level of 7November 10, 2025, for a pain level of 7November 10, 2025, for a pain level of 7November 11, 2025, for a pain level of 8November 11, 2025, for a pain level of 6November 12, 2025, for a pain level of 10November 12, 2025, for a pain level of 6November 13, 2025, for a pain level of 6November 14, 2025, for a pain level of 6November 14, 2025, for a pain level of 5 November 15, 2025, for a pain level of 4November 15, 2025, for a pain level of 6November 16, 2025, for a pain level of 6November 16, 2025, for a pain level of 6November 16, 2025, for a pain level of 6November 17, 2025, for a pain level of 6November 18, 2025, for a pain level of 6 Documentation showed that non-pharmacological interventions were not attempted or documented prior to any of the 32 above administrations, as required by standard nursing practice and pain management guidelines. The medication order on September 30, 2025, for Tramadol HCL oral tablet 50 mg, give 50 mg by mouth every 12 hours as needed for pain did not specify the level(s) of pain for which the medication was intended to treat.Additionally, the MAR documented narcotic pain medications were administered to Resident 136 outside the parameters of the provider order on the following dates:November 1, 2025, administered for a pain level of 6 when the order specified a pain level of 7-10October 24, 2025, administered for a pain level of 5 when the order specific pain level of 6-10An interview was conducted with the Director of Nursing (DON) on November 20, 2025, at 11:40 AM to review the aforementioned information regarding the lack of nonpharmacological interventions and administering the medication outside of the ordered parameters. 28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records, facility policies, professional guidelines, staff interviews, resident observation (including wound observation) and staff interview, and documentation review, it was determined the facility failed to implement appropriate interventions consistent with professional standards of practice to prevent the development and worsening of a pressure injury for one resident (Resident 44) and further failed to conduct timely and thorough assessment of a pressure sore and initiate timely treatment to promote healing and prevent worsening of an existing pressure sore for one resident (Resident 77) of 30 residents reviewed.Findings include: According to the National Pressure Injury Advisory Panel (NPUAP) (2025, September) a pressure injury is localized damage to the skin and underlying soft tissue. The skin injury occurs due to intense and/ or prolonged pressure or pressure in combination with shear. The NPUAP (2025) further writes that the heel is among the most common sites on the body to experience a pressure injury, especially the posterior (back) aspects of the heel rim even when a support surface with pressure redistribution properties is used. Furthermore, in immobile and critically ill individuals, the heel commonly ensures extended pressure from resting on the full body support surface or pillow does not receive appropriate preventive care and positioning. The NPUAP emphasizes another common site for pressure injury is the sacrum due to its bony prominence and lack of cushioning. Preventive measures include various interventions including the use of a high-quality static pressure- reducing mattress, and staff assisting and encouraging mobility, and applying barrier creams. A review of facility policy, Prevention of Pressure Ulcers/ Injuries last reviewed on January 20, 2025, revealed the facility will identify risk factors for pressure injury and place appropriate interventions to address such risk factors. The policy noted the Licensed Nurse will inspect the resident's skin weekly and the skin will be inspected daily when performing or assisting with personal care or activities of daily living (ADLs) (dressing, bathing, grooming, toileting, eating, & transferring). The policy indicated residents are provided with appropriate prevention and treatment to encourage skin integrity and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes according to the policy. A review of facility policy, Pressure Ulcer/Skin Breakdown Clinical Protocol, last reviewed on January 20, 2025, indicated that nursing staff and practitioners will assess and document a resident's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and report/document the following: full assessment of pressure ulcer including location, stage (refers to severity of tissue damage), length, width, and depth, presence of exudate (drainage) or necrotic (dead) tissue, pain assessment, resident's mobility status, including support surfaces, and all active diagnoses. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. A clinical records review revealed Resident 44 was admitted to the facility on [DATE] with a diagnosis of hydronephrosis (kidneys are swollen because the urine was not flowing from the kidney and bladder), venous insufficiency (veins in the legs are damaged and prevent blood flow), and end stage renal disease (the last stage of kidney disease where the kidneys are not functioning well or at all). A significant change, comprehensive Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated July 26, 2025, revealed Resident 44 was moderately cognitively impaired with a BIMS score of 10 (BIMS, Brief Interview for Mental Status, section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information). A BIMs score of 10 indicated Resident 44 typically experiences difficulties with complex decision making and memory for recent events. The significant change MDS dated [DATE], identified Resident 44 was dependent upon two individuals for repositioning, dressing, toileting, and transfers. Additional clinical review noted Resident 44 was at risk for pressure injury. A July 24, 2025, Braden score (instrument to evaluate the risk for skin breakdown due to pressure) revealed a score of 16. The score of 16 indicated moderate risk for pressure injury. Review of Resident 44's care plan, in effect at the time of the survey November 21, 2025, confirmed Resident 44 had actual skin impairment and the potential for further skin impairment related to fragile skin, decreased mobility, and malnutrition. As of August 31, 2025, interventions included but were not limited to changing the position of Resident 44 every 2 to 3 hours and as needed, elevating heels off bed with a pillow, and applying lotion daily with morning and evening care and additionally if needed. Review of Resident 44's clinical record included a narrative note on August 31, 2025, at 6:10 AM describing an open area of skin on Resident 44's right heel measuring 2 cm (length), 2cm (width), and 1cm (depth). A treatment for the area was ordered and included cleansing the area with normal saline (salt containing solution), Xeroform (dressing with medicated ointment) to the area covered by border gauze (dry dressing) every day. A consultation with the wound care provider was initiated on August 31, 2025. Further review of a facility document, Open Area Review, dated August 31, 2025, documented a Pressure Area, Stage II (partial thickness skin loss with loss of the outermost layer of the skin) on the right heel and included the measurement and treatment described above. The description on the Open Area Review also included the presence of serosanguinous drainage (a mixture of clear watery fluid and blood from the area). The next description on the document is dated September 9, 2025, and identified the area on the right heel at a Stage III (a wound where the skin has broken open and the damage extends into the deeper tissue beneath the skin. It looks like a deep hole) area measuring 4cm (length), 3cm (width), and 0.2 cm (depth). There was also noted a moderate amount of serosanguinous drainage documented on the September 9, 2025, observation. The evaluation of the right heel open area on September 9, 2025, identified an increase in size and deteriorating status. On August 31, 2025, the open area was identified as Stage II pressure area compared to the Stage III pressure area designation on the September 9, 2025, observation. The documentation dated September 9, 2025, also noted Resident 44's right heel was evaluated by the consulting wound care physician. An observation of the right heel, open area was completed on November 20, 2025, at 2:38 PM in the presence of Employee 11 LPN (licensed practical nurse). An open area was observed on the right heel, clear, watery fluid was noted in the open area and on the former dressing. Employee 11 removed the former dressing with the assistance of application of a moist dressing as the former dressing on the right heel adhered to the open area and could not be removed freely. The right heel open area was observed to have a bright red center, there was depth to the area, was oval shaped covering most of the right heel, and observed to have a dry, white perimeter. A clinical record review of the Documentation Survey Report v2 revealed that Resident 44's comprehensive care plan included an intervention for heel elevation to prevent skin injury. Heel elevation refers to positioning the feet so that the heels are lifted completely off the surface of the bed to remove pressure, which is a known contributing factor to pressure injuries. Review of the August 2025 Documentation Survey Report v2 identified that there was no documentation verifying that Resident 44's heels were elevated off the bed on the following dates: August 4, 6, 7, 8, 9, 16, 24, 25, 27, 28, and 31. Additionally, there was no evidence that the heels were elevated during the evening shift on August 8 and August 26. The document also lacked verification that the resident's heels were elevated during the night shift on August 31. For the month of August 2025, there was no evidence that heel elevation was implemented on a total of 14 occurrences as required to reduce pressure to the skin. A review of the Documentation Survey Report v2 for September 2025 revealed continued absence of documentation verifying implementation of heel elevation. The report lacked evidence that Resident 44's heels were elevated on the following dates: September 6, 22, 23, 26, 28, and 29. There was no documentation verifying that heel elevation was completed during the evening shift on September 5, 6, 12, 16, 18, 19, and 29. Additionally, there was no documentation verifying that heel elevation occurred during the night shift on September 30, 2025. For the month of September 2025, there were 14 instances in which there was no evidence that heel elevation was implemented to prevent further skin injury. The Documentation Survey Report v2 for August 2025 also identified that Resident 44's care plan required repositioning every two hours. Repositioning refers to changing the resident's body position at regular intervals to relieve and redistribute pressure to prevent skin breakdown (damage to the skin that may progress to open wounds). Review of the report revealed no documentation verifying that repositioning occurred during night shift on August 1, 2025. The report also lacked documentation confirming repositioning on August 4, 6, 7, 8, 9, 16, 23, 24, 28, 29, and 31. Further review revealed no documentation verifying repositioning during the evening shift on August 8 and August 11. For August 2025, there was no evidence that repositioning was completed every two hours on 12 days as care planned. Review of the Documentation Survey Report v2 for September 2025 identified that there was no documentation verifying that repositioning was completed on September 4, 6, 22, 23, 24, 26, 28, and 29. Evening shift documentation did not include evidence of repositioning on September 5, 6, 12, 19, 20, and 29. The report also lacked verification that repositioning occurred during the night shift on September 5 and September 14. For the month of September 2025, there was no evidence that Resident 44 was repositioned every two hours on 13 days to prevent skin breakdown. During an interview with the Director of Nursing (DON) on November 20, 2025, at 11:40 AM, the information above was reviewed. No additional documentation or information was provided at that time to show that the interventions for heel elevation and repositioning were implemented as outlined in Resident 44's care plan to prevent skin injury and to prevent further deterioration of the open area on the resident's right heel.A review of the clinical record revealed Resident 77 was admitted from the hospital to the facility on October 17, 2025, with diagnoses that included dementia (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 fracture of right humerus (break in the upper arm bone, which connects the shoulder to the elbow). A review of a hospital discharge note dated October 16, 2025, revealed the resident had a Stage 1 (early sign of skin damage caused by pressure appearing as an area of intact skin that is red and does not fade when pressed) pressure ulcer (no size noted) to the sacrum (large triangular bone at the base of the spine). The recommended order was Calmoseptine (moisture barrier ointment that promotes healing of minor skin irritations) mixed with Aquaphor (skin protectant) to groin, inner and posterior thighs, coccyx, sacrum, and buttocks three times per day.A review of an admission nursing skin assessment dated [DATE], revealed the resident had a skin tear to the right wrist. The admission nursing skin assessment did not identify the presence of any pressure ulcers.A review of nursing documentation dated October 18, 2025, identified a follow-up entry related to the admission skin assessment completed on October 17, 2025. The documentation indicated that the resident had an open area on the coccyx (the small bone at the bottom of the spine directly below the sacrum) that measured 1.5 cm by 1 cm by less than 0.1 cm. The documentation did not include a stage, description of the wound's appearance or characteristics, assessment of the wound bed or surrounding skin, or information indicating whether any drainage or odor was present. A pressure ulcer is an injury to the skin and underlying tissue caused by prolonged pressure, and proper assessment includes identifying the stage and describing the wound in detail to guide treatment and prevent worsening. A physician order dated October 17, 2025, documented an order with a start date of October 19, 2025, to cleanse the area with normal saline (a wound cleansing solution), apply Calcium Alginate (a wound treatment that absorbs drainage), and cover with a border dressing once daily for the open area to the coccyx. A physician order dated October 18, 2025, included a direction to consult wound care. A physician order dated October 19, 2025, documented discontinuation of the original dressing order. Also on October 19, 2025, a new physician order directed staff to cleanse the area to the sacrum with normal saline, pat dry, apply Calcium Alginate to the open area, and cover with a border dressing once daily until healed, and to alert the physician if worsening occurred. Review of an Initial Wound Evaluation and Management Summary from an outside wound care specialist dated October 21, 2025, identified that the resident had a Stage III pressure ulcer (full-thickness tissue loss exposing fatty tissue) on the sacrum measuring 1.3 cm (length) by 0.8 cm (width) by 0.2 cm (depth). The wound exhibited moderate serous exudate (thin clear pale-yellow fluid), 30 percent slough (nonviable yellow, tan, gray, green, or brown tissue that is usually moist and may appear soft or stringy), and 70 percent granulation tissue (pink or red moist tissue that forms as a wound begins to heal). The pressure ulcer was debrided (removal of dead tissue) at a depth of 0.3 cm, and healthy bleeding was observed. Following the procedure, the percentage of nonviable tissue in the wound bed decreased from 30 percent to 0 percent. The dressing treatment plan developed by the wound care specialist included applying Calcium Alginate once daily and as needed if saturated, soiled, or dislodged for 30 days, along with gauze island with border dressing once daily and as needed if saturated, soiled, or dislodged for 30 days. Review of Resident 77's October Treatment Administration Record confirmed that the first documented treatment to the pressure ulcer on the sacrum occurred on October 19, 2025. Review of the October Task Documentation Report identified that the task to turn and reposition the resident every two hours was first documented on October 19, 2025, despite the resident being admitted to the facility on [DATE]. Repositioning is a pressure prevention intervention that involves changing a resident's body position at regular intervals to relieve and redistribute pressure to prevent skin breakdown. During an interview with the Director of Nursing (DON) on November 20, 2025, at 11:00 AM, the information above was reviewed. No additional documentation or information was provided at that time to show that the facility completed a timely wound assessment or implemented prompt and adequate measures upon admission to promote healing and prevent worsening of the pressure ulcer on the resident's sacrum. 28 Pa. Code 211.5 (f)(i)(ii)(iii)(v) Medical records.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to follow physician orders for medication administration for three resident out of 27 sampled (Resident 121, 124, and 46). Findings include: 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 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. Review of the facility policy titled Medication Administration last reviewed by the facility on September 6, 2024, revealed that the licensed nurse will administer medications following the Rights of Medication Administration listed below: a. Right Drug b. Right Resident c. Right Time d. Right Dose e. Right Route f. Right Dosage Form. g. Right Reason A review of Resident 121's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include hypertension (high blood pressure) and end stage renal disease (final, permanent stage of chronic kidney disease, where the kidneys can no longer function on their own). A physician order dated December 23, 2024, and discontinued January 16, 2025, was noted for Carvedilol Tablet (used to treat high blood pressure) 6.25 milligrams (mg) daily. Give one tablet by mouth two times a day related to hypertension. Hold this medication if the resident's systolic blood pressure is less than 100 millimeters of mercury (mm Hg) or heart rate is less than 60 beats per minute. Review of the resident's corresponding Medication Administration Records for the months of December 2024, and January 2025, revealed the medication was being administered without documented evidence the resident's blood pressure and/or heart rate had been obtained prior in accordance with physician's orders from December 23, 2024 to January 16, 2025. A review of Resident 124's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include hypertension (high blood pressure) and chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A physician order dated November 29, 2024, remaining current at the time of the survey, was noted for Atenolol tablet (used to treat high blood pressure) 25 milligrams (mg). Give one tablet by mouth one time a day for hypertension. Hold this medication if the resident's systolic blood pressure is less than 100 millimeters of mercury (mm Hg) or heart rate is less than 60 beats per minute. Review of the resident's corresponding Medication Administration Records for the months of November 2024, December 2024, and January 2025, revealed the medication was being administered without documented evidence the resident's blood pressure and/or heart rate had been consistently obtained prior in accordance with physician's orders from November 29, 2024. Review of Resident 46's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included hypertension, depression, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A physician order dated April 15, 2024, remaining current at the time of the survey ending January 24, 2025, was noted for metoprolol tartrate 25mg orally two times a day for hypertension. Instructions included to hold the medication for a blood pressure less than 100 and heart rate less than 60. Further review of the physician orders revealed an additional order dated April 15, 2024, for Norvasc 5mg orally two times a day for hypertension. Instructions for administration were to hold the medication for a systolic blood pressure less than 110 and a heart rate less than 60. A review of the resident's Medication Administration Records dated December 2024 and January 2025 failed to provide evidence that Resident 46's blood pressure or heart rate was monitored prior to the administration of the antihypertensive medications. Interview with the Clinical Operations Executive on January 23, 2025, at 9:30 AM verified that nursing staff failed to consistently obtain Residents 121, 124 and 46 blood pressure and /or heart rate prior to administering the medication to ensure its necessity and adherence to physician prescribed parameters for administration. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f)(i)(x)(xi) Medical records 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies

Based on a review of clinical records and staff interview, it was determined the consultant pharmacist failed to identify drug irregularities (dual anti-depressant therapy and justification for antipsychotic medication) when completing monthly medication reviews and the facility failed to assure that resident's attending physician timely acted upon pharmacist identified irregularities in the medication regimen for two residents out of five residents sampled for unnecessary medications (Residents 114 and 130). Findings included: Review of Resident 114's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia with behavioral disturbances (is a general term that describes the deterioration of memory, language, and other thinking abilities and can be accompanied by behavioral and psychological symptoms such as agitation, anxiety, and psychosis) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that affects how one feels, thinks, and behaves and can lead to a variety of emotional and physical problems). A review of the resident's physician's order dated June 6, 2024, 8:30 PM, revealed an order for Venlafaxine HCL Extended Release 24 Hour (an antidepressant) 75 mg (milligrams), give one capsule by mouth one time a day related to unspecified depression. Additionally, a review physician's orders dated June 7, 2024, at 9:30 AM, revealed the attending physician increased the resident's dose of Venlafaxine HCl ER Tablet Extended Release 24 Hour 75 MG, to give 2 tablets (150 mg) by mouth one time a day related to unspecified depression. A review of nursing progress notes in Resident 114's clinical record revealed a Change in Condition note completed by Employee 3, Licensed Practical Nurse (LPN), dated July 12, 2024, at 11:09 AM, revealed a change in condition assessment was completed related to the resident's attending physician increasing the Venlafaxine related to increased depression. A review of the resident's physician's order dated July 14, 2024, 8:00 PM, revealed an order for Venlafaxine HCL Extended Release 24 Hour 75 mg, give 2 capsules by mouth twice per day at bedtime related to unspecified depression. A review of a Psychiatric Assessment progress note completed by the facility's consultant Psychiatric Mental Health Nurse Practitioner (PMHNP) dated September 25, 2024, at 11:38 AM, revealed Resident 114's mood has deteriorated since last visit (September 18, 2024) and resident agitated and confrontational to other residents. His mood had been deteriorating since before the death of his wife, and only stands to continue to be exacerbated by the grieving process. Furthermore, his poor cognition limits his ability to go through the normal grieving process. Recommend antidepressant coverage at this time and plan to start Mirtazapine (an antidepressant used to treat depression) 7. 5mg orally at bedtime for depression and continue Venlafaxine 75 mg by mouth in the morning for depression and Venlafaxine 150mg by mouth at bedtime for depression. Further review of physician's orders dated September 27, 2024, at 8:30 PM, revealed an order for Mirtazapine oral tablet (an antidepressant used to treat depression) 7.5 mg, give 1 tablet by mouth in the evening for as ordered related to diagnosis of unspecified depression. Despite the presence of duplicate antidepressant therapy (Venlafaxine and Mirtazapine), a review of the consultant pharmacist's medication regimen reviews failed to identify this irregularity. The resident's clinical record lacked documentation of pharmacist recommendations to assess the appropriateness of duplicate therapy or a documented clinical rationale justifying the prescribing of two antidepressants. A review of Resident 130's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia with severe agitation (a person is restless and worried, and unable able to settle down with behaviors that may include pacing, not be able to sleep, or act aggressively toward others) and depression. A review of physician's orders dated August 30, 2024, at 8:30 PM, revealed an order for Olanzapine Oral Tablet 2.5 mg (atypical antipsychotic), for dementia with agitation. CMS regulations require that a clinical rationale or diagnosis must support the use of antipsychotic medications, yet the consultant pharmacist's new admission medication review on September 4, 2024, failed to identify a lack of documented justification for the continued use of Olanzapine. A review of physician's orders in Resident 130's clinical record dated August 30, 2024, at 8:30 AM, revealed orders for Aricept (used to manage dementia and can help improve attention, memory, behavior, and ability to do daily activities) 10 mg, give 1 tablet daily at bedtime related to dementia. Further review of physician's orders revealed an order dated August 31, 2024, at 8:00 AM, for Aricept 5 mg, give 1 tablet by mouth one time a day for dementia. A review of the facility's consultant pharmacist's new admission medication regime review (MMR) dated September 4, 2024, identified the resident had a current order for Aricept and that there were two active orders for 10 mg and 5 mg without specification stating the total dose of 15 mg. Optimal timing for Aricept was to be given at bedtime and indicated the physician's order had 10 mg at bedtime and 5 mg in the morning and requested for the physician to review. The consultant pharmacist identified this discrepancy but failed to ensure timely physician action, as the resident continued receiving the medication as prescribed without clarification or modification through January 8, 2025. Further review of the clinical record failed to reveal that the resident's attending physician timely addressed the consultant pharmacist new admission medication regime review (MMR) that was completed on September 4, 2024, related to prescribing practices for Aricept. An interview with the Director of Nursing (DON) on January 24, 2025, at 10:15 AM, confirmed the consultant pharmacist failed to identify and address medication regimen irregularities for Residents 114 and 130. The DON also confirmed Resident 130's attending physician failed to timely act upon the pharmacist's recommendations and did not provide a documented clinical rationale for the continued use of antipsychotic medication 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director.

Based on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of three residents out of 27 residents sampled (Residents 27, 124, and 102). Findings include: A review of Resident 27's clinical record revealed the resident was transferred to the hospital on November 27, 2024, and returned to the facility on [DATE]. A review of Resident 124's clinical record revealed the resident was transferred to the hospital on November 26, 2024, and returned to the facility on [DATE]. A review of Resident 102's clinical record revealed the resident was transferred to the hospital on December 10, 2024, and returned to the facility on [DATE]. There was no documented evidence the facility provided these residents and/or their representatives written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) at the time of transfer. Interview with the Clinical Operations Executive on January 23, 2025, at 12:45 PM confirmed the facility was unable to provide documented evidence of the provision of written notice of the facility's bed hold policy upon hospital transfer. 28 Pa Code 201.18 (e)(1) Management 28 Pa Code 201.29 (b) Resident rights

Based on a review of facility's abuse policy, clinical records, and select investigative reports and staff interview it was determined the facility failed to assure that one resident (Resident 289) was free from sexual abuse perpetrated by another resident (Resident 102) and one resident (Resident 25) was free from neglect out of 27 residents sampled. Findings included: A review of the current facility policy titled Abuse Prohibition, last reviewed by the facility on September 6, 2024, revealed it is the policy of the facility to provide a safe environment where residents are not subject to mental, physical, sexual, and verbal abuse or neglect by staff, residents, volunteers, consultants, contractors, and other caregivers, visitors or family members. The current policy titled Identifying Types of Abuse last reviewed by the facility on September 6, 2024, defined sexual abuse as non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: a. Unwanted intimate touching of any kind especially of breasts or perineal area. b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity. c. Forced observation of masturbation and/or pornography; and d. Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. A review of Resident 102's clinical record revealed admission to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), hypertension (high blood pressure), and depression. An admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment completed periodically to plan resident care) dated September 27, 2024, indicated the resident was moderately cognitively impaired with a BIMS (brief interview of mental status to a tool to assess the resident's attention, orientation and ability to register and recall new information) a score of 9 (8-12 represents moderate cognitive impairment). Facility documentation indicated a pattern of sexually inappropriate behaviors by Resident 102 prior to the reported incident involving Resident 289: A review of nursing documentation dated September 24, 2024, at 12:27 PM revealed Resident 102 was noted to be sitting close to Resident 91 and making inappropriate comments and gestures of a sexual nature while speaking to her. The nurse approached Resident 102 and explained that his behaviors are inappropriate. Redirection provided with positive effect. A review of nursing documentation On September 26, 2024, at 1:19 AM, Resident 102 was observed naked in the hallway and attempting to enter another resident's room. Resident 102 placed his soiled brief next to a resident's door. Nurse aides provided incontinence care to the resident, and he returned to bed. A review of Resident 102's plan of care, initiated October 3, 2024, revealed the resident had the potential to be verbally aggressive due to dementia, ineffective coping skills, poor impulse control as evidenced by his use of socially inappropriate statements and language, negative statements toward others, and overhead making sexually explicit comments to a female resident. Care plan interventions were as follows: Providing privacy and emotional support as needed. Redirecting him with conversations about his job. Reinforcing that staff are present to assist with care and are honest in their communication. Identifying and minimizing triggers for verbal aggression, such as noise levels. Offering a tour of his surroundings to help de-escalate behaviors. Encouraging him to call his daughter. Supporting participation in activities. Assessing his understanding of situations and behaviors. Encouraging him to express his thoughts and feelings. Providing choices regarding care and activities. Reinforcing positive behaviors with appropriate encouragement A review of Resident 289's clinical record revealed admission to the facility on [DATE], with diagnoses to include Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions). An admission MDS dated [DATE], revealed the resident was severely cognitively impaired with a BIMS score of 3 (a score of 0-7 indicates severe cognitive impairment). Resident 289 did not possess the mental capacity to consent to sexual contact and activity. A review of the Employee 4 (licensed practical nurse) witness statement dated October 7, 2024, at 9:30 AM revealed that Resident 102 was observed in the lunchroom with Resident 289. Resident 289's hand was on Resident 102's lap, while Resident 102 was holding Resident 289's hand on his genital region. Staff immediately intervened, separating the two residents. Resident 289 expressed discomfort and confusion about the incident, stating that it was gross and that they did not understand why it had occurred. Social Services was contacted right away to address the situation. A review of facility documentation dated October 9, 2024, at 4:12 PM showed that the Director of Nursing (DON) was informed of a staff-written statement regarding an incident that occurred on October 8, 2024. The statement described a reportable event, prompting an ongoing investigation. The physician was notified, and the incident was reported to the Department of Health and local law enforcement. The facility also reported the event to Adult Protective Services (AAA). Resident 289's representative was contacted and informed of the situation. Emotional support was provided to Resident 289, who did not recall the incident. As a precautionary measure, Resident 289 was placed on fifteen-minute safety checks, and staff were instructed to ensure that Resident 289 and Resident 102 remained separated. Despite the incident occurring on October 7th 2024 documentation regarding the event and the decision to implement safety measures was not completed until October 9th 2024 resulting in a 2 day delay in reporting and intervention. Interview with the Clinical Operations Executive on January 24, 2025, at approximately 11:15 AM confirmed that Resident 102 displayed sexually inappropriate behaviors, and that the facility failed to ensure that Resident 289 was free from sexual harassment perpetrated by Resident 102 by not implementing sufficient interventions to address Resident 102's identified pattern of inappropriate behaviors. Review of clinical record revealed Resident 25 was admitted to the facility on [DATE], with diagnoses which included depression, arthritis, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of the plan of care for Resident 25 revealed that the resident required the assist of 2 staff members and the use of a sit-to-stand lift for toileting and transfers. Review of facility investigation dated December 26, 2024, at 10:30 AM, revealed that Resident 25 was assisted to the bathroom by Employee 6, nurse aide. Review of witness statement completed by Employee 6, she assisted Resident 25 out of his wheelchair by putting my whole right arm under his right arm. Employee 6 then proceeded to walk the resident to the bathroom with the assistance of a walker, he got unsteady on his feet and began to slowly go backwards. I tried to catch him to ease the fall. He landed on his bottom. Review of witness statement completed by Employee 1, LPN, dated December 23, 2024, indicated that when resident was assigned to new aide, aide was advised he was an Apex [sit-to-stand lift]. Review of personnel file for Employee 6 revealed a hire date of November 5, 2024. According to the employee's file, education was provided regarding the facility's abuse policy and procedures upon hire. Interview with the Director of Nursing on January 24, 2025, at 11 AM confirmed that Employee 6 failed to follow Resident 25's plan of care which resulted in a fall without injury. 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment on one of four resident care units (5th floor). Findings include: An observation on January 23, 2024, at approximately 9:40 AM revealed in a Broda chair in the hallway outside room [ROOM NUMBER] revealed the following: The seat of the chair was heavily soiled with a crusty orange substance. The footrest was heavily soiled with a dried white and brown substance. The rear wheels were heavily soiled with dirt and debris with a significant amount of hair entangled in the base. Further observation of room [ROOM NUMBER] revealed a fall mat on the floor beside the resident's bed (nearest the door). The mat had large tears at its folding point and on the front corner, exposing the internal foam. Interview with Employee 1, licensed practical nurse, on January 23, 2024, at approximately 9:50 AM, confirmed the observations. Interview with the Director of Nursing and Nursing Home Administrator on January 23, 2024, at approximately 1:30 PM both confirmed that resident care equipment is to be maintained in a clean and sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management

APPEAL FILED Based on review of clinical records and select facility investigative reports and staff interviews it was determined that the facility failed to provide necessary staff assistance as planned, and utilize safe technique during assistance with activities of daily living, to prevent an accident resulting in multiple fractures for one out of 11 residents reviewed (Resident CR1). Findings include: A review of Resident CR1's most recent MDS (minimum data set-standardized assessment process conducted at periodic intervals to assess resident care needs) dated (MONTH) 27, 2019, revealed that the resident required extensive assistance of two staff members for bed mobility, toileting, hygiene and transfers. Additionally, the resident was determined to have impairment of movement to both the upper and lower extremities to the one side of her body (right-side) related to [MEDICAL CONDITION] and [MEDICAL CONDITION] due to a cerebral infarct. The resident was severely cognitively impaired with a BIMS score of 5 (brief interview for mental status-a tool to assess cognitive function - a score of 0-7 indicates severe cognitive impairment). A review of the resident's comprehensive plan of care dated (MONTH) 13, 2019, and last updated by the facility on (MONTH) 11, 2019, along with a review of the care card (guide for direct caregivers on the resident's specific needs for assistance with activities of daily living) utilized by the nurse aides revealed that the resident was dependent on two staff members for assistance with bed mobility, toileting, hygiene and transfers. Further review of the resident's clinical record and a facility investigation into a resident incident revealed that on (MONTH) 9, 2019, at 4:15 p.m., the resident was observed on the floor in her room, between the beds, on her left side. The resident complained of left shoulder pain and was observed with a 3 cm round injury to the left temple. The facility fall report noted 911 was called to transfer the resident to stretcher from off of the floor to ER at {hospital name}. The resident was transferred to the hospital and diagnosed with [REDACTED]. A review of the facility investigation into the incident revealed that two nurse aides, Employees 1 and Employee 2, used the hoyer lift to transfer Resident CR1 from the wheelchair into the bed to perform incontinency care on the resident. The resident had been incontinent while attending an activity (bingo) and the nurse aides returned the resident to her room for the transfer into bed, from the wheelchair, to provide incontinency care. According to the statement Employee 1 provided to the facility, Employee 2 left the resident's room to use the restroom and told Employee 1 she would return to assist her in performing Resident CR1's incontinence care. Employee 1's statement further indicated that the resident had been incontinent of bowel. Employee 1 stated that she proceeded to clean the resident while the resident was lying flat in bed. Employee 1 alleged that she waited 10 minutes for Employee 2 to return from the restroom and when she did not return Employee 1 proceeded to turn the resident in bed herself, without the assistance of another staff person. The resident rolled from the bed and landed on her left side on the floor. The resident's bed was described as being in the highest position. There was no evidence that Employee 1 had attempted to summon the assistance of another staff member, as planned and necessary for the resident's care. A review of information dated (MONTH) 9, 2019, submitted by the facility revealed that Employee 1 decided to turn the resident by herself because her coworker was gone for about 10 minutes. She (Employee 1) did not call or request assistance from anyone else. She stated that she rolled the resident over and she went off the bed onto her left shoulder onto the floor. It was noted that an LPN (Employee 3) was on her way up the hall and heard Resident CR1 groaning. Employee 3 went in the room and saw the resident on the floor. Employee 1 was the only one in the room (with the resident). A review of the facility's fall report dated (MONTH) 9, 2019, at 4:15 PM revealed that the resident experienced a witnessed fall. The fall report noted that the resident stated I should never have been rolled. The Supervisor's summary of findings indicated bed mobility assist of 2. Resident was rolled to right side (the resident's affected side) in bed by one and rolled out of bed to floor. Intervention to prevent recurrence was noted as staff CNA disciplined for not having assist of two with care, bed mobility. A review of Employee 2's statement revealed that she had assisted Employee 1 with transferring Resident CR1 into bed. Employee 2 stated that she informed Employee 1 prior to the resident's transfer into bed that she needed to leave to use the restroom. Employee 2 stated that she told Employee 1 to call her back, after she had assembled the supplies necessary for the resident's care. Employee 2 stated that Employee 1 never called her back into Resident CR1's room to assist with the resident's incontinency care. Employee 2, was interviewed on (MONTH) 18, 2019, at 2:55 p.m. She confirmed that she had assisted Employee 1 with transferring Resident CR1 from the wheelchair into the bed for the purpose of providing incontinency care. Employee 2 stated that she had informed Employee 1 that she had to use the restroom. Employee 2 added that Employee 1 had not assembled any of the supplies she needed for the resident's care. Employee 2 stated that she told Employee 1 to call her when she had the necessary supplies assembled. Employee 2 stated that Resident CR1's bed was in the low position when she left the room. Employee 2 stated that Employee 1 never called for her assistance and she made the assumption that someone else had assisted her with Resident CR1's care until she heard a commotion and it was found that the resident had fallen out of bed. Interview with the Administrator on (MONTH) 18, 2019, at 3 PM confirmed that Employee 1 had been providing care to Resident CR1 without the assistance of another staff member as the resident required. The NHA verified that the facility determined that Employee 1 rolled the resident away from her while the resident was in bed, which was in the high position and the resident fell from bed to the floor sustaining multiple fractures. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing Services. Previously cited:1/25/19, 9/25/18.

Based on observations, a review of clinical records, select facility policy and procedures, facility forms/documentation and resident incident/accident reports and staff interviews, it was determined that the facility failed to consistently implement interventions, including adequate and timely staff supervision, designed to promote resident safety and prevent falls for three residents (Residents 62, 132 and 65) and serious injury to two residents (Residents 132 and 65) out of 25 residents reviewed. Findings include: The facility policy entitled, Resident Monitoring, dated as reviewed by the facility on January 2, 2017, revealed that the Charge Nurse would assess the residents' environment and residents' care needs on the unit at the beginning of each shift and throughout the shift. Based on the Charge Nurse's assessment of the residents' environment and residents' care needs the Charge Nurse would assign staff to monitor general resident care needs in the high visibility areas. For those residents that require additional supervision other interventions would be implemented based on the individualized needs of the residents. Should the staff member assigned to monitor the high visibility area need assistance they are to ask verbally for assistance or use the call bell system to summon staff. The Charge Nurse is to ensure that monitoring is completed to meet the residents' care needs. The Charge Nurse will inform the Unit Manager or Nursing Supervisor of any concerns. Staff members assigned to monitor the high visibility area will be relieved by another staff member once off going staff have reported all pertinent information to the on coming staff member. A review of the clinical record revealed that Resident 62 had [DIAGNOSES REDACTED].g., inability to recognize family)), minimal verbal communication, loss of ambulatory abilities, the inability to perform the activities of daily living (ADLs - routine activities that people tend do every day without needing assistance, including eating, bathing, dressing, toileting, transferring , walking and urinary and fecal incontinence), vertigo (episodes of dizziness and a sensation of spinning with certain head movements) and lack of coordination. According to a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 3, 2017, revealed that the resident was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool to used to assess cognitive function, a score of 0-7 indicates severe cognitive impairment), was sometimes understood and sometimes understands others. According to this MDS assessment the resident had periods of disorganized thinking, physical, verbal, behavioral symptoms directed towards others and other behavioral symptoms not directed towards others. The resident required extensive assistance of one staff for most activities of daily living. The resident had functional limitations in range of motion (movement potential of a joint, usually its range of flexion and extension) of the lower extremities and was not steady. The resident was only able to be stabilized with staff assistance for moving from a seated to standing position, walking, moving on and off the toilet and surface to surface transfer between the bed and chair or wheelchair. The resident utilized a walker and wheelchair to assist in mobility. A review of a Fall Risk Assessment indicated that the resident's score of 24 (a score above 10 indicates that the resident is at risk for falling) and the resident had a history of [REDACTED]. According to nursing documentation, the resident frequently exhibited behaviors, which occurred at various times of the day, but also escalated during the evening and night shift. These documented behaviors included being up all night, agitation, restlessness, combativeness, attempting to climb out of a recliner or wheelchair, attempting to ambulate unassisted, resistiveness to care and lack of safety awareness as per nursing documentation on December 10, 2016, at 6:00 AM, January 3, 2017, at 9:30 PM, January 13, 2017, at 9:00 PM, January 31, 2017, at 1:30 AM, 2:00 AM, 3:00 AM, 5:45 AM, February 1, 2017, at 12:45 AM, February 5, 2017 at 1:15 AM, February 17, 2017, at 9:00 PM, February 20, 2017, at 7:15 AM and 7:30 AM, February 21, 2017, at 1:30 AM, 6:00 AM, February 23, 2017 at 6:00 AM, February 26, 2017, at 8:00 PM, February 27, 2017, at 6:00 AM, March 5, 2017, at 6:00 AM, 10 PM, March 6, 2017, at 2:00 AM, March 7, 2017, at 4:00 AM, 9:00 PM, March 8, 2017, at 12:05 AM -12:15 AM, 12:45 AM, March 9, 2017, at 4:00 AM, March 10, 2017, at 10:00 P, March 11, 2017, at 5:00 AM, and March 14, 2017, at 5:00 AM. Observations of the third floor common area on March 17, 2017, and March 20, 2017, revealed that residents were assembled in the common area, which encompassed the nursing station, a kitchenette and a sitting area. During an interview with the Assistant Director of Nursing on March 17, 2017, at 1:55 PM she indicated that the common area is to be supervised by staff assigned to the area in 15 minute increments and residents are not left alone in the common area. According to an interview with Employee 8, a Nurse Aide, on March 20, 2017, at approximately 11:00 AM the staff are assigned in increments of 15 minutes to observe residents in this common area. Residents are not to be left alone when seated in the common area and if staff need to leave their assigned watch, then another staff member is to replace the assigned staff member to watch the residents. The staff member assigned to observe residents in the common area in 15 minute increments is identified as documented on the Watch Sheet. Review of nursing documentation dated March 8, 2017, revealed that between 12:05 AM and 12:15 AM on that date, Resident 62 was seated in a recliner in the common area and was continually moving in the recliner and attempting to get up from the chair. Nursing noted that the resident was given emotional support, fluids, busy hands (item given to the resident to occupy her) and was toileted, but the resident was still restless. Review of nursing documentation completed by Employee 1, a Registered (RN) Nurse Supervisor, on March 8, 2017, at 12:45 AM indicated that a nursing staff member (not identified) called this RN to the nursing unit to evaluate the resident. The resident had gotten herself out of her recliner and landed face first on the floor of the common area (specifically where in the common area was not noted). A nurse aide heard the tab bell alarm (a personal patient safety alarm) sounding and responded to the common area. The resident had sustained a bruise over the bridge of her nose, and a 2.5 centimeter (cm) bump on the right side of forehead above her eye as the result of the fall from the recliner chair. Blood was also noted in the resident's left nostril. Nursing noted that the resident was receiving Warfarin (an anticoagulant medication utilized to thin the blood and prevent blood clot formation). At 1:00 AM on March 8, 2017, the physician was made aware of the resident's fall and directed that the resident be sent to the emergency room for an evaluation due to the resident receiving anticoagulant therapy. At 1:15 AM, the resident was transferred to the hospital. A review of hospital records dated March 8, 2017, indicated that the resident was sent to the emergency room when she apparently fell forward out of her chair and hit the bridge of the nose. It was unclear if the resident lost consciousness. The resident was brought to the emergency department where the resident was mildly lethargic, mumbling and unable to give a history. It was noted that the resident sustained [REDACTED]. It was also noted that the resident had [DIAGNOSES REDACTED] (broad term for any brain disease that alters brain function or structure) likely due to head injury plus a urinary tract infection (an infection in any part of the urinary system). Review of a facility Fall/Found on Floor Event Report, dated March 8, 2017, at 11:45 AM indicated that the resident was sitting in a recliner in the common area. The alarm sounded and when the nurse, Employee 4, LPN (Licensed Practical Nurse), returned to the common area, the resident was flat on her stomach on the floor in front of the recliner chair. The resident said, I hurt myself. I hit my nose. The resident was noted with blood coming from the left nostril. The resident indicated, I was trying to help. It was noted that there was a bruise over the bridge of the resident's nose and a bump over the right forehead. According to a statement provided by Employee 2, a Nurse Aide, as part of the facility's investigation into the resident's fall, Employee 2 had been sitting in the common area with Resident 62, who was the only resident out of bed and in the area at that time. Employee 4 was passing medications at that time and had responded to another resident's (Resident 72's) alarm. Employee 4 stated that she tried to get Resident 72 into bed and the resident said he had to go to the bathroom. Employee 4 called Employee 2 for help and they took Resident 72 to the bathroom. Employees 4 and 2 heard Resident 62's alarm go off and Employee 2 stayed in the bathroom with Resident 72 while Employee 4 responded to Resident 62's alarm. During a telephone interview conducted on March 20, 2017, at approximately 8:35 AM with Employee 1, the 11 PM to 7 AM Registered Nurse Supervisor who had been on duty on March 8, 2017, the employee confirmed that Employee 2, should not have left Resident 62 unattended in the common area on the night of the resident's fall from the recliner. Employee 1 indicated that Resident 62 does not stay in bed to sleep and that she spends most of her time in the recliner in the common area during the night shift. Employee 1 stated that someone should always be there in the common area with the resident. He also stated that there were two Nurse Aides assigned to the unit on the night shift at the time of the fall, Employees 2 and 3, along with the Charge Nurse, Employee 4, LPN. At the beginning of the shift the Charge Nurse will pass medications, get her creams ready (for treatments) and the Nurse Aide will be on watch. When it is time for the Nurse Aides to do rounds (the act of seeing or checking the residents) the Charge Nurse will be on watch. If the Charge Nurse needs help then she will call the RN Supervisor. Employee 1 stated nobody asked for him to stay on watch at that time (of the resident's unattended fall). A telephone interview conducted with Employee 2, Nurse Aide, on March 20, 2017, at approximately 9:30 AM revealed that Employee 2 confirmed that she left Resident 62 alone in the common area to assist Employee 4 (LPN) with another resident (Resident 72), when Employee 4 had called for her help. Employee 2 stated that the other Nurse Aide assigned to the unit that night (Employee 3) was on break at the time Employee 4 requested assistance and Resident 62 subsequently fell after being left unsupervised. Employee 2 also confirmed that Resident 62 does not stay in bed at night, sleeps in the recliner in the common area and that somebody stays on watch so the resident is in visual sight. Employee 2 also relayed that the resident gets restless at night. A telephone interview conducted with Employee 3, Nurse Aide, on March 20, 2017, at approximately 9:50 AM revealed that she, along with Employee 2 and Employee 4 were the only nursing staff assigned to work the unit on the 11 PM to 7 AM shift on March 8, 2017. Employee 3 confirmed that she was on break when Resident 62 fell , leaving only Employees 2 and 4 remaining to work on the unit. Employee 3 stated that when an employee is on watch someone should be physically present in the common area at all times with the resident and confirmed that Employee 2 was to be on watch with Resident 62 when Employee 3 went on break at the time of the resident's fall. Employee 4 was not available for interview during the survey ending March 20, 2017. Review of the Watch Sheet record for third floor (record of the schedule of staff members to be assigned to watch the common area in 15 minute increments when residents are present) dated March 7, 2017, which led into the night shift on March 8, 2017, revealed that the last time a staff member was assigned to remain on watch in the common area was at 3:30 PM (March 7, 2017). The next documentation of a staff member assigned to be on watch was on March 8, 2017, at 7:00 AM. When the Chief Operating Officer was interviewed on March 20, 2017, at approximately 8:30 AM regarding how Resident 62 was being supervised especially when she is in the common area, the Chief Operating Officer indicated that the staff are not necessarily assigned to be on a watch in the common area on the night shift. Interviews with Employees 2 and 3 conducted on March 20, 2017, revealed that the watch of Resident 62 in the common area should have continued during the 11 PM to 7 AM shift while the resident was present in the area. Resident 62 was identified at risk for falls, had a history of [REDACTED]. The facility failed to consistently provide sufficient staff supervision necessary to meet this resident's safety needs and prevent a fall with injury. A clinical record review revealed that Resident 132 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], revealed that the resident was cognitively impaired (a BIMS could not be completed), required the extensive assistance of one staff member for transfers, toileting, and ambulation. Review of the resident's activity of daily living care plan initiated April 25, 2016, revealed that the resident was to be ambulated with hand hold assistance or shadowed. A Fall Risk Assessment completed on January 20, 2017, revealed that the resident scored an 18 indicating that she was at risk for falls. A facility Fall/Found on Floor Report, dated February 18, 2017, at 3:55 AM revealed that Employee 7, a Nurse Aide, documented, I entered room when I saw the resident's call bell light lit. Upon entering the room I found the resident standing to the left side of the bed. I reached behind the bed to turn off the bed alarm. When I turned around to help the resident the resident was found with her back against the wall and her feet were facing the closet door. I stayed with the resident and called for help. According to nursing documentation dated February 18, 2017, and timed for 3:55 AM the resident was noted to be crying and complaining of pain in her right leg. The physician was made aware of the incident on February 18, 2017, at 4:10 AM and requested that the resident be transported to the hospital for evaluation. The resident was transferred to the hospital on the aforementioned date at 4:40 AM and diagnosed with [REDACTED]. A review of the facility's Wireless Nurse Call System policy and procedure reviewed by the facility January 2, 2017, revealed that once the resident's need are met, the staff member presses the cancel button on the call station in the resident's room to turn off the call. A message will be sent to the pagers when a call is canceled. The facility's wireless nurse call system, which is also integrated with residents' personal safety alarms, has the capability to produce details of the time taken to respond to a specific resident's call bell and alarm. At the time of the survey ending March 20, 2017, there was no evidence of the timeliness of the Employee 7's response to Resident 132's call bell. Based on the capability of the facility's wireless nurse call system to account for the timeliness of staff's response to residents' call bells and safety alarms, the facility was asked to provide any evidence of the time taken for Employee 7 to respond to Resident 132's call bell at the time of the resident's fall on February 18, 2017, but the facility declined to provide these wireless nurse call bell system details to the survey team. An interview with Employee 7 on March 20, 2017, at 8:27 AM revealed that Resident 132's bed alarm sounded and she went in the resident's room to answer it. Employee 7 observed the resident standing near the bottom of the resident's bed. The power box connecting to the bed alarm was observed inside the closed drawer of the resident's bedside stand. Employee 7 stated that she turned her back on the resident to silence the personal safety alarm (bed alarm) and when she turned back around the resident had already taken a few steps and had fallen to the floor. Employee 7 stated that she should have tended to the resident's need to use the bathroom before attempting to turn off the bed alarm. Employee 7 stated that the resident was calm when she arrived in the resident's room before the resident fell . Employee 7 also stated that the resident was a hand hold assist with ambulation. Interview with the Director of Nursing on March 17, 2017, at 10:00 AM failed to explain why the staff member attended to the task of turning off the resident's alarm before addressing and meeting the resident's need to be toileted to prevent the resident's fall with serious injury. A review of the clinical record revealed that Resident 65 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired with a BIMS score of 4 and required the extensive assistance of one staff member for transfers, toileting, and ambulation. The MDS assessment also indicated that the resident was unsteady while walking, moving from a seated to standing position and when transferring from the bed, chair and/or wheelchair and was only able to stabilize (balance) with staff assistance. Review of the resident's care plan initiated on April 1, 2016, and revised on December 16, 2016, revealed problematic areas that included impaired communication related to difficulty in understanding at times, cognition lost due to dementia, decline in intellectual functioning, ADL self care deficit related to dementia with behaviors and at risk for falls related to dementia, unsteady gait at times, decreased safety awareness and putting self on floor at times. The care planned interventions at the time and up until January 2017, included a low bed, gripper socks, physical therapy screening as needed, seated in common areas at all times, clip alarm (personal safety alarm clipped to resident) and to walk when restless or agitated. A Fall Risk Assessment completed on October 31, 2016, revealed that the resident scored a 17, indicating that she was at risk for falls. Review of a Physical Therapy Progress and Discharge Summary dated September 12, 2016, revealed that the resident varies from requiring supervision to assist of one, with ambulation and transfers. A review of the nursing documentation from December 3, 2016, at 2:15 PM through January 17, 2017, at 9:00 PM indicated similarly documented behaviors that included the following; restless, delusional - redirection with moderate effect, continual monitoring, resident found in bathroom, increased behaviors this shift, restless, attempting to walk unassisted, very hard to redirect, resident restless continues to self rise from chair & ambulate aimlessly, not easily re-directed - medicated for same, anxious, crying, cursing and attempting to ambulate without assistance, self-rising from chair, screaming and weeping attempting to walk unassisted, staff tried one to one and spoke calmly with resident and ineffective, continuously trying to self rise from chair, unaware of safety and status [REDACTED]. A review of a nurses' note dated December 16, 2016, at 10:50 AM and a corresponding Fall/Found on Floor Report, revealed that the nurse aide, while getting residents ready in the garden room on the Third Floor Nursing Unit, heard a thump and saw the resident lying on the floor (in the garden room) on her side attempting to stand independently. Further review of the report revealed that the resident was unable to realize her limitations, was non-complaint when calling for assistance, has impaired cognition, unsteady gait, walks/propels into objects in path and tries to self-transfer (but requires assist). Interventions implemented at that time to prevent recurrence included seating the resident in kitchen area for meals and in common area at all times. A review of a nurses' note dated January 17, 2017, at 12:25 PM and a corresponding Fall/Found on Floor Report, revealed that during lunch, resident continuously attempted to stand and ambulate becoming resistive to sitting while being fed, resident approached another resident and during (nursing) intervention of trying to redirect resident away from other resident, resident lost her balance and fell into nurse causing nurse to lose balance and both resident and staff fell (lowered) to the floor. Further review of the report indicted that the resident was unable to realize her limitations, was non-complaint when calling for assistance, has impaired cognition, unsteady gait, walks/propels into objects in path and tries to self-transfer (but requires assist). Interventions implemented at the time to prevent recurrence included a physical therapy evaluation and treatment secondary to unsteady gait and balance. Review of a Nursing to Therapy Communication Form dated January 17, 2017, revealed a request for a physical therapy (PT) evaluation due the resident's unsteady gait and balance. At the time, the therapist documented that staff reported the resident is harder to redirect during ambulation and more hunched over holding onto the rail with the assist of one staff and noted will schedule PT evaluation. Review of an initial PT evaluation dated January 19, 2017, at 9:59 AM revealed the, patient (resident) referred to PT secondary to recent fall on nursing unit and recent decline in ambulation and transfers. Per nursing, resident has required increased assistance with transfers and ambulation. Patient appeared more tired and fatigued during session secondary to being up all day and 'roaming' as per nursing. Recommending assist times two (with the assistance of two staff members) for transfers and ambulation at this time and use of wheel chair for transport as needed, secondary to increased fatigue and/or unsafe with ambulation. A review of a nurses' note dated January 19, 2017, at 7:00 AM and a corresponding Fall/Found on Floor Report, revealed that the staff found the resident on the floor in her room sitting up against the wall between the dressers in the room and her left leg was looking externally rotated. The report indicated that the bed alarm sounded and the call bell light went off. In addition, the report revealed that the nurse aide went into the room at approximately 6:30 AM for morning rounds and found the resident on the right side, at the edge of the resident's bed sleeping, and (the aide) repositioned her, also placing pillow as a bolster to minimize likelihood of rolling out of bed - not related to fall as resident found across room. The nurses' note and report indicated that the physician was notified and the resident was transferred to the hospital for evaluation and admitted with a intertrochanteric (the anatomic site of this type of hip fracture is the proximal or upper part of the femur or thigh bone) fracture of the left hip. Further review of the report indicted that the facility noted that the resident is unable to realize her limitations, is non-complaint when calling for assistance, has impaired cognition, unsteady gait, walks/propels into objects in path, tries to self-transfer (but requires assist), is combative and unsteady. At the time of the survey ending March 20, 2017, there was no evidence of the timeliness of the Employee 11's response to Resident 65's call bell and bed alarm. Based on the capability of the facility's wireless nurse call system to account for the timeliness of staff's response to residents' call bells and safety alarms, the facility was asked to provide documented evidence of the time taken for Employee 11 to respond to Resident 65's call bell at the time of the resident's fall on January 19, 2017, but the facility declined to provide these wireless nurse call bell system details to the survey team. An interview with the Chief Operating Officer, Clinical Operations Executive and Director of Nursing on March 17, 2017, at approximately 2:03 PM failed to provide documented evidence that effective safety interventions and/or sufficient and timely staff supervision was provided to this resident, with known unsafe behaviors and at risk for falls, to prevent this fall with serious injury. 483.25(d)(1)(2)(n)(1)-(3) Fee of Accident Hazards/Supervision/Devices Previously cited 1/15/15 28 Pa. Code 211.10(a)(d) Resident care policies Previously cited 2/10/16, 10/9/15, 1/15/15 28 Pa Code 211.12(a) Nursing services. Previously cited 2/10/16, 10/9/15, 1/15/15 28 Pa Code 211.12 (c)(d)(1)(5) Nursing services. Previously cited 3/10/16, 2/10/16, 10/9/15, 1/15/15

Based on review of select facility policy and clinical records, observation and staff interviews, it was determined that the facility failed to timely identify skin impairment for one resident (Resident 144) to prevent further breakdown and failed to implement a physician-ordered treatment to prevent the worsening of a healed pressure area for one of 24 sampled residents (Resident 153). Findings include: Review of the facility's policy entitled "Skin Integrity" dated December 17, 2014, revealed that it is the policy of the facility to ensure quality care to the residents through the identification and prevention/treatment of [REDACTED]. The policy also indicated that the resident's care plan will reflect risk of pressure ulcer development along with interventions and physican orders. Further review of the policy revealed that pressure ulcers can be defined/classified according to the localized injury to the skin and/or underlying tissue. Category II (Stage II) may present as a partial thickness loss of dermis presenting as a dry or shinny shallow open ulcer with a red pink wound bed. Unstageable/Unclassified can be considered unstageable due to the presence of slough (dead tissue that can appear yellow, tan, gray, green or brown) which may obscure the actual depth of the ulcer and the amount of tissue loss and/or eschar (a type of slough that is tan, brown or black) in the wound bed. Unstageable/Unclassified can also be considered unstageable due to suspected deep tissue injury which is defined as a localized area of discolored intact skin (purple or maroon area) due to damage of underlying soft tissue from pressure. A review of the clinical record of Resident 144 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's Braden score dated July 10, 2014, (an assessment tool that determines the risk of pressure sore development) was 16 indicating that the resident was at low risk for the development of pressure ulcers (Braden score 15-18 indicates low risk). Review of an Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment tool completed at specific intervals to plan resident care) dated October 2, 2014, revealed that the resident was moderately impaired in cognition and decision making and required total assistance from staff for bed mobility. The MDS Assessment also indicated that the resident was at risk for the development of pressure ulcers. Review of the resident's comprehensive care plan dated December 13, 2013, revealed that the resident was at risk for skin alteration due to pressure risk, [MEDICAL CONDITION] and diabetes. Interventions at the time included inspection of skin during care for redness and irritation, monitor and document change in skin appearance, apply moisture lotion to dry skin daily with AM and PM care and as needed and provide pressure relief mattress. Further review of Resident 144's care plan revealed that the resident was at risk for alteration in elimination due to history of cervical and [MEDICAL CONDITION] and Alzheimers disease. Interventions at the time included use of incontinent briefs for periods of incontinence. Review of nursing documentation dated August 17, 2014, at 10:00 p.m. indicated that new physician's orders [REDACTED]. The twice a day treatments were performed by staff during the 7 a.m. to 3 p.m. shift and the 3 p.m. to 11 p.m. shift. Review of a corresponding "Open Area Record" dated August 17, 2014, revealed staff identified a macerated area, which was described as reddened, measuring 1 centimeter by 1 centimeter (cm). Further review of the Open Area Record revealed that the area had resolved on September 23, 2014. Review of the September 2014, October 2014 and November 2014 Treatment Administration Records (TAR) revealed that staff continued to perform the twice a day treatments up until November 16, 2014, even though the macerated area on the coccyx, had healed as of September 23, 2014. When interviewed on January 14, 2014, at approximately 8:10 a.m. and 8:50 a.m., Employee 2 (RN) and Employee 3 (RN), were unable to explain why staff continued to perform the treatments after the macerated area had healed in September 2014. Review of nursing documentation dated November 16, 2014, at 3:00 p.m. revealed new orders were obtained for discontinuing the [MEDICATION NAME] to the buttock/coccyx and apply Santyl (preventative skin ointment) to the staged areas on buttocks and cover with moist dressing and change daily and cover sacral area with [MEDICATION NAME] (lightly padded bandage-like dressing) and change every three to five days. Review of a corresponding "Open Area Review" dated November 16, 2014, revealed that three pressure areas were found: a Stage II measuring 1 cm by 1 cm by .2 cm below the coccyx, a Stage II measuring 1 cm by 1 cm by .2 cm on the right buttocks and a Unstageable measuring 4 cm by 2cm by .2 cm on the coccyx. Interventions at the time, included pressure relief mattress. Review of nursing documentation dated November 18, 2014, at 9:00 a.m. revealed that the LPN (Licensed Practical Nurse) noticed a change in the resident's skin and reported it to supervisory nursing staff. Physician orders [REDACTED]. The nursing documentation indicated that the overall area measured 8 cm wide by 8 cm long with several open areas on coccyx measuring 2 cm length by 2 cm width by 0.4 cm depth at one point in center - area is unstageable with 75 % of wound bed is covered with thick slough and 25 % of wound bed is blue/black skin. Further review of the nursing note indicated there is a crease on the right buttock area measuring 0.4 cm length by 0.4 cm width by less than 0.1 cm depth with 100 % yellow slough of wound bed, right buttock also has a Stage II area measuring 0.4 cm length by 0.4 cm width by less than 0.1 cm depth with red bloody wound bed and a small open area above coccyx wound that is Stage II and measures 1 cm length by 0.5 width by less than 0.1 cm depth. The nurse recommended that the Unit Manager contact the doctor to discuss a possible wound care consult. Review of the monthly TARs revealed that the resident received twice a day treatments to the coccyx area even though the area had previously healed and per care plan interventions, staff inspected and monitored the skin during daily care. Despite these ongoing interventions, the three pressure areas were identified at the above stages of breakdown. The facility failed to timely identify the changes in skin integrity to prevent worsening pressure sore development. During interviews with the Director of Nursing (DON) on January 14, 2015, at approximately 8:30 a.m. and on January 15, 2015, at approximately 8:40 a.m. the DON confirmed the development of the pressure ulcers and identification at the stages described. The DON was unable to explain why the skin impairments were not identified more timely during the resident's daily preventative care, provided at least twice a day, near an area on the coccyx that had previously healed. A review of the clinical record revealed that Resident 153 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], revealed her to be severely cognitively impaired, requiring maximum assistance for activities of daily living, at risk for developing pressure areas and always incontinent of bowel and bladder. A review of a facility Open Area Record revealed that Resident 153 developed a recurrent pressure area on the right buttock (ischium) area. The record noted that the pressure area was healed on December 23, 2014. Several treatments were ordered and applied during the course of the wound healing. A physician's orders [REDACTED]. During an observation of incontinence care to the resident on January 15, 2015, at 11 AM the resident was incontinent of a large amount of fecal material. During the observation, it was observed that Resident 153 did not have the [MEDICATION NAME] dressing in place on her right lower buttock area as ordered by the physician. A review of the resident's treatment record for January 2015 revealed documentation that licensed nursing staff had placed a [MEDICATION NAME] on Resident 153's right lower buttock on January 12, 2015, on the 7 AM to 3 PM shift. A review of bowel records for Resident 153 revealed that she had been incontinent of bowel 12 times between January 12, 2015, when the dressing was last documented and the observation of incontinent care was conducted on January 15, 2015. There was no documented evidence that the physician ordered treatment to preserve skin integrity was in place at the time of the incontinence observation or that a dressing was consistently applied on this resident after any episodes of bowel incontinence. During an interview on January 15, 2015, at 11:30 AM, the fifth floor unit manager confirmed that Resident 153's [MEDICATION NAME] dressing was not in place at the time of the observation and further confirmed that there was no documented evidence of any reapplication of the treatment with any of the resident's noted incontinent episodes. 28 Pa. Code 211.10 (a)(c)(d) Resident care policies. 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services. Previously cited 2/7/14