Every finding on record at Embassy of Scranton

Based on clinical record review, review of facility policy, and staff and responsible party interviews, it was determined the facility failed to adequately monitor and respond to significant weight loss and declining food and fluid intake; failed to consistently obtain and evaluate weights; failed to consistently document meal and fluid intake; failed to timely notify the physician and responsible party of significant changes in weight and nutritional status; and failed to evaluate the effectiveness of nutritional and hydration interventions for one of ten residents reviewed (Resident 1) resulting in actual harm to Resident 1, who experienced progressive and significant weight loss and dehydration and subsequently required transfer to and admission at the hospital for acute kidney injury due to dehydration.Findings include: Review of the facility policy titled Weight Policy, last reviewed March 26, 2026, revealed the facility's policy was to attain or maintain each resident's weight within the recommended range, as appropriate to the resident's medical and physical condition. The policy required weights to be obtained timely and accurately, documented, and appropriately addressed. The policy required residents to be weighed upon admission, weekly for the following three weeks, and monthly thereafter unless otherwise ordered by the physician. The policy required the dietitian to be notified of significant weight changes and other concerns related to diet and intake and to track weights for significant weight loss, including loss greater than 5 percent in one month, 7.5 percent in three months, or 10 percent in six months. The policy required the dietitian to work with facility staff to evaluate weight trends and determine additional interventions. The policy also required notification of the physician and responsible party when significant weight changes occurred and identified interventions that could include preferred foods, additional portions, snacks, nutritional supplements, and other individualized measures. In the event the dietitian and the facility staff have determined reasonable interventions have been offered and there is a continued weight loss, the facility will attempt to meet with the resident/resident representative and consult the physician in regard to the resident's choices and clinical indications to make decisions about the use of a feeding tube. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease that can make breathing difficult) and dementia (a condition involving decline in memory, thinking, and other cognitive abilities that can interfere with daily functioning). A review of Resident 1's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 2, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). The MDS documented that Resident 1 required setup or cleanup assistance with eating. Clinical record review revealed that Resident 1 weighed 135.6 pounds on admission on [DATE], and 139.0 pounds on March 27, 2026. According to the facility's Weight Policy, Resident 1 should have been weighed weekly for the following three weeks. However, the clinical record contained no weights for April 3, April 10, or April 17, 2026. The facility did not obtain another documented weight until May 21, 2026, eight weeks after the March 27, 2026, weight. On May 21, 2026, Resident 1 weighed 128.6 pounds, representing a loss of 10.4 pounds, or 7.5 percent significant weight loss, from the March 27, 2026, weight of 139.0 pounds. On May 27, 2026, the dietitian documented the significant weight loss and requested a reweight to verify the loss. The reweight obtained that day was 124.0 pounds. Resident 1 lost 15 pounds, or 10.8 percent, from the March 27, 2026, weight. The clinical record contained no evidence that the facility notified the physician or responsible party of this significant weight loss. On May 29, 2026, the dietitian documented that significant weight loss had been confirmed. The dietitian noted Resident 1 remained on a regular diet and documented meal intake of 75 to 100 percent. The dietitian documented that the cause of the weight loss was unclear, and they initiated fortified foods (products that have extra vitamins, minerals, or other nutrients added during processing to boost their nutritional value) to increase the nutritional content of meals, and ordered weekly weights for four weeks. Subsequent documented weights were:June 1, 2026: 127.4 pounds;June 7, 2026: 125.6 pounds; andJune 14, 2026: 126.8 pounds. On June 24, 2026, the dietitian documented Resident 1's weight had been stable for four weeks and discontinued weekly weights in favor of monthly monitoring. However, the clinical record contained only three documented weekly weights following the May 27, 2026, weight. Four days later, on June 28, 2026, Resident 1 weighed 118.0 pounds, representing an 8.8-pound loss from the June 14, 2026, weight of 126.8 pounds, or 6.9 percent in 14 days. The clinical record contained no evidence that the dietitian evaluated the June 28, 2026, weight loss or that the facility notified the physician or responsible party of this additional significant decline. A nursing progress note dated July 3, 2026, documented that Resident 1's responsible party expressed concern regarding the resident's continued weight loss. The facility then communicated the concern to the Certified Registered Nurse Practitioner (CRNP), who ordered laboratory testing and mirtazapine (Remeron) 7.5 milligrams at bedtime. Mirtazapine is an antidepressant medication that may also increase appetite. A CRNP progress note dated July 6, 2026, documented that Resident 1 had experienced a significant decrease in appetite and a mild increase in oral intake after mirtazapine was initiated. The CRNP directed staff to continue mirtazapine, encourage and monitor Resident 1's nutritional intake, and provide fortified foods. Despite these interventions, Resident 1's documented weights continued to decline as follows:July 2, 2026: 113.2 pounds;July 7, 2026: 114.6 pounds;July 12, 2026: 114.0 pounds;July 19, 2026: 108.4 pounds; andJuly 21, 2026: 106.6 pounds. By July 21, 2026, Resident 1 had lost 29 pounds from the admission weight of 135.6 pounds, representing a severe weight loss of 21.4 percent of the resident's body weight in less than four months. Review of facility documentation further revealed significant gaps in monitoring Resident 1's nutritional and hydration intake. The April 2026 documentation survey report revealed 33 percent of required oral intake documentation was blank. Available meal documentation reflected intake ranging from 50 to 100 percent. The facility documented no fluid intake for 100 percent of the required shifts. The May 2026 documentation survey report revealed 24 percent of required intake documentation was blank. Available documentation reflected meal intake ranging from 51 to 100 percent. The June 2026 documentation survey report revealed 26 percent of required oral intake documentation was blank. Of the shifts containing documentation, 13 percent reflected Resident 1 consumed less than 50 percent of meals. The July 2026 documentation survey report revealed that Resident 1 consumed only 0 to 25 percent of meals on 26 percent of the documented shifts. Because the facility did not consistently document Resident 1's fluid intake, the clinical record did not provide a reliable means to determine the amount of fluid Resident 1 consumed during the period of progressive weight loss and declining oral intake. Laboratory testing obtained on July 9, 2026, revealed a blood urea nitrogen (BUN, a blood test that measures the amount of nitrogen from the waste product urea in the blood and is used, along with other clinical findings, to evaluate kidney function and hydration status) level of 22 milligrams per deciliter (mg/dL), above the laboratory reference range of 6 to 20 mg/dL. The creatinine (a waste product normally filtered from the blood by the kidneys and used to assess kidney function) level was 1.4 mg/dL, above the laboratory reference range of 0.6 to 1.2 mg/dL. The estimated glomerular filtration rate (eGFR, an estimate of how effectively the kidneys filter waste from the blood) was 48 milliliters per minute per 1.73 square meters (mL/min/1.73 m^2). The glucose (the amount of sugar in the blood) level was 65 mg/dL, below the laboratory reference range of 70 to 120 mg/dL. The clinical record contained no documentation demonstrating that the CRNP or physician evaluated or addressed these abnormal laboratory results at that time. On July 14, 2026, at 5:57 PM nursing documented that Resident 1 consumed no food at dinner and that the Registered Nurse Supervisor was informed. The clinical record contained no documentation that the physician was notified of the resident's failure to eat. Despite the resident's continuing weight loss and documented decline in oral intake, on July 15, 2026, the dietitian documented that Resident 1's weight had been stable for two weeks and made no new nutritional recommendations. The dietitian's note did not address the documented decline in meal intake. On July 19, 2026, Resident 1's responsible party contacted the facility and expressed concern that Resident 1 had not been weighed since July 12, 2026. Facility staff subsequently weighed Resident 1 and obtained a weight of 108.4 pounds, representing a loss of 5.6 pounds in seven days. The responsible party requested to speak with a supervisor because of the resident's continued weight loss. On July 19, 2026, the facility communicated the responsible party's concerns to the physician. The physician recommended increasing the appetite stimulant and discussed alternative nutritional support, including a possible tube feeding with the family. On July 20, 2026, staff documented Resident 1 received assistance with meals and exhibited possible swallowing difficulty. The facility obtained a speech-language pathology evaluation, which did not identify swallowing impairment. On July 21, 2026, laboratory testing demonstrated a marked deterioration in Resident 1's kidney function compared with the laboratory results obtained on July 9, 2026. Resident 1's blood urea nitrogen (BUN) increased from 22 milligrams per deciliter (mg/dL) on July 9, 2026, to 42 mg/dL on July 21, 2026. Resident 1's creatinine increased from 1.4 mg/dL to 2.8 mg/dL. Resident 1's estimated glomerular filtration rate (eGFR) decreased from 48 milliliters per minute per 1.73 square meters (mL/min/1.73 m^2) to 21 mL/min/1.73 m^2. An eGFR of 21 represented severely decreased kidney filtration. These abnormal laboratory changes reflected a substantial decline in Resident 1's kidney filtration compared with the July 9, 2026, results in the context of the resident's significant weight loss and poor food and fluid intake. At 3:35 PM on July 21, 2026, nursing documented that CRNP was aware of the new laboratory results. The CRNP issued no new orders at that time. A CRNP progress note entered on July 21, 2026, at 4:45 PM documented that Resident 1 continued to have a very poor appetite despite the increased dose of mirtazapine and identified the resident's weight loss as a significant concern. The CRNP documented that the laboratory values were stable. However, compared with the July 9, 2026, laboratory results, they were abnormal. The CRNP instructed facility staff to ensure Resident 1 was drinking, monitor the resident's urinary output, and transfer Resident 1 to the emergency department if the resident's condition worsened. On July 22, 2026, the dietitian documented that Resident 1 weighed 106.6 pounds. The dietitian documented review of Resident 1's July 9, 2026, laboratory results but did not document review or evaluation of the more recent July 21, 2026, laboratory results, which demonstrated the increased BUN and creatinine and decreased eGFR. On July 22, 2026, nursing documented Resident 1 consumed no food and that the Registered Nurse Supervisor was notified. The clinical record contained no documentation that the facility notified the physician or responsible party at that time that Resident 1 was not consuming food or fluids. On July 22, 2026, at 8:28 PM a physician's progress note documented review of Resident 1's laboratory results and identified acute renal failure likely due to dehydration, failure to thrive, and significant weight loss. The facility subsequently transferred Resident 1 to the hospital for further evaluation and treatment. Hospital records revealed Resident 1 arrived at the hospital on July 22, 2026, at 10:45 PM. Hospital physician documentation dated July 23, 2026, at 1:20 AM identified signs of dehydration, including pale appearance, dry mucous membranes (dryness of the moist tissues lining areas such as the mouth), delayed capillary refill (slower return of blood flow after pressure is applied to the skin), diminished peripheral pulses, and decreased skin turgor (reduced ability of the skin to return to its normal position after being gently pinched). Hospital documentation revealed Resident 1 was admitted with acute kidney injury, dehydration, and severe protein-energy malnutrition (a serious condition resulting from inadequate intake or use of protein and calories needed to maintain body tissues and normal body functions). The hospital nutritional assessment dated [DATE], documented that Resident 1 met criteria for severe malnutrition, with fat loss, muscle loss, and significant weight loss present. During an interview on August 13, 2026, at 12:00 PM Resident 1's responsible party stated she had expressed concerns to facility staff for months because Resident 1 appeared to be losing weight each time she visited. She stated that her concerns in April, May, and June 2026 were not adequately addressed. The responsible party stated that on July 3, 2026, she personally contacted the attending physician's office regarding Resident 1's weight loss and was informed by the CRNP that she had not previously been aware of the resident's weight loss. The clinical record contained no documentation from March 25 through July 3, 2026, demonstrating that the facility notified the physician of Resident 1's progressive and significant weight loss. The facility failed to follow its established weight-monitoring process; consistently monitor and document Resident 1's food and fluid intake; timely identify, evaluate, and respond to significant and continued weight loss and declining oral intake; consistently notify the physician and responsible party of significant changes in the resident's nutritional and hydration status; and evaluate the effectiveness of nutritional and hydration interventions and revise those interventions when Resident 1 continued to experience significant weight loss and declining oral intake. These failures resulted in actual harm to Resident 1. From admission on [DATE], through July 21, 2026, Resident 1's weight decreased from 135.6 pounds to 106.6 pounds, a loss of 29 pounds, or 21.4 percent of the resident's admission body weight. During this period, Resident 1 experienced declining food intake, the facility lacked consistent documentation to determine the resident's fluid intake, and laboratory testing demonstrated worsening kidney function. On July 22, 2026, the facility physician transferred Resident 1 to the hospital for acute renal failure likely secondary to dehydration, failure to thrive, and significant weight loss. Hospital evaluation subsequently identified clinical signs of dehydration, and Resident 1 was admitted with acute kidney injury, dehydration, and severe protein-energy malnutrition. A hospital nutritional assessment further documented severe malnutrition with fat loss, muscle loss, and significant weight loss. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c) (d)(3)(5) Nursing services.

Based on review of facility policy and clinical records, and staff and resident representative interviews, it was determined the facility failed to promptly notify the physician and resident representative of a significant change in condition involving ongoing weight loss for one of ten sampled residents (Resident 1).Findings include: Review of the facility policy titled Notification of Changes, last reviewed March 26, 2026, revealed that the facility must promptly inform the resident, consult with the resident's physician, and notify the resident's representative when a change in the resident's condition requires notification. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult) and dementia (a general term for a loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 1's Quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 2, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). The MDS further indicated that Resident 1 required set-up or clean-up assistance with eating. Review of Resident 1's clinical record revealed that the facility first identified weight loss on May 21, 2026, with continued episodes of weight loss documented through July 22, 2026. Despite the documented weight loss beginning May 21, 2026, the clinical record contained no documented evidence that facility staff notified or consulted Resident 1's physician regarding the resident's weight loss before July 3, 2026. The clinical record also contained no documented evidence that facility staff notified Resident 1's responsible party of the resident's weight loss during this period. The clinical record revealed that the physician first became aware of the resident's weight loss on July 3, 2026, after Resident 1's responsible party contacted the physician. The clinical record contained no documented evidence that facility staff had previously notified the physician of the resident's ongoing weight loss identified beginning May 21, 2026. During an interview on August 13, 2026, at 12:00 PM, Resident 1's responsible party stated that facility staff had not informed her that Resident 1 was experiencing weight loss. The responsible party further stated that she had previously expressed concern to facility staff because she believed Resident 1 was losing weight. During an interview with the Nursing Home Administrator on August 13, 2026, at 3:02 PM, the above findings were reviewed. The facility was unable to provide documented evidence that staff had timely notified Resident 1's physician or responsible party of the resident's ongoing weight loss beginning May 21, 2026, in accordance with the facility's notification policy. 28 Pa Code 211.10 (c) Resident care policies 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services

Based on staff interviews, review of personnel records, employee credentials, facility documentation, and dietary service records, it was determined the facility failed to ensure the food and nutrition services department received the required oversight by qualified personnel after the resignation of the facility's Registered Dietitian (RD). Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian, the director of food and nutrition services, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications: (A) A certified dietary manager; or(B) A certified food service manager; or(C) Has similar national certification for food service management and safety from a national certifying body; or(D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and must receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. A review of the facility-provided job description for the Registered Dietitian (RD) revealed the position was responsible for planning, organizing, developing, and directing resident nutritional care in accordance with current federal, state, and local standards, guidelines, regulations, and facility policies and procedures. The documented major duties and responsibilities of the position included providing registered dietitian services at one or more facilities in accordance with facility policies and procedures; planning, organizing, developing, and directing nutritional care services for residents; assessing and monitoring residents' nutritional status and providing recommendations to clinical and medical staff; observing resident meal services to ensure prescribed diets and diet modifications were followed; educating residents, families, and staff regarding nutrition concepts and dietary modifications; collaborating with members of the interdisciplinary team to ensure modified texture diets and therapeutic diets were appropriate for the resident's medical condition; reviewing menu changes to ensure compliance with facility policy as well as state and federal guidelines; updating diet orders and menu changes as required; conducting routine audits of nutritional care practices; completing nutritional assessments upon admission, readmission, quarterly, annually, and with significant changes in condition; inspecting food service areas for sanitation, organization, safety, and proper staff performance; monitoring residents for weight changes, nutritional support needs, and skin breakdown and making recommendations as indicated; and participating in inspection surveys to ensure compliance with nutritional and dietary policies and procedures in accordance with state and federal requirements. A review of the facility's documented dietitian responsibilities revealed the RD was responsible for documenting resident weight changes in PointClickCare (the facility's electronic health record), completing comprehensive nutritional assessments, reviewing laboratory results and meal intake records, performing nutrition-focused physical assessments, and updating nutrition-related care plans. During an interview on July 15, 2026, at 11:49 AM, the Nursing Home Administrator stated the facility did not have a long-term Registered Dietitian or a Certified Dietary Manager responsible for directing the food and nutrition services department. The Nursing Home Administrator stated routine on-site clinical nutrition coverage was not being provided. During a subsequent interview on July 15, 2026, at 1:30 PM, the Nursing Home Administrator confirmed the facility's Registered Dietitian resigned, with a last day worked of April 24, 2026. The Administrator stated the facility subsequently utilized a Registered Dietitian who provided services remotely (off-site and not present in facility) and also covered multiple sister facilities.A review of the remote Registered Dietitian's documented work records revealed the following time was recorded for services provided to the facility:Sunday May 31, 2026: 4 hoursSunday June 7, 2026: 4 hoursSunday June 14, 2026: 5 hoursSunday June 21, 2026: 5 hoursSunday June 28, 2026: 5 hours The documented hours reflected limited off-site consultation coverage and revealed no documented evidence the Registered Dietitian routinely provided on-site oversight of the facility's food and nutrition services department. The facility was unable to provide documentation demonstrating the Registered Dietitian routinely provided on-site consultation, observed resident meal services, evaluated dietary operations, conducted direct resident nutritional assessments on-site, or performed the on-site oversight responsibilities identified in the facility's Registered Dietitian job description following the resignation of the facility's previous Registered Dietitian. The facility failed to ensure the food and nutrition services department was directed and clinically supported by qualified personnel as required. Specifically, the facility did not employ a qualified food and nutrition services director meeting regulatory requirements and failed to ensure routine on-site consultation and oversight by a qualified Registered Dietitian or other clinically qualified nutrition professional following the resignation of the facility's Registered Dietitian. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Based on observations and staff interviews, it was determined the facility failed to ensure residents had reasonable access to functional telephones that afforded privacy during telephone communications on two of two nursing units.Findings include:During an environmental tour of the second-floor nursing unit on July 14, 2026, at 10:11 AM, no functional portable telephone was available for resident use in a private location. A portable black telephone was observed on a desk behind an enclosed office at the nurses' station. An attempt to operate the telephone revealed there was no dial tone. An interview conducted at that time with Employee 1, a Registered Nurse (RN), revealed the portable telephone had not functioned for an extended period. Employee 1 reported that when residents requested telephone access, staff offered the Nursing Supervisor's cellular telephone. No alternative resident-accessible telephone was available in a location that afforded privacy from being overheard during telephone conversations. An interview with Employee 2, a Licensed Practical Nurse (LPN), on the third-floor nursing unit on July 14, 2026, at 10:45 AM revealed there had not been a functioning cordless telephone available for resident use on the unit for more than one year. Employee 2 reported residents either used the landline telephone located at the nurses' station, where conversations could be overheard by individuals in the surrounding area, or were offered the Nursing Supervisor's cellular telephone. No resident-accessible telephone was available in a private location that permitted confidential telephone communications. The observations and staff interviews demonstrated that the facility failed to provide residents on either nursing unit with reasonable access to a functional telephone located in an area that afforded privacy for telephone communications. During an interview on July 15, 2026, at 3:15 PM, the Nursing Home Administrator confirmed the facility did not provide residents on all nursing units with access to a functional resident telephone that afforded privacy during telephone communications. 28 Pa. Code 201.18(b)(2)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.

Based on observations and staff interviews, it was determined the facility failed to maintain a clean, sanitary, functional, and comfortable environment on two of three resident care units observed (second and third floor resident units). Findings include:On July 15, 2026, at 12:00 PM, observations of the second floor resident hallway revealed a strong, pervasive malodor present throughout the hallway.On July 15, 2026, at 12:10 PM, observations of the third floor resident hallway revealed sticky flooring with visible accumulations of dark-colored dirt and debris along the corners of the hallways.On July 15, 2026, at 12:15 PM, observations of the second floor dining room revealed multiple residents seated for dining while garbage remained beneath several dining tables, including a crushed empty nutritional supplement container, straw wrappers, a used plastic fork, and scattered popcorn on the floor.On July 15, 2026, at approximately 12:20 PM, observations of the hallway outside room [ROOM NUMBER] revealed a pair of used disposable gloves on the floor and multiple dark-colored splatters of an unidentified substance on the hallway floor. The floor surface was sticky and produced an audible sticking sound as individuals walked across it.During an interview on July 15, 2026, at 3:00 PM, the Nursing Home Administrator and Director of Nursing accompanied the surveyor during a review of the above observations and acknowledged the conditions observed.28 Pa Code 201.18(1)(3) Management.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Dating for Food Storage last reviewed by the facility on March 26, 2026, indicated bulk items were to be stored in approved containers with tight fitting lids with a label on the lid and side container with the products name and date the container was filled. The policy stated that all food items requiring time and temperature control should be labeled with the date opened and a use by date indicate when the product is to be discarded. The policy detailed that opened products can be kept for a 7-day period after opening and then discarded. A review of a facility policy titled Sanitary Conditions, last reviewed by the facility on March 26, 2026, revealed all food items requiring refrigeration will be stored above the floor on shelves. The policy revealed all opened food items will be stored in proper containers and labeled and dated. During the initial tour of the dietary department on July 15, 2026, at 10:30 AM, accompanied by the facility's Corporate Dietary Manager, the following observations were made: Upon entering the dietary department, a large amount of dirty water leaked from the dishwashing system onto the kitchen floor in the food preparation area. An outdoor brick supported the leaking pipe. The water had accumulated on the floor and slowly drained toward a floor drain. The Corporate Dietary Manager stated the dishwasher had been leaking for some time and maintenance was aware of the problem. Upon entering the dietary department, a large amount of dirty water leaked from the dishwashing system onto the kitchen floor in the food preparation area. An outdoor brick supported the leaking pipe. The water had accumulated on the floor and slowly drained toward a floor drain. The Corporate Dietary Manager stated the dishwasher had been leaking for some time and maintenance was aware of the problem. The walk-in cooler contained a pizza box with a partially eaten pizza stored on top of pre-made desserts scheduled to be served to residents for lunch that day. The Corporate Dietary Manager stated the pizza belonged to staff working the previous evening and acknowledged staff were not permitted to store personal food in resident food storage areas. The walk-in cooler also contained an opened bottle of thickened milk (milk that has been modified to a thicker consistency for individuals who require thickened liquids to swallow safely). The bottle was marked as opened on June 17, 2026, and remained in the cooler on the date of observation, July 15, 2026. The walk-in cooler contained a package of hot dogs wrapped in aluminum foil. Although a date had been written on the foil, it had become partially erased and was no longer legible, preventing staff from determining when the product had been stored. The produce refrigerator contained an open, partially consumed bottle of Gatorade stored next to fresh produce. The refrigerator also contained a grocery bag holding yogurt and a spoon. The Corporate Dietary Manager stated the items belonged to staff and should not have been stored in the produce refrigerator. During an interview on July 15, 2026, at 2:00 PM, the Nursing Home Administrator reviewed the above findings and acknowledged the facility had not maintained the dietary food storage areas in a sanitary manner consistent with facility policy. 28 Pa. Code 201.18 (e) (2.1) Management.

Based on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain an effective, ongoing program that monitored and sustained corrective actions to prevent the recurrence of previously cited deficient practices related to infection prevention and control, food procurement, sanitary food storage, preparation and service, and qualified dietary oversight.Findings include:During the survey ending May 8, 2026, the facility was cited for failing to implement measures to prevent the potential spread of infection. In response, the facility submitted a Plan of Correction indicating personal protective equipment (PPE), such as gloves, gowns, and other protective items used to reduce the spread of infection, would be provided to residents who required it. The facility further indicated that each resident would be evaluated to determine the need for PPE, nursing staff, nursing assistants, and department managers would receive education regarding identifying residents requiring PPE, department managers would audit the availability of PPE during routine rounds, and the Administrator would review the daily audit results. The Plan of Correction indicated the audit findings would be reviewed during the monthly Quality Improvement meeting, the QAPI Committee would determine whether additional auditing was necessary after three consecutive months of compliance, and monitoring would continue based on the Committee's recommendations. The facility identified July 10, 2026, as the completion date for these corrective actions. However, during the revisit survey ending July 15, 2026, the facility again failed to ensure infection prevention and control measures were consistently implemented under the same regulatory requirement. During the survey ending May 8, 2026, the facility was also cited for failing to ensure sanitary conditions and safe food handling practices in the kitchen. In response, the facility submitted a Plan of Correction indicating the Dietary Director or designee would re-educate dietary staff regarding the facility's sanitation policy and complete kitchen sanitation audits twice weekly to ensure sanitary conditions and resident safety were maintained. The facility further indicated the audit findings would be reviewed during the monthly Quality Improvement meeting, the QAPI Committee would determine whether continued auditing was necessary after three consecutive months of compliance, and monitoring would continue based on the Committee's recommendations. The facility identified July 10, 2026, as the completion date for these corrective actions. However, during the revisit survey ending July 15, 2026, the facility again failed to maintain sanitary conditions and safe food handling practices in the kitchen under the same regulatory requirement. During the survey ending May 8, 2026, the facility was also cited for failing to ensure sufficient qualified dietary oversight. In response, the facility submitted a Plan of Correction indicating the facility had retained an additional Registered Dietitian (RD), a qualified nutrition professional responsible for assessing residents' nutritional needs and overseeing food and nutrition services. The Plan of Correction indicated one Registered Dietitian would conduct weekly on-site visits while another Registered Dietitian would continue to provide remote nutritional oversight. The facility indicated the Corporate Director of Dietary would review the Registered Dietitians' responsibilities to ensure regulatory compliance, the Administrator or designee would audit the Registered Dietitians' weekly hours and on-site visits, and resident care plans identified during the survey would be reviewed and revised, as appropriate. The facility identified July 10, 2026, as the completion date for these corrective actions. However, during the revisit survey ending July 15, 2026, the facility again failed to ensure sufficient qualified dietary oversight under the same regulatory requirement. An interview with the Nursing Home Administrator during the revisit survey acknowledged the previously implemented corrective actions had not been sustained. The recurrence of the same deficient practices following implementation of the facility's Plans of Correction demonstrated that the QAPI Committee failed to effectively monitor, evaluate, and sustain corrective actions. As a result, the Committee did not identify that the corrective measures were ineffective or ensure additional performance improvement activities were implemented to prevent the recurrence of the previously cited deficiencies. Cross Ref. F880, F812, F801 28 Pa. Code 211.12 (d)(1)(5) Nursing Services.28 Pa. Code 201.18 (b)(1) Management.

Based on a review of clinical records, facility policy, resident observations, and resident and staff interviews, it was determined the facility failed to implement infection prevention and control measures consistent with nationally recognized standards of practice for the evaluation and management of suspected scabies for two of 15 residents reviewed (Resident 1 and Resident 2). Findings include:According to the Centers for Disease Control and Prevention (CDC) guidance titled Public Health Strategies for Scabies Outbreaks in Institutional Settings (updated December 18, 2025), residents with confirmed or suspected scabies (a skin condition caused by microscopic mites that burrow into the skin and lay eggs, resulting in intense itching, often worse at night, and a pimple-like rash) should be placed on contact precautions (infection prevention measures that require the use of gowns and gloves during resident care and avoidance of direct skin-to-skin contact). The guidance stated that roommates or close contacts with prolonged skin exposure should be identified, offered prophylactic treatment, and monitored but do not require room isolation. A review of the facility policy titled, Head Lice and Scabies Exposure and Treatment Policy, last reviewed March 26, 2026, indicated residents who contract scabies or head lice are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. According to the policy, proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. Upon signs and symptoms of scabies, the provider will be notified, treatment will be administered according to manufacturer's instructions, the infested resident will be placed in a single occupancy room, and appropriate transmission-based precautions (extra precautions applied when a resident is known or suspected to be infected with disease causing organism that spread via contact, droplets, or airborne route) will be initiated according to the policy. A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with a diagnosis of systolic heart failure (a condition in which the left side of the heart does not pump blood effectively). Resident 2's Brief Interview for Mental Status (BIMS) (a standardized assessment used to evaluate attention, orientation, and short-term memory) dated July 14, 2026, identified a score of 10, indicating moderate cognitive impairment. A score of 8-12 means noticeable difficulties with short-term memory or orientation, such as recalling words or identifying the current date correctly. Observation of Resident 2 on July 15, 2026, at 11:35 AM revealed multiple bright red circular areas on the resident's upper and lower extremities. During interview, Resident 2 reported skin discomfort while gesturing toward the affected areas. A review of Resident 2's clinical record review revealed the admission assessment dated [DATE], documented multiple scratches involving the arms, legs, forehead, and chest. A nursing progress note completed the same evening documented similar findings. A nursing progress note dated July 10, 2026, documented notification of the nurse practitioner, who ordered treatment for possible scabies with Permethrin 5% topical cream (a medication used to kill the mites and eggs that cause scabies). Physician orders dated July 11, 2026, directed staff to apply Permethrin 5% cream from the neck down at bedtime, leave the medication on for eight to fourteen hours, then wash it off the following morning and provide clean clothing. The electronic Medication Administration Record (eMAR) documented administration of Permethrin on July 11, July 12, July 13, and July 14, 2026. Despite ongoing treatment for suspected scabies, the clinical record lacked evidence Resident 2 was placed on contact precautions or that additional infection prevention measures were implemented consistent with CDC guidance or the facility's infection prevention policy. According to the clinical record, Resident 2 underwent evaluation by the wound care nurse practitioner on July 15, 2026, at 6:45 AM. Although the documentation described a Stage IV pressure injury of the sacrum (a very deep wound over the lower back near the tailbone), it did not include any information related to the red, circular areas on Resident 2's extremities. An attempt to contact the wound care nurse practitioner who evaluated and treated Resident 2, on July 17, 2026, at 9:00 AM was unsuccessful, and no return call was received. According to the CDC, Public Health Strategies for Scabies Outbreaks in Institutional Settings (2025, December 18) residents who share a room with an individual diagnosed with scabies do not require room isolation. Residents who share a room with an individual diagnosed with scabies must be promptly identified as close contacts, receive prophylactic treatment as indicated, and be monitored, while contact precautions are implemented for the affected resident. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses to include acute embolism and thrombosis of unspecified deep veins of lower bilateral lower extremities (both legs suddenly developed blood clots in deep veins, and pieces of clots may have already broken off and travel elsewhere in the body). A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates normal thinking and memory; little to no cognitive impairment). Resident 1 resides in the same room as Resident 2. On July 13, 2026, the spouse of Resident 1 communicated concerns stating Resident 1 informed him she was in quarantine due to the roommate (Resident 2) having an infectious disease. The spouse of Resident 1 expressed concern regarding its impact on discharge and physical therapy attendance due to the quarantine. Clinical record review for Resident 1 lacked evidence the facility identified the resident as a close contact following initiation of treatment for suspected scabies in the roommate. The record contained no evidence of provider notification, comprehensive skin assessment, monitoring for signs or symptoms of scabies, consideration of prophylactic treatment, or implementation of additional infection prevention measures. Observation confirmed Resident 1 remained in the shared room on July 14, 2026, at 10:11 AM and was observed in a common lounge area on July 15, 2026, at 11:30 AM. The findings were reviewed with the Director of Nursing on July 15, 2026, at 2:35 PM. During the interview, the DON stated there was uncertainty regarding the cause of Resident 2's skin condition and indicated that scabies had initially been considered among the possible causes. The DON stated Resident 2 had not been placed on transmission-based precautions while the skin condition was being evaluated. During a subsequent interview on July 15, 2026, at 3:15 PM, the Director of Nursing and the Nursing Home Administrator stated the cause of Resident 2's skin condition had not been definitively identified. The clinical record lacked documentation that Resident 2 was evaluated by a skin specialist or that infection prevention measures consistent with the facility's policy and current Centers for Disease Control and Prevention (CDC) guidance were implemented while scabies remained a suspected diagnosis. 28 Pa Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of facility clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop and update a resident-specific baseline care plan to include interim, person-centered interventions necessary to address newly identified care needs for one of 15 sampled residents reviewed (Resident 2).Findings include: According to the Centers for Disease Control and Prevention (CDC) guidance titled Public Health Strategies for Scabies Outbreaks in Institutional Settings, updated December 18, 2025, residents with confirmed or suspected scabies (a contagious skin infestation caused by microscopic mites that burrow beneath the skin, causing intense itching and a rash) should be placed on contact precautions, including the use of gowns and gloves and avoidance of direct skin-to-skin contact. The guidance further states that close contacts should be identified, monitored, and offered prophylactic treatment, as appropriate. A review of the facility's Baseline Care Plan Policy, reviewed March 26, 2026, revealed the facility would develop and implement a baseline care plan within 48 hours of admission. The policy indicated the baseline care plan must include the minimum healthcare information necessary to provide effective, person-centered care until the comprehensive care plan is developed such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. The policy required the baseline care plan to include interventions addressing the resident's current needs and health and safety concerns, including interventions necessary to prevent injury or decline and address identified supervision needs. A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses including acute-on-chronic systolic congestive heart failure (a sudden worsening of symptoms in a person with chronic heart failure in which the heart cannot pump blood effectively). A nursing progress note dated July 9, 2026, at 10:59 PM documented the resident's skin was intact with scratches noted on the arms, legs, and forehead. A nursing progress note dated July 10, 2026, at 4:02 PM documented the Registered Nurse Supervisor contacted the Certified Registered Nurse Practitioner (CRNP) regarding suspected scabies exposure. The CRNP ordered Permethrin 5% topical cream (a prescription medication applied to the skin to treat scabies) as prophylactic treatment, meaning treatment intended to prevent the development or spread of disease following suspected exposure. A physician's order dated July 10, 2026, directed staff to apply Permethrin 5% cream from the neck down at bedtime for 10 days as prophylactic treatment for suspected scabies exposure. A review of the baseline care plan, initiated July 9, 2026, revealed the resident's identified needs included Enhanced Barrier Precautions (infection prevention measures used during high-contact care activities for residents with certain medical devices or wounds). However, after the resident's newly identified need for prophylactic treatment related to suspected scabies exposure, the facility failed to update the baseline care plan to identify the resident's contact precaution status or include individualized interim interventions instructing staff on the infection prevention measures necessary while the resident received treatment. During an interview on July 16, 2026, at 3:00 PM, the Director of Nursing confirmed Resident 2 received prophylactic treatment related to suspected scabies exposure and acknowledged the baseline care plan did not include individualized interventions addressing the resident's contact precautions. The Director of Nursing further confirmed the baseline care plan was not consistent with the facility's Baseline Care Plan Policy. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on a review of clinical records, facility policy, manufacturer's prescribing information, and staff interviews, it was determined the facility failed to ensure medications were free from unnecessary use by administering permethrin cream without adequate clinical indication and for an excessive duration for one of 15 sampled residents (Resident 2).Findings include:Review of the facility policy titled Medication Administration last reviewed March 26, 2026, indicates medications are administered as ordered by the physician and in accordance with professional standards of practice. The policy indicated the facility will administer medications by utilizing best practice guidelines (strategies, methods, or techniques that have been proven through research and evaluation to be effective and efficient in achieving desired results). A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with a diagnosis of systolic heart failure (a condition in which the left side of the heart cannot pump blood effectively throughout the body). A review of Resident 2's Brief Interview for Mental Status (BIMS) assessment, dated July 14, 2026, revealed Resident 2 had a BIMS score of 10, indicating moderate cognitive impairment. The BIMS is a standardized assessment used to evaluate a resident's attention, orientation, and ability to register and recall new information. A score of 8 through 12 indicates moderate cognitive impairment. A clinical record review of the document titled admission Evaluation with Baseline Care Plan v.6 revealed Resident 2 was observed to have multiple scratches and bruising upon admission on [DATE].A Clinical record review revealed an admission skin integrity evaluation on July 9, 2026, documented observed scratches and blisters on bilateral lower extremities. The assessment documented a scratch located on the forehead and upper chest. The assessment documented multiple scratches and bruising of unspecified areas. The goal portion of the assessment documented a goal for the resident to experience healing of the current skin impairment and prevent future skin breakdown.A nursing progress note dated July 10, 2026, at 4:02 PM documented the nurse contacted the nurse practitioner, who ordered permethrin 5% topical lotion (a prescription-strength medication used to treat scabies. It works by paralyzing and killing the mites and their eggs), to prophylactically (to provide medication as a preventative) treat possible scabies (a skin condition caused by tiny mites that burrow into the skin, causing intense itching, and a rash that looks like small pimples or scaly lines).A physician's order dated July 10, 2026, directed staff to apply permethrin 5% cream from the resident's neck down at bedtime for scabies for a duration of 10 days, leave the medication on for 8 to 14 hours, wash it off the following morning, and provide clean clothing after bathing. A subsequent physician order dated July 11, 2026, again directed staff to administer permethrin for 10 days. Review of the clinical record failed to identify documentation of a provider assessment confirming a diagnosis of scabies. The record also lacked documentation of diagnostic evaluation, including dermoscopy (the use of a magnifying device to examine skin lesions) or skin scraping (collecting a small sample of skin to examine under a microscope for scabies mites or eggs), to support treatment with permethrin. Review of the July 2026 Medication Administration Record revealed staff administered permethrin cream on the evenings of July 11, July 12, July 13, and July 14, 2026. According to the manufacturer's prescribing information for permethrin 5% cream, last updated March 9, 2026, a single application is generally sufficient to treat scabies. The prescribing information directs the cream to be applied once, left on the skin for 8 to 14 hours, and then removed by bathing or showering and changing into clean clothing. Approximately 30 grams is usually sufficient for an average adult. The manufacturer's prescribing information states that mild burning, stinging, or itching may occur after application. The prescribing information further explains that persistent pruritus (itching) after treatment may continue even when treatment has been successful and does not indicate treatment failure or the need for additional applications. Retreatment should only be considered 7 to 14 days after the initial application if live mites are demonstrated to remain. Documented adverse reactions include burning, stinging, itching, redness, rash, and skin inflammation. The prescribing information warns that repeated or excessive use may increase the risk of skin irritation and other adverse skin reactions. Observation of Resident 2 on July 15, 2026, at 11:35 AM revealed widespread bright red circular areas involving the upper and lower extremities and sacral area (the lower back and upper buttocks). The affected areas appeared crusted and scabbed, demonstrated extensive scratching, and contained dried blood. During an interview on July 15, 2026, at 11:15 AM, the facility's Infection Preventionist stated they believed Resident 2 had already been cleared of scabies. The Infection Preventionist acknowledged the resident was never placed on transmission-based precautions because both the Infection Preventionist and Director of Nursing believed the resident did not have scabies. During an interview on July 15, 2026, at 2:10 PM, the Director of Nursing stated the physician order should not have directed permethrin treatment for 10 days and acknowledged the order had been entered incorrectly. The Director of Nursing confirmed nursing staff continued administering the medication without recognizing the error and further stated Resident 2 did not have scabies and the medication should have been discontinued. The facility administered permethrin cream without documented clinical evidence supporting its use and continued treatment beyond accepted prescribing recommendations. As a result, Resident 2 received unnecessary medication without an adequate clinical indication and for an excessive duration, exposing the resident to avoidable adverse medication effects, including worsening skin irritation. These findings were reviewed with the Director of Nursing and the Nursing Home Administrator on July 15, 2026, at 3:30 PM. 28 Pa. Code 211.10 (c)(d) Resident care policies.28 Pa. Code 211.12 (d)(1)(5) Nursing services.28 Pa. Code 211.9 (a)(1)(d) Pharmacy services.

Based on clinical record review, facility policy review, external wound care records, hospital records, and staff and family interviews, it was determined the facility failed to provide necessary treatment and services consistent with professional standards of practice to assess, monitor, and treat an existing pressure injury for one of 10 residents reviewed (Resident 1) resulting in actual harm.Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, care planning, and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States, Clinical Practice Guidelines, indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the facility policy titled Pressure Injury Prevention and Management, last reviewed by the facility on March 26, 2026, revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure injury, prevent infection, and prevent the development of additional pressure injuries. The facility defines avoidable as the resident developed a pressure injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included sepsis (the body's extreme and potentially life-threatening response to infection) and methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria resistant to many commonly used antibiotics making infections much harder to treat). A care plan initiated April 18, 2026, identified impaired skin integrity (damage to skin tissue) related to actual open skin areas involving the coccyx (tailbone area), left buttock, and right buttock. Interventions included use of a pressure-reduction mattress, pressure-reduction chair cushion, monitoring wounds for signs of infection or worsening, skin observations during bathing and showering, notification of the wound nurse, physician, and family regarding new or worsening areas, wound measurements, and treatment as ordered. An admission evaluation titled admission Evaluation- Area Skin, dated April 18, 2026, revealed Resident 1 was at risk for alteration in skin integrity related to open skin areas identified on admission. The assessment documented an open area to the coccyx measuring 1 centimeter (cm) by 2 cm by 0.1 cm. Review of the clinical record from April 18, 2026, through May 12, 2026, revealed no documented wound assessments, measurements, reassessments, or weekly skin assessments related to the coccyx wound during this 25-day period despite physician orders, care plan interventions, treatment orders, and the presence of an open wound identified upon admission. Review of a physician's order dated April 18, 2026, revealed an order to cleanse wounds located on the right buttock, left buttock, and coccyx with normal saline, pat dry, and apply Calmoseptine (an over-the-counter moisture barrier ointment used to protect skin from irritation and moisture) every shift and as needed. Review of the Treatment Administration Record (TAR) for April and May 2026 revealed staff documented completion of the ordered wound treatment from April 18, 2026, through May 25, 2026. However, despite documentation indicating treatment was provided, the clinical record contained no documented wound assessments, measurements, reassessments, or weekly skin assessments between April 18, 2026, and May 12, 2026, to evaluate the effectiveness of the treatment or identify wound deterioration. Review of physician orders revealed Resident 1 had an order dated April 18, 2026, directing staff to complete weekly skin assessments every Thursday evening and document the assessment findings in the assessment section of the clinical record. Review of the Medication Administration Record/Treatment Administration Record revealed staff documented completion of the weekly skin assessments ordered. However, review of the assessment section of the clinical record revealed no corresponding skin assessments or assessment findings were documented between April 18, 2026, and May 12, 2026, despite staff documenting completion of the ordered weekly skin assessments. As a result, the clinical record contained no evidence the facility assessed or monitored the condition of the coccyx wound during this period. Review of the clinical record revealed staff were assigned a task to turn and reposition Resident 1 every shift to reduce prolonged pressure on vulnerable skin areas. Review of the April 2026 documentation report revealed staff failed to document completion of turning and repositioning on 13 of 42 reviewed shifts. Review of the May 2026 documentation report revealed staff failed to document completion of turning and repositioning on 26 of 72 reviewed shifts. A review of the clinical record revealed the consent for wound care services was signed on April 21, 2026, and uploaded to the resident's medical record. Despite the signed consent, Resident 1 was not evaluated by the wound care specialist until May 12, 2026, 21 days after the consent was obtained. During an interview on June 11, 2026, at 9:58 AM, the Director of Nursing was unable to provide documentation or communication from the wound care provider supporting the reason for the delay in wound care treatment. An external wound clinic report dated May 12, 2026, 25 days after admission, documented an unstageable pressure injury (a severe pressure injury in which the depth of tissue damage cannot be determined because dead tissue covers the wound) measuring 3.5 cm by 7.5 cm with the depth unable to be determined. The report documented 90 percent yellow fibrinous slough (dead tissue that can delay healing), 10 percent granulation tissue (new healing tissue), moderate bloody and purulent drainage (thick, milky, or cloudy fluid containing infection-related material), and a malodorous (foul-smelling) wound odor. The wound specialist recommended a low-air-loss mattress (a specialized support surface that redistributes pressure and manages moisture to help prevent and treat pressure injuries). Resident 1 was scheduled for a follow-up appointment in one week. The only documented wound measurements identified in the clinical record between admission and the wound clinic evaluation were the admission measurement obtained on April 18, 2026, and the wound clinic measurement obtained on May 12, 2026. Comparison of those assessments revealed the coccyx wound increased from 1 cm by 2 cm by 0.1 cm to an unstageable pressure injury measuring 3.5 cm by 7.5 cm with the depth unable to be determined. An external wound clinic report dated May 19, 2026, documented an unstageable pressure injury measuring 4.1 cm by 7.9 cm with the depth unable to be determined. The wound bed contained 70 percent slough (dead tissue that can delay healing) and 30 percent granulation tissue (new healthy tissue formed during healing). The wound status was documented as unchanged despite an increase in wound measurements since the previous assessment. During the visit, the wound care provider performed a sharp excisional debridement (the medical removal of dead, damaged, or infected tissue using surgical instruments to promote healing and prevent infection) involving 16.2 square centimeters of tissue. Following the procedure, the wound measured 4.1 cm by 7.9 cm with a depth of 0.8 cm. Review of laboratory records revealed a wound culture was obtained on May 12, 2026, at 8:32 AM. Laboratory results available in the clinical record on May 16, 2026, identified multiple organisms within the wound including methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria resistant to many commonly used antibiotics), Pseudomonas aeruginosa (a bacteria commonly associated with serious wound infections), gram-positive cocci (a category of bacteria), and gram-negative bacilli (a category of bacteria). Review of nursing documentation dated May 13, 2026, at 10:36 AM revealed a non-emergent hospital transfer was initiated due to an abnormal wound culture that had been reviewed by the nurse practitioner. A review of a physician progress note dated May 13, 2026, at 3:29 PM documented that Resident 1 underwent a wound culture of the pressure injury that identified numerous bacteria. The physician documented Resident 1 was experiencing fatigue and weakness and noted concern regarding the severity of the wound infection and possible osteomyelitis (an infection of the bone). Based on these findings, the physician ordered transfer to the emergency department for further evaluation, including diagnostic imaging and consultation with an infectious disease specialist (a physician who specializes in the diagnosis and treatment of infections). A review of facility progress notes revealed Resident 1 returned from the emergency department on May 13, 2026, at 7:10 PM with a diagnosis of a urinary tract infection (an infection involving the urinary system). Review of the emergency department records from May 13, 2026, did not identify documentation that the pressure injury was evaluated during that visit. During an interview on June 11, 2026, at 11:00 AM the Director of Nursing stated the facility was unable to provide the transfer documentation that accompanied Resident 1 to the emergency department on May 13, 2026. As a result, the facility was unable to demonstrate that the physician's concerns regarding the wound infection, possible osteomyelitis, and need for wound evaluation were communicated to the hospital at the time of transfer. A review of a physician's progress note dated May 18, 2026, at 10:23 AM confirmed Resident 1 had been transferred to the emergency department on May 13, 2026, for evaluation of the infected wound but returned without the wound being examined. The physician documented that on May 17, 2026, six days after the wound culture was obtained, Resident 1 started on Clindamycin 300 milligrams (an antibiotic medication used to treat bacterial infections) every six hours for 10 days to treat the wound infection. A review of a progress note dated May 25, 2026, at 2:45 PM revealed Resident 1 was again transferred to the emergency department. The progress note did not document the reason for the transfer. A subsequent progress note dated May 25, 2026, at 4:00 PM revealed emergency department staff contacted the facility to determine the reason Resident 1 had been sent to the hospital. Facility documentation indicated the resident was transferred at the family's request and that the resident was asymptomatic (not showing outward signs or symptoms of illness) at the time of transfer despite the resident's ongoing wound infection. During a telephone interview conducted on June 11, 2026, at 1:00 PM Resident 1's emergency contact stated the family requested the May 25, 2026, hospital transfer after observing the wound for the first time since admission. The emergency contact stated the wound appeared significantly worse than expected and described it as very bad, prompting the family to request immediate evaluation at the hospital. A review of hospital records revealed Resident 1 was admitted to the hospital on [DATE], for treatment of the infected pressure injury and a urinary tract infection. Hospital records revealed Resident 1 required transfer on May 29, 2026, to another facility for a higher level of care, where the resident subsequently underwent surgical intervention for management of the wound. Hospital records revealed Resident 1 required surgical intervention on June 1, 2026, including sacral debridement and negative pressure wound therapy (NPWT- the process of applying sterile foam or gauze dressing to the wound bed, sealing it with airtight film, and connecting it to a portable vacuum pump to promote new tissue growth and healing) . The facility failed to assess and monitor Resident 1's existing pressure injury, failed to complete ordered skin assessments, failed to consistently implement and document pressure-relieving interventions, failed to identify and respond to wound deterioration, and failed to ensure timely wound care treatment. As a result, Resident 1's coccyx wound deteriorated from an open area measuring 1 cm by 2 cm by 0.1 cm upon admission to an infected unstageable pressure injury requiring hospitalization, intravenous antibiotic therapy, surgical debridement, and negative pressure wound therapy. This deficient practice resulted in actual harm. On June 11, 2026, at 2:35 PM these findings were reviewed with the Director of Nursing and Nursing Home Administrator. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on a clinical record review and staff interview, it was determined the facility failed to ensure that the required resident information was communicated to the receiving health care provider for two out of 10 residents reviewed (Residents 1 and 2).Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to a hospital emergency department on two separate dates May 13, 2026, and May 25, 2026.A review of Resident 1's transfer records for May 13, 2026, and May 25, 2026, revealed the facility failed to document that it communicated required transfer information to the receiving health care provider. The record lacked evidence that the facility provided the name and contact information of the physician responsible for the resident's care, resident representative contact information, advance directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other information necessary to facilitate continuity of care during the transfer.Review of emergency department records dated May 13, 2026, revealed Resident 1 was returned to the facility with a diagnosis of urinary tract infection (an infection involving any part of the urinary system), despite documentation indicating the resident had originally been transferred for evaluation of a wound (an injury or break in the skin or underlying tissue). The clinical record lacked evidence that the facility communicated the resident's wound-related care needs and treatment information to the receiving provider at the time of transfer. Review revealed the clinical record for Resident 1 lacked evidence that wound treatment information accompanied the resident to the emergency department to assist the receiving provider in evaluating and treating the resident's condition.A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to the emergency department on May 1, 2026. Resident 2 returned from the hospital on May 6. 2026.A review of Resident 2's clinical record revealed the facility failed to document that it communicated required transfer information to the receiving health care provider at the time of transfer. The record lacked evidence that the facility provided the name and contact information of the physician responsible for the resident's care, resident representative contact information, advance directive information, special instructions or precautions for ongoing care, comprehensive care plan goals, and other information necessary to ensure continuity of care.During an interview conducted on June 11, 2026, at 11:30 AM, the Director of Nursing was unable to provide documentation demonstrating the facility communicated the required transfer information to the receiving health care providers for Resident 1 on May 13, 2026, and May 25, 2026, or for Resident 2 on May 1, 2026. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights.

Based on clinical record review, documentation review, resident representative interview, and staff interview, , it was determined the facility failed to ensure that a resident who was dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for one resident out of 10 sampled residents (Resident 1).Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included sepsis (the body's extreme, life-threatening response to an infection and bacteremia (the presence of viable bacteria in the bloodstream). Review of Resident 1's admission Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 22, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of Resident 1's MDS revealed Resident 1 was completely dependent on staff for all showering and bathing needs. The MDS defines bathing as the ability to wash, rinse, and dry the body. An interview with Resident 1's emergency contact on June 11, 2026, at 11:30 AM revealed he had concerns regarding the resident's hygiene and cleanliness. The emergency contact stated he had requested staff clean the resident on multiple occasions because the resident had a noticeable odor and appeared soiled. The emergency contact further stated he marked the resident's brief to determine whether it had been changed and later observed the marked brief remained in place. The emergency contact stated he believed the resident was not consistently receiving scheduled showers. A review of Resident 1's Kardex (a quick-reference care guide used by staff to communicate resident care needs and assigned tasks) revealed Resident 1 was scheduled to receive showers every Monday and Thursday on the evening shift. A review of the Documentation Survey Report V2 for April 2026 and May 2026 revealed that on multiple scheduled shower dates, including April 17, 2026, April 20, 2026, April 23, 2026, April 27, 2026, April 30, 2026, May 4, 2026, May 7, 2026, May 11, 2026, May 14, 2026, May 18, 2026, and May 21, 2026, staff either failed to document that a shower was provided or documented that a bed bath was provided in place of the scheduled shower. The record contained no documented evidence explaining why a bed bath was substituted for a scheduled shower and contained no evidence of a change in the resident's condition that would have prevented showering. A review of the Documentation Survey Report Version 2 further revealed an area designated for documenting AM (morning care) and HS (care provided at bedtime or hour of sleep). This section required staff to document whether bathing and personal hygiene care were provided and whether the resident's bathing preference was followed by indicating a shower, bath, bed bath or partial bed bath. The April 2026 and May 2026 Documentation Survey Reports contained numerous entries in which AM care and/or HS care were left blank or documented as Not Applicable, despite the resident's complete dependence on staff for bathing and personal hygiene care. Examples include:April 18, 2026, AM care was left blankApril 18, 2026, HS care was left blankApril 21, 2026, HS care was left blankApril 22, 2026, HS care was left blankApril 23,2026, HS was documented as Not Applicable. April 26, 2026, HS care was documented as Not Applicable. April 28, 2026, HS care was documented as Not Applicable. April 29, 2026, HS care was documented as Not Applicable. April 30, 2026, HS care was left blank. May 1, 2026, AM care was left blank, and the HS care was documented as Not Applicable. May 2, 2026, AM care and HS care we documented as Not Applicable. May 3, 2025, AM care was documented as Not Applicable. May 4, 2026, AM care and HS care were both documented as Not Applicable. May 5, 2026, AM care was left blank, HS care was documented as Not Applicable. May 6, 2026, AM care was documented as Not provided and HS care was documented as Not Applicable. May 7, 2026, AM care was documented as Not Applicable, and HS care was documented as Not Applicable. May 8, 2026, HS care was left blank. May 9, 2026, HS care was left blank. May 10, 2026, HS care documented as not applicable. May 14, 2026, HS care was left blank. May 15, 2026, AM care was left blank. May 16, 2026, HS care was left blank. During an interview with the Director of Nursing (DON) on June 11, 2026, at 11:00AM, the DON acknowledged that Resident 1 was scheduled to receive showers every Monday and Thursday and acknowledged showers should have been provided as scheduled. The DON was unable to explain why showers were not consistently provided or documented. The above findings were reviewed with the DON on June 11, 2026, at 2:00 PM. The facility was unable to provide documented evidence demonstrating Resident 1 received showers as scheduled or that bathing, and that personal hygiene was provided as directed by the Kardex. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to develop, communicate, and implement an individualized toileting and bowel incontinence management program for one of 10 residents reviewed (Resident 1). The facility failed to establish interventions to ensure timely toileting assistance, routine monitoring for bowel incontinence, and prompt incontinence care for a resident assessed as completely dependent on staff for toileting and always incontinent of bowel.Findings include: A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included sepsis (the body's extreme, life-threatening response to an infection and bacteremia (the presence of viable bacteria in the bloodstream). Review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 22, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). The assessment revealed Resident 1 was completely dependent on staff for toileting hygiene and toileting transfers and was always incontinent of bowel. A review of the resident's person-centered care plan, initiated April 17, 2026, identified the resident was at risk for altered skin integrity related to bowel incontinence and decreased mobility and required preventive skin care measures. However, the care plan failed to include individualized interventions directing staff how to manage the resident's known bowel incontinence and promote timely care to prevent the potential of skin breakdown. The care plan did not include a scheduled toileting program, routine checks to determine whether the resident required changing after an incontinent episode, staff reminders and assistance with toileting, or specific instructions for monitoring and responding to the resident's bowel elimination needs. A review of the resident's Kardex (a nursing information system used to obtain specific care information for each resident), in effect from April 17, 2026, through May 25, 2026, failed to include instructions regarding bowel incontinence management. There was no documented evidence staff were directed to perform routine incontinence checks, provide scheduled toileting assistance, or implement any individualized bowel management program.A review of a three-day voiding diary (a record kept over a continuous 72 hour period that documents the times a resident urinates, amount, episodes of incontinence and related toileting patterns to evaluate bowel and bladder function to plan care) dated April 17, 2026, through April 20, 2026, revealed Resident 1 was incontinent during the majority of documented episodes, indicating an identifiable pattern of bowel and bladder incontinence requiring evaluation and care planning. A review of Documentation Survey Report v2 (general care nursing tasks completed for the resident) for April 2026 revealed Resident 1 was documented as incontinent of bowel during 100 percent of documented bowel elimination episodes. In addition, 28 percent of bowel elimination documentation was left blank on multiple shifts. A review of the Documentation Survey Report V2 for May 2026 revealed Resident 1 was documented as incontinent of bowel during 100 percent of documented bowel elimination episodes. In addition, 36 percent of bowel elimination documentation was left blank on multiple shifts. A review of Resident 1's progress notes revealed a progress note dated May 8, 2026, at 12:49PM documenting that Resident 1's visitor was concerned about Resident 1 experiencing loose stools and the hygienic cleanup of the bowel movements. The note documented Resident 1 had received incontinence care within the previous two hours and that any additional needs were delegated to a nursing assistant. During the survey, the facility administration was requested to provide a policy regarding the assessment, monitoring, and management of bowel incontinence. The facility was unable to provide such a policy.Despite the resident's assessed dependence for toileting, consistent bowel incontinence, identified risk for skin breakdown, documented pattern of incontinence, incomplete monitoring records, and visitor concerns regarding bowel hygiene, there was no documented evidence the facility evaluated the resident's bowel elimination patterns and developed, communicated, or implemented an individualized bowel incontinence management program to ensure timely toileting assistance, routine monitoring for incontinence, and prompt incontinence care. An interview with the Director of Nursing on June 11, 2026, at 11:15 AM, confirmed the facility was unable to provide a policy regarding bowel incontinence management for dependent residents and was unable to provide documentation demonstrating the facility had developed and implemented a planned bowel incontinence management program for Resident 1. 28 Pa. Code 211.10(a)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 3). Findings include: A review of the facility's Dementia Care Policy, reviewed July 2025, revealed the facility would provide appropriate treatment and services to residents diagnosed with dementia to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The policy indicated that the facility would assess residents' needs and develop and implement care plans through an interdisciplinary team approach, including the resident and resident representative, and provide the resources necessary to achieve identified care plan goals. A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnoses including dementia (a condition involving the loss of memory, thinking, reasoning, and other cognitive abilities that interferes with daily functioning). A review of Resident 3's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 14, 2026, revealed the resident was severely cognitively impaired and no BIMS sore (Brief interview for mental status, a tool within the cognitive section of the MDS that is used to access the resident's attention, orientation and ability to register and recall new information) was available at the time of the survey. A review of Resident 3's care plan initiated on June 4, 2026, and revised on June 8, 2026, revealed staff identified behavioral concerns related to dementia, including wandering into other residents' rooms, lying on the floor, refusing meals, and episodes of crying. The care plan goal indicated the resident would demonstrate a reduction in these behaviors. A review of care plan interventions revised on June 4, 2026, revealed staff were instructed to stop and talk with the resident when passing by and monitor for signs and symptoms of anxiety, including fidgeting and crying. A review of additional care plan interventions revised on June 4, 2026, revealed staff were instructed to intervene as necessary to protect the resident's rights and the rights and safety of others, approach and speak with the resident in a calm and reassuring manner, redirect and divert the resident's attention as appropriate, and remove the resident from situations to an alternate location when necessary. During an observation conducted on June 11, 2026, at 12:30 PM, Resident 3 was observed wandering into resident rooms on the second floor. The resident subsequently approached a medication cart located in the hallway while carrying a plastic component from a respiratory treatment device. Resident 3 did not receive respiratory treatments, and the source of the equipment could not be identified during the observation. During an interview at the time of the observation, Employee 1, Nurse Aide, stated Resident 3 wandered throughout the hallways and entered other residents' rooms on a regular basis despite staff attempts to redirect her. Employee 1 stated staff were unable to provide one-to-one supervision because of staffing limitations and could not identify where Resident 3 obtained the plastic respiratory equipment component. During an interview on June 11, 2026, at 11:30 AM, Resident 4, who was assessed as cognitively intact and able to provide reliable information, stated Resident 3 entered her room multiple times each shift on a daily basis. Resident 4 stated Resident 3 would remove a stop sign placed across the doorway, enter the room, touch personal belongings, and handle food items on meal trays. Resident 4 stated she routinely notified nursing staff and requested assistance removing Resident 3 from her room. Despite the facility identifying Resident 3's wandering behavior and revising the care plan with specific interventions intended to redirect, divert, monitor, and remove the resident from situations, when necessary, observations, interviews, and record review revealed the resident continued to wander into other residents' rooms and access items that did not belong to her. There was no evidence that the facility consistently implemented the identified care plan interventions or provided additional supervision or diversional approaches to address the ongoing behaviors. During an interview conducted on June 11, 2026, at 1:00 PM, the Director of Nursing confirmed that the individualized dementia care plan interventions were not implemented for Resident 3. 28 Pa Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, hospital records, physician orders, and staff interviews, it was determined the facility failed to ensure physician-ordered laboratory services were obtained in a timely manner and failed to follow through on ordered laboratory testing for one of seven residents reviewed (Resident 4). Findings included: A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (a condition caused by illness or abnormalities within the body that affect brain function and can result in confusion or altered mental status), dementia (a progressive decline in memory and thinking abilities that interferes with daily functioning), and Stage 3 chronic kidney disease (moderate loss of kidney function). A review of Resident 4's Quarterly Minimum Data Set (MDS, a federally required standardized assessment used to evaluate a resident's condition and care needs) dated May 9, 2026, revealed the resident was severely cognitively impaired. The Brief Interview for Mental Status (BIMS, a standardized assessment used to evaluate memory and cognitive function) was not completed. A review of a physician's order dated April 20, 2026, revealed an order to obtain a urinalysis (a laboratory test of urine used to identify infection or other abnormalities) and culture and sensitivity (a laboratory test used to identify bacteria and determine which antibiotics are effective for treatment) related to a suspected urinary tract infection. Nursing documentation dated April 20, 2026, at 6:58 AM revealed the resident refused to get out of bed to use the bathroom and the urine specimen was not obtained. Nursing documentation dated April 21, 2026, at 1:56 PM revealed the resident was taken to the bathroom; however, staff were unable to obtain a urine specimen and documented they would continue attempts to obtain a urine sample. Nursing documentation dated April 22, 2026, at 1:04 PM revealed the resident's temperature was 97.2 degrees Fahrenheit and the resident was incontinent of urine. Staff documented they were unable to obtain a urine specimen and had contacted the physician. There was no documented evidence that the facility obtained the physician-ordered urinalysis and culture and sensitivity or implemented alternative measures to ensure timely completion of the ordered laboratory testing between April 20, 2026, and April 30, 2026. Nursing documentation dated April 30, 2026, at 1:29 AM revealed the urinalysis and culture and sensitivity specimen was obtained and sent to the laboratory, ten days after the physician's order was issued. Nursing documentation dated May 1, 2026, at 8:17 AM revealed Resident 4 exhibited increased confusion and weakness, a temperature of 101 degrees Fahrenheit, and concentrated, foul-smelling urine. Staff notified the physician and received an order to transfer the resident to the hospital for evaluation. Hospital records dated May 1, 2026, revealed Resident 4 presented with fever, worsening confusion, foul-smelling urine, and vaginal discharge. A urinalysis and culture and sensitivity were obtained at the hospital. The resident was diagnosed with a urinary tract infection, received intravenous antibiotics (medication administered directly into a vein), and was admitted for treatment. Resident 4 returned to the facility on May 6, 2026. The facility did not obtain the physician-ordered urinalysis and culture and sensitivity until ten days after the order was issued. During that period, the resident experienced a decline in condition, including increased confusion, weakness, fever, and foul-smelling urine, and subsequently required hospitalization where a urinary tract infection was diagnosed and treated. During an interview conducted on June 11, 2026, at approximately 1:00 PM, the Director of Nursing confirmed there was a delay in obtaining the physician-ordered urine specimen. 28 Pa. Code 211.12 (3)(5) Nursing services.

Based on staff interviews, review of personnel records, employee credentials, facility documentation, and dietary service records, it was determined that the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department.Findings include: According to current federal regulatory guidance the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. In the absence of a full-time qualified dietitian, the director of food and nutrition services, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications:(A) A certified dietary manager; or(B) A certified food service manager; or(C) Has similar national certification for food service management and safety from a national certifying body; or(D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and must receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. A review of the facility-provided job description for the Registered Dietitian (RD) revealed the position was responsible for planning, organizing, developing, and directing resident nutritional care in accordance with current federal, state, and local standards, guidelines, regulations, and facility policies and procedures. The documented major duties and responsibilities of the position included providing registered dietitian services at one or more facilities in accordance with facility policies and procedures; planning, organizing, developing, and directing nutritional care services for residents; assessing and monitoring residents' nutritional status and providing recommendations to clinical and medical staff; observing resident meal services to ensure prescribed diets and diet modifications were followed; educating residents, families, and staff regarding nutrition concepts and dietary modifications; collaborating with members of the interdisciplinary team to ensure modified texture diets and therapeutic diets were appropriate for the resident's medical condition; reviewing menu changes to ensure compliance with facility policy as well as state and federal guidelines; updating diet orders and menu changes as required; conducting routine audits of nutritional care practices; completing nutritional assessments upon admission, readmission, quarterly, annually, and with significant changes in condition; inspecting food service areas for sanitation, organization, safety, and proper staff performance; monitoring residents for weight changes, nutritional support needs, and skin breakdown and making recommendations as indicated; and participating in inspection surveys to ensure compliance with nutritional and dietary policies and procedures in accordance with state and federal requirements. A review of the facility's documented dietitian's role and responsibilities revealed the RD was responsible for timely documentation of resident weight losses within PCC (Point Click Care, the facility's electronic health record system), completion of comprehensive nutritional assessments, review of laboratory values and meal intake records, completion of nutrition-focused physical assessments, and updating resident care plans related to nutritional needs. During an interview on May 5, 2026, at 11:49 AM, the facility's dietary manager reported the facility's long-term Registered Dietitian had resigned and stated she was unsure who was currently covering the position. The dietary manager further stated no routine clinical nutrition coverage was provided on-site at the facility. During an interview on May 5, 2026, at 1:30 PM, the Nursing Home Administrator (NHA) confirmed Employee 12, the former Registered Dietitian, resigned with a last day worked of April 24, 2026. The NHA stated a remote (off-site and not present in facility) Registered Dietitian provided coverage after the resignation and confirmed the remote RD also provided services to sister facilities. A review of the remote Registered Dietitian's time records from April 24, 2026, through May 8, 2026, revealed the following off-site hours were documented for the facility:April 30, 2026: 1.5 hoursMay 1, 2026: 1.25 hoursMay 5, 2026: 1.25 hoursMay 6, 2026: 2.5 hoursMay 7, 2026: 2.0 hours The documented hours reflected limited off-site consultation coverage and revealed no documented evidence the Registered Dietitian routinely provided on-site oversight of the facility's food and nutrition services department. During a phone interview on May 8, 2026, at 8:55 AM, the facility's corporate Registered Dietitian confirmed the remote Registered Dietitian did not routinely conduct on-site oversight of the dietary department, staff training, direct resident observations for nutritional assessments, or monitoring of meal services. The corporate RD further reported she had no knowledge regarding untimely nutritional documentation or specific resident nutritional concerns occurring within the facility. The facility failed to ensure routinely scheduled on-site consultation and clinical oversight by a qualified Registered Dietitian or other clinically qualified nutrition professionals following the resignation of the facility's Registered Dietitian. The facility utilized a remote Registered Dietitian who did not routinely provide on-site oversight of resident nutritional care, meal service observations, dietary operations, or direct resident nutritional assessments. The facility's failure to provide adequate on-site Registered Dietitian oversight for the clinical aspects of food and nutrition services created the potential for inadequate monitoring and follow-up of residents with weight loss or nutritional concerns, incomplete or untimely nutritional assessments and documentation, deficient oversight of meal services and dietary operations, and lack of coordination of residents' clinical nutritional care needs. F692, F803 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Based on review of facility policies, facility records, observations, and resident and staff interviews, it was determined the facility failed to ensure meals were prepared and served in accordance with the planned menu, failed to provide nutritionally comparable substitutions when menu items were unavailable, failed to document and review substitutions by a Registered Dietitian and failed to notify residents of menu changes for seven of 22 residents interviewed (Residents 11, 15, 39, 59, 60, 74, and 76). Findings include: A review of a facility policy entitled Menu Substitution Policy last reviewed by the facility on March 26, 2026, indicated the purpose of the policy was to ensure residents of the long-term care facility receive nutritionally adequate meals while honoring physician's orders, therapeutic diets, food allergies, cultural and religious preferences, and resident rights when menu substitutions are necessary. The facility shall provide appropriate food substitutions when planned menu items are unavailable, refused, contraindicated, or inconsistent with a resident's prescribed diet or preferences. All substitutions shall be nutritionally comparable and consistent with the resident's care plan, physician's orders, and dietary restrictions. Additionally, all substitutions must be nutritionally comparable to the original item, be documented according to facility when clinically significant, and be reviewed and signed off by the Registered Dietitian (RD). An observation of the facility's planned menu served during the survey, beginning Tuesday, May 5, 2026, through Friday, May 8, 2026, revealed the facility utilized Fall/Winter Menu 2025-2026, Week 2. Review of the Week 2 menu posted on the second-floor resident bulletin board revealed the planned lunch meal for Tuesday, May 5, 2026, included sausage and sauerkraut, warm German potato salad, seasoned carrots, and chilled tropical fruit cup. The posted alternative or always available menu included hamburgers, chef salad, grilled ham and cheese, or peanut butter and jelly. Observation of the lunch meal service on the second floor on May 5, 2026, at 12:28 PM, revealed residents were served kielbasa (a seasoned smoked sausage), mashed potatoes, and sauerkraut. Resident meal trays did not contain the planned warm German potato salad, seasoned carrots, or chilled tropical fruit cup listed on the posted menu. An interview with Resident 39, a cognitively intact resident, on May 5, 2026, at 1:00 PM, revealed meals were frequently not served as listed on the weekly menu. Resident 39 stated food items were often substituted or omitted without replacement. Resident 39 reported disliking the lunch meal consisting of kielbasa, mashed potatoes, and sauerkraut and stated a staff member was obtaining food from outside the facility to accommodate her preferences. Resident 39 reported her meal preferences were not being honored or updated. Interviews conducted with cognitively intact Residents 11, 15, 59, 60, 74, and 76 on May 6, 2026, at 10:14 AM, collectively revealed meals were frequently not served as posted on the menu and residents were not informed of last-minute menu changes. The residents further reported menu substitutions occurred almost daily. The residents stated that during the resident council meeting held on April 30, 2026, the dietary manager informed residents that some desserts were being removed from the menu due to budgetary constraints. A confidential staff interview conducted on May 7, 2026, at 11:20 AM, revealed some planned menu items for the Tuesday lunch meal were not received with the food order and required substitutions. The individual reported the facility did not receive German potato salad and substituted mashed potatoes. The individual further reported carrots and tropical fruit were unavailable and no additional items were available for substitution. The confidential interview also revealed the planned lunch meal for May 7, 2026, included a garlic bread stick and Prince [NAME] vegetable blend (a mixed vegetable blend consisting of carrots, wax beans, and green beans). However, garlic bread sticks were not received with the facility food order delivered on May 6, 2026, and were not substituted because insufficient items were available for replacement. The individual further reported the Prince [NAME] vegetable blend was unavailable and substituted with green beans. The individual stated weekly food orders were reviewed by the corporate dietitian and food items were often not approved or were unavailable, resulting in menu items not being substituted and leaving the facility with limited replacement options. Review of the Week 2 menu posted on the second-floor bulletin board revealed the planned lunch meal for Thursday, May 7, 2026, included spaghetti and meatballs, Prince [NAME] vegetable blend, garlic bread stick, and assorted cookies. Observation of the lunch meal service on the second floor on May 7, 2026, at 12:55 PM, revealed resident trays did not include garlic bread sticks and green beans were served instead of the planned Prince [NAME] vegetable blend. Residents were not notified of the menu changes. Review of the facility's substitution logs for February 2026, March 2026, and April 2026, failed to reveal documentation that a Registered Dietitian reviewed substitutions for nutritional adequacy or signed off on substitutions made to the planned menu. An interview with the corporate Registered Dietitian on May 8, 2026, at 8:50 AM, revealed the dietary manager submitted weekly food orders through an electronic ordering system for review prior to final submission. The corporate RD stated she had no knowledge of menu items requiring substitution or omission. The above findings were reviewed with the corporate RD; however, no explanation was provided regarding why food items necessary to fulfill the planned menu were not available or why frequent substitutions occurred. The facility failed to provide documentation related to the dietary manager's submission of weekly food orders to the corporate Registered Dietitian. Review of the food order intended to fulfill Week 2 of the facility menu revealed food items necessary to prepare the posted menu were not ordered, substituted with nutritionally comparable items, or delivered by the food vendor. Missing or omitted food items included German potato salad, carrots, garlic bread sticks, and Prince [NAME] vegetable blend. During an interview with the Nursing Home Administrator (NHA) on May 8, 2026, at 11:00 AM, the above findings were reviewed and confirmed. Refer F801 Refer F 804 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.6 (a) Dietary services. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.29(a) Resident rights.

Based on observations, resident and staff interview, and test tray results, it was determined that the facility failed to ensure meals were served in a palatable and visually appealing manner and at safe and appetizing temperatures during in-room meal service for two test trays observed on the second and third floors during lunch meal service. (Residents 11, 15, 59, 60, 74, 76, 39, 30).Findings included: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. An interview with Resident 39, on May 5, 2026, at 1:00 PM, a cognitively intact resident, stated the lunch meal served, consisting of kielbasa, mashed potatoes, and sauerkraut, included foods she disliked and reported that her food preferences were not consistently honored or routinely updated to meet her dietary preferences. Resident 39 further stated the meals served were frequently visually unappetizing and unpalatable. Observation of Resident 39's lunch tray on May 5, 2026, revealed the meal consisted primarily of white-colored food items served on a white plate. The planned chilled tropical fruit cup was not included on the tray. The color of the food blended into the plate and lacked visual appeal. In addition, excessive liquid from the sauerkraut spread across the plate and mixed into the mashed potatoes and kielbasa, resulting in an unappetizing appearance. Interviews conducted with six cognitively intact residents, Residents 11, 15, 59, 60, 74, and 76, on May 6, 2026, at 10:14 AM, revealed the residents collectively reported meals were frequently not served according to the posted menus and residents were not routinely informed of last-minute menu substitutions. The residents stated menu substitutions occurred almost daily. The residents further reported that during the resident council meeting conducted on April 30, 2026, the dietary manager informed residents that some desserts were being removed from the menu due to budgetary constraints. Observation of the second-floor lunch tray pass conducted on May 6, 2026, at 12:20 PM, revealed the first meal cart arrived on the unit at 12:23 PM, and staff immediately began distributing resident meal trays. The final tray was delivered at 12:39 PM. The final tray distributed, identified as Resident 30's tray, was removed from the meal cart for test tray sampling. Resident 30's lunch tray consisted of mashed sweet potatoes, chopped broccoli, mixed vegetables provided in accordance with the resident's preference for no meat items, and strawberry ice cream. Food temperature testing of Resident 30's tray revealed the mashed sweet potatoes were served at 126 degrees Fahrenheit, the chopped broccoli was served at 127 degrees Fahrenheit, and the mixed vegetables were served at 121 degrees Fahrenheit. The temperatures of the food items were below the federally recognized safe hot holding temperature of 135 degrees Fahrenheit. Taste testing of the sampled meal revealed the mashed sweet potatoes, chopped broccoli, and mixed vegetables were served lukewarm, unseasoned, bland, and unpalatable. Observation of the strawberry ice cream revealed the product was excessively melted and partially liquified at the time of service, resulting in an unappetizing consistency. The facility failed to ensure meals were served in a timely manner, at safe and appetizing temperatures, and in a visually appealing and palatable condition. During an interview conducted on May 6, 2026, at 2:00 PM, the Nursing Home Administrator confirmed the above observations. Refer F 803 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department and in one out of two resident nourishment room areas (second floor).Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). A review of a facility policy entitled Dating for Food Storage last reviewed by the facility on March 26, 2026, indicated bulk items were to be stored in approved containers with tight fitting lids with a label on the lid and side of container with the products name and date bin was filled. The facility's policy entitled Use and Storage of Food Brought in by Family or Visitors last reviewed by the facility on March 26, 2026, indicated the facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. All food items must be already prepared by the family or visitor, and food must be labeled with content and date. The prepared items brought into the facility must be consumed within three days. If not consumed within three days, food will be thrown away by facility staff. The initial tour of the dietary department conducted and confirmed with the facility's dietary manager on May 5, 2026, at 11:15 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified: Upon entry of dietary department observed Employee 1, Dietary Aide, handing food service equipment without a beard guard to cover facial hair. Observations of the janitor's closet revealed a malodorous mildew smell and observed an uncovered storage bin full of soiled rags and wet mop heads. Observed the condenser fan, inside of the department's produce cooler, was corroded with ice crystals. The dietary manager reported that maintenance department was aware. However, the facility could not provide documented evidence of identifying ice corrosion covering the walk-in cooler prior to the surveyor's inspection. Observations inside of the dry storage room revealed flour stored in a bulk storage containing an ill-fitting lid that was exposing contents to environmental contaminants. Underneath the food storage shelving and perimeter of the storage room, observed debris and several deceased insects. Observations of the facility's second floor resident pantry area on May 5, 2026, at 12:15 PM, revealed inside of the resident freezer was an open gallon of chocolate ice cream covered in ice crystals and appeared to have melted and refrozen, that was not properly labeled or dated. Also, observed open cans of energy drinks left inside of the freezer. Observed the inside of the resident's refrigerator contained the following items that were opened and unlabeled: sticks of butter were discolored and deformed, a fast-food sandwich, a Styrofoam container of a red-orange liquid, five gallons of whole milk, and a sandwich. Additionally, the left wall had reddish-brown splatter running down the wall with a black colored substance with debris adhered along the perimeter of the room. A revisit to the dietary department on May 7, 2026, at 11:20 AM, revealed that multiple cases of food inside of the walk-in cooler, walk-in freezer, and dry storage area were left in direct contact with floor. An interview with a dietary staff member, who wished to remain anonymous, reported the food order arrived the day before but no staff were available to put it away and the dietary manager was busy tending to other kitchen duties. Interview with the Nursing Home Administrator (NHA) on May 8, 2026, at 2:00 PM, confirmed all food storage areas in the dietary department and resident nourishment room areas were to be maintained in a sanitary manner to ensure food safety. 28 Pa. Code 201.18 (e) (2.1) Management. 28 Pa. Code 211.6 (f) Dietary Services.

Based on observations, review of clinical records, facility policies, facility investigative documentation, video surveillance, and resident and staff interviews, it was determined the facility failed to ensure that the environment remained as free of accident hazards as possible and failed to provide adequate supervision and environmental safety to prevent an avoidable accident. This failure placed one of eight residents reviewed (Resident 1) in Immediate Jeopardy to their health and safety due to the high likelihood of serious injury or death from falls or self-harm.Findings include: A clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include anxiety (a mental health condition characterized by excessive worry or fear) and major depressive disorder (a mental health disorder characterized by persistent low mood, loss of interest in activities, low energy, poor concentration, appetite changes, sleep disturbances, and suicidal thoughts). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 24, 2025, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A review of an admission MDS assessment dated [DATE], revealed that Resident 2 (Resident 1's wife, who also resided in the same room) was cognitively intact with a BIMS score of 15 A review of Resident 1's care plan initiated on November 19, 2025, identified depression and anxiety with goals to reduce symptoms through medication and non-pharmacological interventions (such as one-to-one interaction, change in position or scenery, redirection, and diversional activities). The care plan did not include Resident 1's documented history of suicide attempts until after the incident on January 25, 2026. Resident 1's care plan revealed they had been identified by the state PASRR (Preadmission Screening and Resident Review) process as a level II PASRR (screening used to identify serious mental illness or intellectual disability requiring specialized services). A review of outside hospital documentation provided by the facility of a discharge summary with instructions dated November 19, 2025, revealed that during the hospital admission Resident 1's medication regimen had changed and the Prozac (an antidepressant medication) had increased from 40 mg (milligrams) to 60 mg daily, trazodone (an antidepressant medication) 25 mg had been ordered three times a day for anxiety, continued Ativan (antianxiety medication) 0.5 mg twice daily, discontinued their sertraline 100 mg (generic for Zoloft, an antidepressant), and instructed to follow up with a psychiatrist and primary care physician. A review of physician's orders dated November 19, 2025, revealed orders for fluoxetine 20 mg (generic for Prozac, an antidepressant), one tablet daily in the morning for depression, and lorazepam (generic for Ativan). 0.5 mg, one tablet twice a day for anxiety, and trazodone 0.5 mg (antidepressant used to treat depression, anxiety and sleep problems) every eight hours as needed for depression. A review of an elopement evaluation for Resident 1 dated November 19, 2025, revealed a score of 8, which indicated that a 5 or higher may be at risk for elopement from the facility. It was noted that Resident 1 stated he wanted to leave but made no attempt to leave, and he was documented as not currently being an elopement risk. A review of physician's orders dated November 24, 2025, revealed an order for hydroxyzine (an antihistamine, a medication used to treat allergies, that is also used to treat anxiety) 25 mg, one tablet every 8 hours as needed for anxiety, and an order for trazodone 50 mg, to give half a tablet at bedtime for depression. A review of Employee 8's, Certified Registered Nurse Practitioner (CRNP) progress notes dated December 2, 2025, revealed Resident 1 was admitted for therapy services with possible long-term placement due to being unable to care for himself at home, particularly with his wife. Resident 1 verbalized stress regarding his wife and seemed very depressed. It was noted that the resident reported that he was so stressed at home because of the issues with his wife that he overdosed at some point. A review of a psychology progress note from the Licensed Clinical Social Worker (LCSW) for Resident 1, dated December 5, 2025, revealed the resident was evaluated due to his history of depression and anxiety and was previously admitted to an inpatient psychiatric hospital in December 2024 and August 2025. It was noted that Resident 1 appeared guarded and withdrawn throughout the session. A review of Employee 10's, Licensed Practical Nurse (LPN), progress note dated December 9, 2025, at 1:37 PM revealed Resident 1 was continuously pacing in his room and hallways and repeatedly struck his head against the wall despite verbal redirection. The note indicated his behavior appeared to be escalating, with increased restlessness and rapid breathing. No visible injury was noted. Resident 1 did not respond to verbal reassurance or orientation attempts. A review of physician's orders dated December 13, 2025, for Resident 1 revealed an order for fluoxetine 20 mg, two tablets daily in the morning for depression; clonazepam (an antianxiety medication) 0.25 mg daily at bedtime for anxiety; and hydroxyzine 25 mg twice a day, every morning and at bedtime for anxiety, with an additional 25 mg every 24 hours as needed for insomnia if the resident wakes up in the middle of the night. The resident's lorazepam was discontinued on December 13, 2025. A review of Employee 9's psychiatric CRNP progress note for Resident 1 dated December 16, 2025, revealed diagnoses that included depression and anxiety. The resident was observed sitting in his room drowsy but arousable and admitted to continued depression and intermittent anxiety. A review of Employee 8's, CRNP progress note dated December 17, 2025, revealed the resident reported feeling anxious and appeared to be having a panic attack. He stated that his wife's repetitive speech and fixation on topics significantly contributed to his anxiety and made it difficult for him to relax. The resident expressed a desire to go home but acknowledged that his home was not in livable condition. He did not want to move to a separate room or place fault on his wife due to her Alzheimer's disease (a brain disorder that progressively impairs memory and thinking). He stated he would feel better at home but admitted to experiencing similar anxiety there. The CRNP noted that Resident 1's desire to return home suggested the need to assess the viability of that option and address home condition issues. A review of Employee 6's, LPN, progress note, dated December 20, 2025, at 1:20 PM revealed Resident 1 was noted with increased anxiety and agitation and was pacing back and forth in his room and hallways. The resident pulled the nurse to the side and stated he felt that he was struggling and continued to make mistake after mistake. After speaking with Employee 6, he agreed to speak to the psychiatrist. A review of psychology progress notes from the LCSW dated December 26, 2025, revealed that the Director of Nursing provided additional clinical insight stating Resident 1 and his wife (Resident 2), who resided in the same room, were known to have had numerous attempted joint suicides with psychiatric hospitalizations. Resident 1 continued to present with high anxiety and reported his nerves were horrible and that he felt dizzy and trapped. Resident 1 repeatedly requested medication changes and stated, so there's really nothing you can do for me, and remained guarded. A review of Employee 7's, Registered Nurse (RN) progress notes dated December 26, 2025, at 11:47 PM revealed that while in session with psychology, Resident 1 sat in his wheelchair, leaning forward with his head on the bed, brought his knees to the floor, and then lay on his back in a manner described as purposeful. A review of Employee 8's, CRNP progress note dated December 26, 2025, revealed Resident 1 felt anxious and could not sleep. The plan was to continue current medications, follow psychology recommendations, and consider a room change to separate the resident from his wife to reduce nighttime triggers. A review of a physician's orders for Resident 1 dated December 29, 2025, revealed an order for fluoxetine 20 mg, two tablets daily in the evening for depression, and for hydroxyzine 25 mg every 12 hours as needed for anxiety for 14 days. A review of Employee 9's psychiatric CRNP progress note for Resident 1 dated December 30, 2025, revealed the resident was being seen for his history of anxiety and depression and was seen pacing in the hallways. It was noted Employee 9 redirected him to a chair, and it was difficult due to the resident's anxiety and restlessness. Resident 1 appeared disheveled (disordered and untidy). The resident admitted to continued depression and anxiety. Staff reported frequent falls, likely related to increased restlessness. A review of Employee 8's CRNP progress note dated January 2, 2026, revealed Resident 1 continued to report anxiety, wanted to go home, and worried about his wife. The resident was noted to have significant psychiatric issues and was being followed by in-house psychiatric services. A review of Employee 9's psychiatric CRNP progress note for Resident 1 dated January 13, 2026, revealed the resident was being seen for his depression and anxiety and was lying in bed wringing his wrists and appeared noticeably restless and disheveled. Employee 9 redirected him to a chair with difficulty due to anxiety and restlessness. The resident reported depressed mood and continued anxiety and described new onset visual hallucinations (seeing things that are not present) and stated it has happened before. Staff reported increased confusion and depression. Employee 9 assessed the resident continued with worsening mood disturbances and an increase in hallucinations with worsening depression. At that time, Resident 1 met criteria for MDD (major depressive disorder) with psychotic disturbance (severe form of depression with persistent sadness and loss of interest along with psychotic symptoms or fixed false beliefs which can increase the risk of unsafe behavior or self-harm). A review of physician's orders dated January 14, 2026, revealed an order for fluoxetine 20 mg three tablets daily in the evening for depression, and clonazepam 0.25 mg (antianxiety medication) two times a day for anxiety. A review of psychology progress notes dated January 16, 2026, revealed the Resident 1 appeared less restless and stated he had been alright, though he avoided eye contact. A Geriatric Depression Scale screening was performed, and the resident scored in the range indicating major depression. Employee 8 CRNP reported the resident had been extremely anxious and encouraged separation from his wife throughout the day due to her triggering his distress. A review of psychology progress notes from the LCSW for Resident 1, dated January 16, 2026, revealed he was being seen for his history of depression and anxiety, and the resident appeared less restless than in previous sessions and stated he has been alright and avoided eye contact. A GDS (Geriatric Depression Scale) depression screening was performed, and the resident scored significantly, indicating major depression. They noted from the medical CRNP that it was reported that the resident was seen to be extremely anxious and encouraged to find separate space away from his wife throughout the day, as it seems she may trigger his distress. A review of Employee 1's, RN supervisor progress notes at 4:05 PM on January 25, 2026, revealed the note summarized events that occurred earlier that day. According to the entry, at the beginning of the shift Resident 1 was observed lying in bed and was at baseline with no complaints. At 11:00 AM staff were informed that Resident 1 had vomited and was having difficulty urinating. On assessment, the bladder was soft and not distended. The resident was offered medication for nausea but refused and became verbally abusive. Employee 1 encouraged the resident to calm down; however, the resident continued to be verbally abusive and laid himself on the floor. Resident 1 then got up independently and returned to bed. Employee 1 returned to the medication cart and was later informed by Resident 2 that her husband, Resident 1, had jumped out of the window. Employee 1 verified this information, activated emergency services by calling 911, and remained with Resident 2 due to safety concerns. A review of investigative documentation provided by the facility dated January 25, 2026, documented by the Director of Nursing at 12:55 PM, revealed that Resident 1 was in his room with his wife, and during lunchtime he received his meal tray and complained of the inability to urinate and was assessed by the Employee 1, RN Supervisor, and noted to have no abdominal distension. When Employee 1 left the room after the assessment, the resident's wife (Resident 2) yelled out to staff that Resident 1 had jumped out of the second-floor window and landed on the first-floor landing that was below his window. Following the event, 911 was called immediately. Resident 1 was wrapped in blankets to keep him warm. The resident was also assessed by the EMTs (Emergency Medical Technicians) and was then taken to the hospital. The resident was noted to be talking with police when the ambulance arrived. The facility noted the safety screw was removed from Resident 1's window, which allowed the window to fully open. The facility audited all other resident windows after the incident occurred to ensure resident safety. The facility was unable to determine how the screws were removed from the window, no screws, tools, or sharp objects were found in the room. Resident 2 stated she observed Resident 1 jump out of the window and could not stop him. A review of Employee 2's, Nursing Aide (NA), witness statement dated January 25, 2026, at 12:57 PM revealed that while passing trays, the supervisor ran down the hallway yelling emergency and reported that Resident 1 had jumped out of the window. Employee 2 ran outside and observed Resident 1 on the ground while staff contacted 911. A review of a witness statement dated January 25, 2026, at 1:00 PM, from Employee 1, RN Supervisor, revealed that he was told by Resident 2 that Resident 1 jumped out of the window Employee 1 verified the information and activated emergency services and stayed with Resident 2 for safety and brought her to the dining area. A review of a witness statement dated January 25, 2026, at 1:15 PM, from Employee 3, NA, revealed that Resident 2 came out of the room yelling that Resident 1 had jumped out of the window, and they ran and saw Resident 1 lying outside. Employee 3 then ran to get help and blankets to cover him up while waiting for police and an ambulance to arrive. A review of a witness statement dated January 25, 2026, at 1:15 PM, from Resident 2, revealed she had watched Resident 1 open the window and jump out and did not stop Resident 1 from jumping out. A review of outside hospital documentation dated January 25, 2026, at 1:35 PM revealed that per EMS, Resident 1 fell from a second-story window and laid in the snow for 10 minutes. EMS documented a body temperature of 90.8 degrees Fahrenheit (hypothermia, a dangerously low body temperature that can be life-threatening). Resident 1 complained of back pain. Initial emergency department temperature at 1:28 PM was 92.3 degrees Fahrenheit by tympanic (ear). Physical examination revealed a laceration (torn wound of the skin) above the left eye, ecchymosis (bruising) of the abdomen and left knee, and a thigh abrasion. The emergency department physician documented a final diagnosis of chest wall contusion (bruise caused by a blow or impact) following a fall. A review of outside hospital psychiatric documentation dated January 27, 2026, at 8:39 AM, revealed the consultation was for a possible suicide attempt. Resident 1 reported not recalling jumping from the window and admitted to feeling sad at times, poor sleep, decreased energy and concentration, and anhedonia (loss of interest or pleasure). A 302 involuntary commitment (legal process that allows a person to be hospitalized for mental health treatment against their will when they are determined to be a threat to self or others) was petitioned by police and upheld by the emergency physician. Based on evaluation and history of prior suicide attempts and depression, inpatient psychiatric admission was recommended with one-to-one supervision for safety and elopement risk. During an interview on January 28, 2026, at 11:00 AM with Employee 4, Maintenance Director, revealed that at the time of the incident, Resident 1's right-side window was not secured and could open fully and that the screen had been knocked out. Employee 4 stated that windows were not routinely inspected and were last checked one year prior. Employee 4 stated that after the incident an audit of all the windows was completed, and he inserted a regular [NAME] head screw into all the windows for safety. The facility was unable to provide evidence that the safety screws were in place immediately after the event. An observation of Resident 1's left side window, in the presence of Employee 4, at 11:00 AM, revealed it was secured to permit the window to open no more than 3.5 inches by utilizing a rubber window stopper. Employee 4 had stated prior to the incident that the rubber window stoppers are what was utilized at the facility to prevent the windows from opening fully. Observation of Resident 1's right-side window, from which he jumped out of, revealed it did not have a rubber stopper. The surveyor attempted to remove the rubber stopper that was present on the left side of the window, and it did not come off. Employee 4 stated you would most likely need a special tool to remove the rubber stopper, and they are not easily removed. Employee 4 confirmed it was possible that Resident 1's right-side window possibly did not have the rubber stopper prior to the incident, but that it was not known, due to no recent window inspections. Employee 4 stated that moving forward, they removed the regular [NAME] head screws that were inserted on January 25, 2026, and inserted a special star tip screw that requires a special drill bit to remove and a wooden dowel to prevent the windows from opening fully. This process with adding the star tip screws and wooden dowels was started on the evening of January 26, 2026, and currently was ongoing to complete all the windows at the facility. Employee 4 also noted there were windows on the first floor that were crank windows, and the facility had ordered special parts to prevent them from opening fully, but they had not arrived yet. An interview with Employee 1, RN Supervisor, on January 28, 2026, at 1:36 PM, revealed that Resident 1 had been at baseline and had been cared for since admission. Employee 1 stated Resident 1 was frequently concerned about Resident 2. Employee 1 left the room for 15 minutes after providing care to Resident 2 and was then informed that Resident 1 had jumped out of the window. Employee 1 returned to the room and observed the window open, activated EMS, removed Resident 2 from the room, and threw blankets down to Resident 1. Following surveyor inquiry on January 28, 2026, at 1:58 PM, the facility provided video surveillance evidence from January 25, 2026, with a timeline. Facility documentation indicated the resident exited the window at 1:07 PM, and the resident was located by staff at 1:11 PM and wrapped in blankets. EMS arrived at 1:13 PM, and the resident was on the stretcher in the ambulance at 1:23 PM. Resident 1 was transported to the hospital at 1:32 PM. A telephone interview conducted on January 28, 2026, at 2:30 P.M., with Employee 5, Nutrition Services, revealed he was delivering food to the unit on January 25, 2026, when he heard a nurse yell that Resident 1 went out the window. Employee 5 entered the room, and when he saw Resident 1, he left the building to attend to him. Employee 5 was the first to provide care to Resident 1 and reported that Resident 1 said ouch but did not communicate any additional information to him. Employee 5 covered Resident 1 with blankets that were being thrown to him from the open window. During an interview with Resident 2 on January 28, 2026, at 2:36 PM, it was revealed that Resident 1 opened the window easily and stated that he just opened it. Resident 2 stated that there was no one in the room at the time other than Resident 1 and denied any mention of anything related to jumping prior to the event. At the time of the incident, Resident 1's room window was capable of being opened fully without restriction. Facility-wide observation identified that some windows were restricted to opening three to four inches using rubber strips or other limiting devices, while other windows did not have security measures in place (rubber window stoppers). The facility's investigative documentation authored by the Director of Nursing stated that the resident had removed safety screws from the window to open it fully; however, interviews and observations revealed that no screws were in place on Resident 1's window prior to the incident. The facility's first placement of screws into windows occurred after the incident as an initial corrective action to restrict window openings. Observation of first-floor crank windows (no resident rooms; however, residents had access to these areas) on January 28, 2026, at 3:00 PM, revealed the windows could be opened 15.75 inches, and the facility was waiting for ordered parts to restrict them. This failure to ensure window security constituted an environmental hazard and placed residents at risk for falls and self-harm. On January 25, 2026, the resident jumped from the second-floor window, 25 feet, landing on a porch and into snow. The resident sustained chest trauma and was found with a body temperature of 90.8 degrees Fahrenheit by EMTs. The resident's injuries and hypothermia demonstrate actual serious harm. Given the resident's known history of suicidal ideation and worsening depression without increased supervision, the unsecured window created a high likelihood of death or serious injury. The presence of other unsecured windows created ongoing risk to additional residents. The facility was notified of the Immediate Jeopardy on January 28, 2026, at 3:10 PM, and the IJ template was provided to the facility at 3:24 PM. An immediate plan of correction was requested and received on January 28, 2026, and accepted on January 28, 2026, at 6:35 PM. The facility's corrective action plan included: 1. The resident was transported from the facility to the hospital emergency room and admitted , and a safety device was placed in all windows in the facility that would not allow them to open past 4 inches. 2. An audit was completed of all windows in residents' rooms and common areas to ensure that window safety devices are in place. Residents with a history of suicide attempts will be reviewed to ensure they have psychiatric services in place, psych medications are reviewed, care plans are updated if needed, and a suicide risk assessment is completed. Should they trigger for suicide risk, appropriate actions will be taken as per our Suicide Threats policy. Newly admitted residents from November 1, 2025, through November 28, 2025, will have their antidepressant medications reviewed and compared to their hospital discharge instructions to ensure that they are ordered correctly. 3. Maintenance will ensure that all windows have been addressed so that they cannot open past 4 inches, and maintenance or a designee will perform random window safety audits weekly x 4, then ongoing monthly. The DON/Designee will audit all new admissions during the morning meetings to check for a diagnosis or history of suicide attempts and clinical recommendations implemented if positive for suicidal ideations. The DON/Designee will also compare the hospital discharge summary for antidepressant medication orders to ensure they match the physician's orders. Results of audits will be presented to risk meetings weekly, then to the QUAPI committee once done monthly for further review and recommendations. 4. All facility staff will be educated on suicide prevention, suicide threats, the six steps to identifying and addressing behavioral symptoms, and window safety. 5. Maintenance or the designee will continue to monitor safety window checks weekly x 4, then monthly x 3. The DON/Designee will continue to audit all new admissions during morning meeting to check for a diagnosis or history of suicide attempts and clinical recommendations implemented if positive for suicidal ideations weekly x 4 weeks, then monthly x 3. The DON/Designee will also compare the hospital discharge summary for antidepressant medication orders to ensure they match the physician's orders weekly x 4 weeks and then monthly x 3. An interview with Employee 4, on January 28, 2026, at 5:05 PM, revealed that the new safety features, which included the new star tip screws and wood dowel were in place in all resident windows, common areas, and stairways as of January 28, 2026, at 5:05 PM, and all of the crank windows in the facility were screwed shut from the outside. Following verification of the implementation of the corrective action plan, a tour of the facility, and a review of education, the Immediate Jeopardy was lifted on January 28, 2026, at 6:45 PM. 28 Pa. Code 201.18 (e)(1) Management.28 Pa Code 211.10 (a)(c) Resident care policies.28 Pa. Code 211.2(d)(3) Medical Director.28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of clinical records and select resident incident/accident reports and staff interview, it was determined that the facility failed to timely re-evaluate the effectiveness of planned safety interventions and revise the resident's fall prevention plan to include the provision of supervision necessary to prevent falls and serious injury, a closed head injury with intracranial bleeding, to one of two residents sampled (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include vascular dementia , muscle weakness, diabetes and repeated falls. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated [DATE], revealed that the resident's cognition was severely impaired, the resident was hard of hearing, Spanish was her primary language and she required staff assistance with ambulation. A review of Resident 1's care plan, initiated February 1, 2023, revealed that the resident was at risk for falls due to ambulatory dysfunction, impaired cognition, weakness and multiple falls with fracture with interventions to apply a bed sensor pad alarm, chair alarm and a motion sensor pad. The resident's care plan, dated [DATE], also noted that the resident was at risk for falls; non -compliance with transfer status - self transfers, is transfer assist x 1. Resident has the behavior of playing with the bed remote and placing bed on its wheels. Resident has behavior of unplugging bed/chair alarms, turning off wall motion sensor. A review of nursing documentation and incident reports dated between [DATE], and [DATE], revealed that Resident 1 incurred eight falls in the facility, without injuries, during that time period. The interventions planned for fall prevention during this timeframe were the application of a clip alarm in the resident's bed and wheelchair, a motion sensor alarm placed in the resident's room, the resident's bed in the lowest position and dycem (a non slip material used to prevent sliding out of the chair) to the resident's wheelchair according to these incident reports and the resident's care plan. Select incident reports during [DATE], and [DATE], and nursing documentation revealed the following: On [DATE] at 10 AM, Resident 1 was found on the floor in front of her bathroom. The bed and wheelchair alarms were not sounding and found to been turned off. On [DATE] at 10:15 AM, Resident 1 was found on the floor outside her bathroom. The clip alarm was off the resident and had been placed on her bed. On [DATE] at 8:05 PM., Resident 1 was found on the floor in her room. The chair alarm was not working and the motion sensor was not turned on. On [DATE] at 3:04 PM, Resident 1 was found on the floor in her room. The resident removed her chair alarm and placed it in her dresser drawer. A review of an incident report dated [DATE] at 8:33 AM revealed Resident 1's roommate alerted nursing staff that Resident 1 needed assistance. Resident 1 was found on the floor of the bathroom in the resident's room. Her wheelchair was in the locked position, located next to her bed. The bed sensor pad on the bed, as well as, the motion sensor were not sounding. The facility's report noted that the resident has been known to shut off the alarms. The report further indicated that upon (staff) entering the resident's bathroom, the resident was observed with her head at the bottom of the tub and her legs stretched out. The resident self-transferred with no adaptive equipment and no socks and shoes on her feet. The resident was alert and oriented and able to follow commands. A neuro assessment was performed and within normal limits per baseline with no complaints of pain. The resident had a large, closed head injury on the back of her skull. One plus edema (swelling) noted in her hands and feet bilaterally. The physician was contacted and the resident was sent to the hospital. A review of nursing documentation dated [DATE] at 3:47 PM revealed that Resident 1 was admitted to the hospital with a diagnosis subdural hematoma (occurs when a blood vessel in the space between the skull and the brain (the subdural space) is damaged. Blood escapes from the blood vessel, leading to the formation of a blood clot (hematoma) that places pressure on the brain and damages it). A review of hospital documentation dated [DATE], at 9:50 PM revealed that Resident 1 presented to the emergency department for evaluation after a fall. She states that she had a misstep, striking the posterior right side of the back of her head when she fell backwards. A review of CT scan (diagnostic imaging study) of the head and brain completed at the hospital on [DATE], revealed critical results of a large acute hemorrhagic contusion in the anterolateral right frontal lobe, contusion likely represents hyperacute hemorrhage; additional hemorrhagic contusions in the right posterior frontal lobe and right temporal lobe, acute thin hematohygroma in the anterior right frontal convexity, scattered acute subarachnoid hemorrhages in the right cerebral convexity and scalp hematoma in the left parietal temporal region. Resident 1 was admitted to the hospital from the ER with subarachnoid hemorrhage from a closed head injury. The hospital documentation summary indicated that Resident 1 presented to the hospital on [DATE], after a fall. The patient was found to have the injuries noted above. The patient was admitted to trauma and acute care surgery. The patient had consultations from a neurosurgery. The patient became increasingly lethargic and had worsening acute respiratory failure. Resident 1 was pronounced deceased on [DATE] at 2:41 P.M. The hospital discharge death summary dated [DATE], revealed the following DISCHARGE DIAGNOSES: Subarachnoid hemorrhage following injury, no loss of consciousness; Contusion of right cerebral hemisphere; Subdural hematoma; Acute respiratory failure; Shock; Brain compression. PRELIMINARY CAUSE OF DEATH: Traumatic Brain Injury; Acute Respiratory Failure During an interview [DATE] at approximately 3 P.M., the Nursing Home Administrator confirmed that Resident 1 had known repeated behaviors of removing and turning off her alarms. The NHA also verified that Resident 1 often attempted to self ambulate to the bathroom. The NHA confirmed that the facility staff was aware of the resident's unsafe behaviors of self-ambulating and removing and turning off her safety alarms. The facility was aware that the use of the alarms proved ineffective in preventing the resident's repeated falls. The facility failed to timely revise the resident's safety plan and include the resident's need for increased staff supervision in response to the resident's known behaviors and repeated falls, which resulted in the resident's fall with serious head injury. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on observations, a review of clinical records and select facility investigation reports and staff interviews, it was determined that the facility failed to provide necessary staff supervision for a resident with a history of falls and unsafe behaviors that increased the resident's risk for falls and injuries to prevent falls with serious head injuries, a subarachnoid hemorrhage and an intercranial hemorrhage, for one resident out of 8 residents reviewed (Resident 1 ). Findings include: A review of the clinical record of Resident 1 revealed admission to the facility on [DATE], with diagnoses that included cerebral infarction(stroke), toxic [CONDITION(S)], (occurs when toxic chemicals, or a chemical imbalance caused by an infection, affects brain function), anxiety, lack of coordination, was non-verbal and had a history of falls. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 10, 2021, revealed that the resident was severely cognitively impaired, required staff assistance with activities of daily living, including requiring the assistance of one staff for ambulation in hallways, was at risk for falls and has had 2 falls since admission to the facility. A review of nursing documentation dated October 9, 2021, at 9:32 p.m. revealed nursing noted Patient restless and pacing up and down halls; increasing over the course of the past few days. Patient requiring frequent redirection with poor effectiveness to sit for meals, rest periods. A review of nurse's notes dated November 22, 2021 at 10 p.m. revealed that a nurse aide came to charge nurse stating that Resident 1 had blood coming from her mouth. Upon nursing assessment, at first, {Resident 1} would not open her mouth and was noted to have blood all over her mouth and down her gown. The nurse and two nurse aides were able to convince her to open her mouth and a lot of blood came pouring from her mouth. We were able to convince her to open her mouth again, because as we were rubbing her cheeks, we could tell that there was a foreign body in her mouth. It took a couple of minutes, but when she did open her mouth, a big red bingo chip fell out of her mouth and to the floor. We cleaned out her mouth to the best that she would allow at that time. Nurse practioner called, new orders noted to call the dentist and also for nursing to place Resident on every 15 minute checks for 72 hours. Facility documentation indicated the every 15 minute checks were conducted from November 22, 2021, and then discontinued on November 24, 2021. A review of nurse's notes dated November 24, 2021, at 2:11 p.m. revealed that Resident 1's daughter was contacted concerning a room change from the third floor (where several residents run a small store from the resident lounge at the end of the hallway. Items for sale include packaged candy, chips and many other snack items. All of these items are displayed on several long tables, were open and available for resident choice) to the second floor due to Resident 1 touching items at the resident snack shop with redirection being unsuccessful. Resident 1 was transferred on November 24, 2021, to a room on the second floor at that time but returned to her original room on the third floor on that same day after a male resident was paying inordinate attention to her and sitting very close, making Resident 1 very uncomfortable according to the resident's clinical record documentation. A review of nurses notes dated January 10, 2022 at 1:24 p.m. revealed Resident 1 continuously pacing back and forth, going in and out of other resident rooms, taking drinks, straws and tissues from the medication cart (stored next to the nurses desk in the hallway) and other resident rooms despite redirection, food/fluid, toileting and diversional activities. Nursing noted will continue to monitor and redirect. A review of a social services note dated January 11, 2022, at 2:40 p.m. revealed worker visited with {Resident 1}, approaching her in a calm, unhurried manner. She continuously walked back and forth on the unit throughout the interaction. The social worker reviewed the importance of respecting other peers belongings and not going into resident rooms that were not hers. Her comprehension was questionable as {Resident 1} remains verbally unresponsive to staff. She appeared to be calm and content at this time as evidenced by facial expression. A review of a nurses noted dated January 21, 2022, at 9:49 a.m. revealed, this nurse witnessed {Resident 1} walking very fast up and down the hallways. I approached resident and encouraged her to slow down and take her time walking. {Resident 1} then sat down in a chair in the resident dining room for a moment. She then stood up and began walking very fast again. She immediately fell , hitting the left side of her head on the dining room floor. She was alert and basic first aide applied, the physician was contacted and {Resident 1} was sent to the hospital. A review facility investigation report dated January 21, 2022 at 9:31 a.m. revealed, the nurse witnessed Resident 1 walking very fast up and down the hallways. The nurse encouraged her to slow down and take her time walking. The resident sat down in a chair in the dining room for a moment. Resident 1 then stood up and began walking very fast and immediately fell hitting the left side of her face on the dining room floor. The physician was called and the resident was transferred to the hospital for evaluation and treatment. The report identified the predisposing factors for this incident were that the the resident was incontinent, impulsive and had impaired safety awareness. Upon return to the facility, interventions to prevent future falls were noted as the use of a chair and bed alarm. Additional notes included in the investigation report dated January 21, 2022 (no time indicated) revealed Call placed to local hospital for an update on {Resident 1}. Spoke to the resident's emergency room nurse. {Resident 1} was currently having stitches placed to the left side of her forehead. {Resident 1} will be transferred to another hospital to be treated for brain bleed. A review of hospital documentation dated January 21, 2022, at 2:47 p.m. revealed that Resident 1 had a witnessed fall at the skilled nursing facility and was transported to the emergancy room for evaluation and treatment. A CT (CT scan: A computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images) of the head was preformed and revealed a subarachnoid hemorrhage (bleeding in the space that surrounds the brain.) in the area of the right temporal lobe. She was transferred to the receiving hospital for a higher level of care to be evaluated by neurosurgical service. {Resident 1} was admitted to the intensive care unit (ICU) for this head bleed for closer monitoring. She will be seen by neurosurgery as well. The physician assessment included, traumatic brain injury, admit the resident to the ICU, scalp laceration, continue with wound care. Resident 1 was readmitted to the facility on [DATE] at 3:20 p.m. A review of a care plan for at risk for falls, initiated August 6, 2021 revealed new interventions, dated January 28, 2022, after the resident's fall with head injury, were to add a chair and bed alarm. A review of the resident's care plan for wandering behavior, initiated August 12, 2021, revealed the care plan was last reviewed September 8, 2021, but had not been reviewed or updated with any additional interventions since the August 2021 date. There was no documented evidence that the resident's need for staff supervision was identified as a planned intervention to promote this resident's safety and incorporated into the resident's plan of care and implemented by staff. Continued review of the clinical record from the time of the resident's return to the facility on [DATE], through the time of the survey April 6, 2022, the nursing continued to document the resident's unsafe and wandering behaviors. A review of nurses notes dated April 2, 2022 at 7:48 a.m. revealed an RN assessment was completed. {Resident 1} remains alert. No change in level of consciousness (LOC). Makes eye contact. Neurological signs within normal limits. Hematoma ( a collection of blood under the skin) left forehead. Scant amount of bleeding from the left forehead. Laceration measuring 0.5 cm x 0.1 cm. Ice applied . Resident remains nonverbal, at baseline with poor safety awareness. A review of a nurses note dated April 2, 2022 at 8:37 a.m. revealed that the resident was transferred via ambulance to the local hospital. There was no documentation in Resident 1's clinical record of the circumstances surrounding the resident's fall with a second head injury. However, review of a facility investigation report dated April 2, 2022, at 8:09 a.m. revealed that Resident 1 fell while in the resident dining area at 7:45 a.m. and found with her arm resting behind and beneath her. Active bleeding to the left side of her forehead was present. Non-skid socks were on both feet and the resident was continent at the time of the fall. Chair alarm in use according to the report. There were no staff witness statements included with the investigation report available at the time of the survey of the April 6, 2022, which identified the location of staff at the time of the resident's fall, which had occurred during the breakfast meal. A review of hospital documentation dated April 2, 2022, at 11:30 a.m. revealed that {Resident 1} presents to the hospital after fall from a chair with a head strike. The patient was sitting at breakfast and fell forward out of her chair. She did strike her head. LOC (level of consciousness) is unknown. Patient is non verbal and non- interactive at her baseline. A review of a CT scan report dated April 2, 2022, revealed, acute, small subdural hematoma along the midline falx that measures 4 mm in thickness. Neurosurgery was consulted. The resident was admitted to the PCU, (A PCU is a Progressive Care Unit. PCUs, sometimes referred to as intermediate care or step-down units, provide an intermediate level of patient care that bridges the gap between intensive care units and medical-surgical units) for observation and treatment. A review of a nurses note dated April 2, 2022 2:34 p.m. revealed call placed to the hospital for an update. {Resident 1} is admitted to the hospital with intercranial hemorrhage (bleeding inside the skull {cranium})at this time. Resident 1 was readmitted to the facility on [DATE], at 8:28 p.m. A body audit was completed by nursing noting a 1.5 cm, healing laceration with steri-strips intact, and 1.5 cm x 1.5 cm bruise, left forehead above healed laceration. Observations made during the survey of April 6, 2022 at 10:50 a.m revealed that Resident 1 was seated in a geri chair in the third floor resident dining room. The surveyor observed Resident 1 stand up from her chair and begin to pace around the perimeter of the room. She continued to wander, pace the hallways, unmonitored by staff, often increasing her speed. The chair alarm was in place, but not sounding to alert staff of the resident's self-rising and unassisted ambulation. The facility failed to demonstrate that the resident was consistently provided with necessary staff supervision due to the resident's known unsafe behaviors to prevent repeated falls and serious head injuries. The resident fell and sustained a serious head injury on January 21, 2022, which required hospitalization and again incurred a second fall with head injury requiring hospitalization on [DATE]. During an interview April 6, 2022 at approximately 2 p.m., the Nursing Home Administrator (NHA) confirmed that the facility was unable to provide evidence that the facility had consistently provided sufficient staff supervision of this resident at risk for falls and injuries and unsafe behaviors that was known to facility staff and had implemented effective safety interventions to prevent falls and multiple head injuries. 28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing Services 28 Pa. Code 211.11(d) Resident care plan

Based on a review of the facility's abuse prohibition policy and clinical records and staff interview, it was determined that the facility failed to ensure that a resident was free from mental abuse, which compromised the physical condition and negatively affected the psychosocial well-being of one of 10 residents reviewed (Resident 55). Findings include: A review of a facility policy for Abuse Protection reviewed by the facility (MONTH) (YEAR), revealed that residents have the right to be free from verbal, sexual, physical and mental abuse. The facility shall have processes in place include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 25, (YEAR), indicated that the resident was cognitively intact, required extensive assistance of two people for activities of daily living and his mood was depressed, but the resident denied any thoughts of harming himself. A review of the clinical record revealed that Resident 87 was admitted to the facility on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated (MONTH) 15, 2019, indicated that the resident was cognitively intact and his mood was depressed . The resident's care plan initiated (MONTH) 7, (YEAR), indicated that Resident 87 had the potential to exhibit distressed behavioral symptoms as evidenced by the problematic manner in which he acts, characterized by verbal abuse (yelling and cursing at others). A review of nursing documentation, and information dated (MONTH) 12, 2019, at 4:10 PM submitted by the facility revealed that Resident 55 attempted to harm himself by cutting his wrists with the tab of a soda can. Upon facility examination, Resident 55 had superficial scratches and a small amount of bleeding to the left wrist. The physician and ambulance were called and Resident 55 was sent to the hospital for mental health crisis intervention. A review of an employee witness statement dated (MONTH) 12, 2019, (no time), revealed that Employee 3, nurse aide, indicated that she had asked Resident 55 why he was cutting his wrist. Resident 55 replied that his roommate, Resident 87, told him to do it. Resident 55 further stated that he was better off, as well as his family, with him gone. A review of nursing documentation dated (MONTH) 12, 2019, at 4:15 PM revealed that Employee 2 (Registered Nurse - RN) noted called to room by charge nurse who reported that Resident 55 had cut his wrist. Upon examination noted superficial cuts to his inner left wrist with minimal blood loss. Employee 2 noted that during an interview with Resident 55, he stated that the other guy in his room (Resident 87) keeps telling him that he is worthless and a burden on his family, that he can't walk and doesn't try and that we all would be better off without him here. He might as well off himself. Resident 55 said it finally made sense so he tried to (kill himself). A review of hospital discharge records dated (MONTH) 12, 2019, at 6:06 PM revealed that Resident 55 was seen in the hospital emergency department for self mutilating behavior. He was examined and given patient educational materials entitled suicidal feelings: how to help yourself. He returned to the facility on a 1 to 1 safety watch, until mental health services could see him in the morning. Resident 55 returned to the same room he had previously resided, with Resident 87 as his roommate. A review of mental health consultation dated (MONTH) 13, 2019, at 11:00 AM revealed met with Resident 1 in his room. He appeared in no apparent distress at the time of the interview. His affect was [MEDICATION NAME]. His thought process was circumstantial and he self reports depression and hopelessness. He openly discussed his suicidal attempt. He stated I have him (his roommate) telling me that I'm worthless and that I shouldn't be around anymore. He denied suicidal ideation. The mental health clinician recommended to discontinue the 1 to 1 safety watch, to adjust his antidepressant medication and agreed with a room change for him. Resident 55's room was changed after the mental health consultation (MONTH) 13, (YEAR), at 11:00 AM. During an interview on (MONTH) 14, 2019, at approximately 10:00 AM Resident 55 stated that prior to cutting his wrist with the soda can lid, his roommate (Resident 87) had told him multiple times that he is worthless and that he and his family would be better off if he harmed himself. Resident 55 stated that he feels a little better now that he has a different roommate. During an interview (MONTH) 14, 2019, at approximately 1:30 PM Employee 4 (Licensed Practical Nurse - LPN) stated that Resident 87 had been speaking inappropriately to Resident 55 since his admission to the facility. Employee 4 stated that nursing administration was aware of Resident 87's problematic behaviors, which were identified on the resident's plan of care. There was no evidence at the time of the survey that the facility had protected Resident 55 from mental abuse perpetrated by Resident 87, which contributed to Resident 55's suicide attempt. 28 Pa. Code 201.18(e)(1) Management Previously cited 2/6/19, 10/19/18, 7/24/18, 8/26/18, 6/14/18, 3/4/18, 11/2/17 28 Pa. Code 201.29(a)(d) Resident Rights Previously cited 2/6/19, 11.2.17 28 Pa. Code 211.12(a)(c)(d)(3) Nursing Services Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17 28 Pa. Code 211.16(a) Social Services Previously cited 5/16/18, 11/2/17

Based on review of clinical records and staff interview, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development, prevent worsening and promote optimal healing for one of 10 residents reviewed (Resident 55) with pressure sores. Findings include: A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 25, (YEAR), indicated that the resident was cognitively intact, required extensive assistance of two people for activities of daily living including bed mobility (moving to and from lying position, turning side to side and positioning body while in bed) and transfers and was incontinent of bladder and bowel. A review of a Braden Scale (a tool used to determine/predict pressure sore development) dated (MONTH) 21, 2019, revealed that the resident received a score of 16, indicating that the resident was at risk for pressure sore development. A review of the resident's care plan initiated on (MONTH) 31, (YEAR), and revised (MONTH) 25 2019, revealed that the resident was at risk for pressure sore development due to requiring assistance with bed mobility. Planned interventions dated (MONTH) 31, (YEAR), included to conduct weekly skin inspection, nutrition and hydration support as ordered, pressure reducing wheelchair cushion and pressure reduction/relieving mattress, provide thorough skin care after each incontinent episodes and apply barrier cream. Review of the facility's Skin and Wound management System policy, dated as reviewed by the facility (MONTH) 20, (YEAR), indicated the skin management system is designed to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and /or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Practice guidelines directed that an assessment of skin integrity is to be preformed on each resident upon admission to the center by completing a head to toe physical evaluation of skin conditions and a risk evaluation for predicting pressure areas. Ongoing weekly evaluations of residents' skin will be completed and documented in the residents' electronic record and preventative interventions will be implemented for residents identified at risk, as appropriate. A review of nursing documentation on (MONTH) 25, 2019, at 4:30 PM staff reported three new areas to the resident's butt and sacral area. Upon exam by me (registered nurse) that he had three areas of DTI (pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment) all deep purple and blanchable (lesion that loses all redness when pressed is termed). One area #1 right butt I found a dark spot measuring 1.5 cm x 1 cm x .01 cm. Left butt had spot 1.5 cm x 1 cm x .01 cm that included the DTI with an open are next to it. The sacrum had an area 2 cm x 4 cm .01 x cm with DTI at 12 o' clock (location based on the face of a clock) and open area attached below open area. Surrounding tissues red/pink with no MASD (moisture associated skin damage) injury noted but normal in appearance. MD made aware and NON (new order noted) for hydrogel (gel-based wound care dressing which protects and provides a moist wound-healing environment and helps remove dead tissue) wound care to sacrum and left butt, barrier cream to right butt and q (every) 2 repositioning side/side only. Nursing documentation dated (MONTH) 25, 2019, further noted that the resident would be seen by consultant the facility's wound care physician. Further review of nursing documentation and a pressure ulcer investigation tool dated (MONTH) 25, 2019, revealed that Resident 55 was at risk for pressure sore development and had impaired transfer and bed mobility. The documentation noted that this resident had refused repositioning during the past month. However, a review of nursing documentation for the month of (MONTH) 2019 conducted at the time of the survey ending (MONTH) 15, 2019, revealed no documented evidence that the resident had refused turning and repositioning prior to the (MONTH) 25, 2019, discovery of the pressure sores. A review of an initial wound consultant, evaluation and management summary dated (MONTH) 29, 2019, identified an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead skin) or eschar (thick black or brown scabbed dead skin)) measuring 7 cm x 6 cm x 0.2 cm, with light serous (watery, clear fluid) covered with thick, adherent black necrotic (dead) tissue in the resident's sacral area (sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone)). The area was surgical debrided (the removal of dead skin) and a treatment of [REDACTED]. The next wound care consultant visit was documented as completed on (MONTH) 5, 2019. The sacral area was remained unstageable; measuring 13 cm x 7 cm x 0.2 cm with light serous drainage with 50% thick adherent necrotic tissue. The physician documented no change to the condition of this wound. The area was surgically debrided at the bedside. Facility wound tracking dated (MONTH) 12, 2019, indicated a Stage IV pressure area (Full thickness tissue loss with exposed skin, muscle, tendon, ligament or bone in the ulcer), measuring 12 cm x 9 cm x 1 cm, 75% necrotic tissue and 25 % skin. The area was again surgically debrided at the bedside by the wound care physician. Nursing documentation dated (MONTH) 18, 2019, at 11:26 AM revealed that Resident 55 was verbalizing that he wanted to kill himself. The physician was notified and the resident was sent to the hospital for evaluation. Resident 55 was admitted to the hospital (MONTH) 18, 2019. A review of emergency physician history and physical (H & P) dated (MONTH) 19, 2019, at 4:20 PM indicated that while Resident 55 was in the emergency department the resident had been incontinent of bowel. The resident did not want to receive incontinence care until he was admitted to a room in the hospital. The H & P identified skin issues on both his wrists due to the suicide attempt, but no mention of the pressure sore on the resident's sacral area A review of a hospital discharge summary dated (MONTH) 1, 2019, indicated that Resident 55 was admitted to the hospital with [REDACTED]. While a patient at the hospital, Resident 55 had a surgical consult for a sacral wound. The hospital found that the resident had a gangrenous (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) decubitus ulcer (pressure sore), Stage IV. The surgical consult recommended surgical debridement of the area and a diverting [MEDICAL CONDITION] (a surgical procedure to create a [MEDICAL CONDITION], for external bowel movements, in which a bag is placed on the outside of the abdomen to collect feces. This was done so this resident would have no fecal matter in his sacral wound to prevent further decline and infection). A wound vac (also referred to as a negative pressure wound therapy is a machine used to treat advanced bed sores. A wound vac uses a pump to suction fluids from bed sores or other wounds that are difficult to heal on their own) was placed on this resident to promote healing. On (MONTH) 1, 2019, Resident 55 was readmitted to the facility with [MEDICAL CONDITION] and wound vac remaining in place. There was no documented evidence at the time of the survey ending (MONTH) 15, 2019, that the facility had consistently provided turning and repositioning of the resident, both in and out of bed, prior to the discovery of the sacral wound on (MONTH) 25, 2019. Nursing noted on (MONTH) 25, 2019, that the resident had refused repositioning during that past month. However, there was no documented evidence of staff's attempt to reposition the resident or the resident's refusals, prior to the identification of the pressure sore on (MONTH) 25, 2019. Turning and repositioning was noted to be added to the resident's care plan (MONTH) 25, 2019, the day of the pressure sore discovery, although the resident had been identified at risk for pressure sore development since initiation of the resident's care plan, (MONTH) 31, (YEAR). The resident's refusals to be repositioned were not addressed on the resident's care plan nor alternative interventions to promote the resident's compliance. There was no documented evidence that the facility's nursing staff had consistently monitored and assessed the status of the resident's pressure sore between visits by the Wound Care physician to timely identify and address lack of healing or worsening. Interview with the Director of Nursing (DON) on (MONTH) 14, 2019, at approximately 2:00 PM revealed that the facility's contracted Wound Care physician conducts the wound assessments for the residents in the building with pressure areas. The DON stated that other types of resident wounds in the facility are monitored by nursing staff. The DON confirmed that when the Wound Care physician is unable to visit the facility, nursing staff assess and measure the pressure wounds and document the results. The DON confirmed that nursing was not consistently monitoring residents' pressure sores and documenting accurate description of the wounds based on a nursing assessment. The DON also stated that Resident 55 had a standard pressure relieving cushion on his wheelchair and standard pressure relieving mattress on his bed. The DON also confirmed that the intervention of turning and repositioning was not implemented until after the discovery of the resident's wound on (MONTH) 25, 2019. The facility was unable to demonstrate that the frequency of the resident's turning and repositioning had been evaluated for adequacy as the resident's wound worsened. There was no evidence that the facility had consistently provided timely and adequate measures to prevent pressure sore development and prevent worsening of the pressure sore, which required surgical intervention and a [MEDICAL CONDITION]. 28 Pa. Code 211.5(f) Clinical records. Previously cited 2/6/19, 10/19/18, 11/2/17 28 Pa. Code 211.5(g)(h) Clinical records. Previously cited 11/2/17 28 Pa. Code 211.10(a) Resident care policies Previously cited 2/6/19, 10/19/18, 5/16/18, 3/4/18 28 Pa. Code 211.10(d) Resident care policies Previously cited 2/6/19, 5/16/18, 3/4/18 28 Pa. Code 211.12(a)(c)(d)(3) Nursing Services Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17 28 Pa. Code 211.12(d)(5) Nursing Services Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17

Based on clinical record review and staff interview it was determined that the facility failed to effectively monitor the administration of a resident's tube feeding and water flushes regimen to ensure the resident consistently received sufficient nutrition and fluid to prevent adverse consequences of weight loss and dehydration for one resident out of seven sampled (Resident CR2). Findings include: A review of the clinical record revealed that Resident CR2 was admitted to the facility on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. A physician order [REDACTED].) for a total of 1980 calories and 1320 cc volume of feeding formula. The water flushes were ordered at 200 cc every shift and 30 cc of water before and after medications. A Nutrition assessment dated [DATE], noted that the resident required 1920 calories per day and 1668 to 1900 cc fluid per day. The note indicated that the resident was dependent on tube feeding for nutrition and hydration needs and that the resident's nutritional needs were being met by the current tube feeding regimen. The entry also indicated that the resident received medications, which included [MEDICATION NAME] (a diuretic, a medication prescribed to remove excess fluid from the body). A Nutrition Note dated June 4, 2015, indicated that the resident's weekly weight was 148 pounds, which was reflective of a 4% weight loss since admission (the resident's admission weight was 156 pounds). The resident was NPO (nothing by mouth) with total nutritional support via tube feeding. A recommendation to increase the tube feeding to [MEDICATION NAME] 1.5 full strength at 70 cc/hr, times 22 hours, to provide 2310 calories and 1540 cc of feeding was made at that time. However, there was no indication that the administration of the tube feeding was evaluated to ensure that the feeding was being consistently administered as ordered based on the resident's weight loss due to the prior assessment that the initial amount of feeding formula prescribed was considered sufficient to meet the resident's caloric needs and prevent weight loss. A physician order [REDACTED]. A physician order [REDACTED]. Review of the resident's weight record revealed that on June 15, 2015, the resident's weight was 145 pounds, indicative of an additional 3 pound (2%) weight loss since June 4, 2015, and a significant 7% (11 pound) weight loss in one month. Review of the resident's I & O (intake and output) by Day Report from May 26, 2015 through June 15, 2015, failed to show evidence that the tube feeding and flushes were administered as ordered. The daily totals of tube feeding administered varied from 450 cc to 1790 cc per day. The recorded total amount of flushes provided varied from 300 cc to 1360 cc of fluid per day. A physician assistant progress note dated June 15, 2015, indicated that the resident was seen and examined in bed. The note indicated that the resident was confused with low blood pressure today. The entry also indicated that the resident's family member was concerned that the resident was declining. The resident had no fever or chills. The plan was to rule out an infection and dehydration and lab work was ordered. Review of the results of the laboratory testing dated, June 16, 2015, noted that the resident's Blood Urea Nitrogen level (BUN, which can be elevated with [MEDICAL CONDITION] and dehydration) was critically elevated at 126 mg/dl (normal value 7-25 mg/dl) and Creatinine level (also can be elevated with [MEDICAL CONDITION] and dehydration) was elevated at 4.72 mg/dl. A nurses note dated, June 16, 2015, at 11:52 a.m., indicated that the critical lab results were received at the facility and the physician was notified. The resident was noted to be more lethargic and more confusion was noted. The resident was incontinent of a large amount of urine. A physician order [REDACTED]. A nurses note dated, June 16, 2015, 8:24 p.m., indicated that the resident was admitted to the hospital with [REDACTED]. Review of the hospital History and Physical report dated June 16, 2015, noted that the resident's chief complaint was a change in mental status and a rash (there was no documentation regarding a rash in the long term care facility nurses note dated June 16, 2015, which was written prior to transfer to the hospital). The resident's repeat blood work was consistent with [MEDICAL CONDITION]. It was noted that the [MEDICAL CONDITION] may be Bactrim related especially since the resident was noted to have a drug rash. The report indicated that the resident was receiving a couple of nephrotoxic (harmful to the kidneys) medications, which included Irbesartan and [MEDICATION NAME]. The plan included removing the resident's [MEDICATION NAME] due to the resident's blood pressure trending low (the report noted the resident's blood pressure was 92/63 in the emergency room ). Review of a hospital Discharge Summary Report dated, June 23, 2015, noted that the discharge [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on July 13, 2015, at 2:30 p.m., confirmed that the resident was receiving multiple medications, which included a diuretic and an antibiotic. The DON was unable to provide documented evidence that the tube feeding and flushes were adminstered as ordered to prevent weight loss and meet the resident's hydration needs. 28 Pa. Code 211.6 (d) Dietary services Previously cited 10/24/14 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 10/24/14, 4/21/15

Based on a review of clinical records and staff interviews it was revealed that the facility failed to ensure that one resident out of seven sampled was free of significant medication errors resulting in an acute clinical condition (Resident CR2). Findings include: A review of clinical records revealed that Resident CR2 was admitted to the facility on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. A review of the clinical record revealed that resident's medications were being administered via gastrostomy tube (a flexible tube placed in the stomach in which medications and liquid nutritional supplements are given to provide calories, nourishment, fluid for residents with difficulty swallowing who are unable to safely swallow foods, fluids, and medications by mouth). A review of admission physician orders [REDACTED]. The medications prescribed for hypertension included: [MEDICATION NAME] HCL Patch 0.2 mg (milligram)/24 hour, one each, every Friday for 22 days, remove old patch before new patch is applied; [MEDICATION NAME]-[MEDICATION NAME] 37.5 mg-25 mg (antihypertensive, which contains a diuretic to remove excess fluid from the body) one tablet via gastrostomy tube daily, and to hold for a systolic blood pressure (When your heart beats, it contracts and pushes blood through the arteries to the rest of the body. This force creates pressure on the arteries. This is called systolic blood pressure. A normal systolic blood pressure is below 120) less than 140; [MEDICATION NAME] 50 mg one tablet via gastrostomy tube hold for systolic blood pressure less than 120, heart rate less than 60; and Irbesartan 300 mg one tablet via gastrostomy tube daily hold for systolic blood pressure less than 140. A review of the resident's May 2015 and June 2015, Medication Administration Records (MARs) revealed multiple discrepancies regarding the administration of the above medications prescribed to treat the resident's hypertension. The MAR failed to indicate that the [MEDICATION NAME] HCL Patch was changed on Fridays, which included May 22, May 29, and June 5, 2015. There was no documented evidence that the patch was discontinued after 22 days as per physician order. There was no documentation to support that the old patch was removed before the new patch was applied. Review of the May 2015 and June 2015, MARs also revealed that the Irbesartan 300 mg was administered to the resident May 21, 2015 through June 6, 2015, June 9, 2015, through June 14, 2015, and June 16, 2015, despite the resident's systolic blood pressure being recorded as less than 140. Review of the May 2015 and June 2015, MARs also revealed that [MEDICATION NAME]-[MEDICATION NAME] 37.5 mg-25 mg was administered to the resident May 22, 2015 through May 28, 2015, May 30, 2015 and May 31, 2015, June 1, 2015 through June 6, 2015, June 9, 2015 through June 14, 2015, and June 16, 2015, despite the resident's systolic blood pressure being less than 140. A physician order [REDACTED]. A physician assistant progress note dated, June 15, 2015, indicated that the resident was seen and examined in bed. The entry indicated that the resident was confused with low blood pressure today. The note also revealed that the resident's family member was concerned that the resident was declining. The resident had no fever or chills. The plan was to rule out an infection and dehydration and lab work was ordered. Review of the laboratory report dated June 16, 2015, noted that the resident's Blood Urea Nitrogen level (BUN; which can be elevated with [MEDICAL CONDITION] and dehydration) was critically elevated at 126 mg/dl (normal value 7-25 mg/dl) and Creatinine level (also can be elevated with [MEDICAL CONDITION] and dehydration) was elevated at 4.72 mg/dl. A nurses note dated June 16, 2015, at 11:52 a.m., noted that the critical lab results were received and physician notified. The resident was noted to be more lethargic and more confusion was noted. The resident was incontinent of a large amount of urine. A physician order [REDACTED]. A nurses note dated June 16, 2015, 8:24 p.m., indicated that the resident was admitted to the hospital with [REDACTED]. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance). Review of the hospital History and Physical (H & P) report dated June 16, 2015, indicated that the resident's chief complaint was a change in mental status and a rash (there was no documentation of a rash in the long term care facility nurses note dated June 16, 2015, which was written prior to transfer to the hospital). The resident's repeat blood work was consistent with [MEDICAL CONDITION]. The H & P noted that the resident's [MEDICAL CONDITION] may be Bactrim related especially since the resident was observed to have a drug rash. The report noted that the resident was on a couple of nephrotoxic (harmful to the kidneys) medications, which included Irbesartan and [MEDICATION NAME]. The hospital's plan included removing the resident's [MEDICATION NAME] due to the resident's blood pressure trending low (the report noted the resident's blood pressure was 92/63 in the emergency room ). Review of the hospital Discharge Summary Report dated, June 23, 2015, indicated that the resident's discharge [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on July 13, 2015, at 2:30 p.m., confirmed that the resident was receiving multiple medications to treat the resident's hypertension, which included a diuretic which had the potential to contribute to kidney failure and dehydration. During a telephone interview with the DON on July 17, 2015, at 10:00 a.m., it was confirmed that after the resident's discharge, the facility identified the discrepancies in the administration of the resident's medications. However, the DON was unable to provide documented evidence that the medication errors, that occurred during the resident's stay were not contributory to the resident's acute kidney failure. Refer to F322 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 10/24/14, 4/21/15

Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to sufficiently monitor residents' hydration status and initiate applicable measures to maintain adequate hydration status for two residents out of 23 sampled (Resident 33 and Resident 47). Findings include: Review of the facility's Protocol for Intake and Outputs reviewed/revised by the facility September 1, 2014 revealed that the following residents are placed on Intake and Output to monitor fluid balance: Residents receiving TPN/IV Therapy; Residents receiving [MEDICAL TREATMENT]; Residents on Fluid Restriction; Residents with specific MD orders for intake and output; Residents that trigger a Sentinel event of Dehydration until resolved either by lab work or clinical signs of Dehydration until resolved either by lab work or no clinical signs of Dehydration; Upon initiation of enteral feedings for the first 2 weeks; Output only for residents with indwelling catheters; At nursing discretion, based upon clinical evaluation (including but not limited to: persistent diarrhea/vomiting, heavily exudating wounds, fever. The protocol indicated that when a resident is placed on intake and output monitoring, if a resident does not meet their daily fluid needs 3 consecutive days the physician will be notified. Nursing will document the notification in the medical record progress notes and assess the resident for dehydration. A review of the clinical record of Resident 33 revealed that she was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The resident has been on diuretic therapy ([MEDICATION NAME]) as per physician's orders [REDACTED]. Review of her current comprehensive plan of care initiated on April 21, 2014, revealed that the resident was at risk for inconsistent intake secondary to [MEDICAL CONDITION] diagnosis. Interventions planned by the facility included to monitor meal consumption daily and to offer fluids between meals and when rendering care and to provide 90 ccs 2 Cal supplement twice daily. A subsequent plan of care, which was initiated on October 22, 2014, indicated that the resident was at risk for hydration related to a history of abnormal lab work (BUN & creatinine) and a history of admission to the hospital with [MEDICAL CONDITION]. Care planned interventions included to monitor intake and output if indicated, notify physician of signs/symptoms of fluid excess/fluid deficit, observe appearance of mucous membranes and behavior changes, obtain and monitor lab work per physician order [REDACTED]. Provide diet, fluids per physician's orders [REDACTED]. According to a nutritional assessment dated [DATE], the resident's intake of food was between 50-100% and she was on diuretic therapy ([MEDICATION NAME]). She required between 1486-1800 ccs fluid in a 24 hour period. Nutritional interventions were to include, but not limited to, monitoring of lab work and to offer routine snacks/fluid. The nutritional goals were that the resident will show no signs/symptoms of dehydration. Nursing documentation on May 9, 2014, at 12:36 PM indicated that the results of laboratory studies were received and the resident had a critical elevated BUN (Blood Urea Nitrogen) of 103 and a elevated creatinine of 4.72. A urine specimen was unable to be obtained because the resident only voided 50 ccs of fluid on that shift. The physician was called and ordered that the resident be sent to the emergency room for evaluation. The resident was admitted to the hospital on that same date. Review of a hospital history and physical dated May 9, 2014, revealed that the resident was admitted to the hospital on May 9, 2014. The resident's BUN (Blood Urea Nitrogen) was 112 mg/dl and a Creatinine was 3.7 mg/dl and diagnosed with [REDACTED]. Nursing documentation dated May 15, 2014 at 5:17 PM indicated that she was readmitted to the facility on that date. A nutritional assessment dated [DATE], revealed that the resident required 1486-1800 ccs in 24 hours, had a predicted/potential for inconsistent appetites related [MEDICAL CONDITION] diagnosis, [MEDICAL CONDITION], and swallowing difficulty with resulting texture downgrade to puree. The assessment noted that the facility will honor food preferences, monitor the resident's weight and by mouth intakes. It was also noted that her appetite for meals and snacks does continue to meet her assessed needs to assist with (improving) lab results. Nursing documentation on May 18, 2014, at 1:22 PM indicated that the resident required spoon feeding by nursing staff and that her appetite was fair. Nursing documentation on June 25, 2014 at 10:36 AM revealed that the resident complained of general malaise and the physician was notified. A return call from the physician was noted at 11:20 AM and orders received for blood work, a urinalysis and culture/sensitivity to be obtained the next day. On June 26, 2014 the results of the laboratory testing were received at the facility revealing that the resident's BUN and creatinine were both elevated. The physican was notified and issued an order to transfer the resident to the emergency room for evaluation and treatment. The resident was admitted to the hospital on this same date. Review of hospital consultation records indicated that the resident was admitted to the hospital on June 26, 2014, with acute kidney injury stage III associated with volume depletion, [MEDICAL CONDITION] and metabolic acidosis. Recommendations made at the hospital were for diet modification to get her to the point where she eats enough food to sustain her fluid electrolyte balance and for IV fluid electrolyte therapy. Review of laboratory records dated June 26, 2014 indicated that the resident had a critical BUN (Blood Urea Nitrogen) 89 mg/dl (normal 7-25 mg/dl), Creatinine 3.70 mg/dl (normal 0.60-1.30 mg/dl). A history and physical from the hospital also dated June 26, 2014 indicated that the resident presented to the emergency room with abnormal laboratory values and was admitted to the hospital for further evaluation. The hospital assessment indicated that the resident had dehydration and acute kidney injury secondary to dehydration and a questionable urinary tract infection. She was placed on IV therapy and a broad spectrum antibiotic was initiated. There was no documented evidence that the facility had timely identified this resident's increased risk for dehydration and provided necessary services to prevent dehydration. The facility failed to consistently monitor the resident's fluid intakes and output although the resident's [DIAGNOSES REDACTED]. This was confirmed during interview with the Director of Nursing on October 24, 2014. A review of the clinical record of Resident 47 revealed that she was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Review of the resident's current comprehensive plan of care initiated July 4, 2014, revealed that the resident had the potential for inadequate oral food and beverage intake due to dementia and [MEDICAL CONDITION], need for texture altered diet and thickened liquids. Interventions planned by the facility included to monitor meal consumption daily, to provide 120 ccs honey-thick liquids three times a day and house liquid supplement twice a day. According to a nutritional assessment dated [DATE], the resident had swallowing difficulty, was on an altered texture diet with honey thick liquids. Per the assessment he required between 1500-1798 ccs fluid in a 24 hour period. Nutritional interventions planned included extensive feeding assistance and provision of an additional 120 ccs of honey thick liquids three times a day. The resident's average meal intake was noted as 81%. The nutritional goals were that the resident will show no signs/symptoms of dehydration. A review of meal intakes dated July 25, 2014, through August 1, 2014, indicated that Resident 47 had meal intakes were noted as zero to 100 %. His supplement intakes for that time period also ranged from zero % to 100 %. Nursing documentation on July 21, 2014, at 18:35 PM indicated that Resident 47's appetite and fluid intake were adequate and that meals were fed to him by staff. The next nurses note in the resident's clinical record was dated August 1, 2014 at 10:19 AM and revealed that the resident had a temperature of 100.6 F, was lethargic and rousable only to physical stimuli. The physician was called and lab tests were ordered. The results of the laboratory studies were noted as critical: Sodium 160 MMOL/L (normal 136-145 MMOL/L), chloride 123 MMOL/L (normal 98-17 MMOL/L), BUN 74 MG/DL (normal 7-25 MG/DL), creatinine 2.19 MG/DL (normal 0.60-1.3 MG/DL) {BUN and creatinine are indicators of kidney function and also hydration status}. These lab results were reported to the physician and the resident was sent to the emergency room for evaluation on that date. A hospital history and physical record dated August 1, 2014, at 6:28 PM indicated that Resident 47 was found to be unresponsive with agonal respirations (labored respirations and gasping for air) and hypotensive (low blood pressure), in respiratory distress. He appeared severely dehydrated and was poorly responsive. He was resuscitated with 4 liters of intravenous fluids. He was sent to the intensive care unit. The resident's intake of food and fluids fluctuated from July 25, 2014 to August 1, 2014, at times with 0% intake noted, however there was no documented evidence that the facility had monitored this resident for signs and symptoms of dehydration and adequacy of fluid intake to prevent dehydration. During an interview on October 22, 2014, the facility's corporate Registered Dietitian and the facility Certified Dietary Manager stated that the amount of fluid a resident consumes at each meal are calculated with the meal consumption in percentages, 25, 50, 75 and 100%. During an interview on October 23, 2014 at 9:15 AM, Employee 4 (LPN) stated that fluids consumed at meals are not included in the calculation of resident meal intake. According to Employee 4 fluids are only calculated if the resident is on intake and output monitoring ordered by the physician. During an interview on October 23, 2014 at 9:30AM Employee 5 (a nurse aide) stated that he does not include fluids in calculating a resident's meal consumption. There was no documented evidence that the facility had effectively monitored the resident's fluid intake and provided necessary services to prevent dehydration. This lack of monitoring was confirmed during interview with the Director of Nursing on October 24, 2014. 28 Pa Code 211.10 (a)(c)(d) Resident care policies. Previously cited: 11/01/13 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services. Previously cited: 11/01/13, 3/11/14, 9/16/14

Based on review of clinical records, select facility policy, Accident/Incident Reports, and Event Reports submitted to the State Agency, observation, staff interview and measurement of hot water temperatures and staff interview, it was determined that the facility failed to ensure that the residents' environment remained free of potential accident hazards by failing to maintain hot water temperatures within a safe range to prevent potential injury to residents and failing to provide safety/assistance devices in an area utilized by one of 22 residents sampled (Resident 99). Findings include: Resident 99 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The review of the Admission Minimum Data Set (MDS, an assessment tool completed at admission, then at specific intervals to determine care needs) assessment dated [DATE], indicated that Resident 99 was cognitively intact and required limited assistance of one person for transfers, ambulation, dressing, toilet use and personal hygiene. The review of an Event Report submitted to the State Survey Agency on May 16, 2011 at 4:31 PM revealed that on May 15, 2011, at 11:35 AM, Resident 99 was in the facility's designated smoking area when she backed her wheelchair off the elevated cement pad utilized as a resident smoking area. As a result of Resident 99 backing her wheelchair off of this elevated area, and the resulting fall, a fracture of the lateral left clavicle was determined via x-ray. Observation of the designated resident smoking area at the time of the survey revealed a level cement pad, approximately seven feet, eight inches square, elevated to a point, which was even with the exit door. A vertical drop of six and one half inches was noted on the side of this elevated cement pad located to the left upon exiting the door. Extending outward from the elevated pad is a cement ramp tapering down to parking lot level. Interview with Resident 99 on November 16, 2011, at 9:45 AM, regarding her fall with fracture on May 15, 2011, confirmed that she was backing up in her wheelchair to let another resident pass by to re-enter the facility when she rolled backwards too far and rolled off the edge of the cement pad. Resident 99 confirmed that there no measures in place to prevent a fall from this edge of the cement pad, such as a handrail. guardrail or other type of grab bar or railing. Employee 1, (a nurse aide, was identified in the facility's investigation as having been outside on lunch break when the incident occurred, and provided a witness statement in the investigation of Resident 99's fall. Interview with Employee 1 on November 16, 2011 at 12:10 PM, confirmed that Employee 1 was standing at the corner of the facility and observed a wheelchair " tumbling over backwards " off of the cement pad. Upon reacting to the situation Employee 1 was able to identify the resident involved as Resident 99. Employee 1 confirmed that there were no mechanisms in place to prevent a fall from this edge of the cement pad. Interview with the nursing home administrator on November 15, 2011 at 1:00 PM, at the site of Resident 99's fall, confirmed that Resident 99 backed her wheelchair off of the elevated edge of the cement pad, and further confirmed that at the time of Resident 99's fall, there were no mechanisms in place to prevent a fall from this edge of the cement pad, which would have prevented this fall with injury. Review of the facility policy entitled "Maintaining Water Temperature" dated September 30, 2011, revealed that it is the policy of this facility to maintain water temperature within allowable ranges as regulated by the state and to ensure that the water temperatures are within these allowable ranges. (Per state guidelines, hot water outlets accessible to residents shall be controlled so that that the water temperature does not exceed 110 degrees Fahrenheit). During the initial tour of the facility on November 15, 2011, from approximately 10:05 a.m. to 11:20 a.m., hot water temperatures were tested throughout the facility on all nursing units. The results of the water temperatures obtained were as follows: on the 2nd floor nursing unit in Room 201 bathroom revealed a water temperature of 118.7 degrees Fahrenheit, Room 205 bathroom 118.2 degrees Fahrenheit, Room 217 bathroom 116.7 degrees Fahrenheit, on the 1st floor nursing unit in Room 115 bathroom revealed a water temperature of 120.2 degrees Fahrenheit, Room 102 bathroom 120 degrees Fahrenheit, Room 107 bathroom 116.5 degrees Fahrenheit, the sink in the 1st floor shower room, 120.3 degrees Fahrenheit and on the 3rd floor nursing unit in Room 305 bathroom revealed a water temperature of 115.0 degrees Fahrenheit, Room 308 bathroom 119.5 degrees Fahrenheit. Upon notifying facility staff of these findings, more temperatures were taken with Employee 2 (RN) and with the facility's Maintenance Director on November 15, 2011, at 10:23 a.m., through 10:35 a.m., with the following results: on the 3rd floor nursing unit Room 305's bathroom now revealed a temperature of 118.1 degrees Fahrenheit and the third floor Bathing area a water temperature of 116.0 degrees Fahrenheit Interview with the facility's nursing home administrator on November 15, 2011, at approximately 11:55 a.m., confirmed that these temperatures were not in a range considered to be safe. 483.25(h) Accidents and Supervision Previously cited 10/22/10 28 Pa. Code 205.63(c) Pluming and piping systems for existing and new construction. 28 Pa. Code 201. (e)(1) Management. Previously cited 10/22/2010 28 Pa. Code 207.2(a) Administrator's responsibility. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services. Previously cited 9/20/11, 8/2/11, 10/22/10