Every finding on record at Embassy of Hillsdale Park

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of six residents reviewed (Resident 2) who required hospitalization for hypoxia, congestive heart failure and pleural effusion.Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 22, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included heart failure (heart muscle cannot pump blood and oxygen effectively enough to meet the body's needs). A nurse's note for Resident 2 dated April 16, 2026, at 6:35 p.m. revealed that a new order was obtained by phone following a cardiology appointment that day to increase the resident's Lasix (brand name medication for furosemide) to 40 mg daily, obtain daily weights and notify the cardiologist if the resident had a weight gain of two pounds (lbs.) overnight or 5 lbs. in a week. Physician's orders for Resident 2, dated April 17, 2026, included orders for the resident to be weighed daily related to heart failure and that the cardiologist was to be notified if the resident had a weight gain of two pounds (lbs.) overnight or 5 lbs. in a week; and to administer 40 milligrams (mg) of furosemide (water pill, causes your kidneys to remove excess salt (sodium) and water from your body through urine) every morning related to heart failure. A nurse's note for Resident 2 dated April 30, 2026, at 12:15 p.m. revealed that a telephone call was received from the cardiology office and staff were to continue with the current treatment plan and call for a symptom update on May 5, 2026. There was no documented evidence of any further communication with the resident's cardiology office. Physician's orders for Resident 2, dated May 30, 2026, included an order to administer 20 mg of furosemide every morning related to heart failure. A nurse's note for Resident 2 dated June 1, 2026, at 2:44 p.m. revealed that the CMP (comprehensive metabolic panel-a routine blood test that measures 14 different substances in a sample of blood) was reviewed with the physician and orders were obtained to discontinue Lasix and obtain a BMP (basic metabolic panel-a routine blood test that measures eight substances in a sample of blood) in one week. There was no documented evidence that the BMP was obtained, or that the resident's cardiologist was made aware of the discontinuation of Lasix. A nurse's note for Resident 2 dated June 26, 2026, at 7:36 p.m. revealed that the resident had difficulty breathing and had edema. The family was present and requested that the resident be sent to the hospital for evaluation. A nurse's note at 11:34 p.m. revealed that the resident was being admitted to the hospital for hypoxia (low levels of oxygen in your body tissues), congestive heart failure, and pleural effusion (collection of fluid around the lungs). A nurse's note for Resident 2 dated June 27, 2026, at 11:23 a.m. revealed that the facility received a call from the resident's daughter reporting the resident had ceased to breath at 1:30 am. Weight records for Resident 2 dated June 2026 revealed that on June 3 the resident's weight was 128.8 lbs. and on June 9 the resident's weight was 134.2 lbs., indicating a 5.4 lbs. weight gain in a week; on June 5 the resident's weight was 130.1 lbs. and on June 6 the resident's weight was 131.2 indicating the resident had a 1.1 lb. weight gain overnight; on June 8 the resident's weight was 132 lbs. and on June 9 the resident's weight was 134.2 lbs. indicating the resident had a 2.2 lb. weight gain overnight; on June 20 the resident's weight was 132.4 lbs. and on June 21 the resident's weight was 134.1 lbs. indicating the resident had a 1.7lb weight gain overnight; and on June 22 the residents weight was 136.6 lbs. indicating the resident had a 2.5 lb. weight gain overnight. There was no documented evidence that the cardiologist or facility provider were made aware of the resident's weight gain as ordered. Interview with a Registered Nurse from Resident 2's cardiology office on July 21, 2026, at 1:50 p.m. revealed that the office spoke with a nurse from the facility who verbalized understanding of the plan to continue the resident's current orders and to call the office with symptoms on May 5, 2026. The cardiology office had no further communication from the facility and were never made aware of any lab results, changes in the resident's Lasix orders or weight gains. The resident had an appointment scheduled for the following Monday and the office expected to be made aware of any symptoms or changes in the resident's cardiac (heart) condition at any time that they occurred. Interview with the Nursing Home Administrator on July 21, 2026, at 4:20 p.m. confirmed that there was no documented evidence that the cardiologist was made aware of changes in Resident 2's Lasix and neither the cardiologist nor facility physician were made aware of Resident 2's weight gains as ordered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of six residents reviewed (Residents 2). Findings include: A facility policy for medication administration dated June 17, 2026, included that medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination and infection. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 22, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included hypertension (high blood pressure). Physician's orders for Resident 2 dated November 26, 2025, included for the resident to receive 50 milligrams (mg) of Metoprolol Succinate ER (used to treat high blood pressure, chest pain, and heart failure) every morning for hypertension, hold if the resident's heart rate is less than 60. Review of the Medication Administration Record (MAR) for Resident 2 dated May 2026 through June 2026 revealed that 50 mg of Metoprolol Succinate ER was administered daily at 7:00 a.m. , however, there was no documented evidence that the resident's heart rate was obtained prior to administration, as ordered by the physician. Interview with Nursing Home Administrator and Director of Nursing on July 21, 2026, at 1:38 p.m. confirmed that the heart rate for Resident 2 should have been obtained prior to the administration of Metoprolol to identify if the medication was to be held, however there was no documented evidence that her heart rate was obtained. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one of six residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 22, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included Atrial fibrillation (heart rhythm disorder causing an irregular and fast heart rate), heart failure (heart muscle cannot pump blood and oxygen effectively enough to meet the body's needs) and hypertension (high blood pressure). Physician's orders for Resident 2 dated June 8, 2026, included an order to obtain a BMP (basic metabolic panel-measures eight different substances in your blood) one time only. Nurse's note for Resident 2 dated June 1, 2026, at 2:44 p.m. revealed that the CMP (comprehensive metabolic panel-a routine blood test that measures 14 different substances in a sample of blood) was reviewed with the physician and orders were obtained to discontinue Lasix (water pill, causes your kidneys to remove excess salt (sodium) and water from your body through urine) and obtain a BMP in one week. A review of Resident 2's clinical record revealed no evidence that a BMP was obtained at any time after June 1, 2026. Interview with the Nursing Home Administrator on July 21, 2026, at 4:20 p.m. confirmed that Resident 2 did not have a BMP drawn at any time after June 1, 2026, until her transfer to the hospital on June 26, 2026, as ordered and should have.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of facility policies, as well observations and staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to the facility's hot water temperatures. Findings include:A facility policy for safe water temperatures, dated April 3, 2025, included that water temperatures will be set to temperatures of no more than 120 degrees Fahrenheit (F), or the state's allowable maximum water temperature. Observation made in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 12:45 p.m. revealed that the water felt hot to the touch and the temperature was 120.3 degrees F. Interview with Licensed Practical Nurse 1 at the time of this observation revealed that the water was hot to touch and that she was unaware of any reported concerns by residents, staff, or visitors that the water was too hot. Observations of the Maintenance Director checking water temperatures in the shared bathroom sink between rooms [ROOM NUMBERS] on February 19, 2026, at 12:54 p.m. revealed a temperature of 115 degrees F.Observations of the Maintenance Director checking water temperatures in the bathroom sink in the shared hallway bathroom across from room [ROOM NUMBER] on February 19, 2026, at 12:56 p.m. revealed a temperature of 131 degrees F. An interview with the Maintenance Director at the time of these observations confirmed that the water temperature was too hot and should be between 100 and 110 degrees F. Observations of the Maintenance Director checking water temperatures in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 1:13 p.m. revealed a temperature of 121.6 degrees F. An interview with the Maintenance Director at the time of the observation confirmed that the water temperature was too hot. Interview with the Maintenance Director on February 19, 2026, at 1:50 p.m. revealed that he has not been notified of any concerns by residents, staff, or visitors that the water was too hot, and that he made adjustments to the mixing valves to correct the hot water temperature. Interview with the Nursing Home Administrator on February 19, 2026, at 2:10 p.m. confirmed that the water temperatures in the residents' room should not have been that high, and that the Maintenance Director had made adjustments to decrease the hot water temperature. 28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 33 residents reviewed (Residents 5).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia. A physician's order and care plan for Resident 5, dated September 12, 2025, indicated that the resident was to use a bed and chair alarm per the family's request.Observations of Resident 5 on February 17, 2026, at 10:32 a.m. revealed that the resident was in the hallway in his chair and had an alarm in place.Review of the Treatment Administration Records (TAR's) and nurse aide documentation for Resident 5, for November and December 2025, and January and February 2026, revealed that there was no documentation by staff that the resident's bed and chair alarms were in place.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documentation in Resident 5's clinical record indicating that the chair and bed alarms were in place.28 Pa. Code 211.5(f) Clinical Records.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment by ensuring that residents' wheelchairs were in good repair for one of 33 residents reviewed (Resident 61). Findings include: The facility's policy for safe and homelike environment dated April 3, 2025, revealed that the facility will provide a safe, clean, comfortable and homelike environment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 1, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, used a scoot and go wheelchair, and had diagnoses that included Paranoid schizophrenia and dementia. Observations of Resident's 61 scoot and go wheelchair on February 17, 2026, at 12:59 p.m. revealed that the leather on both arm rests had black tape wrapped around them. Observation of Resident's 61 scoot and go wheelchair on February 19, 2026, at 2:25 p.m. revealed that the leather on both arm rests had black tape wrapped around them. Interview with the Nursing Home Administrator on February 19, 2026, at 2:25 p.m. confirmed that Resident 61's scoot and go wheelchair had black tape around the leather armrests should have been repaired or replaced. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of policies and clinical records, as well as interviews with staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for three of 33 residents reviewed (Residents 7, 11, and 26). Findings include:The facility policy regarding hand hygiene, dated April 3, 2026, included that hand hygiene is a general term for cleaning your hands with soap and water or the use of an antiseptic hand rub. The use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The facility policy regarding medication administration, dated April 3, 2026, included that medications are administered by licensed nurses or other staff that are licensed to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administering medication per facility policy and product. Remove medication from its source, taking care not to touch medication with bare hands. The facility policy regarding enhanced barrier precautions (EBP), dated April 3, 2026, revealed that the facility would implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of a gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at an increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). The facility was to make gowns and gloves available immediately outside of the resident's room. High contact care activities include wound care: any skin opening requiring dressing. EBP will be used for the duration of the affected resident's stay in the facility or until resolution of the wound heals or the indwelling medical device is removed. Observation of medication administration for Resident 7 on February 20, 2026, at 6:43 a.m. revealed that Licensed Practical Nurse 3 donned gloves and administered eye drops to the resident. Upon completion of the administration of the eye drops, the Licensed Practical Nurse removed her gloves and proceeded to the medication cart and prepared and administered medications to another resident. Licensed Practical Nurse 3 did not complete hand hygiene after removing her gloves or before preparing and administering medication to the next resident. During an interview with Licensed Practical Nurse 3 on February 20, 2026, at 6:55 a.m. she stated I don't think we have to clean our hands between every resident. I am very careful not to touch anything with my bare hands. Observation of medication administration for Resident 11 on February 20, 2026, at 6:35 a.m. revealed that Licensed Practical Nurse 4 dropped a small white pill on the top of the medication cart when preparing the resident's medication then picked the pill up with her bare hands and placed it in a medication cup with other medications. Licensed Practical Nurse 4 proceeded into the resident's room and administered the medication. Interview with Licensed Practical Nurse 4 at the time of the observation confirmed that she should not have touched the resident's medication with her bare hands. An interview with the Nursing Home Administrator on February 20, 2026, at 7:33 a.m. confirmed that pills should not be touched with bare hands, and that hand hygiene should have been performed after glove removal and before providing meds to the next resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated January 22, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had diagnoses that included diabetes and dementia, and had pressure ulcers. Physician's orders for Resident 26 dated June 6, 2025, included an order for the resident to have Enhanced Barrier Precautions in place every shift. Gloves and gowns to be worn when providing wound care: chronic wounds such as pressure ulcers, or diabetic foot ulcers. Physician's orders for Resident 26 dated January 9, 2026, included an order for the resident to have skin prep applied to her left heel every day and evening shift for wound care. Physician's orders for Resident 26 dated January 16, 2026, included an order for the resident to have her right ankle cleansed with 0.125 % Dakin's solution (topical antiseptic to cleanse infected wounds), apply calcium alginate (highly absorbent wound dressing), to the wound bed, an ABD pad (abdominal pad-a thick, highly absorbent medical dressing), and rolled gauze daily and as needed for wound care. Observation of wound care treatment for Resident 26 on February 20, 2026, at 8:51 a.m. revealed that Licensed Practical Nurse 5 donned gloves and removed the soiled dressing from the resident's right ankle. She then removed her gloves, applied clean gloves and cleansed the resident's right ankle with Dakin's solution and applied the calcium alginate, ABD pad, gauze, and tape. She then removed her gloves and went into the bathroom and washed her hands. Licensed Practical Nurse 5 then donned clean gloves, removed the sock on the resident's left foot, removed her gloves, applied clean gloves, applied skin prep to the resident's left heel, and removed her gloves. She then proceeded to clean up her supplies and put items back on the treatment cart. She exited the resident's room without performing hand hygiene.Interview with Licensed Practical Nurse 5 on February 20, 2026, at 9:07 a.m. revealed she should have worn a gown while providing wound care to Resident 26, however she did not because there were no supplies on the unit to use. She revealed that she washed her hands twice during wound care, although handwashing was only observed once, and that she did not wash her hands after completing the resident's wound care and before or immediately after exiting the resident's room and going into another resident's room. An interview with the Nursing Home Administrator on February 20, 2026, at 10:48 a.m. confirmed that a gown should have been worn during Resident 26's wound care, hand hygiene should have been performed each time gloves were removed, and that hand hygiene should have been performed after completion of wound care. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 33 residents reviewed (Resident 9). Findings include:The facility's policy regarding care plans, dated April 3, 2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents medical, nursing, and mental and psychosocial needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 2, 2026, revealed that the resident was cognitively intact, was understood, could understand, and required supervision with care needs.Interview with Resident 9 on February 17, 2026, at 10:42 revealed that she has been having diarrhea for a while, and still has to take medication. A nursing note for Resident 9 dated January 28, 2026, indicated that she had a colonoscopy.Physician's orders for Resident 9, dated October 21, 2025, included an order for the resident to receive 2.5-0.025 milligrams (mg) of Lamotil (an antidiarrheal medication) every six hours as needed for for diarrhea. Physician's orders for Resident 9, dated January 28, 2026, included an order for the resident to receive 2.4 grams (gm) of Mesalamine (an anti-inflammatory medication) twice a day for ulcerative colitis (chronic inflammatory bowel disease).There was no documented evidence that a care plan was developed to address Resident 9's chronic diarrhea and ulcerative colitis.Interview with the Nursing Home Administer on February 19, 2026, at 12:13 p.m. confirmed that Resident 9 did not have a care plan to address her chronic diarrhea and ulcerative colitis with medications.28 Pa. Code 211.11(d) Resident care plan.28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 33 residents reviewed (Resident 68). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 68, dated December 20, 2025, revealed that the resident was understood and could understand others, was cognitively intact, and had diagnoses that included hypertension (high blood pressure), and heart failure. A care plan, dated June 14, 2024, revealed that staff were to give all cardiac medications as ordered by the physician.Physician's orders for Resident 68, dated July 15, 2025, included an order for the resident to receive 12.5 milligrams (mg) of Coreg (used to treat high blood pressure) two times a day for hypertension. Staff was to hold the medication for a blood pressure reading of less than 90/60 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm).Review of Resident 68's Medication Administration Record (MAR) for October and November 2025, and February 2026, revealed that the resident's pulse was less than 60 bpm at 7:00 a.m. on October 1, 4, 5, 9, 14, 15, 22-24, and 27-29, November 1, 2, 5-7, 10-12, 16, 19-21, 25-27, 29, and 30, 2025, and February 3, 4, 7, 8, 11-13, 16-18, 2026; however, there was no documented evidence that Coreg was held as ordered by the physician.Interview with the nursing Home Administrator on February 19, 2026, at 11:32 a.m. confirmed that there was no documented evidence that Resident 68's Coreg was held as ordered on the above dates and times.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 77).Findings include: The facility's policy for storage of controlled medications dated April 3, 2025, revealed that the destruction/disposal of controlled medications should include a licensed nurse and a licensed pharmacist or authorized nurse supervisor. Documentation on the narcotic record will include the name of the resident, medication, prescription number, amount being destroyed, date of disposition and names and signatures of both the persons disposing of the medication. Physician's orders for Resident 77 dated September 13, 2024, included an order for the resident to receive 0.5 milligrams of Lorazepam (controlled medication for anxiety) one time a day. A nursing note for Resident 77 dated December 23, 2025, revealed that the resident ceased to breath at 4:14 a.m. A controlled narcotic sheet for Resident 77, received on December 1, 2025, revealed that 29 doses of Lorazepam were received. On December 22, 2025, the controlled narcotic sheet revealed that 9 doses of Lorazepam were remaining. There was no documented evidence that the remaining 9 doses of Lorazepam were destroyed and verified by two licensed nurses. Interview with the Nursing Home Administrator on February 20, 2026, at 11:35 a.m. confirmed that there was no documented evidence that Resident 77's Lorazepam was destroyed by two licensed nurses per the facility's policy. 28 Pa. Code 211.9(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in a medication cart. Findings include:The facility's policy regarding medication storage, dated April 3, 2025, revealed that the facility will maintain and control access to medication carts for licensed and approved personnel. Observations on February 19, 2026, at 2:11 p.m. revealed that Licensed Practical Nurse 2 walked out of the medication room on the ambulatory care unit, leaving the medication cart unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood. Interview with Licensed Practical Nurse 2 on February 19, 2026, at 2:14 p.m. confirmed that the medication cart was unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood, and that both should have been locked. An interview with the Nursing Home Administrator on February 19, 2026, at 2:39 p.m. confirmed that the medication cart should have been locked when unsupervised, and the medication room door should have been closed and locked when the medication room was unsupervised. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending March 6, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 20, 2026, identified repeated deficiencies related the development of individualized care plans, providing quality care, ensuring that the resident's environment was free from accident hazards, and preventing issues with the accountability of controlled medications (drugs with the potential to be abused). The facility's plan of correction for a deficiency regarding the development of individualized care plans, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were developed for their individual needs. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 6, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on March 6, 2025, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards. The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.Refer to F656, F684, F689, F75528 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for one of 33 residents reviewed (Resident 5).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included dementia.A nursing note for Resident 5, dated September 7, 2025, revealed that at 1:25 p.m. the resident had a witnessed fall in the hallway resulting in a skin tear to her left ring finger and a reddened area on the left side of her forehead. She was transferred to the hospital and admitted with altered mental status, a head injury, and seizures.Review of Resident 5's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer, or that the ombudsman was notified regarding her hospitalization of September 7, 2025.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documented evidence that Resident 5 and their representative were notified in writing of their transfer to the hospital, or that the ombudsman was notified regarding the hospitalizations.28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 54). Findings include: The facility's policy for abuse, dated November 8, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 11, 2025, revealed that the resident was rarely understood, could rarely understand, and had diagnoses that included Alzheimer's disease and Down's syndrome. A care plan for Resident 54, dated January 29, 2024, revealed that the resident was at high risk for elopement and had impaired cognitive function. Interventions for Resident 54 indicated that if she was wandering in a potentially unsafe area or situation redirect to safer area and offer diversional activities. A quarterly MDS assessment for Resident 56, dated November 11, 2024, revealed that the resident was understood and could understand others, and had diagnoses that included dementia. A care plan for Resident 56, dated April 15, 2024, revealed that she exhibited behaviors that included physically abusive attacks on staff and/or other residents, scratching, refusal of care and meals, and yelling and screaming. Interventions for Resident 56 included redirecting residents who were attempting to enter her room because this upsets her. A nursing note for Resident 54, dated August 11, 2024, at 7:23 p.m. revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm. The facility report, dated August 11, 2024, at 6:50 p.m. indicated that Resident 54 was attempting to get into Resident 56's room. Resident 56 then grabbed Resident 54's arm causing three scratch marks. The nurse aide removed Resident 54 from the room. A nursing note for Resident 54, dated August 23, 2024, at 1:32 p.m. revealed that the nurse was notified that the resident was witnessed lying in Resident 56's bed. Resident 56 was observed hitting Resident 54 on her waist. No injuries were noted, and staff removed Resident 56 from her room. A nurse aide witness statement, dated August 23, 2024, revealed that she walked into the room after she heard Resident 54 yelling for help. She observed Resident 56 and another resident standing over top of Resident 54 slapping her and yelling, Get out! The residents were separated, and the registered nurse was notified. There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering. A nursing note for Resident 54, dated September 5, 2024, at 3:43 p.m., revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm. A nursing note for Resident 54, dated September 5, 2024, at 7:55 p.m., revealed that Resident 54's left arm remained slightly pink where fingernail marks occurred from the altercation earlier. The resident was observed staying in her room for a long time after the incident and if you stated her name, she would jump and become very fidgety. There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering. Interview with the Nursing Home Administrator on March 6, 2025, at 9:56 a.m. confirmed that Resident 56 had multiple abusive interactions with Resident 54 and that there was no documented evidence that staff was monitoring Resident 54 when wandering. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding wound treatments were followed for one of 33 residents reviewed (Resident 74). Findings include: A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). Physician's orders for Resident 74, dated March 1, 2025, included orders to cleanse the resident's right lateral diabetic foot ulcer with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply betadine (a solution used to treat and prevent infection) to the base of the wound, and secure with abdominal dressing (used for a wound with large amounts of drainage or used as padding for pressure points and cushioning) and rolled gauze (used to hold the dressing in place) daily and as needed. Observations of Resident 74's wound care on March 5, 2025, at 10:08 a.m. revealed that Licensed Practical Nurse 2, with gloved hands, cleansed the resident's right lateral foot with normal saline, removed her gloves, washed her hands, applied new gloves, applied betadine to the wound, and left the wound open to air. Interview with Licensed Practical Nurse 2 on March 5, 2025, at 11:52 a.m. revealed that she was not aware that the wound to Resident 74's right lateral foot was to be covered with an abdominal dressing and wrapped with rolled gauze. Interview with the Nursing Home Administrator on March 5, 2025, at 12:22 p.m. confirmed that the order for Resident 74's wound to her right lateral foot included an order to cover the wound with abdominal dressing and wrap with rolled gauze. She confirmed that the wound should have been covered and wrapped. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 9, 31). Findings include: The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 18, 2025, revealed that the resident was cognitively impaired, was rarely understood, and could rarely understand others. A care plan, dated October 13, 2021, revealed that hospice was to be notified if the resident goes into cardiac arrest. Physician's orders for Resident 9, dated July 19, 2024, revealed that the resident was discharged from hospice care. Interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that the resident was no longer on hospice and her care plan should have been updated to reflect that. A quarterly MDS assessment for Resident 31, dated January 16, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had no pressure ulcers or wounds, and had diagnoses that included diabetes, peripheral vascular disease (a disease causing poor blood circulation to lower limbs), and acquired absence of the left leg below the knee. A skin integrity care plan for Resident 31, dated May 9, 2019, included an intervention for a stump shrinker to be worn to shape the amputation site for a possible prosthesis (an artificial body part) and an intervention for contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) related to Methicillin-resistant Staphylococcus aureus (MRSA) infection (type of staph bacteria resistant to many antibiotics making treatment difficult). Review of Resident 31's clinical record revealed no documented evidence that the resident continued to wear a stump shrinker and no documented evidence that the resident had a MRSA infection requiring contact precautions. Interview with the Nursing Home Administrator on March 6, 2025, at 9:55 a.m. confirmed that Resident 31's care plan should have been revised to reflect that the stump shrinker was no longer used and that the resident was no longer on contact precautions for MRSA. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide proper positioning in a wheelchair for one of 33 residents reviewed (Resident 38). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated November 29, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included Alzheimer's dementia and depression. Physician's orders for the resident, dated September 17, 2024, included orders for the resident to be seated in a Broda chair (modified wheelchair) at all times when out of bed with bolsters bilaterally to trunk, skil-care back pillow, and leg rests on during transport and off after transport. Observations on March 3, 2025, at 10:19 a.m. revealed that Resident 38 was sitting in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest. Observations on March 6, 2025, at 10:40 a.m. revealed that Resident 38 was in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest. Interview with the Director of Rehabilitation on March 6, 2025, at 10:40 a.m. confirmed that the bilateral bolsters were not in place on Resident 38's Broda chair per physician orders. Interview with the Nursing Home Administrator on March 6, 2025, at 11:19 a.m. confirmed that Resident 38 did not have the bilateral bolsters to prevent the resident from leaning. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 33 residents reviewed (Resident 74). Findings include: A facility policy for baseline care plans, dated November 8, 2024, indicated that the facility will develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission orders and physician's orders. Interventions shall be initiated that address the resident's current needs including any special needs such as for intravenous therapy (administration of fluids and/or medications directly into a person's vein). A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m., revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time. Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of Heparin (an anticoagulant medication used to keep intravenous catheters open and flowing freely); for the registered nurse to change the PICC dressing, extension set, and cap every seven days on the day shift and as needed for leakage, blockage and/or soilage; and for staff to measure the external catheter length from insertion site to the end of the injection cap in centimeters (cm) on admission, with each dressing change every seven days on the day shift and as needed. Review of Resident 74's clinical record revealed no documented evidence that a baseline care plan was developed to address the resident's PICC and related PICC care. Interview with the Nursing Home Administrator on March 5, 2025, at 12:17 p.m. confirmed that there was no documented evidence that a baseline care plan was developed to address Resident 74's PICC and related PICC care. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing to ensure that the call bell was within reach for one of 33 residents reviewed (Resident 27). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 13, 2024, indicated that the resident was cognitively impaired and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had recent falls, and staff were to ensure the call bell was within reach. The facility's call bell policy, dated November 8, 2024, indicated that the call bell would be within easy reach and secured if needed. Observations of Resident 27 on March 3, 2025, at 10:38 a.m. revealed that the resident was sitting in his wheelchair in the middle of his room with his call bell lying on his bed out of the resident's reach. Interview with Resident 27 at that time revealed that he does not get help when needed because his call bell has been out of reach. Interview with Nurse Aide 1 at that time revealed that Resident 27 was capable of using his call bell and it should have been placed within her reach. Interview with the Nursing Home Administrator on March 4, 2025, at 10:25 a.m. confirmed that the call bell should have been within Resident 27's reach. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 33 residents reviewed (Resident 29). Findings include: The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 4, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, was receiving hospice services, and had a diagnosis of Alzheimer's disease. Physician's orders for Resident 29, dated February 6, 2025, revealed that the resident was admitted to 365 Hospice on February 4, 2025. Review of Resident 29's clinical record revealed that there was no documented evidence that a care plan was developed to address the resident's need for hospice services. An interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that there was no documented evidence that a care plan was developed to address Resident 29's need for hospice services. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible for one of 41 residents reviewed (Resident 42) who used assist rails, resulting in a fracture, failed to follow physician-ordered and care-planned interventions for one of 41 residents reviewed (Resident 38), and failed to complete thorough investigations of falls to determine the possible cause(s) for one of 41 residents reviewed (Resident 38). Findings include: The facility's policy regarding the proper use of side rails, dated March 11, 2022, revealed that side rails/bed rails were adjustable metal or rigid plastic bars that attached to the bed. They were available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Examples of bed rails included, but were not limited to side rails, bed side rails, safety rails, grab bars and assist bars. As part of the resident's comprehensive assessment, the following components would be considered when determining the resident's needs, and whether or not the use of side/bed rails met those needs: medical diagnosis, conditions, symptoms and/or behavioral symptoms; size and weight; sleep habits; medications; acute medical or surgical interventions; underlying medical conditions, existence of delirium; ability to toilet self safely; cognition; communication; mobility (in and out of bed); and risk of falling. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 14, 2022, revealed that the resident was cognitively impaired and required extensive assistance from staff for his daily care tasks, including bed mobility. A care plan, revised November 16, 2020, revealed that the resident was to use halos (round assist rails) on each side of the bed to aid in repositioning. Side Rail Screenings for Resident 42, dated November 26, 2021, and February 14, 2022, revealed that the resident was using a side rail for positioning or support, had an alteration in safety awareness, demonstrated poor bed mobility, had difficulty moving to a sitting position on the side of the bed, and that side rails of any type were not recommended at the time. A nursing note, dated March 31, 2022, at 12:39 a.m. and again at 12:53 a.m. revealed that Resident 42 was unable to use the halo bar to reposition himself. Upon assessing the resident, he had a bruised area noted to the right forearm that measured approximately 13.0 x 11.0 centimeters (cm). He was unable to perform hand grasp with the right hand and stated that he thought he broke it but was unsure of what happened. An x-ray report, dated March 31, 2022, revealed the resident had an acute mildly displaced (out of line) oblique (at an angle) fracture of the distal shaft of the right ulna (wrist area) with mild soft tissue swelling noted. The facility's investigation, dated March 31, 2022, revealed that Resident 42 had a bruise from the right forearm down to the ulna bone measuring 13.0 x 11.0 cm. The area of bruising was consistent with the height of the halo bar. It was decided to pad the halo bars. The investigation revealed that abuse and neglect were ruled out; however, there was no documented evidence in the investigation that Resident 42 had been screened on two occasions and that side rails of any type were not indicated for use. Interview with the Nursing Home Administrator on June 30, 2022, at 2:46 p.m. revealed that she was aware of the results of Resident 42's side rail screens and that assist rails were not indicated for use; however, she was not sure when the halo bars were put on Resident 42's bed or why. She confirmed that if the side rail screen did not recommend the use of a side rail/assist rail, they should not have been put on the bed. The facility's policy regarding fall management, dated March 11, 2022, revealed that the facility would identify each resident who is at risk for falls and develop a plan of care and implement interventions to manage falls. The facility will provide an environment that is free from potential hazards. If a fall occurs, the licensed nurse will assess the resident for an injury from the fall immediately and initiate an investigation of the reason for the fall and implement an immediate intervention to attempt in preventing future falls based upon the root cause. The interdisciplinary team will review the falls routinely to determine the most appropriate type of intervention to be implemented to attempt preventing future incidents from occurring. All reports of resident falls within the facility are monitored through the Quality Assurance Performance Improvement (QAPI) process and routine meetings. The facility's policy regarding accidents/hazards, dated March 11, 2022, revealed that resident accidents/hazards will be reviewed and investigated to maintain resident safety. The licensed nurse will investigate the incident/accident to attempt to determine the reason or root cause of the accident/incident. The licensed nurse will complete an accident/incident form and gather interview statements from the appropriate facility staff, resident, and/or family visitor. The Director of Nursing will review incident reports daily, and as needed, with follow-up interventions and documentation as needed. The incident reports would be monitored at a minimum monthly to identify patterns and trends, as well as for the need for system management through identification of individual resident risk and/or environmental safety management. A quarterly MDS assessment for Resident 38, dated May 1, 2022, revealed diagnoses that included stroke and dementia, that he was usually understood and could understand, and required extensive assistance from staff for his daily care tasks including with his bed mobility. A care plan for the resident, dated September 27, 2019, and revised June 11, 2021, revealed that the resident has an ADL self-care performance deficit related to confusion and dementia and required extensive assistance from two staff for his bed mobility. A care plan, dated September 27, 2019, and revised December 27, 2021, revealed that the resident was at a moderate risk for falls. Staff was to ensure that the resident's call light was within reach and encourage him to use it for assistance as needed, leave the overhead night light on at bedtime, and place items that the resident wants close to him. A care plan, dated August 14, 2021, revealed that the resident had a potential risk for falls related to poor safety awareness and a history of falls. Staff was to ensure the call light was within reach at all times and the high-low bed was to be in lowest position while occupied. Physician's orders, dated June 18, 2022, included an order for the resident to have a fall mat to the left side of his bed. A Fall Risk Assessment for Resident 38, dated June 17, 2022, revealed that the resident was considered a high risk for falls. The resident is confused and unsteady on feet. Interventions included assisting the resident with transfers as needed; placing the bed against the wall; encouraging the resident to participate in therapies as ordered; ensuring the call light is within reach at all times; the high-low bed was to be kept in the lowest position while occupied; low bed with mat as ordered; non-skid footwear while out of bed; nursing to complete a fall risk assessment upon admission, quarterly, and as needed; observe for side effects from [CONDITION(S)] medication usage; reducing clutter in resident's room; and therapy to screen/evaluate when indicated. A progress note for Resident 38, dated June 24, 2022, at 10:55 p.m. (approximate) revealed that Licensed Practical Nurse 1 entered the resident's room and the resident was found lying on the floor on his right side. The bed was not in the lowest position and the fall mat was not in place. Staff report that the resident was climbing out of bed at shift change and the resident was layed back down in bed. A registered nurse was summoned to the unit. No new injuries were noted. New interventions included placing a body pillow to the resident's left side when in bed and if attempting to climb, the resident would be gotten out of bed. A witness statement completed by Nurse Aide 2, dated June 24, 2022, revealed that she last saw Resident 38 at 9:55 p.m. in bed when she helped second shift (2:00 p.m. - 10:00 p.m.) lay the resident down because he was sitting up in bed. Incontinent care was last provided at 9:30 p.m. The resident has a fall mat and low bed, which was not in place at the time of the incident. Interview with the Director of Nursing and Assistant Director of Nursing on June 29, 2022, at 3:00 p.m. confirmed that Licensed Practical Nurse 1's progress note for Resident 38, dated June 24, 2022, and Nurse Aide 2's witness statement, dated June 24, 2022, indicated that the fall mat was not in place and that the bed was not in the lowest position. Interview with Licensed Practical Nurse 1 on June 29, 2022, at 3:58 p.m. revealed that when she walked in to get Resident 38's temperature at 10:55 p.m. she found him on the floor beside his bed. He was lying on the floor with his head towards the door and his legs were under his Broda chair (a specialized type of wheelchair). She indicated that the bed was approximately eight inches higher than it should have been and the fall mat was folded in half under his bed. She indicated that in the past he may have accidently hit the bed controller with his foot, but they have it velcroed to the outside of the foot board and there would be no way that he could have gotten the bed controller. She also indicated that there would be no way that he would be able to lift the fall mat. They did not hear him fall because of another resident who has his TV loud. Licensed Practical Nurse 1 found him when she went into his room and indicated that Nurse Aides 3 and 4 were in the room providing care to the resident prior to the time she found him. Interview with Nurse Aide 3 on June 29, 2022, at 4:35 p.m. revealed that she and Nurse Aide 4 were trying to change the resident's shirt because he was sitting up in his Broda chair, then put him into bed. He was grabbing at them when they were doing that. Once they got his shirt changed, they placed him back into bed. Nurse Aide 3 thought that Nurse Aide 4 placed the fall mat, and Nurse Aide 3 cannot remember if the bed was lowered. Interview with Nurse Aide 2 on June 30, 2022, at 9:09 a.m. revealed that she came in to begin her shift (10:00 p.m. to 6:00 p.m.) and punched in. She went and found the 2:00 p.m. to 10:00 p.m. nurse aides that were working to tell them that she would help them make rounds. She found them in Resident 38's room. They had the resident in his bed and said that they were almost finished with his care, so she left to begin her duties for her shift. When she left the room the bed was not in a low position and the fall mat was not placed. She indicated that she thought the nurse aides providing the care would do that. She then was summoned back into the resident's room by Licensed Practical Nurse 1 due to her finding the resident on the floor. At that time the bed was not in the lowest position and the fall mat was not in place. Interview with Nurse Aide 4 on June 30, 2022, at 2:08 p.m. revealed that her and the girl who was training that night had put Resident 38 in bed and was changing him. Then Nurse Aide 2 and Nurse Aide 4 went back again because he was sitting up in bed. Nurse Aide 3 then came back, so Nurse Aide 2 and Nurse Aide 4 left the resident room and Nurse Aide 4 gave report to Nurse Aide 2. When they left, Nurse Aide 3 was moving the bedside table back. She was not sure if the bed was in a low position. She indicated that she never moves the bed when she is providing care to a resident. She was not sure if the fall mat was in place. There was no documented evidence that witness statements were obtained from all staff working when the incident occurred, or that the investigation determined why the resident's care-planned interventions were not in place at the time of the fall. Interview with the Director of Nursing on June 30, 2022, at 1:55 p.m. confirmed that not all staff were interviewed, and that there was no documented evidence that all care-planned interventions were in place at the time of Resident 38's fall on June 24, 2022. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 41 residents reviewed (Resident 62). Findings include: The facility's abuse policy, dated March 11, 2022, indicated that the facility would not tolerate abuse, neglect and exploitation of its residents or misappropriation of resident property. The facility would investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff should immediately report all such allegations to the Nursing Home Administrator and to the Pennsylvania Department of Health in accordance with the procedures in the policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated May 26, 2022, indicated that the resident could be understood and understands others, was cognitively impaired, had physical and verbal behaviors, required the extensive assistance of two staff with daily care tasks, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility investigation documents, dated June 13, 2022, at 8:00 a.m. revealed that Licensed Practical Nurse 7 reported to the Nursing Home Administrator that on June 11, 2022, Nurse Aide 8 made a statement to Resident 62 that she was going to shoot him with a gun. The investigation also revealed that Resident 62 was not a credible witness and when assessed, did not recall the event. A written statement from Licensed Practical Nurse 7, undated, revealed that on June 11, 2022, Nurse Aide 8 stated that she threatens Resident 62 with a gun and threatens to blow his head off if he does not be good. Nurse Aide 8 stated that Licensed Practical Nurse 7 could go ahead and write her up and she would sign it because she threatens Resident 62 everyday with it. A telephone interview from Nurse Aide 8, dated June 13, 2022, at 8:03 a.m. revealed that her and Nurse Aide 9 were in the shower room with Resident 62 providing incontinent care when Resident 62 became verbally and physically aggressive. To calm him down, Nurse Aide 8 stated, Settle down or I am going to shoot you; I have a gun in my car. Nurse Aide 8 told the Assistant Director of Nursing, who interviewed her, that she knew she was going to get herself in trouble for saying what she did to Resident 62. A telephone interview from Nurse Aide 9, dated June 13, 2022, at 8:15 a.m. revealed that her and Nurse Aide 8 were in the main bathroom when Resident 62 became upset. Nurse Aide 8 told Resident 62 that she had a gun. A telephone interview from Licensed Practical Nurse 7, dated June 13, 2022, at 11:00 a.m. revealed that Nurse Aides 8 and 9 took Resident 62 up to the main bathroom and provided incontinence care. The two nurse aides were sitting at the nurse's station charting and Nurse Aide 8 said to Nurse Aide 9, Did you see how fast Resident 62 calmed down after threatening him? I learned a while ago to say I have a lot of guns and going to blow his head up to straighten him up when he is acting up. Licensed Practical Nurse 7 then stated that Nurse Aide 8 said, Go ahead and write me up for saying that; I will sign it. Licensed Practical Nurse 7 did not immediately report to the registered nurse. Facility investigation documents, dated June 13, 2022, at 8:00 a.m. revealed that Nurse Aide 8 had previously received education on the facility's abuse policy. The facility's investigation also determined that abuse was susbstantiated. Observations on June 27, 2022, at 11:30 a.m. revealed that Resident 62 was sitting in a Broda chair (special chair) in front of the nurse's station and was not interviewable. An interview with Licensed Practical Nurse 7 on June 30, 2022, at 2:10 p.m. confirmed that Nurse Aide 8 was at the nurse's station and told her that she said she was going to shoot Resident 62, and Nurse Aide 9 told her the same thing. Interview with the Nursing Home Administrator on June 30, 2022, at 2:39 p.m. confirmed that Nurse Aide 8 threatened Resident 62 that she was going to shoot him with a gun, to which she admitted to, and that mental abuse was substantiated. The survey team applied the reasonable person concept in determining the psychosocial outcome(s) for this deficiency. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of established infection control guidelines, the facility's policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable infections, by failing to follow infection control guidelines from the Centers for Disease Control (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for 10 of 21 residents reviewed (Residents 4, 5, 6, 8, 10, 12, 13, 14, 15, 16). The facility's failure created a situation in which five of these residents (Residents 5, 6, 8, 10, 12) were placed in Immediate Jeopardy related to a lack of proper infection control procedures for cohorting residents. Findings include: Pennsylvania Health Alert Network (PA-HAN) - 530, regarding Long-Term Care Facility Guidance for Testing and Cohorting (for outbreaks and exposure to COVID-19 - a contagious [MEDICAL CONDITION] disease that can cause a variety of symptoms, including breathing problems, fever and cough), dated October 7, 2020, revealed that residents needed to be cohorted to separate units in three zones, based on test results: 1. COVID-19 positive residents (Red Zone) were residents with a positive test and still within the parameters for transmission-based precautions. 2. Potentially exposed residents (Yellow Zone) were residents with a negative COVID-19 test who remained asymptomatic but were within 14 days of possible exposure to COVID-19. 3. Unexposed (Green Zone) were any residents in the facility who were not tested and were thought to be unexposed to COVID-19. Staff should be designated by zone as much as possible to minimize risk to exposed (Yellow) and non-exposed (Green) residents. The best option was for staff to always work on the same unit or zone and not to cross over to other units or zones. Staff could work in two or more exposed (Yellow) units. Ideally, staff would not work in the COVID-19 positive (Red) unit and then return to an exposed (Yellow) or unexposed unit/zone (Green). Zones were to be clearly marked with limited access signs or temporary barriers to prevent unnecessary foot traffic to the area. Equipment should be dedicated ideally to each unit, and if necessary, shared only between units of the same zone. Full Personal Protective Equipment (PPE - gloves, gown, respirator, protective eyewear) must be used to care for residents in COVID-19 positive (Red) and COVID-19 negative potentially exposed (Yellow) zones. The PA-HAN also included that individuals who were COVID-19 positive were to be kept in their room or apartment as feasible with the door closed. Anything that the COVID-19 positive resident may need to leave the room for (e.g. food, water, etc.) was to be brought to that resident so that they avoided the use of common areas such as kitchens and communal living spaces. Patients were to wear a facemask or cloth face covering to contain secretions during transport. If patients could not tolerate a facemask or cloth face covering, or one was not available, they were to use tissues to cover their mouth and nose while out of their room. Guidance from the Centers for Disease Control (CDC - a national public health agency), dated April 30, 2020, included that residents of nursing homes who have a confirmed COVID-19 infection, regardless of symptoms, should be transferred to a designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 fourteen days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents, if space is not available for them to remain in a single room. The facility's policy regarding care for a resident with suspected or confirmed COVID-19, dated December 8, 2020, indicated that the facility had designated areas to care for suspected and/or positive COVID-19 residents. The facility was to follow the CDC recommendations when caring for the residents, who should be cared for in a single-person room with the door closed, and a sign placed on the door. A COVID-19 test result for Resident 3, dated November 28, 2020, revealed that the resident was positive, and a COVID-19 test result for Resident 5, dated November 28, 2020, revealed that the resident was negative. Daily census information revealed that Residents 3 and 5 were roommates prior to Resident 3's positive test result on November 28, 2020, and there was no documented evidence that either resident was moved following the test results which showed that Resident 3 was positive, but Resident 5 was negative. A COVID-19 test result for Resident 5, dated November 30, 2020, which was completed because the resident was displaying symptoms, revealed that the resident was positive. A COVID-19 test result for Resident 7, dated December 4, 2020, revealed that the resident was positive, and a COVID-19 test result for Resident 6, dated December 4, 2020, revealed that the resident was negative for COVID-19. Daily census information revealed that Residents 6 and 7 were roommates prior to Resident 7's positive test result on December 4, 2020, and there was no documented evidence that either resident was moved following Resident 7's positive test result. Observations of Residents 6 and 7 on December 7, 2020, at 12:50 p.m. revealed that they resided in the same room with no barrier between them. The residents were both in their beds, and Resident 7 had a small fan on her bedside stand and it was blowing across her bed and in the direction of Resident 6. A COVID-19 test result for Resident 9, dated December 3, 2020, revealed that the resident was positive, and a COVID-19 test result for Resident 8, dated December 7, 2020, revealed that the resident was negative. Daily census information revealed that Residents 8 and 9 were roommates prior to Resident 9's positive test result on December 3, 2020, and there was no documented evidence that either resident was moved following Resident 9's positive test result. Observations of Residents 8 and 9 on December 7, 2020, at 12:46 p.m. revealed that they resided in the same room with no barrier between them. A COVID-19 test result for Resident 11, dated December 4, 2020, revealed that the resident was positive, and a COVID-19 test result for Resident 10, dated December 7, 2020, revealed that the resident was negative. Daily census information revealed that Residents 10 and 11 were roommates prior to Resident 11's positive test result on December 4, 2020, and there was no documented evidence that either resident was moved following Resident 11's positive test result. Observations of Residents 10 and 11 on December 7, 2020, at 12:55 p.m. revealed that they resided in the same room with no barrier between them. Resident 11 was in a wheelchair, which was approximately three feet away from Resident 12, who was in his bed. A COVID-19 test result for Resident 17, dated December 1, 2020, revealed that the resident was positive, and a COVID-19 test result for Resident 12, dated December 7, 2020, revealed that the resident was negative. Daily census information revealed that Residents 12 and 17 were roommates prior to Resident 17's positive test result on December 1, 2020, and there was no documented evidence that either resident was moved following Resident 17's positive test result. Observations of Residents 12 and 17 on December 7, 2020, at 12:46 p.m. revealed that they resided in the same room with barrier between them. Interview with the Infection Preventionist on December 8, 2020, at 3:15 p.m. confirmed that a COVID-19 positive resident should not be roommates with a COVID-19 negative resident, especially with no barrier between the residents. She also confirmed that residents should not be closer than six feet to each other and that Resident 7's fan should not have been in use after the resident tested positive for COVID-19. A current facility list of residents who resided in the Red Zone (COVID-19 positive) included Residents 4, 13, 14, 15 and 16. However, COVID-19 test results for these residents showed that they were negative. Observations in the Red Zone on December 7, 2020, from 12:45 p.m. to 1:15 p.m. revealed that there were no signs on Resident 4, 13, 14, 15 and 16's rooms to denote that these residents' rooms were actually considered a Yellow Zone (exposed but not positive). All resident room doors in the Red Zone were open to the hallway, including the rooms of residents who tested positive for COVID-19. Interviews with Nurse Aides 1 and 2 on December 7, 2020, at 1:02 p.m. and 1:10 p.m., respectively, revealed that they were unaware that not all of the residents on the unit were positive for COVID-19. Observations in the Yellow Zone on December 8, 2020, at 2:03 p.m. revealed that Nurse Aides 3 and 4 provided care to Resident 12. There were two piles of soiled linen on the floor, which included towels, bed linens, and a used incontinent brief. After completing the care and opening the privacy curtain, the nurse aides put the linen from the floor into a clear plastic bag and left the room. Interview with Nurse Aides 3 and 4 on December 9, 2020. at 11:05 a.m. revealed that when working in the Yellow Zone, they leave soiled/used linens in the room until they complete all of a resident's care; however, they should not have placed the soiled linens on the floor. Interview with the Infection Preventionist on December 9, 2020, at 11:30 a.m. confirmed that soiled/used linens were to be placed in a bag and not directly on the floor. Guidance from the CDC regarding Managing COVID-19 in Nursing Homes and Symptoms of COVID-19, dated May 13, 2020, and updated November 20, 2020, revealed that facilities were to actively monitor all residents upon admission and at least daily for fever (temperature of 100.0 degrees Fahrenheit or greater) and symptoms consistent with COVID-19. Ideally, facilities were to include an assessment of oxygen saturation (percentage of oxygen in the blood) via pulse oximetry (device used to measure the percent of oxygen in the blood). People with the following symptoms could have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. The facility's policy regarding care of residents with suspected or confirmed COVID-19, dated December 8, 2020, included that at a minimum, all residents would be monitored daily for increased temperature, a pulse oximetry reading below 90 percent on room air, shortness of breath, malaise, chills, muscle aches, loss of taste or smell, headache and gastrointestinal upset. A facility census report, dated November 27, 2020, revealed that Resident 4 was admitted to the facility on that date. A [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 4, 2020, revealed that the resident was negative for COVID-19. Review of Resident 4's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 7, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated September 15, 2020, revealed that the resident was understood, could understand, required extensive assistance from staff for daily care tasks, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 7, 2020, revealed that the resident was negative for COVID-19. Review of Resident 8's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 21 through December 7, 2020, revealed that with the exception of November 25 and 28, and December 4, 2020, there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly MDS assessment for Resident 10, dated August 11, 2020, revealed that the resident was understood, could understand, required extensive assistance from staff for daily care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 7, 2020, revealed that the resident was negative for COVID-19. Resident 10's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly MDS assessment for Resident 12, dated October 28, 2020, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 7, 2020, revealed that the resident was negative for COVID-19. Review of Resident 12's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly MDS assessment for Resident 13, dated August 3, 2020, revealed that the resident was cognitively impaired, required assistance for daily care, and had medical [DIAGNOSES REDACTED]. However, review of Resident 13's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through 30, and December 2, 3, 5, 6 and 7, 2020, revealed that there was no documented evidence that the resident was checked for signs and symptoms of COVID-19. An annual MDS assessment for Resident 14, dated October 9, 2020, revealed that the resident was cognitively impaired, required extensive assistance for daily care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 7, 2020, revealed that the resident was negative for COVID-19. Review of the resident's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly MDS assessment for Resident 15, dated September 13, 2020, revealed that the resident was alert and oriented, required supervision with care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated November 28, 2020, revealed that the resident was negative for COVID-19 and that she refused testing on December 1 and 4, 2020. Resident 15's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. An admission MDS assessment for Resident 16, dated November 5, 2020, revealed that the resident was alert and oriented, required assistance with daily care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated November 28, 2020, revealed that the resident was negative for COVID-19 and that she refused testing on December 1 and 4, 2020. Resident 16's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. A quarterly MDS assessment for Resident 6, dated August 28, 2020, revealed that the resident was alert and oriented, required assistance with daily care, and had medical [DIAGNOSES REDACTED]. A COVID-19 test result, dated December 7, 2020, revealed that the resident was negative for COVID-19. Resident 6's vital sign records, Medication and Treatment Administration Records, assessments, and nursing notes, dated November 20 through December 8, 2020, revealed that there was no documented evidence that the resident was checked daily for signs and symptoms of COVID-19. Interview with the Regional Nurse and the Infection Preventionist on December 9, 2020, at 1:35 p.m. confirmed that residents should be monitored daily for signs and symptoms of COVID-19, and the daily monitoring should be documented in the clinical record. On December 8, 2020, at 2:52 p.m. the Regional Nurse was informed that the health and safety of residents were in Immediate Jeopardy due to cohorting COVID-19 positive and negative residents in the same room, and for failing to follow established infection control guidelines. The facility submitted and implemented an immediate action plan that included ensuring that each resident's most recent COVID-19 test result was reviewed. Residents who tested negative were moved out of the rooms where they were previously residing with residents who tested positive, and a designated Yellow Zone was created. Residents were placed in the Red and Yellow Zones according to their most recent COVID-19 test results. The facility developed an infection control education plan for all current and future staff, including agency staff, and staff who were currently off work related to testing positive for COVID-19. The education included cohorting positive and negative residents in the proper infection control zones. The Immediate Jeopardy was lifted on December 9, 2020, at 2:49 p.m. when it was confirmed that the facility moved all residents into the correct infection control zones in accordance with the COVID-19 test results, posted signage for each infection control zone, educated the majority of staff, and developed and implement a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of two residents reviewed (Resident 1), which resulted in Resident 1 becoming unresponsive and requiring medical intervention to correct a dangerously low blood sugar level. Findings include: The facility's medication administration policy, dated (MONTH) 15, (YEAR), indicated that medications were to be administered in a safe and effective manner. Staff were to review the five rights (the right resident, right medication, right dose, right time, and right route) three times, and prior to removing the medication package/container from the cart/drawer they were to check the Medication Administration Record [REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 22, (YEAR), indicated that the resident was confused and had [DIAGNOSES REDACTED]. The resident's care plan, dated (MONTH) 19, (YEAR), revealed that staff were to administer diabetes medications as ordered by the physician. physician's orders [REDACTED]. The order was changed on (MONTH) 12, 2019, at 10:56 p.m. and should have read that the resident was to receive 5 units of Humalog (fast-acting insulin), 100 units/ml before meals; however, the order was transcribed (written into the record) for the resident to receive 100 units of Humalog (fast-acting insulin), 100 units/ml before meals, and 5 units of Humalog (100 units/ml) before meals. A medication error report, dated (MONTH) 19, 2019, revealed that on (MONTH) 15, 2019, at 7:00 a.m. the physician's orders [REDACTED]. Nursing notes for Resident 1, dated (MONTH) 15, 2019, indicated that Licensed Practical Nurse 1 misinterpreted the Humalog order and 100 units of insulin was administered to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 then returned to the resident's room at a documented time of 11:35 a.m. and found the resident unresponsive. The resident's blood sugar reading was 10 milligrams per deciliter (mg/dL) (normal blood sugar for a person with diabetes is 70 to 100 mg/dL before meals). Licensed Practical Nurse 1 called the registered nurse and stated that the resident was crashing. At this time the resident was assessed by the registered nurse and was lethargic, hard to arouse, and cold and clammy. Licensed Practical Nurse 1 stated that one tube of [MEDICATION NAME] (a gel administered orally to raise blood sugar) was given, and the resident's blood sugar was rechecked and the reading was 38 mg/dL. The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of [MEDICATION NAME] was given at this time, and the resident's blood sugar was checked 10 minutes later and was 47 mg/dL. The physician was updated at 11:40 a.m., and orders were received to administer 1 mg of [MEDICATION NAME] intramuscularly (IM - injected into the muscle), every 15 minutes for a blood sugar less than 60 mg/dL, if the resident had symptoms and was unable to take anything by mouth. At 11:43 a.m. the resident received IM [MEDICATION NAME] for a blood sugar result of 38 mg/dL and at 12:02 p.m. for a blood sugar result of 24 mg/dL. The physician was notified, and new orders were received for 1 ml of [MEDICATION NAME] (medication used to raise blood sugar levels) IM to be given, and the [MEDICATION NAME] was administered at 12:20 p.m. with blood sugar response of 78 mg/dL. Interview with the Director of Nursing on (MONTH) 22, 2019, at 3:14 p.m. confirmed that Resident 1's insulin order was entered into the electronic clinical record incorrectly and Licensed Practical Nurse 1 administered 100 units of Humalog insulin to Resident 1. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.9(a)(1) Pharmacy services. Previously cited 9/6/18. 28 Pa. Code 211.12(d)(1)(3) Nursing services. Previously cited 1/24/18, 8/9/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/6/18, 1/24/18, 8/9/17.

Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for one of two residents reviewed (Resident R1). Findings include: Undated manufacturer's instructions for the baseboard heater used in Resident R1's room indicated that they were high performance heaters designed to operate at higher outlet temperatures than conventional heaters, that they were hot when in use, and to avoid burns, bare skin was not to touch the hot surfaces. The heater could be directly mounted to the wall; however, due to the higher outlet temperatures, the wall surface may get to the temperature of 138 degrees Fahrenheit. The instructions also indicated that combustible materials such as clothes were to be kept away from the heater, and that any objects or materials that were located within specified distances of the heater should not discolor, stretch or shrink upon extended exposure to temperatures of 200 degrees Fahrenheit. Observations on March 25, 2016, at 9:40 a.m. revealed that Resident R1's room had a baseboard heater, approximately five feet in length and located directly on the floor to the right side of the resident's bed. A [DIAGNOSES REDACTED]. The resident's care plan, dated March 22, 2016, indicated that he was at risk for falls and was to transfer with supervision. A nursing note for Resident R1, dated March 22, 2016, indicated that at 11:50 p.m. staff heard the resident yelling from his room, and he was found on the floor with his back against his bed and his right foot against the baseboard heater. The heater was very hot, so his foot was removed from the heater. The registered nurse was called and found that the resident had a second degree burn to his foot (a burn severe enough to cause blistering). Nursing notes, dated March 23, 2016, revealed that the resident was wearing a non-skid sock on his right foot at the time of the fall and had a second degree burn on the bottom of his right foot that measured 5.9 centimeters (cm) x 8.9 cm with a depth of 0.1 cm. Interviews with the Nursing Home Administrator and the Maintenance Manager on March 25, 2016, at 9:05 a.m. and 10:45 a.m., respectively, revealed that prior to Resident R1's incident of March 22, 2016, they were unaware of the hot surface temperatures of the facility's baseboard heating units, and there were no interventions in place to protect residents from burns. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 8/13/15. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 8/13/15.