Every finding on record at Embassy of Tunkhannock

Based on a review of select facility policies, clinical records, facility investigation documentation, and staff interviews, it was determined the facility failed to implement required fall prevention interventions for one resident assessed as high risk for falls (Resident 1), and failed to ensure the correct level of assistance was documented and consistently provided for one of 10 residents (Resident 2) sampled. These failures resulted in Resident 1 and Resident 2 sustaining falls that caused harm with major injury.Findings include: A review of the Fall Prevention and Management Policy last reviewed by the facility on January 23, 2026, revealed each resident will be assessed for fall risk on admission, quarterly, and after any fall happens. If risks are identified, preventative measures will be put into place and added to the resident's care plan. All falls will be reviewed and investigated. The policy documented in the event of a fall, the resident will be assessed by a licensed nurse, the physician and responsible party will be notified, interventions aimed at preventing future falls will be implemented, and the fall risk assessment will be updated. A review of the facility's admission agreement revealed residents admitted to the facility have the right to a safe, clean, comfortable homelike environment, including but not limited to receiving treatment and support for daily living safely. The agreement details the facility will ensure that the resident can receive care and services safely. A review of a contract agreement with an outside hospice provider revealed the facility can admit a Hospice Resident for Respite Services (provides short-term relief for primary family caregivers, ranging from a few hours of in-home support to a multi-day residential stay) subject to the facility's admission policies and procedures. The facility will provide hospice with the admission policies and procedures, and the facility will maintain adequate records to meet the regulatory requirements. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (a blocked blood vessel cuts off oxygen and blood flow to the brain, causing brain tissue to die) and essential hypertension (high blood pressure that has no clear, single medical cause). Review of the admission Evaluation dated July 1, 2026, revealed Resident 1 was admitted to the facility, receiving hospice services as a respite care admission. Resident 1's assessment revealed they required a 1 person assist with bed mobility, transfers, personal hygiene, toilet use, and bathing. The assessment revealed Resident 1 had impaired cognitive process for daily decision making. Review of progress notes revealed an admission summary dated [DATE], documenting Resident 1 is legally blind, confused at baseline, frequently incontinent of bowel and bladder, experiences sun downers (a state of increased confusion, anxiety, and restlessness that starts in the late afternoon or evening as the sun goes down), and is a high risk for falls due to frequent self-transferring. A review of the plan of care revealed no documented evidence the facility developed a care plan for Resident 1 who was identified as high risk for falls nor implemented interventions to prevent falls and promote safety while residing in the facility. A progress note dated July 3, 2026, at 10:30 PM revealed Resident 1 experienced an unwitnessed fall in her room. The resident was assessed with no injuries identified. The staff documented a new intervention of every 15-minute checks would be implemented. A review of Resident 1's clinical record revealed no documented evidence the facility implemented the 15-minute checks after the fall on July 3, 2026, despite Resident 1 experiencing a fall within the facility. A progress note dated July 5, 2026, at 5:30 AM revealed Resident 1 had an unwitnessed fall in her room. The resident was observed climbing off the floor into her bed and telling staff that she fell and landed on her hip. Upon assessment Resident 1 was unable to move her left leg or hip and was observed yelling out in pain. The physician was made aware and ordered the resident to be transported to the emergency department for evaluation. A review of hospital documentation revealed Resident 1 underwent CT Scan imaging (medical imaging test that combines multiple images from different angles to produce images of the inside of the body). The CT scan revealed a closed nondisplaced fracture of left pubis (a break in the pubic bone of the pelvis), and a lumbar transverse process fracture of the L1 and L2 vertebrae (a break in the bony wing-like projection on the side of a lower spine). A review of a progress note dated July 5, 2026, at 1:01 PM revealed Resident 1 continued to be treated in the hospital emergency room for a fracture of the pelvis, L1 and L2 vertebrae and would be returning to the facility with orders to follow up with her attending physician. The facility failed to initiate and complete a comprehensive investigation into Resident 1's July 5, 2026, fall to identify the root cause.The facility failed to implement fall prevention measures upon admission for a resident who had been identified as having a high risk for falls. In addition, the facility failed to develop and implement appropriate interventions after Resident 1's fall on July 3, 2026, which contributed to the resident sustaining a subsequent fall on July 5, 2026.During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 19, 2026, at 12:00 PM the above findings were reviewed. The NHA and DON acknowledged there was no documented evidence that the facility developed and implemented fall prevention interventions to ensure the safety of Resident 1, resulting in the resident experiencing two falls in the facility and sustaining a major injury.A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life) and osteoarthritis (the most common joint disease. It happens when the smooth cushion at the ends of your bones wears down over time.)A review of a Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 3, 2026, revealed that Resident 2 was severely cognitively impaired with a BIMs score of 00 (the BIMS test is used to get a quick snapshot of how well you are functioning cognitively. It is a required screening tool used in nursing homes to assess cognition. A score of 0-7 indicates severely impaired cognition). It was identified that the resident was completely dependent (staff does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity with rolling to the left and right in bed).A review of Resident 2's physician orders revealed on order dated November 3, 2021, for an assistance level of two staff for bed mobility. As of the survey dated August 19, 2026, the order was still active.A review of the resident's plan of care for physical functioning deficit related to mobility impairment revealed planned interventions dated July 30, 2025, for Resident 2 to receive maximal assistance when completing rolling in bed.A review of a nursing note dated August 9, 2026, at 7:15 PM revealed that staff were called to the resident's room by Employee 1, (nurse aide), who had been providing care. The resident was found lying on the floor on the right side of the bed, moaning, grimacing, and reaching toward the left side of her head. The back of the resident's head was resting in a pool of blood, and a laceration was noted on the left ear. Abnormal lung sounds were present bilaterally (both lungs). Pain medication was administered, and the physician was notified of the fall. A new order was received to transfer Resident 2 to the hospital for further evaluation and treatment.A review of a nursing note dated August 10, 2026, at 1:40 PM revealed Resident 2 returned to the facility with sutures to the left ear and a left arm sling.A review of the facility's investigation documentation revealed that on August 9, 2026, Employee 1 was providing incontinence care to Resident 2 without the assistance of another staff member. Employee 1 reported that she had one hand placed on the resident's hip while reaching for a washcloth with the other hand. At that moment, the resident moved her leg over the side of the bed, causing her body to follow, and the resident rolled out of the bed. Employee 1 then left the resident to obtain assistance. The resident sustained a laceration to the left ear and was transferred to the hospital for evaluation. The resident returned to the facility on August 10, 2026, with sutures to the left ear and fractures to the left seventh and ninth ribs.A review of a witness statement dated August 10, 2026, at 7:10 AM revealed that Employee 1 stated the resident was soiled and she was attempting to clean her. Employee 1 indicated she did not want to leave the resident soiled, so she performed care on her own. She reported that when she reached for a washcloth, the resident rolled off the side of the bed.Hospital documentation was requested at the time of the survey. The facility failed to provide the surveyor with the hospital documentation indicating they were unable to obtain it.An interview with Employee 1 on August 19, 2026, at 11:15 AM revealed that she was aware Resident 2 had difficulty with bed mobility but was unaware the resident required the assistance of two staff members. Employee 1 stated this information was not documented on the resident's Tasks/Kardex (a concise, centralized quick reference system summarizing a resident's care plan, medical orders, and daily needs). She further indicated that any resident requiring additional assistance should have this information documented in the Kardex to ensure staff are aware of the required assistance level.An interview with the DON on August 19, 2026, at 12:00 PM confirmed that a resident's assistance level is required to be documented in both the care plan and the Kardex for staff to review prior to providing care. The DON was unable to explain why the Kardex did not reflect Resident 2's required assistance level.A review of Resident 2's care plan and Kardex showed the facility failed to document that the resident required the assistance of two staff members for bed mobility, despite the presence of a physician's order directing additional assistance and the MDS indicating 2 staff members were necessary for care.The facility failed to ensure Resident 2 was provided the proper assistance level, causing Resident 2 to have a fall from the bed resulting in injury.During an interview on August 19, 2026, at 2:00 PM, the NHA and DON acknowledged that the facility failed to ensure the proper level of assistance was provided to Resident 2, resulting in the residents fall, sustaining fractures to the seventh and ninth ribs, and requiring sutures to the left ear. 28 Pa. Code 211.5(f)(i)(iv)(v)(viii) Medical Records28 Pa. Code 211.10 (c)(d) Resident Care Policies28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing Services

Based on review of clinical records and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that a licensed nurse assessed, monitored, and documented a resident's condition following an unwitnessed incident for one of three residents reviewed (Resident 1).Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of resident care regarding documenting assessments clinical problems, communications with other health care professionals regarding the resident communication with and education of the resident, family, and the resident's designated support person and other third parties. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a group of symptoms affecting memory, thinking, judgment, and the ability to perform everyday activities) and depression. A review of Resident 1's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 18, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 3 (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 01 through 07 indicates cognition is severely impaired), was independent for ambulation, and also used a wheelchair. During an interview on May 20, 2026, at 9:45 AM, the Nursing Home Administrator confirmed that on May 16, 2026, prior to 6:00 PM, Resident 1 exited the facility without staff awareness and was subsequently located sitting on a sidewalk adjacent to the facility's main entrance approximately 25 feet from the building. During an observation of the area on May 20, 2026, at 10:00 AM, the Director of Nursing (DON) stated that a nurse aide announced that a resident was outside and requested supervisory assistance. The DON reported that she responded to the area and found Resident 1 sitting on the sidewalk. The DON stated she was the first licensed nurse to assess the resident. The DON reported that the resident was upset, stated she was leaving to look for her car, and was assisted into a wheelchair and returned to the nursing station. The DON stated she completed a brief visual assessment of the resident but did not document her assessment findings, resident status, or the care provided. The DON indicated that she did not document the incident in the clinical record. The DON stated that she did a quick head to toe assessment of the resident but did not document the brief assessment she completed or ensure that the resident was fully assessed and documented by the RN Supervisor. A review of the clinical record failed to reveal documented evidence of a nursing assessment following the incident. Further review failed to reveal documentation regarding the resident's physical condition, assessment findings, monitoring, resident response, nursing interventions, or communications regarding the resident's status following the incident. During an interview on May 20, 2026, at 10:00 AM, the DON confirmed there was no documented evidence of a nursing assessment, resident monitoring, or nursing documentation following the May 16, 2026, incident when Resident 1 was found outside the facility after exiting without staff awareness. ReferF689 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services. 28 Pa. 211.5 (f)(ii)(iii)(ix) Medical records.

Based on observation, review of clinical records, review of a facility policy, information submitted by the facility to the state agency, and staff interview, it was determined that the facility failed to provide adequate supervision and ensure planned safety interventions were effectively implemented to prevent a resident exiting the facility without staff awareness.for one of three residents reviewed (Resident 1).Findings include: Review of the facility's Elopement and Wandering Resident Policy last reviewed January 26, 2026, indicated the facility ensures that residents who exhibit wandering behavior and, or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and, or any necessary supervision to do so. Guidelines include: The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to prevent accidents or elopements. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. Post elopement a nurse will perform a physical assessment, document, and report findings to the physician. Any new physician orders will be implemented and communicated to the resident representative. Staff may be educated on the reasons for the elopement and possible strategies for avoiding such behavior. Documentation in the medical record will include findings from nursing and social service assessments, physician and family notification, care plan discussions, and consultant notes as applicable. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a group of symptoms affecting memory, thinking, judgment, and the ability to perform everyday activities) and depression. A review of Resident 1's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 18, 2026, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 3 (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 01 through 07 indicates cognition is severely impaired), was independent for ambulation, and also used a wheelchair. A physician order, originally dated June 18, 2021, directed staff to check placement and function of the resident's Wander guard bracelet (a wearable alarm device designed to alert staff when a resident attempts to leave a secure area) every shift. A review of Resident 1's care plan, initiated June 18, 2021, revealed the resident was at risk for elopement and injury related to wandering behavior and attempts to leave the facility associated with dementia, anxiety, and agitation. Interventions included redirecting the resident away from exits as needed based on behaviors. A review of Resident 1's Wander and Elopement Evaluation dated December 12, 2025, revealed the resident scored an eight. The assessment indicated that a score of five or greater identified a resident as being at risk for elopement. The evaluation further directed staff to check placement and function of the resident's Wanderguard bracelet each shift. During an interview on May 20, 2026, at 9:45 AM, the Nursing Home Administrator confirmed that on May 16, 2026, prior to 6:00 PM, Resident 1 exited the facility and was later located on a sidewalk approximately 25 feet from the facility's main entrance. The Administrator stated the resident wore a Wanderguard bracelet and was identified as being at risk for elopement. The Administrator further stated the facility's investigation determined that a visitor entering a passcode at the front entrance temporarily disengaged the alarm function, allowing the resident to exit through the doorway while it remained open. During an interview on May 20, 2026, at 9:45 AM, the Nursing Home Administrator confirmed that on May 16, 2026, prior to 6:00 PM, Resident 1 exited the facility and was located on a sidewalk approximately 25 feet from the facility's main entrance. The Nursing Home Administrator confirmed that the director of nursing contacted him on May 16, 2026, about the incident and reported to him that the resident was outside for a short time. The Nursing Home Administrator stated the resident wore a Wander guard bracelet and was identified as being at risk for elopement. The Nursing Home Administrator stated the facility's investigation determined that a visitor entered a passcode at the front entrance, which temporarily disengaged the alarm function and allowed the resident to pass through the doorway while it remained open. Following the incident the main door passcodes were changed to prevent family members from entering a passcode which momentarily disengages the alarm to prevent resident elopements when visitors are entering or exiting the building. During observation on May 20, 2026, at 10:00 AM in the presence of the director of nursing (DON) of the sidewalk area where the resident was observed, the DON confirmed the resident was seated on the sidewalk adjacent to the facility entrance. The DON stated she responded and observed Resident 1 outside the facility. The resident was combative at the time and the resident stated that she was leaving and looking for her car. The DON stated that she did a quick head to toe assessment of the resident but did not document the brief assessment she completed or ensure that the resident was fully assessed by the RN Supervisor. Staff returned the resident to the facility and provided supervision at the nurses' station. Observation conducted on May 20, 2026, at 11:05 AM in the presence of the Maintenance Director, Nursing Home Administrator, and Chief Operating Officer revealed that the resident's alarm bracelet was functioning and activated an alarm when brought near the main entrance. During the observation the front doors could not be opened without entering a passcode. However, if the person with the alarmed bracelet exited through the door after the passcode was entered and the door was still ajar the person with the alarmed bracelet could also go through without it sounding an alarm. As a result, the facility decided to have the alarm bracelet company reassess the system. A sign was posted to alert staff and visitors to ensure no residents are allowed to exit the building without facility approval. The elopement book in the lobby area contained pictures of all residents at risk for elopement. The passcode was changed to limit the number of staff who have access to the passcodes until the system could be fully assessed. Visitors and staff are now required to ring the doorbell for entry and ask for staff assistance when exiting the facility. During an interview on May 20, 2026, at 1:00 PM, the Nursing Home Administrator confirmed Resident 1, who had been identified as being at risk for elopement, exited the facility without staff awareness. The Nursing Home Administrator acknowledged that the facility's elopement prevention interventions were not effective at the time of the incident. Refer F68428 Pa Code 201.14(a) Responsibility of Licensee.28 Pa Code 201.18(b)(1) (e)(1) Management.28 Pa. Code 211.10(a)(c) Resident care policies28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services

Based on a review of clinical records, select facility policies, documentation provided by the facility, observations, and staff interviews, it was determined the facility failed to ensure residents were free of significant medication errors and failed to implement effective procedures to accurately identify residents prior to medication administration. This failure resulted in an Immediate Jeopardy situation when a nurse administered a narcotic medication (morphine sulfate) prescribed for Resident 50 to Resident 51, causing profound bradycardia (abnormally slow heart rate) requiring emergency transfer to the hospital and administration of naloxone (a medication that reverses the effects of opioid overdose) on two occasions. Additionally, the facility failed to ensure an effective system for resident identification, placing 9 of 65 residents reviewed (Residents 6, 7, 12, 23, 34, 48, 53, 59, and 65) at risk for serious injury, harm, impairment, or death.Findings include: A review of the facility policy titled Medication Administration, last reviewed by the facility on January 23, 2026, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. The policy indicated residents are to be identified by photograph in the electronic health record prior to medication administration. A review of the facility policy titled Resident admission Procedure, last updated April 9, 2026, indicated a photograph of the resident will be obtained and uploaded to the electronic health record to ensure accurate identification of residents. Clinical record review revealed Resident 50 was admitted [DATE], with diagnoses that included senile degeneration of the brain (a condition characterized by loss of cognitive functioning such as memory, thinking, and reasoning sufficient to interfere with daily life). A review of Resident 50's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 10, 2026, revealed that Resident 50 was severely cognitively impaired with a BIMS score of 5 (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 01 through 07 indicates cognition is severely impaired). A clinical record review revealed that Resident 51 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 51's annual MDS assessment dated [DATE], revealed that Resident 51 was severely cognitively impaired with a BIMS score of 3 (a score of 01 through 07 indicates cognition is severely impaired). Review of Resident 50's clinical record revealed a physician order dated February 21, 2026, for Morphine Sulfate concentrate solution 20 mg/ml, give 0.5 ml by mouth one time daily. Morphine sulfate is a Schedule II controlled substance (a drug with accepted medical use but high potential for abuse, addiction, and serious adverse effects). Resident 50 also had an order dated July 19, 2024, for Levothyroxine sodium 25 mcg (a medication used to treat thyroid hormone deficiency) to be administered daily in the morning. A progress note dated April 6, 2026, at 6:30 AM revealed that at 5:30 AM, Employee 1, an agency (agency staff are employees of an external company that fill the facility's vacancies as needed) registered nurse (RN), entered the shared room of Residents 50 and 51 to administer medications. Employee 1, RN, called out Resident 50's name. Resident 51 responded with huh. Employee 1 administered morphine sulfate 0.5 ml and levothyroxine sodium 25 mcg intended for Resident 50 to Resident 51 without verifying the resident's identity using a photograph or another reliable identification method. A progress note dated April 6, 2026, at 6:30 AM documented by Employee 1, agency RN, revealed that at 5:30 AM, Employee 1 was administering medications. The progress note indicated Employee 1 entered the room shared by Residents 50 and 51 and called out Resident 50's name. According to the progress note, Resident 51 responded, huh. The progress note documented that Employee 1 approached Resident 51 and identified the medications prepared for administration, specifically morphine sulfate 0.5 ml and levothyroxine sodium 25 mcg. The progress note indicated Resident 51 responded, okay, and Employee 1 administered Resident 50's medications to Resident 51. The progress note further indicated that after leaving the room and returning to the computer to document, Employee 1 realized the medications had been administered to the wrong resident. According to the progress note, Employee 1 immediately obtained Resident 51's vital signs and requested Employee 2, Nurse Aide, remain with the resident while Employee 1 made the required notifications. The progress note documented Employee 1 contacted 911, the physician, and the resident representative. The progress note indicated Resident 51's blood pressure was 90/50 mm Hg (millimeters of mercury, a measurement of the force of blood moving through the arteries; a typical adult blood pressure is approximately 120/80 mm Hg), heart rate was 38 beats per minute (normal adult heart rate is typically 60 to 100 beats per minute), respirations were 12 breaths per minute (breathing rate), and oxygen saturation was 98% (oxygen saturation measures the percentage of oxygen carried in the blood; normal levels typically range from 95% to 100%). Emergency medical services were contacted and Resident 51 was transferred to the hospital. Community hospital emergency department documentation dated April 6, 2026, revealed Resident 51 arrived at the emergency department at 6:42 AM with accidental opiate poisoning (a condition that occurs when an opioid medication, such as morphine, causes harmful effects on the body including slowed breathing, decreased heart rate, decreased level of consciousness, or risk of death) and profound bradycardia (an abnormally slow heart rate, generally fewer than 60 beats per minute). The documentation indicated Resident 51 was administered the incorrect medication at the nursing facility and presented with bradycardia (a condition characterized by an abnormally slow resting heart rate, typically fewer than 60 beats per minute). The documentation indicated emergency medical services reported the resident's heart rate was as low as 29 beats per minute with systolic blood pressure 100 mmHg. Additional documentation revealed blood pressure of 86/64 mm Hg, respirations of 20 breaths per minute and continued clinical instability. The resident was in acute distress (a serious medical condition requiring immediate attention). Continued review of community emergency department documentation dated April 6, 2026, revealed Resident 51 experienced profound bradycardia (an abnormally slow heart rate, generally fewer than 60 beats per minute) likely related to an accidental administration of morphine at the nursing facility. The emergency department documentation indicated Resident 51 required two administrations of naloxone hydrochloride (naloxone HCl) 0.2 mg (a life-saving medication designed to rapidly reverse an opioid overdose by restoring normal breathing). The documentation indicated that following the second administration of naloxone 0.2 mg, Resident 51's heart rate increased to the mid-50 beats per minute range, and blood pressure improved. Continued monitoring documented a systolic blood pressure of 134 mmHg and heart rate ranging from the low 50s to 65 beats per minute. Emergency department documentation indicated Resident 51 was discharged from the hospital on April 6, 2026, at 6:41 PM after stabilization of vital signs. A facility progress note dated April 6, 2026, at 8:00 PM documented that upon Resident 51's return to the facility from the emergency department, the physician issued new orders to monitor vital signs every shift for three days and to conduct safety checks every 30 minutes for 24 hours. A review of documentation provided by the facility revealed that following the medication error incident on April 6, 2026, the facility provided education to licensed nursing staff regarding medication administration. A review of training materials titled Medication Administration and Documentation -Education revealed staff were instructed to identify residents prior to and during medication administration. However, review of the education materials failed to reveal specific procedures staff must follow to accurately identify residents, particularly residents who are cognitively impaired (have difficulty understanding or communicating information) or residents without photographs available in the electronic health record. Observation conducted on April 9, 2026, at 8:25 AM revealed Employee 3, Licensed Practical Nurse (LPN), administering medications to Resident 53 while referencing the electronic health record. The electronic health record included a designated location for a resident identification photograph; however, no photograph was present for Resident 53 at the time of medication administration. During interview on April 9, 2026, at 8:35 AM Employee 3, LPN, stated staff use photographs in the electronic health record to identify residents prior to medication administration. Employee 3 confirmed Resident 53 did not have a photograph available for identification and was unable to explain why the photograph was not present. Employee 3, LPN, indicated that she is familiar with the residents at the facility and is able to identify the residents; however, she was unsure how staff unfamiliar with residents would accurately identify residents without photographs. During interview on April 9, 2026, at 8:55 AM Employee 4, Registered Nurse (RN), confirmed staff rely on resident photographs in the electronic health record to identify residents prior to medication administration. Employee 4 confirmed that there are a few residents at the facility that do not have photographs uploaded to the electronic health record for identification. Employee 4 stated staff may ask residents to state their name when the resident is cognitively intact. Employee 4 was unable to describe a consistent method used to identify residents who are cognitively impaired. During interview on April 9, 2026, at 9:00 AM Employee 5, LPN, confirmed facility policy requires staff to identify residents prior to medication administration. Employee 5 stated photographs in the electronic health record are used for resident identification; however, some residents do not have photographs available. Employee 5 indicated staff may rely on familiarity with residents or nameplates located on resident room doors to identify residents. Employee 5 acknowledged agency staff unfamiliar with residents may have difficulty accurately identifying residents when photographs are not available. A review of clinical records revealed Residents 48, 53, 65, 6, 7, 12, 59, 34, and 23 did not have photographs uploaded to the electronic health record for resident identification until surveyor inquiry was made on April 9, 2026. Fourteen percent of residents reviewed did not have photographs available to assist staff in accurately identifying residents prior to medication administration. The facility failed to implement its internal policy requiring resident photographs to be uploaded to the electronic health record. The facility did not establish an alternative reliable identification process for residents without photographs. Clinical record review revealed:Resident 7 admitted [DATE], BIMS score 12, indicating moderate cognitive impairment (reduced ability to reliably recall or communicate information).Resident 12 admitted [DATE], BIMS score 12, indicating moderate cognitive impairment.Resident 53 admitted [DATE], BIMS score 15, indicating cognition intact (able to reliably communicate information).Resident 6 admitted [DATE], BIMS score 15, indicating cognition intact.Resident 48 admitted [DATE], BIMS score 13, indicating cognition intact.Resident 65 admitted [DATE], BIMS score 13, indicating cognition intact.Resident 59 admitted [DATE], BIMS score 13, indicating cognition intact.Resident 23 admitted [DATE], BIMS score 15, indicating cognition intact.Resident 34 admitted [DATE], BIMS score 15, indicating cognition intact. The facility identified photographs in the electronic health record as the primary method used by staff to verify resident identity prior to medication administration. In the absence of photographs, staff reported relying on familiarity with residents, resident statements of identity, or room nameplates. These methods are not reliable for residents with cognitive impairment and are not reliable for staff unfamiliar with residents, including agency nurses (nurses employed by an external staffing company who may not routinely work in the facility). Without a consistent and reliable identification process, agency staff or newly assigned staff may not be able to accurately identify residents prior to medication administration. The facility did not implement an alternative identification method to ensure accurate resident identification when photographs were not available. A review of nurse staffing schedules dated April 2, 2026, through April 9, 2026, revealed agency nurses accounted for 5.97% of the licensed nursing staff during that time period, increasing the likelihood that staff unfamiliar with residents may rely on photographs or other identification methods to ensure accurate medication administration. During an interview on April 9, 2026, at 9:30 AM the Director of Nursing (DON) confirmed Employee 1 administered morphine sulfate 0.5 ml and levothyroxine sodium 25 mcg intended for Resident 50 to Resident 51, resulting in transferring to the emergency department for treatment of opiate poisoning. The DON confirmed facility policy requires photographs to be available in the electronic health record to assist staff in identifying residents prior to medication administration. The DON stated that previously admissions staff were responsible for uploading resident photographs; however, that position had been eliminated due to staffing changes. The DON was unable to provide documentation of competency validation, orientation records, or training specific to resident identification procedures for Employee 1. During a phone interview on April 9, 2026, at 2:53 PM, Employee 1 confirmed she administered morphine sulfate 0.5 ml and levothyroxine sodium 25 mcg intended for Resident 50 to Resident 51 on April 6, 2026. Employee 1 stated she was an agency nurse, and this was her second shift in the facility. Employee 1 stated she was unfamiliar with the residents and did not know Resident 51 was severely cognitively impaired. Employee 1 indicated she reviewed an orientation packet prior to her first shift but could not recall receiving instruction regarding a specific procedure to accurately identify residents prior to medication administration. During phone interview on April 9, 2026, at 3:08 PM, Employee 2, Nurse Aide (NA), stated that on April 6, 2026, at 5:45 AM, Employee 1 was frantic and in tears and requested Employee 2 remain with Resident 51 until emergency medical services arrived to transport the resident to the hospital. Immediate Jeopardy was identified on April 9, 2026, at 11:15 AM due to the facility's failure to implement procedures to ensure residents are free from significant medication errors. The facility failed to ensure staff accurately identified residents prior to medication administration, resulting in administration of a narcotic opioid medication to the wrong resident and requiring emergency transfer for life-saving medical treatment. Additionally, the facility demonstrated a systemic failure to implement an effective resident identification process, placing residents, at risk for serious injury, harm, impairment, or death. The facility was notified of the Immediate Jeopardy on April 9, 2026, at 11:19 AM and the IJ template was provided to the facility. The facility's Immediate Jeopardy removal plan was provided to the survey team on April 9, 2026, at 3:45 PM and included the following: 1. The facility identified nine residents who do not have photographs in the electronic health record.2. Photographs of seven of the nine residents were taken between 10:12 AM and 10:25 AM on April 9, 2026. At 10:30 AM on April 9, 2026, photographs for all seven residents were uploaded to the electronic health record. Two residents were not in the facility at the time and photographs will be completed immediately upon their return. At 12:20 PM on April 9, 2026, one resident returned to the facility, and the resident's photograph was taken and immediately uploaded to the electronic health record.3. An audit of all residents' electronic health records was completed. Facility staff determined that eight of nine residents had photographs taken and uploaded to the electronic health record for identification purposes. The system process for resident identification was reviewed. The facility policy states that photographs of residents for identification purposes will be added to the electronic health record upon admission.4. The facility ordered wristbands for all residents containing the residents' name and date of birth as a secondary identification method. The wristbands are expected to arrive at the facility on April 13, 2026.5. Resident photographs will be updated in the electronic health record as necessary and will be reviewed annually during resident care planning meetings by the Social Services Director or designee.6. The Nursing Home Administrator (NHA), Registered Nurse Supervisor, or designee will ensure resident photographs are taken on the day of admission and uploaded to the electronic health record for identification purposes during medication administration. A medical wristband containing the resident's name and date of birth will also be applied in accordance with the resident admission procedure.7. Education for Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) began at 10:30 AM on April 9, 2026, and remains ongoing to ensure nursing staff follow the policy regarding the five rights of medication administration (right resident, right medication, right dose, right route, and right time). Education emphasizes use of photographs in the electronic health record to identify residents and prevent administration of medication to the wrong residents. Employees working the second shift will receive education prior to accepting resident assignments. Education regarding procedures for obtaining resident photographs and uploading images into the electronic health record is available in the RN Supervisor's office. The facility utilizes one agency for nursing staff. The agency received a copy of the education materials, which must be completed by agency staff prior to accepting shifts in the facility. No agency staff are currently scheduled. The orientation packet for agency staff will be updated to include the revised admission procedure and updated medication administration policy.8. Audits of new admissions will be conducted by the NHA or designee to ensure photographs are uploaded appropriately into the electronic health record. The Quality Assurance Committee was notified of the Immediate Jeopardy and plan of correction. Audits of photograph identification for new admissions will be conducted daily for two months, with results reported to the Quality Assurance Committee for review and alternative actions as required. The facility implemented corrective actions on April 9, 2026, including obtaining resident photographs, uploading photographs to the electronic health record, initiating staff education regarding the five rights of medication administration (right resident, right medication, right dose, right route, right time), and implementing a secondary resident identification method utilizing wristbands containing resident name and date of birth . Verification of implementation of corrective actions was completed onsite April 9, 2026. The Immediate Jeopardy was lifted April 9, 2026, at 3:45 PM. Refer F627Refer F658Refer F835 28 Pa. Code 211.12 (b)(1) Management. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on review of clinical records, facility provided investigative documentation, select facility policies, applicable state professional nursing standards, and staff interviews, it was determined the facility failed to provide nursing services in accordance with professional standards of practice, resulting in actual harm. The facility failed to ensure a licensed nurse correctly identified a resident prior to medication administration for one of 11 residents reviewed (Resident 51). The failure resulted in the resident receiving another resident's prescribed opioid medication, causing adverse clinical effects requiring emergency medical treatment.Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicates the registered nurse is responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.14 Functions of the RN (Registered Nurse) requires the following: The RN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings, and past experiences in nursing situations. The RN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. (a) A licensed RN may administer a drug ordered for a patient in the dosage and manner prescribed in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. A review of the facility policy titled Medication Administration, last reviewed by the facility on January 23, 2026, indicated medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. The policy indicated that staff are to verify resident identity prior to medication administration, including use of the resident's photograph in the medication administration record. Resident 50 and Resident 51 are roommates. Clinical record review revealed Resident 50 was admitted to the facility February 14, 2024, with diagnoses including senile degeneration of the brain (a condition involving progressive decline in memory, thinking, and reasoning abilities). Review of the quarterly Minimum Data Set (MDS, a federally required standardized assessment used to evaluate resident status and guide care planning) dated February 10, 2026, revealed that Resident 50 was severely cognitively impaired with a BIMS score of 5 (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 01 through 07 indicates cognition is severely impaired). Clinical record review revealed Resident 51 was admitted [DATE], with diagnoses including dementia (a disorder characterized by decline in memory, thinking, and reasoning that interferes with daily functioning). Review of the annual Minimum Data Set, dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. Resident 50's clinical record revealed physician orders for Morphine Sulfate oral concentrate 20 milligrams per milliliter (mg/ml), a potent opioid pain medication used to treat moderate to severe pain. The medication is classified as a Schedule II controlled substance; it has a high potential for abuse, addiction, and dependency, give 0.5 milliliters (ml) by mouth one time daily, initiated February 21, 2026. Opioids may slow breathing and heart rate and can cause serious adverse effects when taken inappropriately. Resident 50 also had an order for Levothyroxine sodium 25 micrograms (mcg) by mouth daily, initiated July 19, 2024. Levothyroxine is a medication used to treat a thyroid hormone deficiency. A nursing progress note dated April 6, 2026, at 6:30 AM documented that at 5:30 AM Employee 1, RN agency, (agency staff are employees of an external company that fill the facility's vacancies as needed) entered the room shared by Residents 50 and 51 and called out Resident 50's name. According to the progress note, Resident 51 responded, huh. The progress note documented that Employee 1 approached Resident 51 and identified the medications prepared for administration, specifically morphine sulfate 0.5 ml and levothyroxine sodium 25 mcg. The progress note indicated Resident 51 responded, okay, and Employee 1 administered Resident 50's medications to Resident 51. The nurse documented that after leaving the room and returning to the computer to document medication administration, she realized the medications had been administered to the wrong resident. The documentation indicated Employee 1 immediately obtained Resident 51's vital signs and requested Employee 2, nurse aide, remain with the resident while emergency services were contacted. Documentation revealed Resident 51's blood pressure was 90/50 millimeters of mercury (mm Hg) (blood pressure measures the force of blood pushing through arteries; normal adult blood pressure is approximately 120/80 mm Hg), heart rate was 38 beats per minute (normal adult resting heart rate typically ranges from 60 to 100 beats per minute), respirations were 12 breaths per minute, and oxygen saturation was 98 percent (oxygen saturation measures the percentage of oxygen carried in the blood; normal levels typically range from 95% to 100%). Hospital records revealed Resident 51 arrived at the emergency department at 6:42 AM with abnormal vital signs including heart rate of 29 beats per minute and low blood pressure. Documentation indicated the resident was alert but disoriented. Hospital documentation indicated Resident 51 received two doses of Narcan (naloxone, a medication used to reverse the effects of opioid medications during overdose) to treat opioid poisoning (a condition that occurs when an opioid medication, such as morphine, causes harmful effects on the body including slowed breathing, decreased heart rate, decreased level of consciousness, or risk of death) and profound bradycardia (an abnormally slow heart rate, generally fewer than 60 beats per minute). resulting in bradycardia (dangerously slow heart rate). The resident was monitored and discharged back to the facility with a diagnosis of accidental opioid poisoning. During a phone interview on April 9, 2026, at 1:00 PM, Employee 1, RN, stated she administered medication to the wrong resident and confirmed she did not follow accepted medication administration practices to verify the correct resident prior to administering medications. The employee confirmed that she did not follow the 5 rights of verifying medication and that she was apologetic for the error. Accepted standards of nursing practice require licensed nurses to follow the 5 Rights of Medication Administration (right resident, right medication, right dose, right route, and right time), a safety process used to ensure medications are administered accurately and safely. During an interview on April 9, 2026, at 2:00 PM the Director of Nursing indicated facility policy requires staff to verify resident identity prior to medication administration. The facility failed to ensure nursing services were provided in accordance with accepted standards of nursing practice, including verification of the correct resident prior to medication administration. Failure to follow the 5 Rights of Medication Administration resulted in Resident 51 receiving another resident's opioid medication and experiencing adverse clinical effects requiring emergency medical treatment, constituting actual harm. 28 Pa. Code 211.12 (b)(1) Management. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on a review of clinical records, facility policies and procedures, job descriptions, facility investigative documentation, and staff interviews, it was determined the facility failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Nursing Home Administrator and Director of Nursing failed to ensure implementation, oversight, and enforcement of effective systems to support accurate resident identification prior to medication administration and resulted in Immediate Jeopardy when an opioid medication was administered to the wrong resident (Resident 51), requiring emergency medical intervention.Findings included: A review of the facility's Nursing Home Administrator's (NHA) job description signed June 1, 2024 revealed that the NHA is responsible for directing the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to residents at all times The job description indicated the NHA is responsible for developing and maintaining written policies and procedures that govern the operation of the facility. The NHA is responsible for interpreting the facility's policies and procedures to employees, residents, and government agencies. The NHA is responsible to consult with department directors concerning the operation of their departments to assist in eliminating or correcting problem areas, ensure that all facility personnel follow established safety regulations, and ensure that residents receive care in a manner and in an environment that maintains or enhances their quality of life without affecting the safety and rights of other residents. The NHA is also responsible to ensure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physician functional status. A review of the Director of Nursing (DON) job description, signed and dated January 26, 2026, revealed that under the supervision of the NHA and Medical Director, the DON is responsible for planning, organizing, developing, implementing, evaluating, and directing the overall operation of the Nursing Services Department in accordance with current federal, state, and local laws, regulations, and professional standards. The job description identified the DON as responsible for ensuring the highest practicable level of quality nursing care is always provided. The DON is further responsible for developing, maintaining, and periodically updating nursing policies and procedures that govern day-to-day nursing operations, as well as ensuring staff are educated on and compliant with those policies. The job description also identified responsibility for coordinating nursing services with other departments to ensure continuity of care and the resident's total plan of care is consistently implemented. A review of the facility policy titled Medication Administration, last reviewed January 23, 2026, required licensed nurses to follow professional standards of practice and the five rights of medication administration, including verification of the right resident prior to administering medication. The policy required staff to utilize the resident's photograph in the Medication Administration Record (MAR, a clinical record used to document medications administered) as part of the identification process. A review of the facility policy titled Medication Administration, last reviewed January 23, 2026, revealed medications are to be administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice to ensure safe and accurate medication administration. The policy requires nurses to follow the five rights of medication administration, which include confirming the right resident (verifying the correct individual), right drug (verifying the correct medication), right dose (verifying the correct amount), right route (verifying the method of administration, such as by mouth), right time (verifying the correct scheduled time), and right documentation (recording the medication in the Medication Administration Record (MAR), a clinical record used to document medications administered). The policy also requires the nurse to remain with the resident until medications are taken. The policy further requires staff to verify the resident's identity by reviewing the resident's photograph in the MAR prior to and during administering medications. A review of the facility policy titled Resident admission Procedure, last updated April 9, 2026, required staff to obtain and upload resident photographs to the electronic health record to support accurate identification of residents. As cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care (F760) 483.45(f)(2) Pharmacy Services, Employee 1 agency Registered Nurse (RN) administered morphine sulfate (a potent opioid pain medication that can slow breathing and heart rate) and levothyroxine (a medication used to treat thyroid deficiency) intended for Resident 50 to Resident 51. Although Resident 51 had a photograph available in the electronic health record, Employee 1 did not utilize the photograph or another reliable identifier to confirm the resident's identity prior to medication administration. Employee 1 called out Resident 50's name, and Resident 51 responded verbally. Employee 1 proceeded with medication administration without further verification of identity. Resident 51 experienced adverse effects including bradycardia (an abnormally slow heart rate) and required transfer to the emergency department where naloxone (a medication used to reverse opioid effects) was administered to prevent further clinical decline. In addition, record review revealed multiple residents did not have photographs available in the electronic health record until surveyor inquiry on April 9, 2026, indicating the facility did not consistently implement its identification process and did not ensure an alternative reliable method for resident identification was consistently used by staff. The NHA and DON failed to ensure effective systems were implemented, monitored, and enforced to support staff compliance with facility policy and professional standards for resident identification prior to medication administration. The facility failed to ensure staff consistently follow established identification protocols designed to prevent medication errors. The facility's failure to effectively manage and oversee operations resulted in a breakdown of medication administration safeguards and placed residents at risk for serious harm or death. Immediate Jeopardy was identified on April 9, 2026, at 11:15 AM, as the facility's noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was removed on April 9, 2026, at 3:45 PM, following implementation of corrective actions. Refer F760 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code: 201.12 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code:211.12(c) Nursing Services.

Based on a review of clinical records, resident and staff interviews, and facility provided documentation, it was determined the facility failed to ensure that residents who were 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 11 sampled residents (Residents 51). Findings include: A review of a facility policy titled Personal Care Procedure, last reviewed by the facility on January 23, 2026, revealed it is the policy of the facility to provide and assist resident care and hygiene to each resident based on their individual status and needs. The policy defined personal care to include bathing, showers, oral care, and grooming. The policy further detailed that for residents who need assistance, it is the responsibility of the staff to provide as much help as needed, which may include total assistance for residents who are confused, or physically unable to do it themselves. The policy revealed that nail care is to be completed during showers with cleaning and trimming as needed. After the procedure is completed, the care is to be documented in the nurse's notes or point of care area, if the resident refuses, the staff is to document the refusal. A review of Resident 51's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation (a common, often chronic arrhythmia characterized by rapid, disorganized electrical activity in the heart's upper chambers causing a fast, irregular heartbeat), and dementia (a progressive syndrome characterized by a decline in memory, language, and thinking severe enough to disrupt daily life). Review of Resident 51's Annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 11, 2026, revealed that Resident 51 was cognitively impaired with a BIMS score of 3 (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 0-7 indicates severe cognitive impairment). The MDS further detailed that Resident 51 was totally dependent on staff for assistance with bathing and personal hygiene. A review of Resident 51's Kardex (a quick-reference summary for staff to guide delivery of care) documented that Resident 51 was scheduled to receive showers on Wednesday and Saturday during the evening shift, the Kardex documented Resident 51 preferred taking showers over bed baths, or baths. A review of the Documentation Survey Report v2 for March 2026 and April 2026 revealed that showers were completed as scheduled, including the most recent shower documented on April 8, 2026, at 9:59PM. Observation conducted on April 9, 2026, at 12:00PM revealed Resident 51 to have visible buildup and grime under five out of five fingernails on both hands. The nails were observed to have debris trapped under the nails, with greyish black residue under the fingernail tips. The facility was unable to provide any documentation to support Resident 51 had refused nail care, despite receiving a shower 1 day prior to the observation of her nails. The facility was unable to provide any documentation that Resident 51's fingernails had been cleaned, as defined in the facility policy. The above findings were reviewed with the Director of Nursing on April 9, 2026, at 3:30PM. The facility could not provide documented evidence of staff following facility policy to ensure residents received appropriate personal care. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(5) Nursing services.

Based on review of clinical records and staff interview, it was determined the facility failed to ensure necessary resident-specific clinical information was communicated to the receiving health care provider at the time of an emergent transfer to the hospital for one of 19 residents reviewed (Resident 51).Findings include:A review of Resident 51's clinical record revealed the resident was admitted to the facility on [DATE], and transferred to the emergency department on [DATE]. The resident had an advance directive indicating a no code status (no code means that in the event the resident's heart or breathing stops, cardiopulmonary resuscitation (CPR) is not to be initiated). A progress note dated [DATE], at 6:30 AM revealed that at 5:30 AM Resident 51 was administered another resident's medication. Specifically, Resident 51 accidentally received morphine sulfate 0.5 ml (morphine sulfate is a potent opioid medication used to treat moderate to severe pain; opioid medications can slow breathing and heart rate and may cause life-threatening complications when given inappropriately). Emergency Medical Services (EMS) were contacted, and the resident was transferred to the emergency department for evaluation and treatment related to the medication error. Clinical record review revealed no documented evidence that the facility communicated necessary clinical information to the receiving health care provider at the time of transfer. Specifically, there was no documentation indicating the facility provided information regarding the medication error, including the name of the medication, dosage, time administered, or the clinical circumstances related to the accidental opioid exposure. Additionally, there was no documented evidence that the facility communicated other essential information necessary for continuity of care, including the resident's advance directive status, special instructions, precautions for ongoing care, baseline condition, or comprehensive care plan goals, as appropriate, to ensure a safe and effective transition of care. During an interview conducted on [DATE], at 3:45 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide documented evidence that the facility communicated Resident 51's necessary clinical information to the receiving health care provider at the time of the emergent transfer on [DATE]. Refer F76028 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(3) Nursing services.

Based on a review of the statement of deficiencies from the survey ending January 30, 2026, it was determined the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to the facility's food and nutrition services department and implement effective plans to correct and prevent further quality deficiencies related to timely identification of changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification of the attending physician and the resident's responsible party of a significant weight.Findings included: A review of a facility policy entitled Quality Assurance Performance Improvement, last reviewed by the facility January 23, 2026, indicated the facility developed and maintains an effective, comprehensive, data-driven quality assurance and performance improvement program that focuses on indicators of the outcomes of care and quality of life and will utilize the best available evidence to design and measure indicators of quality and have facility goals that reflect processes of care and facility operation that have been shown to be predictive of desired outcomes for residents. During a survey completed on January 30, 2026, deficient facility practice was identified under the requirement of food and nutrition services related to timely identification changes in nutritional parameters, implementation of appropriate nutritional interventions, and notification to the attending physician and the resident's responsible party of a significant weight loss. In response, the facility developed a plan of correction to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by February 28, 2026, and indicated that the following would be performed: Current residents will be reviewed to determine if a significant weight loss has occurred in the past month, and if so, a nutritional assessment will be completed, interventions will be implemented as appropriate, the resident's care plan will be adjusted as appropriate, and the resident's physician and responsible party will be notified. The regional dietician/designee will educate the registered dietician on identification of significant weight loss, initiation of nutritional assessment, implementation of interventions to prevent further weight loss, and adjustments to the resident's care plan. The ADON/designee will re-educate the licensed nursing staff on the identification of a significant weight loss and notification of the registered dietitian and the resident's physician and responsible party. Residents with identified significant weight loss will be audited weekly by the registered dietitian/designee to ensure that there is a new nutritional assessment completed, implementation of interventions to prevent further weight loss, and adjustments to the residents' care plan. These audits will be performed weekly for four weeks and monthly for 3 months, and the results of these audits will be brought to the facility QAPI meeting monthly for further review and recommendation. This corrective plan was to be in place by February 28, 2026. However, during the survey ending March 24, 2026, continuing deficient facility practice was identified with these same requirements. A review of Resident 3's weight record revealed the following documented weights: January 4, 2026: 124 pounds February 1, 2026: 120 pounds March 3, 2026: 117 pounds March 15, 2026: 118 pounds March 22, 2026: 114.5 pounds. The March 22, 2026, weight reflected a loss of 3.5 pounds, representing approximately 3 percent body weight loss in one week, and a 7.5 percent change since January 4, 2026. The clinical record failed to reveal documentation that a reweight was obtained to verify this significant change. A review of a weight change note completed by the facility's remote RD (the RD works offsite and is not routinely physically present in the facility and provides dietary oversight through electronic record review and communication with staff) dated February 21, 2026, at 11:48 PM, in response to a weight alert for the February 1, 2026, value. The RD documented a weight loss of 3 percent (4 pounds) and that the resident receives a 4 oz. nutritional shake twice a day and recommended a 4 oz. nutritional shake with meals (three times a day). A review of physician orders revealed an order dated March 4, 2026, at 11:02 AM, for a house commercial shake, 4 oz., with meals, eleven days after it was recommended by the RD. A review of a weight change note completed by the facility's remote RD dated March 9, 2026, at 9:12 PM, in response to a weight alert for the March 3, 2026, value. The RD documented a weight loss of 10 percent (14 pounds) over 180 days and recommended a 4 oz. frozen nutritional treat with dinner and weekly weights for the resident. A review of physician orders revealed an order dated March 9, 2026, at 9:36 PM, for weekly weights. A review of physician orders revealed an order dated March 17, 2026, at 10:47 AM, for 4 oz. frozen nutritional treats with dinner, eight days after it was recommended by the RD. The clinical record failed to reveal documented evidence that the recommended nutritional interventions, including the 4 oz. nutritional shakes with meals and 4 oz. frozen nutritional treat with dinner, were implemented in a timely manner following the identification of weight loss. Additionally, the clinical record failed to reveal documented evidence that Resident 3's attending physician and responsible party were notified of the significant weight loss on March 22, 2026. During an interview on March 24, 2026, at 3:30 PM, the Director of Nursing confirmed that the facility failed to demonstrate timely notification of the physician and responsible party regarding the resident's significant weight loss and timely implementation of nutritional interventions. The facility's quality assurance monitoring plan failed to identify ongoing deficient practice with the facility's monitoring for Resident 3's nutritional status. Refer F692 28 Pa. Code 201.18(e)(4) Management.28 Pa Code 211.10 (c)(d) Resident care policies.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident's responsible party of a significant weight loss for one of 12 sampled residents (Resident 3).Findings included: A review of a facility policy entitled Weight Policy, last reviewed by the facility January 23, 2026, indicated resident weights would be obtained in a timely and accurate manner and documented and responded to appropriately. Upon admission or readmission, weights will be obtained and documented. The resident will be weighed every week for the following three (3) weeks, then monthly unless ordered otherwise by the medical doctor (MD) or nurse practitioner (NP) or the registered dietitian (RD). If a weight showed the same or greater variance, a nurse would verify the weight was obtained correctly. Significant weight losses of 5 percent in one month, 7.5 percent in three months, and/or 10 percent over six months will be tracked by the RD. The RD will work with the facility staff during the routine weight meeting to review resident weight changes and determine any additional interventions for the resident's weight change. The MD and responsible party (RP) will be made aware of significant changes in weight, and the RD or MD may order specific nutritional interventions, supplements, or other interventions if indicated. A review of Resident 3's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and major depressive disorder (a mental health condition characterized by persistent low mood and loss of interest in usual activities). A review of Resident 3's Quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 5, 2026, revealed the resident was severely cognitively impaired with a BIMS score of 1 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates severe cognitive impairment). A review of Resident 3's comprehensive care plan, initiated March 4, 2024, identified nutritional problems or potential nutritional problems related to advanced age, mechanically altered diet texture (food texture modified to reduce chewing or swallowing difficulty), and thickened liquids (liquids modified to reduce risk of choking). Goals included maintaining weight within 3 percent of 124 pounds and consuming 75 percent of at least two meals served daily. Planned interventions included providing the diet as ordered, fortified foods (foods with added calories or protein) with all meals, a 4 oz. nutritional shake with meals (a calorie and protein supplement), a 4 oz. magic cup/frozen nutritional supplement daily, obtaining weights as ordered, and RD (Registered Dietitian) evaluation with recommendations as needed. A review of Resident 3's weight record revealed the following documented weights: January 4, 2026: 124 pounds February 1, 2026: 120 pounds March 3, 2026: 117 pounds March 15, 2026: 118 pounds March 22, 2026: 114.5 pounds. The March 22, 2026, weight reflected a loss of 3.5 pounds, representing approximately 3 percent body weight loss in one week, and a 7.5 percent change since January 4, 2026. The clinical record failed to reveal documentation that a reweight was obtained to verify this significant change. A review of a weight change note completed by the facility's remote RD (a registered dietitian providing nutrition oversight through electronic clinical record review rather than on-site presence) dated February 21, 2026, at 11:48 PM, in response to a weight alert for the February 1, 2026, value, documented a weight loss of approximately 3 percent (4 pounds). The RD noted the resident received a 4 ounce nutritional shake twice daily and recommended a 4 ounce nutritional shake with meals (three times daily). A review of physician orders revealed an order dated March 4, 2026, at 11:02 AM, for a commercial nutritional shake 4 ounces with meals, eleven days after the RD recommendation. A review of a weight change note completed by the remote RD dated March 9, 2026, at 9:12 PM, in response to a weight alert for the March 3, 2026, value, documented a weight loss of 10 percent (14 pounds) over 180 days and recommended a 4 ounce frozen nutritional supplement with dinner and weekly weights. A review of physician orders revealed an order dated March 9, 2026, at 9:36 PM, for weekly weights. A review of physician orders revealed an order dated March 17, 2026, at 10:47 AM, for a 4 ounce frozen nutritional supplement with dinner, eight days after the RD recommendation. The clinical record failed to reveal documented evidence that recommended nutritional interventions, including the 4 ounce nutritional shakes with meals and 4 ounce frozen nutritional supplements with dinner, were implemented in a timely manner following identification of weight loss. Additionally, the clinical record failed to reveal documented evidence that Resident 3's attending physician and responsible party were notified of the significant weight loss on March 22, 2026. During an interview with the Director of Nursing on March 24, 2026, at 2:00 PM, the above findings were reviewed. The Director of Nursing confirmed no additional documentation could be provided to demonstrate timely notification of the physician and responsible party or timely implementation of recommended nutritional interventions related to the identified weight changes. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on a review of clinical records, the facility's abuse, neglect, and exploitation policy, information provided by the facility, and resident and staff interviews, it was determined the facility failed to report alleged violations of resident-to-resident abuse for two of 12 residents reviewed (Residents 1 and 2).Findings include: A review of the facility policy titled Abuse, Neglect, and Exploitation, last reviewed by the facility on January 23, 2026, revealed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation. The policy indicates that an alleged violation is a situation or occurrence that is observed or reported by staff, a resident relative, or others but has not yet been investigated and, if verified, could be an indication of non-compliance with federal requirements related to mistreatment, exploitation, neglect, or abuse. The policy indicates reporting of all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specified timeframes: immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include spondylosis (arthritis of the spine). 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 March 17, 2026, 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 through 15 indicates cognition is intact). A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included diabetes (a condition resulting in high levels of sugar in the blood) and intellectual disabilities (a developmental condition involving limitations in reasoning, learning, and problem solving that affect daily functioning). A review of Resident 2's quarterly MDS dated [DATE], revealed the BIMS interview was not completed because the resident was rarely or never understood. Further review of MDS Section C1000 Cognitive Skills for Daily Decision Making revealed Resident 2 was moderately impaired in cognitive skills for daily decision making (difficulty making routine decisions). in the ability to make decisions regarding tasks of daily life. A review of Resident 1's care plan initiated August 7, 2018, revealed behavioral concerns that included verbal agitation and aggression towards staff and verbal aggression towards the roommate and roommate's family. Interventions included not positioning the resident near others who disturb the resident, attempt interventions before behaviors begin, and helping the resident avoid situations or people that are upsetting to him to prevent escalation of behaviors. A review of investigative documentation provided by the facility dated February 7, 2026, revealed Resident 1 wheeled Resident 2 in Resident 2's wheelchair into Resident 2's room and shut the door. Documentation indicated the nursing supervisor initiated safety monitoring checks every 30 minutes for two nursing shifts for Resident 2 and provided education to Resident 1 regarding not pushing other residents' wheelchairs. Investigative documentation dated February 7, 2026, revealed facility review of video footage confirmed Resident 1 wheeled Resident 2 into Resident 2's room and shut the door before returning to his own room. The documentation indicated staff entered Resident 2's room shortly after the event and remained with the resident for several minutes. Investigative documentation dated February 8, 2026, revealed Resident 1 was interviewed by the Nursing Home Administrator regarding the event. The document indicated Resident 1 pushed Resident 2 into her room because she was acting out and shut the door.An interview conducted March 24, 2026, at 11:45 AM with Employee 1, nurse aide (NA), revealed Employee 1 observed Resident 1 wheel Resident 2 approximately two feet into Resident 2's room and shut the door. Employee 1 recalled Resident 1 appeared annoyed and stated words to the effect that Resident 2 should remain in the room stating, If you act up, you are going to stay in the room. Employee 1 NA reported opening the door, checking on Resident 2, and bringing Resident 2 to the nursing station to ensure safety. Employee 1 NA indicated Resident 2 did not appear to understand that Resident 1 was upset or angry. Investigative documentation dated February 16, 2026, at 10:00 AM revealed Resident 1 was observed ramming/intentionally striking Resident 2's wheelchair multiple times with his own wheelchair. Resident 1 was provided with education that he cannot be running his wheelchair into others and needed to leave Resident 2 alone. Documentation indicated the residents were separated and Resident 2 was moved to a different nursing unit for safety. A progress note dated February 16, 2026, at 10:01 AM documented Resident 1 intentionally ran into Resident 2's wheelchair multiple times and was instructed to stop the behavior. During an interview on March 24, 2026, at 12:30 PM, Resident 1 indicated he did not believe he harmed Resident 2 and reported that he sometimes assisted Resident 2 to her room when she appeared upset. During an interview on March 24, 2026, at 1:46 PM, the nursing home administrator (NHA) confirmed that he investigated allegations of resident-to-resident abuse between Residents 1 and 2. The NHA confirmed that he did not report the allegations of resident-to-resident abuse involving incidents that occurred on February 7, 2026, and February 16, 2026, to the state agency or adult protective services. The facility failed to identify incidents as allegations of resident-to-resident abuse (actions by one resident that cause or could cause physical or emotional harm to another resident) that must be reported to the required external agencies within required timeframes, regardless of investigation outcome. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1)Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10(d) Resident care policies.

Based on staff interview and a review of employee credentials, it was determined the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department.Findings include: A review of a facility provided job description for the Registered Dietitian (RD) indicated the position purpose includes planning, organizing, developing, and directing the nutritional care of the residents in accordance with current federal, state and local standards, guidelines, regulations and established facility policies and procedures. Major duties and responsibilities included the following: to provide registered dietitian services in one or more sites according to policies and procedures; plan, organize, develop, and direct the nutritional care of the residents in accordance with current federal, state and local standards, guidelines and regulations; assesses/monitors the residents' nutritional status and provides recommendations to clinical/medical staff; observes resident meal services to ensure diets are correct and modifications are followed; educates residents, families, and staff on nutrition concepts and diet modification; work with other members of the interdisciplinary team to ensure that modified texture or therapeutic diets are in compliance with the resident's medical condition; reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines; updates diet orders and menu changes as required; conducts audits of relevant nutritional care on a routine basis; completes nutritional assessments on residents on admission, readmission, quarterly, annually, and with any changes in condition as per guidelines; performs inspections of food service areas for sanitation, order, safety, and proper performance of assigned duties; monitors residents for weight changes, nutrition support, and skin breakdown, and makes recommendations as needed; and participates in inspection surveys, ensuring compliance with nutritional and dietary policies and procedures as per state and federal guidelines. During an interview conducted on January 28, at 12:00 PM, the Nursing Home Administrator (NHA), reported the facility's RD worked 24-32 hours per pay period (two-week intervals) and most hours worked were remotely (off-site) with one day per pay period on-site on a Saturday or Sunday. The NHA confirmed the RD had a full-time job elsewhere and was not available to the facility during regular day shift hours of 8:00 AM to 4:00 PM. Additionally, the NHA reported that since the RD could not perform duties on-site, the facility's full-time certified dietary manager (CDM) reviews weights, performs admission interviews with residents or families and communicates the information to the RD for the assessment and documentation to be performed remotely. The NHA also confirmed the RD did not conduct on-site supervisory oversight of the food and nutrition services department, including staff training, direct observation of residents for nutritional assessments, or monitoring of meal services. The facility failed to ensure compliance with federal requirements by not providing the necessary on-site oversight and consultation by a qualified dietitian or clinically qualified nutrition professional. This failure created the potential for inadequate monitoring and coordination of food and nutrition services necessary to meet residents' clinical and nutritional needs. Refer F 69228 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18 (b)(1)(3)(e)(1)(6) Management.

Based on staff interviews and review of facility training and orientation records, it was determined that the facility failed to ensure that all employees received required annual education on the facility's abuse prohibition policy and procedures. Findings include: A review of the facility's policy entitled Abuse, Neglect, Exploitation and Misappropriation of Resident Property last reviewed by the facility on January 23, 2026, indicated the facility would educate its staff upon hire and annually thereafter regarding the facility's policy concerning abuse, neglect, exploitation and misappropriate of resident property and how to handle resident-to-resident abuse and injuries of unknown sources. During an interview with the Nursing Home Administrator (NHA) on January 30, 2026, at 12:45 PM, the NHA reported that the Human Resources Director position was eliminated in mid-December 2025 due to budgetary reductions and that the responsibilities of the position were reassigned to administration. The NHA provided the educational content intended for the facility's annual abuse prevention training program. However, the facility was unable to provide documented evidence demonstrating that the annual abuse prevention education was completed for facility staff. The NHA provided the educational content intended for the facility's annual abuse prevention training program. However, the facility could not provide documented evidence demonstrating that the annual abuse prevention education was completed for facility staff. Additionally, the interview on January 30, 2026, at 12:55 PM, confirmed that documentation verifying completion of the facility's mandatory annual abuse prevention training could not be located. As a result, the facility was unable to demonstrate that its required annual abuse prevention training program was implemented to ensure that all facility staff received the facility's abuse prohibition policy and procedures to identify and report abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention. 28 Pa. Code 201.20(a)(b) Staff development. 28 Pa Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (c) Resident care policies.

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings on a quarterly basis for two of four quarters (Quarter 1 and Quarter 2 of 2025). Findings include:: A review of the facility policy titled Quality Assurance Performance Improvement (QAPI) last reviewed by the facility on January 23, 2026, revealed the would develop and maintain an effective, comprehensive, data-driven QAPI program. However, the policy did not clearly identify required QAPI committee membership, did not specify required participation of the Medical Director or a designated physician representative, and did not outline attendance expectations or accountability for participation in quarterly meetings. A review of QAPI committee meeting sign-in sheets for the period of March 2025 through January 2026 revealed that although QAPI meetings were conducted quarterly, the Medical Director or the Medical Director's designated physician representative was not in attendance at the meetings held on March 19, 2025; July 17, 2025; and September 22, 2025, representing two of four quarters reviewed in 2025. Interview with the Director of Nursing and the Nursing Home Administrator on January 30, 2026, at 11:00 AM confirmed review of the findings related to the absence of the Medical Director or designee from the identified QAPI committee meetings. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 201.18 (e)(1)(3) Management.

Based on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to implement procedures to fully screen four employees out of five to ensure they were eligible for employment in a long term care nursing care facility. (Employees 1, 2, 3, and 4).Findings include: A review of the facility's Resident Abuse policy last reviewed by the facility on January 23, 2026, revealed the requirement for screening potential employees including obtaining references from the most recent or previous employer. Review of employee personnel files revealed the following: Employee 1 (Licensed Practical Nurse): Hired on September 30, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility. Employee 2 (Social Services): Hired on November 4, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 3 (Dietary Aide): Hired on November 17, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the most recent former employer. Employee 4 (Nurse Aide): Hired on July 18, 2025. The application listed previous employers, but there was no documentation showing the facility had contacted the employees' most recent former employer. Interview with the Nursing Home Administrator (NHA) on January 29, 2026, at 1:15 PM confirmed there was no evidence that previous employers were contacted for information regarding the employees' past work history. The facility failed to follow its own abuse prohibition policy by not verifying previous employment for two out of five new hires. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.19 (1) Personnel records.

Based on review of clinical records, select facility policy, observation, and staff interview, it was determined that the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for two out of the 23 residents sampled (Resident's 4 and 58).Findings include: A review of the facility policy titled Medication Administration, last reviewed by the facility on January 23, 2026, revealed that medications are to be administered by licensed nurses or other staff authorized to do so by the state, as ordered by the physician, and in accordance with professional standards of practice to prevent contamination, infection, and medication errors. The policy further requires that the licensed nurse administering a medication immediately document the resident's name, date and time of administration, dose, route of administration, and the signature of the nurse on the medication administration record. The policy also requires that medications classified as controlled substances (medications regulated by law due to their potential for misuse or dependence) be documented on a controlled substance record to ensure accurate tracking and accountability. A review of the clinical record revealed Resident 58 was admitted to the facility on [DATE], with diagnoses that included vascular dementia with behavioral disturbance (a condition caused by reduced blood flow to the brain that affects memory, thinking, and behavior) and generalized anxiety disorder (a condition characterized by persistent and excessive worry that interferes with daily functioning). A review of the clinical record revealed a physician's order dated August 21, 2025, for Lorazepam 0.5 milligrams (mg) by mouth three times daily related to generalized anxiety disorder. Lorazepam is a Schedule IV controlled substance, a medication with accepted medical use but regulated due to its potential for misuse or dependence. Review of facility records revealed the facility utilizes a Controlled Drug Receipt/Record/Disposition Form to track, monitor, and reconcile controlled substances and a Medication Administration Record (MAR) to document each administered dose, including the date, time, medication, and staff administering the medication. A comparison of Resident 58's Controlled Drug Receipt/Record/Disposition Form with the MAR for the period of August 1, 2025, through January 2026, revealed three entries on the controlled substance record indicating Lorazepam 0.5 mg was used; however, there was no corresponding documentation on the MAR to indicate that the medication was administered to the resident. The discrepancies occurred on the following dates and times:September 6, 2025, at 6:00 AMSeptember 14, 2025, at 5:00 AMJanuary 2, 2026, at 4:00 PM The absence of MAR documentation for doses recorded as used on the controlled substance record indicated a failure to ensure accurate medication administration documentation and reconciliation.A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) and muscle weakness (reduced muscle strength that limits the ability to perform daily activities). The record further revealed Resident 4 was admitted to hospice care (specialized care focused on comfort and symptom management for individuals with a life expectancy of six months or less). Further review of the clinical record revealed a physician's order dated October 10, 2025, for Morphine Sulfate concentrated oral solution 20 mg per milliliter (ml), with instructions to administer 0.25 ml by mouth three times daily related to musculoskeletal symptoms. Morphine Sulfate is a Schedule II controlled substance, meaning it has a high potential for misuse and requires the highest level of monitoring, documentation, and accountability. A review of the clinical record revealed a physician's order dated October 10, 2025, for Morphine Sulfate concentrated oral solution 20 mg per milliliter (ml), with instructions to administer 0.25 ml by mouth three times daily related to musculoskeletal symptoms. Morphine Sulfate is a Schedule II controlled substance (high potential for misuse and requires the highest level of monitoring, documentation, and accountability). A comparison of Resident 4's Controlled Drug Receipt/Record/Disposition Form with the MAR from October 10, 2025, through January 2026, revealed three entries on the MAR indicating that Morphine Sulfate was administered; however, there was no corresponding documentation on the controlled substance record to indicate that the medication was removed, administered, or otherwise accounted for. The discrepancies occurred on the following dates and times:October 19, 2025, at 11:30 AMNovember 15, 2025, at 5:00 PMNovember 16, 2025, at 12:53 AM The absence of controlled substance documentation for doses recorded as administered on the MAR indicated a failure to maintain accurate and complete controlled medication records. An interview was conducted on January 29, 2026, at 10:45 AM, with the Director of Nursing (DON) to review the above findings related to the facility's failure to implement effective procedures to reconcile Resident 4 and Resident 58's-controlled substance medications. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to timely identify changes in nutritional parameters, implement appropriate nutritional interventions, and notify the attending physician and the resident's responsible party of a significant weight loss for one of 18 sampled residents (Resident 5).Findings included: A review of a facility policy entitled Weight Policy, last reviewed by the facility January 23, 2026, indicated resident weights would be obtained in a timely and accurate manner, and documented and responded to appropriately. Upon admission or readmission weights will be obtained and documented. The resident will be weighed every week for the following three (3) weeks, then monthly unless ordered otherwise by the medical doctor (MD) or nurse practitioner (NP) or the registered dietitian (RD). If a weight showed the same or greater variance, a nurse would verify the weight was obtained correctly. Significant weight losses of 5 percent in one month, 7.5 percent in three months, and/or 10 percent over six months will be tracked by the RD. The RD will work with the facility staff during the routine weight meeting to review resident weight changes and determine any additional interventions for the resident's weight change. The MD and responsible party (RP) will be made aware of significant changes in weight, and the RD or MD may order specific nutritional interventions, supplements, or other interventions if indicated. A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included generalized muscle a reduction in muscle strength affecting multiple muscle groups) irritable bowel syndrome ( IBS, a disorder affecting the stomach and intestines that may cause abdominal pain, bloating, diarrhea, or constipation), and major depressive disorder (a mental health condition characterized by persistent low mood and loss of interest in usual activities). A review of Resident 5's comprehensive care plan, initiated January 12, 2024, identified nutritional problems or potential nutritional problems related to advanced age, mechanically altered diet texture, and mild protein store depletion (a condition in which the body's protein reserves are reduced). Goals included maintaining weight, avoiding significant weight changes, and consuming 75 percent of meals served. Planned interventions included providing the diet as ordered, obtaining weekly weights, and RD evaluation with recommendations as needed. A review of physician orders revealed an order dated December 15, 2025, at 1:53 AM, for weekly weights. A review of Resident 5's weight record revealed the following documented weights:December 21, 2025, at 1:05 PM: 120.5 poundsDecember 28, 2025, at 10:03 AM: 121.5 poundsJanuary 4, 2026: 121.5 poundsJanuary 11, 2026, at 10:32 AM: 105 poundsThe January 11, 2026, weight reflected a loss of 16.5 pounds, representing approximately 13.5 percent body weight loss in one week. The clinical record failed to reveal documentation that a reweight was obtained to verify this significant change. Review of a weight change note completed by the facility's remote RD (the RD works offsite and is not routinely physically present in the facility and provides dietary oversight though electronic record review and communication with staff) dated January 15, 2026, at 3:19 PM, in response to a weight warning for the January 11, 2026, value. The RD documented a weight loss of 13.2 percent (16 pounds) greater than one month and 9.1 percent (10.5 pounds) in three months and recommended that a reweight be obtained due to significant weight loss. Resident 5's weight had not been rechecked until January 16, 2026, at 1:43 PM, when the resident's weight was recorded as 106 pounds and continued to reflect a significant weight loss. A subsequent RD note dated January 16, 2026, at 4:39 PM, documented a significant weight loss of 12.4 percent (15 pounds) in less than 30 days and 8.2 percent (9.5 pounds) in three months. The note documented the resident's body mass index (BMI), which is a measure of weight relative to height used to screen nutritional risk, as 20.7 (within normal range). The RD recommended fortified foods with all meals and a 4 ounce nutritional shake (a high-calorie, high-protein supplement) with lunch and dinner. An RD progress note dated January 23, 2026, at 2:21 PM, documented the resident's weight from January 18, 2026, was 106.2 pounds and noted the resident was tolerating a mechanical soft diet with thin liquids and consuming approximately 75 percent of meals served. The RD documented the resident was to receive 4-ounce nutritional shakes with lunch and dinner. However, the clinical record failed to reveal documented evidence that the recommended nutritional interventions, including the 4-ounce nutritional shakes with lunch and dinner, were implemented in a timely manner following the identification of the significant weight loss on January 11, 2026. Additionally, the clinical record failed to reveal documented evidence that Resident 5's attending physician and responsible party were notified of the significant weight loss. Further review of the weight record revealed a recorded weight of 104 pounds on January 25, 2026, representing an additional weight loss of 2.2 pounds from the previous recorded weight. During an interview with the Director of Nursing (DON) on January 29, 2026, at 2:13 PM, the above findings were reviewed. The Director of Nursing confirmed that no additional documentation could be provided to demonstrate timely notification of the MD and responsible party regarding the resident's significant weight loss or timely implementation of nutritional interventions. The Director of Nursing also confirmed that reweights were not completed in a timely manner. Cross Ref. F943 28 Pa Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on observations, clinical record review, and resident and staff interviews, it was determined the facility failed to ensure that residents with limited mobility received the necessary services, equipment, and assistance to maintain or improve mobility for one of 18 residents reviewed (Resident 1).Findings Include: Review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which include cerebral ischemia (a condition in which reduced blood flow to the brain limits oxygen and nutrients needed for brain function) and flaccid hemiplegia to the right dominant side (a condition where there is complete paralysis or weakness of the muscles on one side of the body). These conditions affected Resident 1's ability to move and use the right hand and arm. A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 22, 2025, revealed that Resident 1 was severely cognitively impaired with a BIMS score of 5 (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 0-7 indicates cognition is severely impaired). Review of Resident 1's current physician orders revealed an order dated August 11, 2022, for a functional position hand splint to the right hand and wrist with instructions to wear it continuously, perform skin checks every shift, and remove it only for hygiene before reapplying it. Review of Resident 1's current care plan reflected the same intervention, which directed that the right hand splint always remain in place, be removed each shift for skin inspection, and that staff monitor for skin breakdown. The care plan was initiated July 20, 2022. During an observation conducted in the dining room on January 29, 2026, at 11:00 AM Resident 1 was observed without the ordered right hand splint in place. The splint was observed lying on the resident's bedside table rather than being applied as ordered. A review of Resident 1's Documentation Survey Report v2, which reflected care tasks completed for December 2025 and January 2026, revealed inconsistent, incomplete, and conflicting documentation related to restorative and functional nursing services intended to maintain mobility. Multiple entries were documented as not applicable or left blank. Documentation revealed the following: On December 8, 2025, evening shift was documented as not applicable.On December 9, 2025, evening shift was documented as not applicable.On December 13, 2025, evening shift was documented as not applicable.On December 18, 19, 20, 24, and 25, 2025, the day shift was documented as not applicable.On January 4 and January 18, 2026, the day shift was documented as not applicable.On January 27, 2026, the evening shift was documented as not applicable. On January 29, 2026, the same date the resident was observed without the splint at 11:00 AM., documentation indicated the splint had been applied at 7:04 AM, which conflicted with direct observation. During an interview with the Director of Nursing on January 29, 2026, at 1:30 PM, the Director of Nursing was unable to provide documented evidence that Resident 1's functional nursing program, including the ordered right-hand splint intended to maintain mobility and prevent loss of function, was consistently implemented according to the physician's order and care plan. 28 Pa. Code: 211.5(f)(i)(ii) Medical records. 28 Pa Code 211.12 (c)(d)(5) Nursing services.

Based on observations, clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure Licensed Practical Nurses (LPNs) were properly trained and validated as competent prior to administering intravenous (IV) medications through a central venous catheter for one of twenty-three residents reviewed (Resident 52). Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) require the following:The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145 b. IV therapy curriculum requirements:(f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under S 21.145 a (relating to prohibited acts), and only under supervision as required under paragraph (1). (1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician assistant, podiatrist or dentist). (g) An LPN who has met the education and training requirements of S 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under S 21.145 and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (3) Administration of IV fluids and medications. (4) Observation of the IV insertion site and performance of insertion site care. (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. A review of a facility policy titled Catheter Insertion and Care-Flushing Central Vascular Access Devices (tube placed into a large vein near the heart to deliver medications or fluids) and Midline Catheters last reviewed by the facility on January 23, 2026, revealed the facility is to verify the scope of practice for Registered Nurses and Licensed Practical Nurses and competency requirements for this procedure with the State Nurse Practice Act. Clinical record review revealed that Resident 52 was admitted to the facility on [DATE], with diagnosis to include pneumonia (an infection that inflames the air sacs of the lungs ) and septic arterial embolism (an infected blood clot that travels through the blood stream), and was admitted to the facility with a PICC line (a peripherally inserted central catheter, a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). A review of the clinical record revealed physician orders dated January 17, 2026, to administer the following medications through the intravenous (IV) catheter:Normal Saline Flush (Sodium Chloride Flush), 10 milliliters IV every eight hours to maintain patency (to keep the catheter open and prevent blockage).Ceftriaxone Sodium, 2 grams IV once daily until February 21, 2026. Ceftriaxone Sodium is an antibiotic medication used to treat bacterial infection and was ordered related to an intestinal abscess (a pocket of infection in the intestine).Vancomycin HCL, 1,000 milligrams IV twice daily until February 21, 2026. Vancomycin HCL is an antibiotic medication used to treat serious bacterial infections and was also ordered related to an intestinal abscess. During an observation of medication administration on [NAME] Hall on January 29, 2026, at 8:45 AM, Employee 5, a Licensed Practical Nurse (LPN), was observed washing her hands, putting on gloves, flushing the resident's peripherally inserted central catheter (PICC line) with normal saline, and administering Ceftriaxone Sodium through the PICC line. The facility was unable to produce any documentation verifying that Employee 5, LPN had current competency validation, supervision documentation, or internal training specific to PICC line administration. During an interview conducted on January 29, 2026, at 10:30 AM, the Director of Nursing (DON) confirmed that the facility did not provide education or training to LPNs for the administration of medications through PICC (central) lines. The DON further stated that it was the facility's policy that only Registered Nurses were permitted to administer medications via central lines. Despite this stated policy, an LPN was observed administering IV medication through a PICC line without documented training or competency validation, indicating the facility failed to ensure nursing services were provided in accordance with professional standards and failed to ensure staff were properly trained prior to performing high-risk nursing procedures. 28 Pa. Code 201.20(a) Staff Development. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa Code 211.12(c)(d)(1)(2)(3)(5) Nursing services.

Based on facility policy and clinical record review and staff interview, it was determined the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised as needed to accurately reflect their current needs and services required for one of 23 residents sampled (Resident 45).Findings include: A review of the facility policy entitled Comprehensive Care Planning last reviewed on [DATE], revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. A clinical record review revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for a prolonged period.) and cerebral infarction (a type of stroke where the blood flow to the brain is blocked or reduced). A review of Resident 45's clinical record revealed a document labeled Advance Directive (a written or verbal instruction that states a person's wishes for health care treatment or names another person to make health care decisions if the person becomes unable to make those decisions) dated [DATE], that indicated Resident 45 did want Cardiopulmonary Resuscitation (CPR) (a lifesaving technique used in emergencies when the heart stops) . A review of Resident 45's comprehensive care plan, last revised on [DATE], failed to reflect Resident 45's Advanced Directive choice for CPR and indicated Resident 45's code status (a patient's preference regarding emergency treatment, particularly in situations when their heart or breathing stops) was Do Not Resuscitate (DNR). An interview with the Director of Nursing on [DATE], at 11:00 AM confirmed the facility failed to review and revise Resident's 45's care plan to accurately reflect their code status. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 28 Pa Code 211.10 Resident care policies.

Based on a review of clinical records, select resident investigative reports, and staff interview, it was determined the facility failed to consistently provide sufficient staff assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls with serious injuries for one resident out of 7 sampled residents. (Resident 1). Findings include: A review of clinical records revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include muscles weakness, congestive heart failure (condition that occurs when the heart can't pump enough blood to meet the body's needs) and generalized anxiety disorder (condition that involves excessive and persistent worrying that interferes with daily life). A Quarterly Minimum Data Set assessment (MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated September 14, 2024, revealed the resident was cognitively impaired with a BIMs score (brief interview for mental status tool is used to get a quick snapshot of how well you are functioning cognitively. It is a required screening tool used in nursing homes to assess cognition) of 4 (0-7 indicating severely cognitively impaired). The assessment indicated the resident was independent with wheelchair use. A review of the resident's plan of care initially dated July 22, 2024, revealed the resident was at risk for falls related to a decline in functional status and non-compliance with transfers. A review of a Fall Risk Evaluation dated September 3, 2024, identified Resident 1 as at high risk for falls. A review of a progress notes dated December 19, 2024, at 5:41 PM revealed the resident had a fall in the hallway. The resident was being assisted with transportation to the dining room for dinner when the resident fell forward out of her wheelchair and hit her face on the floor. The fall resulted in a 7 cm x 7 cm hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) over her left eye, a 1cm laceration (cut) under her left eye and complaints of pain when trying to move her left arm and shoulder and subsequent transfer to the hospital. A review of a facility investigative report dated December 19, 2024, at 5:32 PM revealed the resident was being transported by Employee 1 NA (nurse aide) to the dinette for supervised dining. It was indicated the resident pitched herself forward and fell from her wheelchair. A review of a witness statement from Employee 1 dated December 12, 2024, revealed the employee stated she informed the resident that she would help her to the dining room for dinner. The employee indicate that she started pushing her towards the dining room and then noticed the resident started to lean forward which prompted the employee to stop the wheelchair. The employee stated she stopped the wheelchair and the resident lunged forward onto the floor. A review of hospital records dated December 19, 2024, revealed the resident had an X-ray completed on her left shoulder. The results indicated the resident had a dislocation (when bones separate at a joint) of the left humeral head (the rounded end of the upper arm bone, or humerus, that forms the ball of the shoulder joint). Further review of the hospital records dated December 19, 2024, revealed the resident had a CT scan (a noninvasive medical imaging procedure that uses Xray and computers to create detailed pictures of the inside of the body) of the head and brain. The results indicated the resident had a comminuted depressed fracture (a broken bone that has broken into three or more pieces and are pressed downward) of the left orbital floor (bone that surrounds the eye) and a suspected nondisplaced fracture (a broken bone where the pieces of the bone remain aligned and don't move out of place) of the right orbital wall. An interview with the Nursing Home Administrator (NHA) on December 30, 2024, at approximately 1:00 PM revealed all residents should have leg rests in place when being transported by staff in wheelchairs. Furthermore, the NHA stated at the time of the resident's fall leg rests were not in place on the resident's wheelchair. The facility failed to properly utilize leg rests to transport a resident to the dining room resulting in the resident falling from the wheelchair and sustaining a major injury. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the facility failed to implement effective safety measures to prevent Resident 1 from falling, resulting in serious injury and hospital transfer. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1.Facility would be unable to change the outcome of the event that occurred with the resident on December 19, 2024. 2. All residents were assessed to determine if they can self-propel at a wheelchair/other ancillary chair level. Residents were audited to determine if leg rests were available for all wheelchairs/other ancillary chairs in the facility. Leg rests were obtained for all wheelchairs that are being utilized by residents. Leg rests bags have been ordered that will attach to all wheelchairs that will hold bilateral leg rests for immediate transport with leg rests. 3.Policy updates to be completed in cooperation with corporate clinical liaison, IDT (interdisciplinary team) and QAPI (quality assurance performance improvement) teams. Education was completed with all staff on December 21, 2024, and ongoing educations for agency personnel, vendors, and family members next time they are in the building to ensure that no resident is transported within the facility without leg rests on their chair, unless that resident can self-propel their wheelchair with verbal cues or independently. 4.Audits occur two times weekly by the nursing supervisor/administration to ensure no facility transport is occurring without leg rests to chairs. Audits will also present the ability to educate on the spot and provide supervision in unusual situations of behaviors when residents will not utilize leg rests or are unable to communicate during behavioral outbursts. Audits will continue for 30 days with results to the QA (quality assurance) committee for review, assessment and to ensure compliance with the new policy. The facility's compliance date was December 21, 2024. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

Based on a review of clinical records, select incident reports and facility policy, and staff interview it was determined that the facility failed to provide necessary supervision of a resident with known unsafe behaviors to prevent a fall resulting in serious injuries, a fracture left humeral head and fracture of the left nasal bone, for one out of 20 sampled residents (Resident 12). Findings include: A review of a facility policy entitled Falls Management System that was provided by the facility on May 21, 2024, indicated that each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs, as appropriate, to prevent accidents. It is the policy of this center to provide each resident with appropriate evaluation and interventions to prevent falls and minimize complications if a fall occurs. A review of Resident 12's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included vascular dementia [is a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory], cognitive communication deficit [are problems with communication caused by impaired cognitive processes, such as attention, memory, perception, and language], symbolic dysfunction [refers to the breakdown in communication that occurs when symbols, such as words, gestures, or facial expressions, are misinterpreted or misunderstood], anxiety [fear characterized by behavioral disturbances], and dysphasia (difficulty swallowing). An admission Nursing Assessment - Section 6. Fall Risk dated March 4, 2024, at 1:21 p.m., revealed that Resident 12 was assessed as a high fall risk. Nursing documentation in the resident's clinical record following the resident's admission on March 4, 2024, revealed that the resident required assistance of one staff with activities of daily living and assist of two with transfers out of bed to the wheelchair daily daily. Employee 1, LPN noted that the resident was oriented to self but had confusion to location and situation. The resident was able to resident able to make needs known to staff but was non-compliant with alarms. Staff had observed the resident ambulating around room and pushing her bed side table and stated to this author {Employee 1} I went to college, how much money do you make? Safety device in place and functioning and will continue to monitor, call bell within reach. Additionally, a nurse progress behavior note completed by Employee 1, a LPN, dated March 8, 2024, at 10:58 a.m., revealed that the resident was continuously standing up from her wheelchair and was non-compliant with safety devices. Resident was standing up in lobby and attempting to walk around during activities and stated, I want to go home, I need to go home to my mother for supper. what do you want me to do, do you want me to hit you or slap it out of you. You just need to leave me alone, goodbye. The resident continued standing up out of chair, post therapy and one-to-one, fluids, toileting, and activities were ineffective, and the resident was grabbing at other people's hand as they walked by and yelled [NAME]. Safety devices were in place and functioning and will monitor. A Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 11, 2024, revealed that the resident had severe cognitive impairment, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds) behavior of this type occurred 1 to 3 days. The MDS noted that the resident's behaviors significantly put the resident at risk for physical illness or injury and the resident used daily bed and chair alarm [any physical or electronic device that monitors resident movement and alerts the staff when movement is detected]. Resident 12's care plan revised March 15, 2024, identified that the resident was at risk for falls with prevention interventions to anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and provide a prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear such as nonskid sock when ambulating or mobilizing in wheelchair, and use chair/bed electronic alarm and ensure the device is in place as needed. Progress notes dated March 11, 2024, through March 20, 2024, revealed that the resident displayed behaviors such as combativeness and non-compliance with care, punching, and slapping at staff, crying/weeping, was difficult to console or redirect, and continued to exhibit unsafe behaviors. A review of a SBAR (Situation Background Assessment Recommendation - a communicate tool) completed by Employee 2, a Licensed Practical Nurse (LPN), dated March 20, 2024, at 8:09 p.m., revealed that the resident had a change in condition related to a fall. Vitals were as follows: pulse: 107, respiration rate: 24, temperature: 98.4, pulse oximetry: O2 98.0 % room air, and had pain. Employee 2 noted that she heard crying and found the resident lying on the floor {in the resident's room} with a small amount blood noted from resident's nose. Supervisor {Employee 3} called to room and assessment was performed and the resident's Primary Care Provider responded to send resident to ER (emergency department) for evaluation. An incident report completed by Employee 3, a Registered Nurse (RN), dated March 20, 2024, at 8:38 p.m., revealed that at 7: 45 p.m., Resident 12 was found lying on her back, on the floor in her room, in front of the door. Resident noted to have scant amount of sanguineous (bloody) drainage under her nose and was awake and alert with confusion per norm. This nurse {Employee 3} attempted to ask resident what happened, resident started to say that she got out of bed and then became emotional with incomprehensible speech. Emotional support given. Vitals obtained and as charted. Resident stated that her head hurt and attempted to reposition herself and proceeded to cry out when she moved her left shoulder. Able to move right arm without difficulty. Legs equal in length and no external foot rotation noted with plus two pitting edema (swelling) noted to bilateral lower extremities. Skin was intact. While trying to safely reposition the resident, she became lethargic and less responsive to verbal stimuli than baseline. Noted predisposing situation factors {to the fall} included ambulating without assistance, bare feet or inappropriate footwear, non-compliance with safety instructions, incident during unassisted self-transfer from bed, bed in lowest position, and safety mat(s) at side of the bed. The on-call physician was contacted and ordered to send resident to the ER (emergency room ) and the responsible party (RP) was notified with 911 called. Resident 21's clinical record revealed that she returned to the facility on [DATE], at 6:56 am, with diagnoses of minimally displaced fracture (broken) left humeral head (bone in the upper arm) and a minimally displaced fracture of the left nasal (nose) bone. The facility was aware of the resident's confusion to location and situation, unsafe behaviors, and non-compliance with safety measures, including alarms, but failed to provide the resident with the necessary supervision, at the level and frequency required, to prevent this fall during which the resident sustained multiple fractures. During an interview with the Director of Nursing (DON) on May 21, 2024, at 12:00 p.m., confirmed that the facility failed to provide adequate supervision of a resident (Resident 12) with known unsafe behaviors to prevent falls and from sustaining major injuries, fractures to the left humeral head and left nasal bone. 28 Pa. Code 211.12 (d)(5) Nursing services. 28 Pa. Code 211.10 (a)(d) Resident care policies

Based on observation, a review of clinical records and select incident reports, and staff interviews it was determined that the facility failed to consistently provide individualized resident care, consistent with professional standards of practice, to prevent the development of an avoidable mucosal membrane pressure injury, with pain for one resident out of two sampled residents (Resident 23). Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address 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 Resident 23's clinical record revealed he was admitted to the facility on [DATE], with diagnoses including cerebral infarction, protein - calorie malnutrition, left hip pressure ulcer, and contracture of left, and right knee, and right upper arm. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 15, 2023, revealed that the resident was severely cognitively impaired with a BIMS score of 03 (the Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). The resident had functional impairment of both the left and right upper and lower extremity, and was dependent on staff for lower body dressing. A review of a Quarterly Braden Scale (a tool used to determine/predict pressure sore development) dated November 16, 2023, revealed that Resident 23 scored a 15, indicating that the resident was at mild risk for pressure sore development. The resident had a current physician orders for suprapubic catheter (a suprapubic catheter is a medical device that helps drain urine from your bladder. It enters your body through a small incision in your abdomen) care, initially dated October 7, 2022, to monitor the suprapubic catheter site for any changes or signs/symptoms of infection, an order initially dated October 9, 2022, and renewed on November 11, 2022. The resident's care plan, dated January 13, 2022, indicated that the resident has pressure ulcer stage 4 to left hip and a mucosal membrane pressure injury to underside of penis and the potential for more pressure ulcers related to decreased mobility, foley catheter use, and history of stage 4 pressure area left distal medial foot, as per revision March 4, 2024. The resident's care plan noted the resident's use of the suprapubic catheter 14 fr 30 cc related obstructive uropathy secondary to benign prostatic hyperplasia (BPH) [enlargement of the prostate gland] and failed voiding trial date-initiated June 16, 2022, with an intervention to provide catheter care as per physician order also initiated June 16, 2022. An eINTERACT SBAR Summary for Providers note (Situation, Background, Assessment, and Recommendation (or Request), is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) dated November 16, 2023, 0230 hrs (2:30 AM) revealed that the resident had a change in skin condition. A fluid filled blister on the resident's right thigh had developed. Recommendations were to apply skin prep to right thigh blister every shift (QS) until resolved. The SBAR note failed to identify the blister's appearance including its size, measurements, color, and surrounding tissue's appearance. A review of Resident 23's Treatment Administration Record (TAR) for November 2023, revealed on November 16, 2023, apply skin prep to right thigh intact blister QS until resolved every shift, discontinued November 24, 2023. A medication administration note dated November 24, 2023, 0259 (2:59 AM) indicated that the area had resolved. At the time of the survey, on May 19, 2024, at approximately 9:10 AM, the survey team requested any evidence that the facility had to describe the description of the blister including size, color, the surrounding tissue's appearance and potential causative factor. During interview of May 19, 2024, at approximately 10:15 AM, the Director of Nursing (DON) stated that no further information was available. A review of a weekly skin review - V3 document dated February 14, 2024, indicated that the resident's skin was intact, no new skin issues noted, but to see existing wound sheets. A nurses note dated February 17, 2024, at 11:34 AM, indicated that the nurse called the resident's responsible party (RP) and left a brief message that the resident had a new skin issue and to please return call. A review of facility incident report dated February 17, 2024, at 11:02 AM, entitled skin integrity, revealed open area noted along underside of penis, area cleansed and covered with non-adhesive dressing. Resident has a suprapubic catheter. Resident unaware of injury. MD and RP aware. RN assessment performed, peri guard in place. Will monitor until resolved. Review of a wound evaluation flow sheet V-5, dated February 17, 2024, week 1, revealed that this wound was not continuing documentation of a wound currently being tracked as noted in weekly skin review dated February 14, 2024. The resident was noted with open area on underside of penis from meatus to midway down shaft. Tunneling noted at meatus side approximately 0.3 cm at 12 o'clock. Resident expresses pain as tunnel is assessed, denies pain otherwise. Able to visualize resident's urethra. Open area measures 5 centimeter (cm) length x 2 cm width x 0.5 cm depth. A small, serous, thin amount, without odor of exudate (fluid that leaks out of blood vessels into nearby tissue) was noted. The wound bed is 100 % granulation tissue, and the wound margins are defined, with the surrounding tissue intact, without redness or swelling. Treatment cover with dressing until wound care evaluate. A nurses note dated February 18, 2024, at 10:56 AM, noted day 1, open area to underside of penis, area appears healed. Resident denies pain/discomfort. However, a wound evaluation flow sheet V-5, dated February 20, 2024, week 2, revealed that the resident's open area on the penis was mostly unchanged (from February 17, 2024). A review of consultant wound specialist note dated February 27, 2024, revealed the initial evaluation of the penis as, its etiology (cause) is pressure related, mucosal membrane pressure injury measuring 4 cm x 4.8 cm, 0.1 cm epithelial wound bed, with the edges intact, scant serous exudate without odor. Treatment recommendations cleanse with normal saline, apply Mupirocin ointment to base of the wound leave open to air (OTA) twice daily (BID) and as needed (PRN). Wound was likely sustained from catheter use with hypospadias (congenital condition in which the opening of the penis is on the underside rather than the tip). A physician order was noted February 28, 2024, for Mupirocin external ointment 2 % (topical antibiotic) apply to penis topically every day and evening shift for treatment. Cleanse underside to penis, pat dry, apply Bactroban (antibiotic) and leave OTA. Notify MD if sign/symptom of infection present. A physician progress note dated February 29, 2024, noted a evaluation of the penis revealed the ventral surface of the penile shaft has erythema (redness), without evidence of significant infection. No significant open areas are noted. No obvious drainage. Suprapubic catheter in place. The suprapubic catheter was underneath his penis abutting and rubbing up against the area of irritation. Assessment/Plan, penile irritation, continue with Mupirocin. We will ensure that the suprapubic catheter is on the outside of the brief so that it can not irritate the ventral surface of the penile shaft. Wound care to follow. The facility failed to assure appropriate positioning of the suprapubic catheter tubing to prevent the development of a pressure sore on the resident's penis. After the development of the avoidable pressure sore, a physician order dated February 29, 2024, was noted ensure suprapubic tubing is out of brief so it can not irritate under surface of penis every shift. A review of consultant wound notes dated March 5, 2024, revealed that the stage of the pressure sore was noted as Mucosal Membrane Pressure injury that measures 14 sq cm. (Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these injuries cannot be staged).Wound notes dated March 12, 19, 26, 2024, and April 2, 2024, revealed that the resident's wound remained mostly unchanged. On April 9, 2024, the consultant revealed the wound was improving despite its measurements. The area was pressure related, mucosal membrane pressure injury measuring 3.7 cm x 3.5 cm, 0.1 cm epithelial wound bed, with the edges intact, no exudate. Treatment recommendations cleanse with normal saline, apply Mupirocin ointment to base of the wound leave (OTA) twice daily (BID). Wound notes dated April 16, 23, 30, 2024, revealed the wound remained mostly unchanged. A wound note dated May 7, 2024, revealed the pressure wound is stable measuring 3.5 cm x 2.5 cm, 0.1 cm epithelial wound bed, with the edges intact, without exudate. Treatment recommendations cleanse with normal saline, apply Mupirocin ointment to base of the wound leave (OTA) twice daily (BID). The most recent wound note dated May 14, 2024, revealed the pressure wound was stable, measuring 3.5 cm x 2.2 cm, 0.1 cm epithelial wound bed, with the edges intact, without exudate. Treatment recommendations cleanse with normal saline, apply Mupirocin ointment to base of the wound leave (OTA) twice daily (BID). Observation of the resident's penile pressure injury on May 20, 2024, at approximately 1:45 PM, with the resident's approval, in the presence of the Director of Nursing (DON), revealed a clean, superficial oval shaped wound on the penile shaft, without drainage or odor. The wound bed appeared moist, pinkish red. The wound measured 3.8 cm x 1.7 cm x 0.2 cm, (as measured by the DON) without tunneling/undermining. During this observation the resident appeared comfortable without any signs of discomfort. During an interview with the Director of Nursing May 20, 2024, at approximately 1:50 PM, confirmed that the facility failed to ensure that the tubing from the resident's suprapubic catheter was positioned in a manner that did not create pressure on the resident's penis resulting in a pressure sore, that the caused the resident pain. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Based on a review of clinical records, select facility investigation reports, and information submitted by the facility and staff interview, it was determined that the facility failed to ensure that staff used safe technique and/or provided sufficient staff assistance during care to prevent an avoidable fall, that resulted in a scalp laceration (wound that occurs when skin, tissue, and/or muscle is torn or cut open) and traumatic subarachnoid hemorrhage [a medical emergency which involves bleeding into the space between the surface of the brain and the arachnoid (one of three coverings of the brain)] for one of three residents reviewed (Resident 58). Findings include: A review of the clinical record revealed that Resident 58 had diagnoses, which included Alzheimer's disease and dementia (group of thinking and social symptoms that interferes with daily functioning). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 4, 2021, revealed that the resident was severely cognitively impaired. The resident required extensive staff assistance of two staff for transfers, bed mobility (how resident moves from lying position, turns side to side, and positions body while in bed), toileting, and ambulation according to the MDS assessment. A review of the resident's care plan, in effect during May 2021, revealed that the resident's plan of care did not direct staff to consistently use two staff members for bed mobility. Bed bolsters, to define the perimeter of the bed, were planned for the resident's safety in bed according to the current plan of care Review of Resident 58's May 2021 Documentation Survey Report (tasks performed by the direct care staff caring for the resident) revealed that the resident was provided the assistance of both one staff member or two staff members, for the task of bed mobility between the dates of May 1, 2021 and May 28, 2021. Interview with the Director of Nursing during the survey ending June 16, 2021, revealed that the nurse aides would determine the amount of staff assistance the resident may require with bed mobility at any given time. The DON stated that nurse aides would provide either the assistance of one staff or two staff members depending on staff's determination of the resident's endurance at the time the care was being provided. A review of a facility incident investigation dated May 28, 2021, at 11:25 PM revealed that Resident 58 was found lying on the on the right side of the bed on the fall mat. A laceration was noted to the top of the resident's scalp. The investigation revealed that prior to the incident Resident 58 was in bed receiving care from nursing staff. Review of Employee 1 (nurse aide) witness statement indicated that when Employee 1 rolled the resident over in bed, to apply cream on the resident's bottom, Resident 58 rolled out of bed and onto the floor. Employee 1 was on the left side of the resident's bed, used a draw sheet to roll the resident towards the right side of the bed and the resident, along with the right bed bolster, fell on to the floor. Employee 2's (temporary nurse aide) witness statement indicated that Employee states that she directly witnessed the fall that occurred on Friday May 28, 2021, at 9:45 PM. Employee 2 states that she walked into the resident's room to initiate a brief check on resident and observed Employee 1 on the left side {of the bed} pick up the draw sheet and use it to roll resident over to the right side of the bed to complete brief change, when the resident rolled off the bed and onto the floor. Employee 2 indicated that both bolsters were on the bed and the right bolster fell off the bed with the resident at the time of the fall. Through questions, employee described the resident as not being in the middle of the bed when she was rolled to the right side. Resident was assigned to Employee 1 as part of her work assignment. Employee states that both bolsters were fastened securely when the resident was placed in bed prior to the incident. Employee indicated that fall mats were located on both sides of the bed. Employee also indicated that the resident can be changed in bed with one assist. At the time of the fall, employee called out for LPN and was then sent to get the RN Supervisor. Review of information submitted by the facility dated May 28, 2021, to the state agency regarding the incident revealed that bed bolsters (applied to the sides of the mattress to define the perimeter of the mattress to help prevent falls) were present on both sides of the resident's mattress prior to the fall. Staff (employee 1) had been rolling the resident when the bed bolster on the opposite side came loose (the bolsters were noted to be manually loosened by employee 1 to provide care) and the resident rolled out of bed onto the floor. Staff education was immediately initiated on proper technique of bed positioning during care. As a result of the fall, Resident 58 sustained a laceration on the right forehead which measured 3 cm by 0.5cm by 0.5cm. The physician and responsible party were notified. A physician order was obtained to transfer the resident to the hospital emergency room for evaluation and treatment. Resident 58's hospital History and Physical dated May 29, 2021, at 2:43 AM revealed that a computed tomography (CT scan- computerized x-ray) of the head identified a full-thickness right anterolateral (occurring in front and to the side) scalp laceration with underlying trace acute posttraumatic right frontal lobe (located directly behind the forehead) subarachnoid hemorrhage. The resident was admitted to the hospital for follow-up for this injury. Interview with the director of nursing on June 16, 2021 at 11:30 AM failed to provide evidence that care was provided to Resident 58 in a manner, that ensured safe technique or sufficient staff assistance to prevent this avoidable fall with serious injury to Resident 58. 28 Pa Code 211.12(a) Nursing services 28 Pa Code 211.12 (c) Nursing services 28 Pa Code 211.12 (d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of clinical records, observations ans staff and resident interviews, it was determined that the facility failed to consistently provide planned care and services, consistent with professional standards of practice, to prevent pressure sore development and promote healing of pressure sores for one out of four sampled residents (Resident 91). 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 and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [REDACTED].e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 91 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the resident's care plan initiated (MONTH) 5, (YEAR), revealed that the resident was at risk for alteration in skin integrity. Interventions planned were noted as pressure reduction device to wheelchair and mattress. A review of quarterly Minimum Data Set assessment dated (MONTH) 6, 2019 (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was cognitively intact, required extensive assistance with activities of daily living, to include bed mobility, transfers, dressing, toilet use, hygiene, and bathing and was at risk for developing pressure areas. A review of a nursing evaluation dated (MONTH) 30, 2019, upon the resident's readmission to the facility after a hospitalization , revealed that the resident had a Stage I pressure area to the resident's right heel, measuring 3 cm x 3 cm, a Stage I pressure area (A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft) to the resident's left heel, measuring 3 cm x 3 cm, an unstageable area (is a sore whose severity cannot be determined with a visual exam. This is usually due to the exudate, or slough, covering the wound), to the resident's left toe measuring 0.3 cm x 0.2 cm and an unstageable area to the resident's left toe measuring 0.5 cm x 0.3 cm, A review of the resident's updated care plan dated (MONTH) 30, 2019, revealed that the resident was at risk for pressure ulcers, actual or at risk, due to assistance required in bed mobility, diabetes and heel wound. New interventions planned were to float the resident's heels when in bed (the resident's heels should be positioned in such a way as to remove all contact between the heel and the bed). The resident's care plan was revised again on (MONTH) 22, 2019, to include the approach of turning and repositioning the resident every hour. A review of nursing documentation dated (MONTH) 22, 2019, at 9:31 PM revealed staff discovered an unstageable left heel ulcer after noticing blood on the resident's bedsheet during care. The nurse aide reported the finding to the nurse, who cleansed the area with normal saline solution and wound cleanser; hydrogel was applied and the area was covered with clean dry dressing. A review of a facility ulcer and pressure sore investigation dated (MONTH) 22, 2019, at 9:43 PM, revealed that an unstageable pressure ulcer was discovered on left heel, measuring 2.5 cm in length x 2.0 cm in width x 0 in depth, described as black eschar (Eschar is dead tissue found in a full-thickness wound) to the center surrounded by 25 % slough (A layer dead tissue separated from surrounding living tissue, as in a wound or sore), serosanguineous (drainage pale red or pink color) drainage, thin watery, with surrounding pink tissue area. New interventions put into place at the time of the discovery of the pressure area on (MONTH) 22, 2019, were to apply heel bows (medical designed to offload pressure from the heel of a non-ambulatory individual to help prevent pressure ulcers) to bilateral feet, while in bed. A physician order [REDACTED]. A new order was noted on that date to provide prevalon boots (boot heel protection device that completely offloads the heel to help prevent the development of heel pressure ulcers) while in bed, every shift. According to interview with the Director of Nursing (DON) on (MONTH) 3, 2019, the resident was noted to kick the heel bows off and therefore an order was obtained for prevalon boots. There was no documented evidence in the nursing progress notes or resident's care plan regarding the resident's known behavior of kicking off the heel bows planned to promote healing and prevent worsening of the pressure sores. The facility had assessed the resident as cognitively intact, but was unable to provide documented evidence of education provided to the resident regarding the benefit of heel bows in an effort to promote compliance with their use. A review of a wound evaluation completed by the wound specialist dated (MONTH) 30, 2019, revealed that the resident had an unstageable necrosis pressure area to the left heel measuring 3 cm by 5 cm by not measurable cm, 100 % thick adherent black necrotic tissue (eschar). Recommendations were to apply Santyl (a sterile enzyme [MEDICATION NAME] (removal of damaged tissue from a wound) ointment) once daily and dry protective dressing for 30 days, off load the wound and reposition per facility policy. A review of a progress note dated (MONTH) 25, 2019, at 5:13 PM, revealed a recommendation from therapy that the resident was a candidate for total mechanical lift due to the resident's inconsistent performance with transfers. According to interview with the DON on (MONTH) 3, 2019, the resident became bed bound at that time. A review of the facility's documentation regarding turning and repositioning the resident dated (MONTH) 4, 2019, through (MONTH) 3, 2019, revealed several days on which staff had documented only two occassions within a 24 hour period when the task was completed. The remaining documentation of turning and repositioning consisted solely of the times the task was completed at the beginning of each shift or indicating that the task was completed before their shift had ended. A review of documentation of the implementation of the approach of floating heels at all times when in bed dated (MONTH) 4, 2019, through (MONTH) 3, 2019, revealed several days when staff documented that the approach was carried out during only two shifts of nursing duty within a 24 hour period. The remaining documentation consisted of times the task was completed at the beginning of shifts or that the task was completed before the nursing shift ended. An observation of the resident's left heel wound on (MONTH) 3, 2019 at 1:05 PM, revealed the resident lying in bed with a prevalon boot to his right foot (the foot without the pressure sore) and a heel bow and gauze at the bottom of the resident's bed, not on the resident's foot. The resident's left foot, which had the unstageable pressure area was completely exposed. There was no dressing intact and no prevalon boot in place as prescribed. The resident's bare left heel was positioned directly atop the sheet with bloody drainage approximately eight inches by 3 inches in diameter, observed on his sheet. Interview attempts at that time revealed that the resident was unable to state why his left foot was exposed, why it was not off loaded or why the protective boot was not in place. The resident was asked if the staff reposition him, elevate his feet or encourage him to reposition himself and he was unable say, but did indicate that he was in pain. Interview with the Employee 1 (Registered Nurse), Employee 6 (Licensed Practical Nurse) and Employee 7 (Nurse Aide) on (MONTH) 3, 2019, at 1:15 PM, while observing the resident's wound, revealed that none of the employees were able to explain why the resident left heel wound was exposed, lying on the sheet without a covering, a prevalon boot or elevation off the bed. During an observation of the resident's left foot wound on (MONTH) 3, 2019, at 1:15 PM, it was observed the wound covering the outer aspect of the heel, defined wound margins with slough around the outer portion of the wound and the wound was red/brown in color. The depth of the wound could not be observed, but bloody drainage was observed. Further interview with Employee 7, whose resident caseload included Resident 91, on Ocotber 4, 2019, at 9:50 AM, regarding why the prevalon boots were not applied to both of the resident's feet, revealed that Employee 7 stated there was one one prevalon boot and one heel bow present from the previous shift. Employee 7 stated that she assumed that was what should be in place. Employee 7 acknowledged that she did not look at the resident's Kardex or care plan to confirm the proper measures that should be in place for the resident's feet/heels. An interview with the DON on (MONTH) 4, 2019 at 12:15 PM acknowledged that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for this resident at risk for skin breakdown. The DON also provided no explanation why the resident was not utilizing the ordered prevalon boot to his left heel or why the wound was exposed during the surveyor's observation on (MONTH) 3, 2019. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services Previously cited 6/17/19, 2/20/19, 11/30/18 28 Pa. Code 211.5(f) Clinical records

Based on a review of clinical records and information submitted by the facility and staff interviews, it was determined that the facility failed to utilize safe techniques, the required assistance devices and sufficient level of staff assistance, during transfers to prevent an accident resulting in severe injury, a fractured lower leg, to one resident (Resident 29) out of 23 residents reviewed. Findings include: A review of the clinical record revealed that Resident 29 was admitted to the facility on (MONTH) 26, 2014, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated (MONTH) 9, (YEAR), revealed that the resident's cognition was severely impaired and that she required extensive assistance with two persons for bed mobility (how the resident moves to and from lying position, turns side to side and positions their body while in bed or alternate sleep furniture) and for transfers between surfaces including to/or from: bed, chair, wheelchair and/or standing position. The resident's care plan, dated (MONTH) 9, (YEAR), revealed a problematic area of the resident's deficit in physical functioning related to mobility impairment, memory loss, dementia, cognitive impairment and abnormal posture with a care planned intervention for the assist of two staff for transfers. A nurses' note dated (MONTH) 2, (YEAR), at 7:45 PM indicated that the nurse was called to the resident's room as the resident's left leg appeared very slightly rotated to the left. The note further stated that the doctor was consulted and orders were obtained for an x-ray of the left leg. A nurses' note dated (MONTH) 2, (YEAR), at 10:25 PM revealed the oncoming nurse supervisor checked on the resident and the rotation and swelling was worse. The nurse indicated that she consulted with the Director of Nursing and decided to keep the x-ray appointment in-house (in the facility). Results from the x-ray dated (MONTH) 3, (YEAR), at 2:20 AM revealed an acute displaced proximal tibial fracture extending to the lateral tibial plateau (a [MEDICAL CONDITION] bone below the knee) and an acute impacted [MEDICAL CONDITION] neck (a fracture in which the calf bone breaks into multiple fragments which are driven into each other on the lateral side of the tibia below the knee joint). A review of a Pennsylvania Department of Aging, Act 13 Mandatory Abuse Report, (a state mandated report form for investigation of alleged abuse) dated (MONTH) 6, (YEAR), and documentation submitted by the facility also dated (MONTH) 6, (YEAR), revealed that on (MONTH) 2, (YEAR), at approximately 7:45 PM Employee 2 (NA-nurse aide) transferred Resident 29 from her wheelchair to her bed by herself and without the use of a mechanical lift. The nurse aide seated the resident on the bed and then placed the resident in a supine position (lying on a surface with the face up) when the NA realized there was physical problem with the resident's left knee. Further review of the two aforementioned reports revealed the resident is an assist of 2 for bed mobility per physican's orders, her plan of care and facility policy. The reports also indicated that the employee (Employee 2) did not follow the resident's care plan by using the mechanical lift and having another person assist her with the resident's care, resulting in this resident's fracture. Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 2 on (MONTH) 4, (YEAR), revealed that the nurse aide hugged the resident and sat her on the bed and when I lifted her legs up on the leg pillow, I noticed her left leg was not normal. I immediately went to get the nurse. During an interview with the Nursing Home Adminstrator (NHA) on (MONTH) 28, (YEAR), at approximately 11:55 AM he indicated that when interviewed regarding the resident's injury, Employee 2 stated that she had transferred the resident by herself before, on occasion, without the lift or with the assistance of another staff member. An interview with the NHA on (MONTH) 29, (YEAR), at approximately 2:10 PM confirmed that the nursing staff failed to use safe nursing techniques when transferring the resident to her bed. The nurse aide transferred the resident, without additional staff assistance and without the use of the mechanical lift, during the provision of personal care, and the resident sustained [REDACTED]. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 11/4/16 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(a)(c) Nursing services Previously cited 12/27/17, 10/27/17, 3/9/17, 11/4/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/27/17, 3/9/17, 11/4/16

Based on a review of clinical records, facility documentation and select facility policies and procedures and staff interview, it was determined that the facility failed to provide nursing services, which met professional standards of quality according to Title 49, Professional and Vocational Standards Chapter 21 State Board of Nursing during medication administration to one out of two residents reviewed resulting in a significant medication error requiring medical intervention to treat the affected resident (Resident A1). Findings include: According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of the following functions: (4) Carries out nursing care actions which promote, maintain and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. A review of facility policies and procedures for Medication Administration-General Guidelines last revised in June 2015, revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five rights of medication administration are to be followed for each medication being administered: the right resident, right drug, right dose, right route and right time. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Check #1: Select the medication -label, container and contents are checked for integrity, and compared against the Medication Administration Record [REDACTED]. Check #2: Prepare the dose -the dose is removed from the container and verified against the label and the MAR by reviewing the five rights. Check #3: Complete the preparation of the dose and re-verify the label against the MAR indicated [REDACTED]. A review of the facility's policy and procedure for Intravenous (existing or taking place within, or administered into, a vein or veins) Pain Management revised May 2013, revealed that prior to the administration of intravenous pain medication, a review of the physcian's order for the medication is to be conducted and then confirm the type and amount of medication, route and rate of administration. Check the medication label and verify against the order. A review of documentation submitted by the facility dated February 20, 2017, revealed that Resident A1 received Hospice (a type of care and philosophy of care that focuses on lessening, without curing, a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) services for pain management. The resident was receiving [MEDICATION NAME] (brand name [MEDICATION NAME], a narcotic pain medication), 2 milligrams per hour basal rate (is the rate of continuous supply of some chemical or process) and 2 milligrams, as needed, every 15 minutes, up to 8 milligrams per hour, self administered by the resident via a bolus (a single dose of a drug or other medicinal preparation given all at once) button. The [MEDICATION NAME] was provided via a cassette (pre-filled cartridge containing a specific concentration and volume of the drug prepared at the pharmacy) inserted into and delivered by a CADD/ PCA (continuous ambulatory drug delivery/patient controlled [MEDICATION NAME] is delivery mode that require a continuous rate of infusion, patient-controlled demand doses, or both, such as patient-controlled [MEDICATION NAME]. The continuous delivery mode allows the infusion of drug at a constant, programmed rate) pump. The facility's documentation dated February 20, 2017, revealed that the initial label, dated February 9, 2017, on the medication cassette of [MEDICATION NAME] noted a concentration of 2 milligrams per milliliter and a self administered bolus rate at 2 milligrams, as needed, every 15 minutes, up to 8 milligrams maximum dose per hour. On February 17, 2017, the Hospice RN (Registered Nurse), replaced the [MEDICATION NAME] medication cassette with a new medication cassette. (At the time of the survey ending March 9, 2017, it could not be determined if the cassette of [MEDICATION NAME] had been changed between February 9, 2017, until February 17, 2017). The Hospice RN placed a new medication cassette of [MEDICATION NAME] in the CADD/PCA pump on February 17, 2017, and it infused continuously until February 20, 2017. Progress note documentation dated February 20, 2017, at 12:50 PM revealed that the resident was unresponsive and was twitching. Documentation at 3:00 PM on February 20, 2017, revealed that the resident was only responsive to tactile (touch) and/or verbal stimuli, with attempts to open eyes and was not taking in any fluids or food. According to documentation submitted by the facility dated February 20, 2017, in response to the pharmacy's questions regarding the amount of milliliters left in the [MEDICATION NAME] cassette, it was discovered that the cassette containing [MEDICATION NAME], changed by the Hospice RN on February 17, 2017, contained 10 milligrams of [MEDICATION NAME] per milliliter versus the previous cassette that contained 2 milligrams per milliliter as prescribed for the resident's pain management. The Hospice RN relayed to the facility that the rate of drug delivery was set according to the concentration of [MEDICATION NAME] per milliliter of the old cassette, but the Hospice RN failed to check the medication label on the new cassette to verify the drug concentration per milliliter of [MEDICATION NAME] was consistent with the physician's orders [REDACTED]. The Hospice RN failed to ensure that the label of the drug cassette reflected the prescribed dosage of [MEDICATION NAME] for this resident. As a result, the resident was received 10 milligrams per hour of [MEDICATION NAME] continuously and 10 milligrams per milliliter every 15 minutes per hour rather than the physcian ordered amount of 2 milligrams per milliliter per hour and 2 milligrams per milliliter every 15 minutes per hour from February 17, 2017, when the cassette was exchanged until February 20, 2017. On February 20, 2017, the resident became unresponsive and was twitching according to nursing documentation. Progress notes dated February 20, 2017, at 3:38 PM revealed that [MEDICATION NAME] 0.4 milligrams per milliliter, a one time dose (used to treat narcotic overdoses in an emergency situation) was adminstered intravenously and that the resident became more responsive and was able to respond to verbal commands. At 3:54 PM, documentation revealed that the resident was more awake, responsive with comprehensible sounds with name called, able to move on own, cough and was able to tolerate sucking on an ice cube orally. Interview with the Director of Nursing Services (DON) on March 9, 2017, at 12:00 PM confirmed that the Hospice RN who exchanged the cassette on February 17, 2017, did not check the pharmacy labeled narcotic cassette for the correct dose concentration of [MEDICATION NAME] per volume. The Hospice RN set the rate of infusion on the pump according to the prescribed dose per volume noted on the previous cassette. The pump was set for continous infusion at a rate of 2 milligrams, but it was actually delivering 10 milligrams per hour of [MEDICATION NAME] continuously and 10 milligrams per milliliter every 15 minutes per hour. The Hospice RN failed to verify the five rights of medication administation, including the right medication at the right dose was being administered at the physcian ordered rate resulting harm to the resident who suffered a narcotic overdose medication error. Refer F333 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 11/4/16, 10/23/15

Based on a review of documentation submitted by the facility dated February 20, 2017, and select facility policy and procedures and staff interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and required corrective treatment (medication to reverse a narcotic overdose) following the medication error for one of two residents reviewed (Resident A1). Findings include: A review of facility policies and procedures for Medication Administration -General Guidelines last revised in June 2015, revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Five rights of medication administration are to be followed for each medication being administered: the right resident, right drug, right dose, right route and right time. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. Check #1: Select the medication -label, container and contents are checked for integrity, and compared against the Medication Administration Record [REDACTED]. Check #2: Prepare the dose-the dose is removed from the container and verified against the label and the MAR by reviewing the five rights. Check #3: Complete the preparation of the dose and re-verify the label against the MAR indicated [REDACTED]. A review of documentation submitted by the facility dated February 20, 2017, revealed that Resident A1 received Hospice (a type of care and philosophy of care that focuses on lessening, without curing, a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) services for pain management. The resident was receiving [MEDICATION NAME] (brand name [MEDICATION NAME]), a narcotic pain medication, 2 milligrams per hour basal rate (is the rate of continuous supply of some chemical or process) and 2 milligrams as needed every 15 minutes up to 8 milligrams per hour self administered by the resident via bolus (a single dose of a drug or other medicinal preparation given all at once) button. The [MEDICATION NAME] was provided via cassette (pre-set cartridge containing the prescribed concentration and volume of the drug) inserted and delivered by a CADD/ PCA (continuous ambulatory drug delivery/patient controlled [MEDICATION NAME] is delivery mode that require a continuous rate of infusion, patient-controlled demand doses, or both, such as patient-controlled [MEDICATION NAME]. The continuous delivery mode allows the infusion of drug at a constant, programmed rate) pump. The facility's documentation submitted February 20, 2017, revealed that the initial label on the medication cassette of [MEDICATION NAME] noted a concentration of 2 milligrams per milliliter and a self administered bolus rate at 2 milligrams, as needed, every 15 minutes up to 8 milligrams maximum dose per hour. On February 17, 2017, the Hospice RN (Registered Nurse), exchanged the [MEDICATION NAME] medication cassette with a new labeled medication cassette. The Hospice RN placed this new labeled medication cassette of [MEDICATION NAME] in the CADD/PCA pump on February 17, 2017, and it infused continuously until February 20, 2017. Progress note documentation dated February 20, 2017, at 12:50 PM revealed that the resident was unresponsive and was twitching. Documentation at 3:00 PM on February 20, 2017, revealed that the resident was only responsive to tactile (touch) and/or verbal stimuli with attempts to open eyes and was not taking in any fluids or food. According to documentation submitted by the facility dated February 20, 2017, in response to the pharmacy's questions regarding the amount of milliliters left in the [MEDICATION NAME] cassette, it was discovered that the cassette containing [MEDICATION NAME] changed by the Hospice RN on February 17, 2017, contained 10 milligrams of [MEDICATION NAME] per milliliter versus the previous cassette that contained 2 milligrams per milliliter as prescribed for the resident's pain management. As a result, the resident was receiving 10 milligrams per hour of [MEDICATION NAME] continuously and 10 milligrams per milliliter every 15 minutes per hour rather than the physcian ordered amount of 2 milligrams per milliliter per hour and 2 milligrams per milliliter every 15 minutes per hour from February 17, 2017, when the cassette was exchanged until February 20, 2017. On February 20, 2017, the resident became unresponsive and was twitching according to nursing documentation. Progress notes dated February 20, 2017, at 3:38 PM revealed that [MEDICATION NAME] 0.4 milligrams per milliliter, a one time dose (used to treat narcotic overdoses in an emergency situation) was adminstered intravenously and that the resident became more responsive and was able to respond to verbal commands. At 3:54 PM, documentation revealed that the resident was more awake, responsive with comprehensible sounds with name called, able to move on own to sides and cough and is able to tolerate sucking on an ice cube orally. An interview with the Director of Nursing Services (DON) on March 9, 2017, at 12:00 PM confirmed that the resident received 10 milligrams per hour of [MEDICATION NAME] continuously and 10 milligrams per milliliter every 15 minutes per hour. The Hospice RN failed to verify the five rights of medication administation, including the right medication at the right dose was being administered at the physcian ordered rate resulting in a narcotic overdose medication error. Refer F281 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(a)Resident care policies Previously cited 11/4/16, 10/23/15 28 Pa. Code 211.10(c)Resident care policies Previously cited 11/4/16 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 11/4/16, 10/23/15

Based on review of clinical records and select facility protocols and procedures, observation and staff interview, it was determined that the facility failed to accurately assess skin impairment for one resident (Resident 103) and failed to consistently monitor skin breakdown to promptly identify deterioration and implement timely intervention to prevent worsening of a pressure sore for one resident (Resident 4) out of 23 sampled residents. Finding include: A review of the facility's Skin Care Protocols procedures entitled "Skin Integrity Guidelines" and "Wound Evaluation Flow Sheet " reviewed by the facility May 2, 2011, revealed the purpose is to provide a systemic approach and monitoring process for skin and to decrease pressure ulcer formation by identifying those residents who area at risk and developing interventions. The Director of Nursing/designee will be responsible to implement and monitor the program with wound status being monitored on a weekly basis. The Wound Evaluation Flow Sheet is initiated when a new wound is identified. It is updated at least weekly, reviewing status/change in wound from the previous week. The following steps are needed for completion of the wound evaluation flow sheet: one wound per sheet; identify location; date when the wound was identified; indicate the type of wound; pressure ulcers are to be staged-use the NPUAP (pressure ulcer guidelines) for determining the correct stage; wounds are measured utilizing a clock format to ensure consistency and accuracy with measurement; describe exudates, wound bed and periwound (area surrounding primary wound site). Clinical record review revealed that Resident 103 had [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set Assessment (data collection tool completed at specific intervals to identify care needs) revealed the resident was modified in cognition and decision making, had recall only after cueing and was hearing impaired. The resident required assistance from staff for activities of daily living to include bed mobility and hygiene. The review of the Wound Evaluation Flow Sheet initially dated March 31, 2011, for Resident 103 revealed that an open area had been identified on the resident's coccyx region on March 31, 2011. There was no documented evidence of the nature of the wound, (pressure, non-pressure), measurement of the wound or exudates (drainage) from the wound area on that date. The Wound Evaluation Flow Sheet lacked the above documentation for April 6, 2011 and April 11, 2011. Interview with the Wound Care Nurse, RN on October 10, 2011 at approximately 10:00 a.m., failed to provide documented evidence that the wound was thoroughly assessed and accurate documentation maintained on the Wound Evaluation Flow Sheet according to established facility procedures to provide a systemic approach and monitoring process for skin. A review of the clinical record revealed that Resident 4 had [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated [DATE], revealed him to be severely cognitively impaired, required assistance from staff for bed mobility, transfers and activities of daily living, incontinent of bowel and bladder and was at risk for pressure sores. A review of the resident's plan of care for potential for altered skin integrity initiated September 18, 2010, revealed interventions as planned to provide pressure reducing wheelchair cushion, provide pressure reduction/relieving speciality mattress, skin assessment to be completed per living center policy, incontinence management every shift, apply barrier creme after each incontinent episode, toilet resident post meals, three times a day and turning and repositioning schedule every 2 hours, every shift. A review of a nurse's note and Wound Evaluation Sheet dated May 26, 2011, revealed that Resident 4 sustained an abrasion on his right buttocks measuring 1 cm x 0.3 cm. The physician was notified and a treatment was ordered to cleanse area with soap and water, cover with [MEDICATION NAME] (dressing that promotes healing of wounds. [MEDICATION NAME] provides a moist environment to the wound. It has a flexible [MEDICATION NAME] outer foam layer and an adhesive skin contact layer) change every three days. The next Wound Evaluation Sheet notation was dated June 1, 2011 and the resident's right buttock area was now noted as a skin tear measuring 1.4 cm x 0.9 cm x 0.1 cm. A corresponding facility investigation report dated June 1, 2011 at 1:50 PM revealed that the abrasion on Resident 4's right buttock had opened and was now measuring 1.4 cm x 0.9 cm. The causal factor noted on the investigation report was. "[MEDICATION NAME] not effective. CNA (nurse aide) notified the nurse that an area on his right buttock was bleeding and there was an open area where the abrasion was." The resident's physician was notified and ordered staff to cleanse the area with wound cleanser, apply triple antibiotic ointment and apply dry dressing twice a day until healed. A review of corresponding treatment administration sheets dated from June 1, 2011 through July 7, 2011 revealed that the treatment was performed and the area on the resident's right buttock was noted as healed July 7, 2011. A review of the Weekly Wound Evaluation Sheets revealed entries dated June 1, 2011 and June 15, 2011, a period of 14 days between wound assessments. There was no documented evaluation of this wound noted on June 7, 2011 as per facility procedures for use of the Wound Evaluation Sheets. A new physicians order dated July 7, 2011, directed staff to apply Skin Prep (a liquid film-forming dressing that forms a protective barrier on the skin) to right buttocks every shift as a preventative measure. A review of a Wound Evaluation Flow Sheet and corresponding nurses note dated July 23, 2011 at 10:31 PM revealed that the area to the resident's right buttock reopened and measured 1.5 cm x 0.7 cm, with no stage noted. The physician was notified and ordered staff to cleanse the wound with wound cleanser, apply triple antibiotic ointment and cover with a dry dressing twice a day. The next entry on the weekly Wound Evaluation Flow Sheet record was dated August 17, 2011. The resident's right buttock wound measured 2 cm x 2 cm, was identified as a Stage II, (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister) with a scant amount of sero-sangunous drainage, granulation and slough noted and described as "wound larger, wet frequently due to incontinence, treatment changed." The new treatment was noted as "clean right buttock with wound cleaner and apply thin [MEDICATION NAME], change every three days." There was no corresponding nurses notes related to this change in wound treatment. There was no documented evidence of the completion of the weekly Wound Evaluation Flow Sheet for this area on the resident's right buttock between July 23, 2011, and August 17, 2011. The next entry on the weekly Wound Evaluation Flow Sheet record was dated September 6, 2011, and described the area as a Stage II, 2 cm x 2 cm x 0.1 cm open area with slough, a red area around the wound measuring 6 cm x 6 cm. There was a dark area noted from 9 o'clock to 3 o'clock along the wound edge. The surrounding tissue was noted as red. The physician was notified and a new treatment was ordered, Medi-honey (dressings provide a moist, occlusive environment conducive to optimal wound healing) and dry dressing to right buttocks every day. A corresponding nurses note dated September 6, 2011 at 1:54 PM revealed that there was no drainage or odor noted from the wound There was no documented of the completion of the weekly Wound Evaluation Flow Sheets for this pressure area between August 17, 2011, and September 6, 2011. A nurses note dated September 10, 2011 at 12:41 PM revealed that the area on the resident's right buttock was reddened and warm to touch with a foul smelling odor noted. The resident's treatment dressing was removed due to saturation. The physician was called and ordered Keflex (an antibiotic)500 mg by mouth three times a day. Nursing notes dated September 11, 2011 through September 12, 2011 revealed the resident's right buttock wound was warm to touch and foul smelling. A review of the Weekly Wound Evaluation Flow sheet dated September 12, 2011 revealed the that the right buttock wound was a Stage II, measuring 9 cm x 6 cm x 0.1 cm, with scant amount of serosanguinous drainage, foul smelling and necrotic and the surrounding skin red. A corresponding nurses note dated September 6, 2011 at 11:45 PM revealed "Resident lethargic, increased temp, Tylenol given for temp. 100.5, temp at 5:45 PM 103.9 physician contacted, send resident to emergency room ." The resident was sent to the hospital at 6:15 PM. on September 6, 2011. A review of physician consultation report dated September 13, 2011 revealed the physical examination as "on the right buttock region there is a very large decubitus (pressure sore), which depth is unclear at this point in time. It is assumed to be relatively deep. There is a lot of black eschar (slough or piece of dead tissue that is cast off from the surface of the skin) on the skin. Area is approximately 10 cm across with irregular border of gangrene. It is moveable, indicative of a wet gangrene (decay and death of tissue resulting from an interruption of blood flow to a certain area of your body Gangrene is referred to as "wet" if there's a bacterial infection in the affected tissue) and there is an area of surrounding [MEDICAL CONDITION] and inflammation and induration around the entire area extending for about 4-5 cm beyond the area of skin necrosis (dead tissue). The wound impression was noted as "wet gangrene, right buttock ulceration with abscess formation and [MEDICAL CONDITION], which is quite significant." The surgical procedure treatment was noted as "full thickness of skin and subcutaneous tissue down to the muscle with necrotic tissue." A review of turning and repositioning records dated July 2011, August 2011 and September 2011 revealed that Resident 4 was out of bed, in his wheelchair from 8 AM until 6 PM on most days. There was no documented evidence that this resident was repositioned while out of bed in a wheelchair for periods up to 10 hours a day. A review of bowel and bladder records dated July 2011, August 2011 and September 2011 indicated that Resident was incontinent of bowel and bladder. Observation conducted on October 13, 2011 at 2 PM of Resident 4's right buttock wound revealed that the resident had been incontinent of bowel. The dressing and the wound were contaminated with feces. Employee 3 (RN) cleansed the wound with wound cleanser. She then measured the wound as a round surface. The measurements were noted as 6 cm x 7 cm x 0.2 cm. Observation revealed, however, that the wound shape was irregular and Employee 3 did not measure the area from the outermost edge, which would have made the measurement larger. There was black, necrotic tissue with slough noted at the right top half and middle area of the wound. The right lower part of the wound was dark red in color. The left side of the wound had a large skin flap over a deep, crater like area measuring 0.2 cm (in depth). Loose skin was noted on the left lower edge of the wound. The bottom edge of the wound was red. There were three reddened areas noted on the skin around the wound site. Employee 3 (RN) stated at the time of the wound treatment that the paper tape used on the dry dressing over the wound had caused skin irritation. She also stated that Resident 4 was always incontinent of bowel and bladder and urine and stool contaminate the wound. During an interview October 13, 2011, at 2:30 PM Employee 3 confirmed that she did not assess Resident 4's wound weekly because she was doing other nursing duties. She further stated that no other RN completed the wound assessments when she was unable to do so. 28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services. Previously cited 11/24/10, 1/28/11 28 Pa Code 211.10 (a)(c)(d) Resident care policies Previously cited 11/24/10, 1/28/11