Every finding on record at Embassy of Wyoming Valley

Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation on August 11, 2026, at 9:05AM during the tour of the food and nutrition services department conducted with the Food Service Director (FSD), revealed multiple unsanitary conditions that had the potential to contaminate food and food contact surfaces, increasing the risk of food-borne illness. There were no paper towels available at the handwashing sink. There were no extra rolls of paper towels stored with dietary paper supplies. Housekeeping was called to deliver paper towels. There was a thick layer of dust inside the paper towel dispenser when it was opened to replace the paper towels. The condensation hose (a hose that transports moisture produced by the ice machine to a floor drain) of the ice machine was in direct contact with the floor drain. There was no air gap (space between ice machine's drain line and the floor drain) to prevent contamination of the ice supply in the event of a drain back-up. The perimeter floor areas were visibly soiled with dirt and debris including under the ice machine, counters, and stove area. Three plastic cereal/soup bowls identified as clean contained food debris. Observation of the reach-in refrigerator revealed an opened five pound bag of Mozzarella cheese and an opened package of sliced deli ham which were not dated when opened. The outer edge of the can opener in the cook's area was visibly soiled. Interview with the FSD at the time of the observations confirmed that the food and nutrition services department was to be maintained in a sanitary manner. 28 Pa. Code 201.18 (e) (2.1) Management.28 Pa Code 211.6(f) Dietary services.

Based on a review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to notify a resident's responsible party of a significant change in condition, specifically a fall with a head injury, and the resulting physician-ordered treatment, for one of 14 sampled residents (Resident 1). Findings include: A review of the facility policy titled Fall Prevention and Management Policy, dated January 24, 2026, revealed it is the facility's policy that following a resident fall, the resident's responsible party will be notified.Resident 1 was admitted to the facility on [DATE], with a diagnosis of late-onset Alzheimer's disease (a progressive disorder of the brain that causes memory loss, impaired thinking, and changes in behavior that begin later in life). A review of Resident 1's (quarterly) Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 11, 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 3 reflects major difficulty in recalling recent information and indicates pronounced issues with orientation to time, such as remembering the year, month, or day of the week). A review of a late-entry nursing note dated June 2, 2026, revealed Resident 1 sustained a fall with a head injury on May 29, 2026, at 2:45 AM. The nursing note documented that the physician was notified and issued orders to cleanse the skin injury to the resident's right forehead, apply antibiotic ointment, and leave the area open to air. The physician also ordered Tetanus Immune Globulin administered by intramuscular injection (an injection given into a muscle that provides immediate antibodies to help protect against tetanus following certain high-risk wounds). Review of the clinical record failed to reveal documentation that the resident's responsible party was notified of the resident's fall with head injury or the physician's treatment orders following the change in the resident's condition. During an interview conducted on June 23, 2026, at 3:20 PM the Nursing Home Administrator and the Director of Nursing confirmed the resident's responsible party was not notified of Resident 1's fall with injury or of the physician-ordered treatment following the resident's change in condition. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policy, Treatment Administration Records and staff interviews, it was determined that the facility failed to provide nursing services in accordance with professional standards of practice by failing to ensure licensed nursing staff administered a physician-ordered wound treatment as prescribed for one of 14 residents reviewed (Resident 1).Findings include: A review of the facility policy titled Charting and Documentation last reviewed on January 24, 2026, revealed that all services provided (including medications and treatments) shall be documented in the medical record. The guidelines indicated that documentation of procedures and treatments will include the date and time the treatment was provided, the name and title of the individual providing the care and completing the documentation of care. Resident 1 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's disease with late onset (a disease that causes progressive memory loss and decline in thinking abilities). 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 11, 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 3 reflects major difficulty in recalling recent information and indicates pronounced issues with orientation to time, such as remembering the year, month, or day of the week). A review of the physician's order dated May 30, 2026, directed staff to clean a laceration (deep cut in the skin) on Resident 1's right forehead with normal saline solution (clean water with a small, balanced amount of salt mixed in), apply antibiotic ointment (germ fighting cream), and cover the area with a bandage. A review of the June 2026 Treatment Administration Records (TAR) (the legal documents used to record treatments), revealed nursing staff did not complete the prescribed treatment to the right forehead on June 1, 2026, or June 2, 2026. An interview with the Nursing Home Administrator and Director of Nursing on June 23, 2026, at 2:30 PM reviewed the above findings and acknowledged the facility failed to ensure the physician-ordered treatment was administered as prescribed. 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 (c)(d)(1)(3)(5) Nursing services.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to maintain an accurate and complete clinical record for one of 14 sampled residents (Resident 1).Findings include: Review of the facility policy entitled, Fall Prevention and Management Policy, dated January 24, 2026, indicated in the event of a fall, details of the fall will be gathered and documentation completed as indicated. The procedure guidelines included: update the fall assessment, conduct neurological checks (evaluations to identify any hidden brain injuries or issues after someone hits their head) if the resident is observed to hit one's head, and complete post fall documentation for 72 hours. Resident 1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease with late onset (a progressive condition that causes memory loss and impaired thinking). 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 11, 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 3 reflects major difficulty in recalling recent information and indicates pronounced issues with orientation to time, such as remembering the year, month, or day of the week) Clinical record review revealed a late-entry nursing note dated June 2, 2026, documenting that Resident 1 sustained a fall with a head laceration (a tear in the skin) on May 29, 2026, at 2:45 AM. A review of the facility's investigative documentation completed at the time of the incident revealed Resident 1 had been sleeping in another resident's room and was being assisted back to her own room. During the transfer, Resident 1, who was able to ambulate without assistance, swung her arms and attempted to throw a photo album toward two staff members. During the incident, Resident 1 fell, struck her head, and sustained a 3-centimeter laceration to the right forehead with active bleeding. A review of the Neurological Evaluation Flow Record revealed neurological evaluations were initiated at 2:45 AM on May 29, 2026. Documentation included Resident 1's vital signs (blood pressure, heart rate, respirations, and temperature), level of alertness, pupil assessment, mobility, and pain. The flow record directed staff to complete neurological evaluations every 15 minutes for one hour, every 30 minutes for four hours, every hour for two hours, and every shift thereafter for 72 hours.Review of the clinical record revealed the last documented neurological evaluation was completed at 7:00 AM on May 29, 2026. The medical record contained no documentation that neurological evaluations were completed thereafter. Specifically, the clinical record did not contain documentation for the evaluations due at 7:30 AM, 8:30 AM, and 9:30 AM on May 29, 2026, or the required evaluations during the remaining evening and night shifts on May 29, 2026, and continuing through the day shift on May 30, 2026. Review of the narrative progress notes (written descriptions that explain what happened) revealed the May 29, 2026, fall was documented as a late-entry nursing note dated June 2, 2026. The next narrative entries were documented on June 2, 2026, at 10:39 AM and June 2, 2026, at 11:59 PM. The clinical record contained no follow-up narrative documentation related to Resident 1's condition on May 30, May 31, or June 1, 2026, despite the facility policy requiring post-fall documentation for 72 hours following the incident. During an interview on June 23, 2026, at 2:30 PM, the above information was reviewed with the Nursing Home Administrator and Director of Nursing who acknowledged the clinical record was incomplete and omitted required documentation related to the May 29, 2026, fall. 28 Pa Code 211.5(f)(xi) Medical records. 28 PA. Code 211.12 (c)(d)(1)(3) (5) Nursing services.

Based on observations, it was determined the facility did not provide a clean, comfortable, and homelike environment for residents on three of three floors observed.Findings include:An observation conducted on March 12, 2026, at 9:15 AM in resident room [ROOM NUMBER] revealed the floor contained visible dust, food particles, debris, and dirt located under and around the resident's bed, including the area near the window and between beds. Red-colored liquid droplets were observed dispersed across the floor surface. The flooring along the perimeter walls appeared discolored. The baseboards were observed to be detached and falling away from the wall, exposing unpainted wall surfaces beneath. An observation conducted on March 12, 2026, at 9:20 AM throughout the third-floor hallways revealed multiple stains on the floors. Debris was observed throughout the hallways, including crushed food particles, straw wrappers, and empty sugar packets. Splatters of a white liquid substance were observed on the hallway floors. An observation conducted on March 12, 2026, at 9:40 AM of the third-floor dining area revealed food debris on the floor beneath a dining table. A follow-up observation on March 12, 2026, at 12:00 PM revealed the same food debris remained present beneath the table.An observation conducted on March 12, 2026, at 12:00 PM in the third-floor hallway across from the nurse's station revealed a handrail bent downward toward the floor. The handrail was loosely attached to the wall with four screws. Two holes were observed in the wall at the location of the handrail. The handrail had chipped and peeling paint.An observation conducted on March 12, 2026, at 12:30 PM in the front day room on the second floor revealed two beds stored in the corner of the room.An observation conducted on March 12, 2026, at 1:00 PM in the first-floor library revealed brown stains on the wall and a gouged area with missing paint located above the baseboard. During an interview on March 12, 2026, at 2:30 PM, the above observations were reviewed with the Nursing Home Administrator. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on a review of facility policy, prior survey findings, the facility's Plan of Correction (POC), and observations made during the revisit survey, it was determined the facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, monitored, and corrected ongoing deficient practice related to environmental cleanliness and maintenance.Findings included:Quality Assurance and Performance Improvement (QAPI), which is a systematic and ongoing process used by a facility to identify problems, implement corrective actions, and ensure those actions are effective and sustained over time, was reviewed. A review of the facility policy titled Quality Assurance Performance Improvement, last reviewed by the facility on January 23, 2026, revealed the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life. The facilities' QAPI program shall address all systems of care and management practices, include clinical care, quality of life, and resident choices, utilize the best available evidence to design and measure indicators of quality, and have facility goals that reflect the process of care and facility operation that have been shown to be predictive of desired outcomes for residents and reflect the complexities of the services provided at the facility. A review of the survey completed January 30, 2026, revealed the facility was previously cited for failing to maintain a safe, clean, comfortable, and homelike environment throughout the facility whereas the facility failed to provide housekeeping services to maintain a clean and orderly environment throughout the facility.A review of the facility's submitted Plan of Correction (POC), which is the facility's written plan describing how it will correct identified deficiencies, prevent recurrence, and monitor ongoing compliance, with a completion date of March 10, 2026, revealed the facility implemented corrective actions that included cleaning identified areas, re-educating environmental services staff, conducting routine audits of resident rooms and common areas, and reporting audit results to the QAPI committee for ongoing monitoring and evaluation. However, observations conducted throughout the facility during the revisit survey on March 12, 2026, revealed continued concerns with environmental cleanliness and maintenance across multiple floors, including resident rooms, hallways, dining areas, and common spaces. These findings were consistent with previously cited concerns and demonstrated that corrective actions were not sustained. The continued presence of environmental concerns after implementation of the Plan of Correction demonstrated that the facility's QAPI program failed to effectively monitor the identified problem, analyze the underlying causes, and ensure that corrective actions were consistently implemented and maintained. The facility's QAPI monitoring activities failed to identify the recurrence of deficient practice related to housekeeping and maintenance and failed to ensure that previously implemented corrective actions resulted in sustained compliance with regulatory requirements. Refer F584 28 Pa. Code 201.18(e)(4) Management.28 Pa Code 211.10 (c)(d) Resident care policies.

Based on observation, resident and staff interviews, and review of facility dietary schedules, menus, and dietary records, it was determined the facility failed to consistently maintain sufficient dietary staff to effectively carry out the functions of the food and nutrition services department. This failure resulted in meals not being consistently served at palatable temperatures, the planned menu not being followed, and the food and nutrition services department not being maintained in a sanitary manner. Findings include: Review of the facility census revealed that on January 27, 2026, the facility census was 93 residents. Resident interviews conducted during the survey, which began on January 27, 2026, and concluded on January 30, 2026, revealed multiple concerns regarding the palatability of meals (the acceptability of food based on taste, texture, smell, and serving temperature). An interview with Resident 12 on January 27, 2026, at 12:00 PM revealed the resident reported food was frequently served cold and was not palatable. An interview with Resident 26 on January 27, 2026, at 12:30 PM revealed the resident did not like the food and was tired of being served meals that were cold. An interview with Resident 30 on January 27, 2026, at 12:45 PM revealed the resident stated the facility was aware he did not like the food and that meals were consistently cold. An interview with Resident 1 on January 28, 2026, at 10:30 AM revealed the resident generally liked the food but reported it was frequently not hot enough when served. Observation of the dietary department on January 28, 2026, at 12:00 PM, along with review of the facility's Daily Food Temperature Logs (recorded at each meal) for January 19 through January 28, 2026, revealed required meal temperatures were not consistently recorded. Breakfast and lunch temperatures were not documented on January 19, January 24, January 25, January 26, and January 27, 2026. Breakfast temperatures were also not recorded on January 28, 2026. Interview with the Food Service Director (FSD) at that time confirmed food temperatures were required to be recorded for each meal. A test tray evaluation was conducted on the Third Floor Nursing Unit on January 28, 2026, during the lunch meal. The test tray arrived at the nursing unit at 12:16 PM and consisted of a hot dog on a bun, corn, pork and beans, ice cream, milk, and coffee. The meal was served on Styrofoam plates, and coffee was served in a thermal mug. At 12:28 PM, after the last resident had been served, food temperatures were taken and revealed the following: Hot dog on bun measured 111 degrees Fahrenheit, below the required minimum hot holding temperature of 135 degrees Fahrenheit.Corn measured 106 degrees Fahrenheit, below the required minimum hot holding temperature of 135 degrees Fahrenheit.Pork and beans measured 122.6 degrees Fahrenheit, below the required minimum hot holding temperature of 135 degrees Fahrenheit. The hot dog, corn, pork and beans tasted only lukewarm and were not palatable. Review of dietary staffing schedules revealed limited staffing levels relative to the facility census and workload. On January 27, 2026, the dietary department schedule included one morning cook from 5:30 AM to 2:00 PM, one evening cook from 11:00 AM to 7:30 PM, one dietary aide from 6:30 AM to 1:00 PM, one dietary aide from 11:30 AM to 6:00 PM, one dietary aide from 4:00 PM to 8:00 PM, and one dietary aide assigned to assist with food delivery and storage ( truck), with no specific hours identified. Review of dietary staffing schedules for January 28 and January 29, 2026, revealed similar staffing patterns, consisting of one morning cook, one evening cook, and three dietary aides covering staggered shifts, with no increase in staffing despite meal service demands. Review of the planned menu for Week Four; Friday, revealed the planned dessert was a blonde chocolate chip brownie (non-chocolate counterpart to a traditional brownie). Observation of the tray line during the lunch meal on January 30, 2026, at 11:55 AM revealed the dessert served was a vanilla cake with a wet glazed frosting that did not appear appetizing. Interview with the Food Service Director at that time confirmed the planned dessert was not prepared and stated he had prepared the incorrect dessert. Interview with the Food Service Director on January 30, 2026, at 12:00 PM revealed that dietary staffing hours were reduced on December 30, 2025. The FSD confirmed dietary aides for the supper meal were reduced from three aides and a cook to two aides and a cook, despite no significant decrease in resident census. The FSD stated that due to the reduction in staffing, he frequently assists with cooking and production duties. The FSD further acknowledged there were sanitation concerns within the kitchen and confirmed he was behind on ensuring completion of required food temperature logs and cleaning assignments necessary to maintain a sanitary food service environment. Interview with the Nursing Home Administrator (NHA) on January 30, 2026, at 1:00 PM confirmed that on December 30, 2025, the corporation reduced total daily dietary staffing hours, including cooks, dietary aides, and the Food Service Director, from approximately 48 to 51 total hours per day to approximately 40 hours per day. The NHA acknowledged that following the reduction, the Food Service Director was required to cook and assist with meal production more frequently due to decreased staffing levels. The facility failed to maintain sufficient dietary staffing to ensure meals were prepared and served in a sanitary manner, served at palatable temperatures, and served as planned according to the established menu. Refer F804, F812 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Based on observation, review of select facility policy, and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of foodborne illness in the food and nutrition services department and failed to ensure that food storage in personal refrigerators was adequately monitored and maintained within safe temperatures to prevent foodborne illness for one resident with a personal refrigerator (Resident 5).Findings include:Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).Review of the food and nutrition services department's Food Temperature Logs Policy last reviewed January 23, 2026, indicated that food temperatures of cold and hot items will be recorded on all menu items for meal service. Observation on January 27, 2026, at 10:00 AM, during the initial tour of the food and nutrition services department conducted with the Food Service Director (FSD), revealed multiple unsanitary conditions. Dirt and debris were observed on the floor throughout the kitchen. Two uncovered sheet cakes were observed on a rolling rack inside the walk-in refrigerator. The ceiling vent located above the ice machine was visibly dust covered, and two ceiling tiles adjacent to the dishwasher were heavily stained. Interview with the FSD at this time revealed the dishwasher had been broken for about one month. The FSD stated that paper products and plastic silverware were being used for meal service. The FSD confirmed that the three compartment sink (commercial kitchen fixture with three basins for manually washing, rinsing, and sanitizing dishes and utensils in distinct stages, following health code standards by using hot, soapy water for washing dishes at a temperature of 110 degrees Fahrenheit, clean water for rinsing, and a chemical sanitizer, with items then air dried on a nearby drainboard to prevent contamination) was being utilized to clean and sanitize the non-disposable kitchen equipment. Review of facility provided documentation revealed the dishwasher became inoperable on November 21, 2025. Documentation further showed a lease for a replacement dishwasher was signed on November 24, 2025, and the facility was awaiting delivery and installation of the new unit.Observation on January 30, 2026, at 10:25 AM, revealed the new dishwasher was in place but not operational, as it was awaiting electrical serviceObservation on January 28, 2026, at 12:00 PM, revealed an accumulation of dirt and debris underneath the tray line area. Observation on January 30, 2026, revealed four food delivery carts identified as clean had visible food stains on both the interior and exterior surfaces. Observation of the steam table at that time revealed water in the individual wells contained food debris from prior meals. The FSD stated the steam table water was changed weekly. Review of facility records revealed there were no documented cleaning schedules available for the months of December 2025 or January 2026. During an interview on January 30, 2026, at 10:40 AM, the FSD confirmed the food and nutrition services department was expected to be maintained in a sanitary manner and that facility policies and procedures were to be followed to ensure food safety and prevent foodborne illness. Review of the facility's Daily Food Temperature Logs from January 19 through January 28, 2026, revealed incomplete documentation. Breakfast and lunch food temperatures were not recorded on January 19, January 24, January 25, January 26, and January 27, 2026. Breakfast temperatures were also not recorded on January 28, 2026. During an interview conducted on January 28, 2026, the FSD confirmed food temperatures were required to be monitored and recorded at each meal. Review of the facility's Resident Refrigerators policy last reviewed January 23, 2026, revealed that it was the policy of the facility to ensure safe and sanitary use of any resident owned refrigerator. Leftover food will be dated upon receipt and discarded within three days. Nursing and housekeeping were to discard any food that was out of compliance during the minimal weekly checks, which was to include assessing properly dated food items and discarding what was outdated, and monitor refrigerator temperatures.During an interview on January 27, 2026, at 11:00 AM, Employee 7 Licensed Practical Nurse stated Cooler Temperature Logs were posted on the outside of resident refrigerators and nursing or housekeeping staff were responsible for monitoring and documenting internal refrigerator temperatures daily. Observation of Resident 5's personal refrigerator located in the resident's room on January 27, 2026, at 11:00 AM, revealed a covered plastic container of food without a date indicating when it was placed in the refrigerator. Employee 7 was unable to identify how long the food had been stored or whether the three-day discard timeframe had been exceeded. Observation of the Cooler Temperature Log posted on the outside of Resident 5's refrigerator on January 27, 2026, at 11:00 AM, revealed the last documented internal refrigerator temperature was recorded on August 1, 2025. During an interview on January 28, 2026, at 9:00 AM, the nursing home administrator was unable to provide additional information to demonstrate staff consistently monitored and documented resident refrigerator temperatures or ensured food was properly labeled and discarded to prevent foodborne illness.Refer F802 28 Pa Code 201.18 (e) (2.1) Management. 28 Pa Code 211.6(f) Dietary services. 28 Pa Code 211.10 (a)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observation, review of documentation provided by the facility, select policies, and staff interview, it was determined that the facility failed to develop and implement a water management program, identify potential factors related to the prevalence of urinary tract infections, and implement interventions based on these factors to decrease the occurrence and further failed to ensure compliance with facility policy to reduce the spread of infection was consistently implemented, including observations made on one out of two nursing units (Second Floor Nursing Unit).Findings include: According to the Centers for Disease Control (CDC) Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, September 30, 2025, Legionnaires' disease is a serious type of pneumonia caused by bacteria called Legionella that live in water. People can get sick when they inhale water containing Legionella from building water systems or devices that are not adequately maintained. A water management program should identify areas or devices in a building where Legionella might grow or spread to people in order to reduce that risk. Legionella water management programs are now an industry standard for large buildings in the United States. A review of the facility policy titled Water Management Program, last reviewed by the facility on January 23, 2026, revealed it is the policy of the facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens in the facility's water systems on a nationally accepted standard (e.g., CDC). It is the facility's policy to establish a water management team to develop and implement the facility's water management program, maintain documentation that describes the facility's water system, and conduct a risk assessment annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. During an interview on January 30, 2026, at 10:00 AM, the Infection Preventionist was unable to provide documented evidence that the facility established a water management team to develop and implement the facility's water management program. During an interview on January 30, 2026, at 12:30 PM, the Nursing Home Administrator was unable to provide documented evidence describing the facility's water system or documentation showing that the facility conducted an annual risk assessment to identify where Legionella or other opportunistic waterborne pathogens could grow and spread within the facility's water system.A urinary tract infection is an infection involving any part of the urinary system, including the bladder or kidneys. Review of the Infection Control Logs dated September 2025 revealed that 50 percent of the facility-acquired urinary tract infections were caused by Escherichia coli and or Proteus mirabilis. These bacteria are commonly found in stool and are associated with inadequate perineal care, which is the cleaning of the genital and anal areas. Review of the Infection Control Log dated October 2025 revealed the percentage of facility-acquired urinary tract infections caused by Escherichia coli and or Proteus mirabilis increased to 87.5 percent. Review of the Infection Control Logs dated November 2025, and December 2025 revealed the rates of facility-acquired urinary tract infections associated with Escherichia coli and Proteus mirabilis were 60 percent and 66.6 percent, respectively. Review of Infection Control Logs dated September 2025 through December 2025 revealed a total of 18 facility-acquired urinary tract infections caused by Escherichia coli and or Proteus mirabilis. Twelve of the affected residents resided on the third floor nursing unit. During an interview on January 30, 2026, at 1:00 PM, the Infection Preventionist was unable to provide evidence that the facility analyzed potential contributing factors related to the increased percentage of urinary tract infections or that reasonable interventions related to staff practices or resident self-care were identified and implemented. An interview with the Infection Preventionist on January 30, 2026, revealed that the facility did not audit staff technique with perineal care to ensure it was properly performed in an effort to potentially reduce the prevalence of causative organisms. In addition, the Infection Preventionist indicated that they did not directly audit call bell response to residents who were incontinent of bowels or needed assistance with bowel hygiene to determine if timely care was rendered to reduce the percentage of infections related to Escherichia coli and Proteus mirabilis. The Infection Preventionist did not analyze if any of the residents with Escherichia coli or Proteus mirabilis were involved in self-care, thus representing education that would need to be provided directly to the residents to reduce occurrence. The Infection Preventionist was unable to answer why over 66% of the facility-acquired urinary tract infections occurred on the third floor. A review of a hand hygiene audit tool for general practice revealed that on September 18, 2025, this audit was completed to ensure staff were observed properly sanitizing hands and practicing good hygiene techniques between residents. The Infection Preventionist indicated this was completed to monitor staff compliance and to reduce infections including urinary tract infections caused by Escherichia coli and Proteus mirabilis. Although from the time of the audit on September 18, 2025, and review of the Infection Control Log for the month of October 2025, there was a 37.5% increase in the prevalence of urinary tract infections related to Escherichia coli and Proteus mirabilis. The Infection Preventionist was unable to indicate based on this data what additional interventions were implemented or what the facility determined to be the causative factor for this significant increase. During an interview on January 30, 2026, at 1:00 PM the Infection Preventionist was unable to provide evidence that the facility identified potential factors into the increased percentage of urinary tract infections and that reasonable interventions associated with the analysis of staff/resident practice were identified as potential causes.Observation of the Second Floor Nursing Unit on January 27, 2026, at 11:30 AM revealed ten wall-mounted hand sanitizing units. Upon attempt to use these units, none dispensed hand sanitizing solution. A review of the facility's hand hygiene policy, last reviewed January 23, 2026, revealed that staff was to perform hand hygiene between resident contact. Observation of Employee 8, Nurse Aide (NA) and Employee 9, NA on January 28, 2026, at 12:30 PM revealed that these employees were delivering meal trays to the residents on the second floor in their respective rooms. Further observation revealed that neither of these employees washed/sanitized their hands between resident rooms. Employee 8, NA, was noted to insert her fingers inside a Styrofoam cup, fill the cup with a liquid beverage, and take it into a resident room. An interview with Employee 8, NA, on January 29, 2026, at 9:00 AM, confirmed that she does not always wash/sanitize hands between residents; however, she would do so more readily if the sanitizing stations on the walls were functioning. An interview with the director of nursing on January 29, 2026, at 9:30 AM, confirmed that all sanitizing stations were fixed and that staff were to cleanse hands between each resident. The facility failed to establish and implement a water management program to reduce the risk of Legionella and other waterborne pathogens, failed to identify potential factors related to the prevalence of urinary tract infections, and implement interventions based on these factors to decrease the occurrence and further failed to ensure compliance with facility policy to reduce the spread of infection was consistently implemented. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations, review of clinical records, facility policy, and staff interviews, it was determined the facility failed to ensure residents' call lights were accessible to reasonably accommodate a resident's need for assistance for three out of 23 residents sampled (Residents 3, 29, 7, and 63).Findings include: Review of the facility policy titled Call Lights: Accessibility and Timely Response last reviewed by the facility on January 21, 2026, indicated that all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secured as needed. Observation on January 27, 2026, at 11:43 AM revealed two staff members exiting Resident 3's room after providing care. Resident 3 was awake and lying in bed. The call bell was observed on the floor under the bed and was not within the resident's sight or reach. Review of Resident 3's care plan dated June 24, 2021, indicated the resident was at-risk for falls with a planned intervention to ensure the resident's call light was within reach. Observation on January 27, 2026, at 11:47 AM revealed Resident 29 was seated in her wheelchair on the left side of the bed. The call bell was observed on the floor on the right side of the bed and was not within the resident's sight or reach. Review of Resident 29's care plan dated November 6, 2025, indicated the resident was at-risk for falls with a planned intervention to ensure the call light was within reach at all times. Observation on January 27, 2026, at 11:50 AM revealed Resident 7 was seated on the edge of the right side of the bed. The call bell was observed lodged under the bedframe and not within the resident's sight or reach. Review of Resident 7's care plan dated June 5, 2025, indicated the resident was at-risk for falls with a planned intervention to ensure the call light was within reach. An interview with Employee 2 (Nurse Aide) on January 27, 2026, at 12:00 PM confirmed the observations and acknowledged Residents 3, 29, and 7 did not have access to a call bell to request staff assistance. Observation on January 28, 2026, at 10:28 AM revealed Resident 3 lying in bed. The call bell was draped over the top mattress on the left side and wedged into the bedframe. The call bell was positioned above the resident's head and not within the resident's reach. Observation on January 28, 2026, at 10:36 AM revealed Resident 29 seated in a wheelchair on the left side of the bed. The call bell was observed on the floor on the left side of the bed and not within the resident's sight or reach. An interview with Employee 3 (Licensed Practical Nurse) on January 28, at 10:40 AM confirmed the observation and stated that Residents 3 and 29 did not have access to a call bell for staff assistance. Employee 3 further confirmed that facility practice requires call bells to be placed within residents' reach at all times. Observation on January 28, 2026, at 9:00AM revealed Resident 63 lying in bed and yelling out for assistance. The call bell was observed on the floor under the resident's bed and was not within the resident's sight or reach. Interview with Employee 6 (LPN) who responded upon surveyor request to provide help to Resident 63 confirmed the observation of the call bell under the resident's bed out of the resident's reach. Employee 6 repositioned Resident 63 who then stopped yelling. Employee 6 confirmed that facility practice requires staff to ensure that call bells are placed within residents' reach at all times. Review of Resident 63's care plan last reviewed December 27, 2025, indicated the resident was at risk for falls with a planned intervention to ensure the call light was within reach. Interview with the Nursing Home Administrator on January 28, 2026, at 1:00 PM confirmed that call bells were to be kept within reach for all residents. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services. 28 Pa. Code 201.29 (a) Resident Rights. 28 Pa. Code 211.10 (c)(d) Resident Care Policies.

Based on observations and resident and staff interviews, it was determined the facility failed to provide a clean, comfortable, and homelike environment for residents, including concerns expressed by six out of six residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94) and four out of 23 sampled residents (Residents 9, 14, 20, and 52).Findings include: An observation on January 27, 2026, at 12:07 PM in resident room [ROOM NUMBER] revealed dust, food pieces, debris, and dirt on the floor and under the window-side resident bed. An observation on January 27, 2026, at 12:09 PM in resident room [ROOM NUMBER] revealed water discoloration stains and pooling near the door side bed. Food pieces and dirt were observed under the door-side bed. The resident toilet was observed with brown stains and discolorations on the seat. The toilet dispenser roll was observed with a 2-inch gap between the metal dispenser and the wall, exposing the inside of the wall. [NAME] debris from the wall was observed on the floor underneath the toilet paper dispenser. An observation on January 27, 2026, at 12:20 PM, revealed the first floor main dining room felt cold. The wall thermostat in the main dining room was set to heat the room to 75 degrees Fahrenheit, but the wall thermometer was indicating the room temperature was 65 degrees Fahrenheit. An interview on January 27, 2026, at 12:20 PM with Residents 20 and Resident 52 who were present in the dining room for lunch stated that it is often cold in the main dining room. Resident 9 was observed to be wrapped in a blanket and stated that she needed to go back to her room right after she eats because it is too cold in the dining room. Resident 14, who was also in the main dining room for lunch, stated, Hey, turn on the heat. During an interview on January 27, 2026, at 12: 22 PM the director of maintenance confirmed that the heat was set at 75 degrees Fahrenheit but was not turning on and needed to be repaired. An observation on January 27, 2026, at 12:25 PM in resident room [ROOM NUMBER] revealed a blue fall mat with brown and gray liquid and discoloration stains. An observation on January 27, 2026, at 12:34 PM in resident room [ROOM NUMBER] revealed a broken toilet dispenser roll. The ceiling above the window-side bed was observed with a line of chipped paint extending for 3 feet. A follow-up observation on January 28, 2026, at 8:55 AM revealed that the first-floor dining room felt cold. The wall thermostat in the main dining room was set to heat the room to 76 degrees Fahrenheit, but the wall thermometer was indicating the room temperature was 63 degrees Fahrenheit. During an additional observation on January 28, 2026, at 9:15 AM, the nursing home administrator confirmed that the temperatures of four walls in the first-floor dining room were 64 degrees Fahrenheit, 62.6 degrees Fahrenheit, 61.2 degrees Fahrenheit, and 62.96 degrees Fahrenheit, respectively. During a resident group interview on January 28, 2026, at 10:00 AM, six out of six residents (Residents 46, 56, 71, 77, 83, and 94) indicated they have a concern about the cold temperatures in the facility's dining room. An observation on January 28, 2026, at 12:22 PM in the third-floor Resident Pantry revealed a counter with pink liquid discoloration stains on the counter and dripping down the brown cabinets, dirt and debris pieces on the floor, a broken electrical outlet, and three ceiling blocks with 1 foot brown water discolorations, and a missing ceiling block. Additionally, the heating/cooling unit was observed with dozens of food pieces inside the radiator fins. An observation on January 28, 2026, at 12:30 PM outside the third-floor Resident Dining room revealed white handrails with chipped and peeling paint. During an interview on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The facility failed to provide a clean, comfortable, and homelike environment for residents. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Based on observation, a review of select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities, including six out of six residents interviewed during a resident group meeting (Residents 46, 56, 71, 77, 83, and 94).Findings included: A review of the facility policy titled Resident and Family Concerns, last reviewed by the facility on January 21, 2026, revealed it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. Information on how to file a grievance or complaint will be available to the resident. A review of the facility policy titled Resident and Family Concerns revealed the facility failed to include the following required information in the policy: the contact information of the grievance official, the contact information of independent entities with whom grievances that may be filed, and the time frame that residents may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance. During a resident group interview on January 28, 2026, at 10:00 AM, six out of six alert and oriented residents (Residents 46, 56, 71, 77, 83, and 94) in attendance indicated they were not informed about the facility grievance process and did not know how to file a grievance. The residents in attendance were unable to explain the grievance process or purpose. Residents 46, 56, 71, 77, 83, and 94 were unable to identify the grievance official and did not know how to file a grievance or how to file a complaint with independent entities such as the local ombudsman or pertinent state agencies. An observation on January 28, 2026, at 10:45 AM of the third-floor dining room revealed an unlabeled black mailbox. There was no information explaining the function or purpose of this box. During an interview on January 28, 2026, at 10:55 AM, Employee 3, LPN, confirmed there was an unlabeled black mailbox in the third-floor dining room. She explained that she believed the box was for resident grievances. Employee 3, LPN, confirmed there was no posted information explaining the function or purpose of the box. During an interview on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The NHA was unable to explain why Residents 46, 56, 71, 77, 83, and 94 indicated they had no knowledge of the grievance process. The facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents, including experiences expressed by 1 out of the 23 sampled residents (Resident 50) and as expressed by residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94)Findings include: A clinical record review revealed Resident 50 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 care plan initiated May 1, 2024, identified Resident 50 as having a chronic decline in intellectual functioning related to dementia. Interventions included encouraging small group activities. During an interview on January 27, 2026, at 12:05 PM, Resident 50's representative indicated that Resident 50 loved music, arts and crafts, coloring, drawing, and painting. Resident 50's representative explained that she has not observed Resident 50 in any activities when she visits and believes that she would benefit from participation in activities she enjoyed. Observation of the third-floor secured memory care unit on January 27, 2026, between 10:45 AM and 12:15 PM revealed no group or individual activities in progress. The activity room was empty, and there was no evidence that activities were occurring in other common areas on the unit. Observation on January 27, 2026, at 11:10 AM in the Sunny Side Cafe dining room revealed five residents present; four were seated in wheelchairs and one resident was standing while bent forward at the waist A television was on; however, no residents appeared engaged with the programming. No staff were present. Further observation of the third floor between 10:45 AM and 11:55 AM revealed that of 20 residents residing in rooms 315-326, 13 residents were observed in bed, and three residents were seated in wheelchairs in their rooms. Only four residents were observed outside of their rooms. Review of the activity calendar for January 27, 2026, indicated a scheduled 11:00 AM Hot Chocolate Bar activity in the activity room; however, no such activity was conducted on the third-floor memory care unit. Observation on January 28, 2026, between 9:35 AM and 10:50 AM again revealed no activities being conducted on the third-floor memory care unit. The activity room remained empty, and no staff were observed providing one-to-one activity interventions. The activity calendar for January 28, 2026, listed Morning News and Music at 9:00 AM and Guided Meditation at 11:00 AM in the activity room; however, these activities were not observed on the third-floor memory care unit. During an interview on January 28, 2026, at 10:20 AM, Employee 3 (Licensed Practical Nurse) stated there were no specific activities being provided on the third-floor memory care unit. Employee 3 reported the facility previously had an activity staff member assigned to the unit who provided daily group and individual activities; however, the position had been eliminated over a month ago. Employee 3 stated current activities were primarily facility-wide and only select residents from the secured unit were able to attend the activities on the first floor based on safety considerations. During an interview on January 28, 2026, at 10:40 AM, Employee 1 (Activity Director) confirmed the Memory Care Coordinator activity position was eliminated mid December 2025. Employee 1 stated group activities were no longer provided on the third-floor memory care unit and residents attended activities off the secured unit only as deemed appropriate. Employee 1 reported there were two activity staff members Monday through Friday and one staff member on weekends. At the time of the survey, the facility census was 93 residents, with 46 residents residing on the third-floor secured memory care unit. During a resident group interview on January 28, 2026, at 10:00 AM, six out of six alert and oriented residents (Residents 46, 56, 71, 77, 83, and 94) indicated dissatisfaction with the facility's activities program. Residents indicated that they do not meet as a resident council (an organized, independent group of residents who meet regularly to discuss concerns, share opinions, and advocate for improvements in their quality of life and care) or gather to discuss recommendations or improvements. Residents 46, 56, 71, 77, 83, and 94 indicated that they are not asked what type of groups and activities they enjoy. During the group interview Resident 56 indicated that there are very few activities available and she would like to have more activities. During the group interview Resident 77 indicated there are no activities on the third floor. She explained that they have to go downstairs to participate in bingo. She indicated that she would like the facility to offer arts and crafts activities. Resident 77 explained that in the past they would play games like Uno and have games available all day but was upset because the facility stopped offering Uno and providing access to the games. She also indicated that reminiscing activities were offered and enjoyed in the past, but the facility no longer provides that activity. During the group interview Resident 46 indicated that she would like to participate in arts and crafts, music, and memory game activities. She explained that there are not enough activities available. During the group interview Resident 71 indicated that there are no activities on the third floor and there have not been for at least a month. She explained that she would like to have more activities available. During the group interview Resident 94 indicated that she would like to participate in arts and craft, music, and cooking activities, but explained that the facility does not offer many activities. During the group interview Resident 83 indicated the only activity available was bingo. She explained that there are no activities on the second floor. Resident 83 indicated that in the past she enjoyed the reminiscing groups where residents talked about positive experiences from the past. She explained that she would like to have the opportunity to participate in these groups again. During an interview on January 30, 2026, at 12:30 PM, the above findings were reviewed with the Nursing Home Administrator (NHA). The NHA confirmed the Memory Care Coordinator activity position was eliminated on December 10, 2025. The facility failed to provide an ongoing program of activities that met residents' interests and supported their physical, mental, and psychosocial well-being.Refer F680 28 Pa. Code: 201.18 (b)(3)e(2) Management28 Pa. Code 211.12(d)(3) Nursing services.

Based on observations, review of facility documentation, review of personnel records, and interviews with staff, it was determined the facility failed to ensure the activities program was directed by a qualified professional for one of one activities personnel files reviewed (Employee 1).Findings include: Review of facility documentation revealed the job description for Activity Director stated the primary purpose of the job position is to plan, organize, develop, direct and implement the overall operation of the Activity Department in accordance with current, federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Continued review of the job description revealed the Activity Director is required to meet one of the following qualifications: be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for certification as a recreations specialist or as an activities professional; or must have, as a minimum, two years' experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting; or must be a qualified occupational therapist or occupational therapy assistant; or must have completed a training course approved by the state. Review of the facility's Department Heads Contact List revealed that Employee 1 (Activity Director) was identified as the Recreation Director. Review of Employee 1's personnel file revealed the employee was hired on December 9, 2025, as the Activity Director. Review of the employee's education and work history revealed no evidence that Employee 1 was a certified therapeutic recreation specialist, had prior experience in a therapeutic activities program, was a qualified occupational therapist or occupational therapy assistant, or had completed a state-approved training course. Observation on January 29, 2026, at 9:00 AM revealed Employee 1 was overseeing an activities program with residents in the activities room. During an interview on January 29, 2026, at 9:26 AM the Nursing Home Administrator confirmed that the Activity Director had not completed any credentialling or training courses required to qualify as a therapeutic recreation specialist, was not recognized as an activities professional by an accrediting body, and did not meet the minimum qualifications for the position. Refer to F679 28 Pa. Code 201.18 (e)(6) Management. 28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on observations, staff interviews, review of manufacturer storage guidelines, and review of facility policy, it was determined that the facility failed to ensure drugs and biologicals were properly stored and that expired or improperly labeled medications were removed from use. Specifically, the facility failed to maintain required refrigeration temperatures for injectable medications used to manage blood sugar levels and failed to discard expired or improperly labeled medications, affecting 11 residents medications in two of two medication rooms observed. (Residents 5, 9, 10, 25, 42, 66, 72, 78, 85, 92, and 94).Findings include: A review of manufacturer storage guidelines for injectable blood glucose-lowering medications, including Glargine, Humalog, Trulicity, Lantus, Novolog, and Lispro (injectable medications used to treat diabetes by lowering blood sugar levels), revealed that these medications require refrigerated storage at temperatures between 36 and 46 degrees Fahrenheit to maintain medication stability and effectiveness. Manufacturer guidance further specifies that these medications must not be frozen, as freezing can damage the medication and render it ineffective or unsafe. Review of the facility's Storage of Medications policy dated January 23, 2026, revealed that the facility shall not use discontinued, outdated, or deteriorated drugs/biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station at the appropriate temperature. During an observation of the second-floor medication room on January 27, 2026, at 9:30 AM, a medication refrigerator was observed with an internal thermometer registering 34 degrees Fahrenheit, which is below the manufacturer-required storage range. The following vials of injectable blood glucose-lowering medications were stored in this refrigerator:Resident 5 -one vial of injectable LantusResident 9 -one vial of injectable NovologResident 10 -one vial of injectable NovologResident 25 -one vial of injectable TrulicityResident 72 -one vial of injectable NovologResident 78 -one vial each of injectable Lispro, Novolog, and LantusResident 85 -one vial of injectable Novolog Storage of injectable medications below the required temperature range increases the risk that the medication may lose effectiveness, which could result in inadequate blood sugar control. During an observation of the third-floor medication room on January 27, 2026, a medication refrigerator was observed with an internal thermometer registering 30 degrees Fahrenheit, indicating freezing-level temperatures. The following vials of injectable blood glucose-lowering medications were stored in this refrigerator:Resident 42 -one vial of injectable LantusResident 66 -one vial of injectable LantusResident 92 -one vial of injectable NovologResident 94 -one vial each of injectable Novolog and Lantus Exposure of injectable medications to freezing temperatures is inconsistent with manufacturer guidelines and may compromise medication integrity. During an observation of the stock medication cabinet located at the second-floor nursing station on January 27, 2026, at 9:30 AM, the following medications were observed available for use despite being expired or improperly labeled:Antacid tablets expired December 2025Zinc ointment expired October 2025One open vial of Simethicone capsules with no documented date of openingOne open vial of Aspirin 81 mg with no documented date of opening An interview with the director of nursing on January 27, 2026, at 9:30 a.m., confirmed that the above injectable blood glucose-lowering agents were to be stored in the refrigerator and maintained between 36-46 degrees Fahrenheit. In addition, all medications once opened should be dated at that time, and any expired medications are to be discarded. 28 Pa. Code 211.12 (c)(d)(3) (5) Nursing services. 28 Pa. Code 211.10(d )Resident care policies.

Based on observations, review of select facility policies, test tray evaluation, review of facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for four of 23 residents sampled (Residents 12, 26, 30, and 1).Findings included: According to the federal regulation 483.60(i)-(2) Food safety requirements, the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility Safe Food Handling Practices Policy last reviewed January 23, 2026, revealed that hot food must be held at 135 degrees Fahrenheit or higher and cold foods must be held at 41 degrees or lower. During an observation of the dietary department on January 26, 2026, at 10:00 AM, the facility's dishwasher was observed to be inoperable. During an interview at that time, the Food Service Director (FSD) stated the dishwasher had been broken for approximately one month and confirmed that disposable paper products and plastic silverware were being used for resident meal service. A review of facility-provided information revealed the dishwasher malfunctioned and became inoperable on November 21, 2025. A review of Resident Food Committee Meeting Minutes dated December 25, 2025, revealed residents expressed concerns that the dishwasher had not yet been repaired and reported that food was being served cold. A subsequent review of Food Committee Meeting Minutes dated January 14, 2026, revealed residents continued to voice concerns that the dishwasher remained unrepaired and requested that hot foods be served on plates rather than Styrofoam. During an interview on January 27, 2026, at 12:00 PM, Resident 12 stated that meals were frequently served cold and not palatable and reported meals being served on Styrofoam containers for several months due to the broken dishwasher. During an interview on January 27, 2026, at 12:30 PM, Resident 26 stated dissatisfaction with the food and reported being tired of receiving cold meals. During an interview on January 27, 2026, at 12:45 PM, Resident 30 stated the facility was aware he did not like the food and reported that meals were always cold. During an interview on January 28, 2026, at 10:30 AM, Resident 1 stated they liked the food but reported it was frequently not hot enough. A test tray evaluation was conducted on the Third Floor Nursing Unit on January 28, 2026, during the lunch meal. The test tray arrived on the unit at 12:16 PM and consisted of a hotdog on a bun, corn, pork and beans, ice cream, milk, and coffee. The meal was served in Styrofoam containers, with coffee served in a thermal mug. At 12:28 PM, after the last resident on the unit was served, food temperatures were measured and recorded as follows:Hotdog on bun: 111 F (below the required minimum of 135 F)Corn: 106 F (below the required minimum of 135 F)Pork and beans: 122.6 F (below the required minimum of 135 F) The hot dog, corn, pork and beans tasted only lukewarm and were not palatable. During an interview on January 28, 2026, at 1:15 PM, the Food Service Director confirmed that meals are required to be served at safe and appetizing temperatures and acknowledged that the test tray temperatures did not meet facility policy or regulatory requirements. A review of Test Tray Audits completed by the Registered Dietitian (RD) on November 21, 2025 (third floor lunch), November 28, 2025 (third floor lunch), December 4, 2025 (second floor lunch), December 12, 2025 (third floor lunch), January 9, 2026 (third floor lunch), and January 15, 2026 (second floor lunch) revealed that multiple hot food items were documented as not being served at palatable temperatures During an interview on January 29, 2026, at 1:40 PM, the Registered Dietitian confirmed that complaints related to cold food had increased since the dishwasher became inoperable. During an interview on January 29, 2026, at 2:30 PM, the Nursing Home Administrator confirmed the facility failed to ensure meals were consistently served at temperatures that were palatable and in accordance with regulatory requirements. Refer F80228 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(3) Management.

Based on a review of clinical records, facility-provided documentation, and employee interviews, it was determined the facility failed to ensure the accuracy and completeness of resident medical records for one of 3 closed records (Resident 98). Findings include:Review of the clinical record revealed that Resident 98 was admitted to the facility on [DATE], and subsequently transferred to the emergency department on November 28, 2025. Following a fall on November 25, 2025, neurological check assessments (routine monitoring for signs and symptoms of head or brain injury) were initiated for Resident 98. Review of these neurological assessments revealed a total of 21 assessments were documented as completed. However, the electronic clinical record indicated the neurological assessment documentation was not finalized or locked until January 7, 2026. A lock date represents the point at which documentation is finalized and made read-only to prevent further alteration. Further review revealed that 13 of the 21 neurological assessments were not signed as completed until after Resident 98 had already been transferred to the emergency department on November 28, 2025. Additional record review revealed the presence of late-entry progress notes. A progress note dated November 27, 2025, at 11:29 AM documented that Resident 98 was awake, alert, oriented to self, and confused per baseline; however, the electronic record indicated this note was created on November 30, 2025, at 2:31 PM. Similarly, a progress note dated November 28, 2025, at 10:37 AM documented that the resident was awake, alert, oriented to self, and confused per baseline, yet the electronic record showed this note was created on November 30, 2025, at 2:38 PM. In addition, the facility provided a certified registered nurse practitioner (CRNP) progress note dated November 26, 2025, and signed at 5:27 PM. This note was not uploaded into Resident 98's electronic clinical record. The facility also provided an amended version of the CRNP progress note dated November 26, 2025, and signed on November 28, 2025, at 6:33 PM; this amended note was likewise not uploaded into the resident's electronic clinical record. During an interview conducted on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The NHA explained that facility staff were temporarily covering the duties and responsibilities of the medical records practitioner while the facility was in the process of arranging consultative medical records services. These findings demonstrated that the facility failed to ensure Resident 98's clinical record was accurate, complete, and reliably maintained. Refer F55228 Pa. Code 211.5 (f)(ii)(iii)(iv)(x)(i) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of facility policy, prior survey findings, the facility's Plan of Correction (POC), and observations made during the revisit survey, it was determined the facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, monitored, and corrected ongoing deficient practice related to environmental cleanliness and maintenance.Findings included:Quality Assurance and Performance Improvement (QAPI), which is a systematic and ongoing process used by a facility to identify problems, implement corrective actions, and ensure those actions are effective and sustained over time, was reviewed. A review of the facility policy titled Quality Assurance Performance Improvement, last reviewed by the facility on January 23, 2026, revealed the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life. The facilities' QAPI program shall address all systems of care and management practices, include clinical care, quality of life, and resident choices, utilize the best available evidence to design and measure indicators of quality, and have facility goals that reflect the process of care and facility operation that have been shown to be predictive of desired outcomes for residents and reflect the complexities of the services provided at the facility. A review of the survey completed January 30, 2026, revealed the facility was previously cited for failing to maintain a safe, clean, comfortable, and homelike environment throughout the facility whereas the facility failed to provide housekeeping services to maintain a clean and orderly environment throughout the facility.A review of the facility's submitted Plan of Correction (POC), which is the facility's written plan describing how it will correct identified deficiencies, prevent recurrence, and monitor ongoing compliance, with a completion date of March 10, 2026, revealed the facility implemented corrective actions that included cleaning identified areas, re-educating environmental services staff, conducting routine audits of resident rooms and common areas, and reporting audit results to the QAPI committee for ongoing monitoring and evaluation. However, observations conducted throughout the facility during the revisit survey on March 12, 2026, revealed continued concerns with environmental cleanliness and maintenance across multiple floors, including resident rooms, hallways, dining areas, and common spaces. These findings were consistent with previously cited concerns and demonstrated that corrective actions were not sustained. The continued presence of environmental concerns after implementation of the Plan of Correction demonstrated that the facility's QAPI program failed to effectively monitor the identified problem, analyze the underlying causes, and ensure that corrective actions were consistently implemented and maintained. The facility's QAPI monitoring activities failed to identify the recurrence of deficient practice related to housekeeping and maintenance and failed to ensure that previously implemented corrective actions resulted in sustained compliance with regulatory requirements. Refer F584 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, facility-provided documentation, and interviews with staff and the resident representative, it was determined the facility failed to ensure that the resident representative was fully informed, in advance and in sufficient detail, by the physician or other practitioner, of the resident's condition, the risks and benefits of proposed treatment, and available treatment alternatives, in order to make an informed decision regarding care. This failure occurred for one of three closed records reviewed (Resident 98).Findings include:According to the National Institute of Health (NIH) and National Library of Medicine, Informed Consent is defined as the cornerstone of medicine, ensuring ethical treatment decisions and patient-centered care. Patients have the right to make informed and voluntary treatment decisions. Informed consent is more than merely a signature on a document; it is a communication process between the clinician and the patient. This process ensures that the patient is fully informed about the nature of the procedure or intervention, the potential risks and benefits, and the alternative treatments available. A clinical record review revealed Resident 98 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and 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 clinical record review further revealed Resident Representative 1 was identified as Resident 98's responsible party/guarantor (the person legally and financially responsible for decisions and payment), substitute decision maker, and primary emergency contact. A review of Resident 98's admission agreement showed Resident Representative 1 signed the agreement on behalf of the resident. The admission agreement stated the facility's commitment to provide professional care and included resident rights, specifically the right to be fully informed in advance about care and treatment, to participate in care planning, and to be informed in advance of any changes in treatment. The agreement further stated the resident, or representative has the right to be informed, in advance and in understandable language, by the physician or other practitioner, of the risks and benefits of proposed care, treatment alternatives, and available treatment options, and to choose the preferred option. A review of Resident 98's admission agreement with the facility revealed Resident Representative 1 signed Resident 98's admission agreement as the resident representative. Further review of the admission agreement revealed the facility is committed to providing professional care and support services that will accommodate residents' medical and personal care service needs. By law you have the following rights: Freedom of Choice-Sec. 1919(c)(1): You have the right to be fully informed in advance about the care and treatment you will receive, to participate in planning your care and treatment, and to be fully informed in advance of any changes in your care plan or treatment.A review of Resident 98's admission agreement with the facility revealed section (c) Planning and Implementing Care. The resident has the right to be informed of and participate in his or her treatment, including: The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to his or her medical condition. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care. The right to be informed in advance, by the physician or other practitioner of the profession, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers. A review of an external Advanced Practice Nurse (APN) notes dated November 25, 2025, at 7:19 PM, revealed Resident 98 was evaluated following a fall with head strike. An APN (a licensed clinician with advanced education and training authorized to assess patients and recommend medical treatment) conducted the assessment through clinical review and video observation. The APN documented the resident's past medical history included dementia (a condition that affects memory, judgment, and the ability to understand and communicate information). The note indicated the resident experienced an unwitnessed fall from standing to the floor, striking her head, and was observed to have a golf-ball-sized mass on the head. The resident was noted to be taking aspirin (an antiplatelet medication that reduces the ability of blood platelets to stick together, which increases the risk of bleeding) and Plavix (another antiplatelet medication that also reduces platelet aggregation and increases bleeding risk). Examination findings, based on nursing assessment and video observation by APN, indicated the resident was alert and responsive and had a large, round mass approximately the size of a fist in the parietal area of the head (the side and top portion of the skull). The APN documented diagnoses of localized swelling, mass, and lump of the head and determined the resident required a computed tomography (CT) scan (a diagnostic imaging test that uses X-rays and computer technology to create detailed images of internal body structures) to rule out an acute intracranial hemorrhage (a life threatening condition involving bleeding inside the skull). The APN documented the condition was an acute new problem, assessed it as critical, recommended reevaluation of the resident's fall-risk care plan, and obtained physician orders for transfer to the emergency department.A review of a progress notes dated November 25, 2025, at 8:11 PM, documented the resident was in the dining room when the resident attempted to stand, became unsteady, and fell to the floor, striking the back of the head. The note documented the registered nurse supervisor was notified and assessed the resident. Vital signs were obtained, an ice pack was applied to the back of the resident's head, and neurological checks (routine monitoring for signs and symptoms of head or brain injury such as changes in level of consciousness, pupil response, strength, or sensation, were initiated. The nurse documented the resident's pupils were equal and reactive, the resident had full range of motion, and no signs or symptoms of pain or discomfort were observed at that time. The progress notes further documented that an external advanced practice nurse was notified and provided an order to transfer the resident to the emergency department for further evaluation. The note indicated the resident representative was informed of the order and declined the transfer at that time. However, the progress note did not document that the resident representative was informed the resident sustained a head strike, did not document the presence or size of any head injury or head mass, and did not document that the resident representative was informed of the potential seriousness of the resident's condition, including the risk of intracranial bleeding (bleeding within the skull). The note did not document that the resident representative was informed that the hospital transfer was ordered to allow diagnostic evaluation, including a computed tomography (CT) scan of the head, to assess for possible internal injury, nor did it document that the risks associated with refusing transfer following a head injury were explained. The progress note documented subsequent neurological checks were within normal limits. The resident was seated in a chair at the nurse's station for closer observation, and the note indicated the resident would continue to be monitored for the remainder of the shift. During a phone interview on January 30, 2026, at 11:42 AM, Resident Representative 1 explained that the facility contacted her on November 25, 2025, to inform her that Resident 98 had fallen and that an APN wrote an order to send the resident to the emergency department. Resident Representative 1 indicated she was informed that the facility did not think there was a need to send the resident to the emergency department. She further stated she was not informed that the resident struck her head, developed a fist-sized mass, was considered critical, or that the transfer was recommended to rule out a potentially life-threatening intracranial hemorrhage. During an interview on January 30, 2026, at 12:05 PM, Employee 4, Licensed Practical Nurse, stated she contacted Resident Representative 1 on November 25, 2025, to report the fall and the APN's order for emergency department transfer. Employee 4 was unable to provide documented evidence that she communicated the critical assessment, head injury findings, size of the mass, or the specific risks associated with declining transfer, including the need for a CT scan to rule out intracranial bleeding. Review of the clinical record confirmed there was no documentation that this information was communicated. During an interview on January 30, 2026, at 12:30 PM, the Nursing Home Administrator (NHA) reviewed the above information and was unable to provide documentation demonstrating the facility ensured Resident Representative 1 received sufficient, detailed information to make an informed decision regarding treatment options following the fall. Specifically, there was no documented evidence the facility communicated the APN's findings that the resident's condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. During an interview on January 30, 2026, at 12:30 PM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence the facility provided detailed information to Resident Representative 1 to make an informed decision about Resident 98's treatment options after the fall on November 25, 2025. Specifically, there was no documented evidence the facility communicated the APN's findings that the resident's condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. The facility failed to ensure the resident representative was fully informed of the risks, benefits, and treatment alternatives, as required, prior to declining the recommended transfer to the emergency department, thereby limiting the resident representative's ability to make an informed decision regarding Resident 98's care. Refer F842 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(7) Medical director. 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services.

Based on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders accurately reflected a the resident's documented resuscitation status for one of 23 residents reviewed (Resident 73).Findings include:A review of a facility policy titled Residents' Rights Regarding Treatment and Advanced Directives, last reviewed by the facility on [DATE], revealed it is the facility policy to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated. Review of the clinical record revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of the right breast (breast cancer) and vascular dementia (a decline in thinking, memory, and cognitive skills caused by reduced or blocked blood flow to the brain, which deprives the brain cells of oxygen and nutrients). Review of the resident's current physician orders at the time of the survey ending [DATE], revealed an order identifying the resident's code status as Full Code, indicating cardiopulmonary resuscitation (CPR) was to be initiated in the event of cardiopulmonary arrest (if breathing stops or if the heart stops beating). The resident's electronic health record also reflected the status of Full Code. Further review of the clinical record revealed a completed and signed Physician Orders for Life Sustaining Treatment, or POLST (a form designed to improve resident care by creating a portable medical order form that records the resident's treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency, taking the resident's current medical condition into consideration) dated [DATE], indicating the resident elected CPR and attempted resuscitation. Review of nursing documentation dated [DATE], at 12:31 AM indicated the resident was admitted to hospice services (end of life care). The documentation stated the resident's son was aware and would be coming to the facility later that day to complete the Do Not Resuscitate (DNR, a medical order directing that cardiopulmonary resuscitation, a life-saving procedure performed when the heart or breathing stops, should not be attempted) paperwork to change the resident's code status. Review of social services documentation dated [DATE], at 6:33 PM indicated the resident's son met with the Certified Registered Nurse Practitioner and hospice staff and expressed that he did not want aggressive treatment for his mother due to her diagnosis of breast cancer. The note further stated confirmation was obtained from the hospice social worker that the resident's code status had been changed to DNR upon admission to hospice on [DATE]. Despite documentation indicating the resident's code status had been changed to DNR, the resident's electronic health record, POLST, and physician orders continued to reflect Full Code status. During an interview on [DATE], at 11:10 AM the Director of Social Services provided the surveyor with a Do Not Resuscitate document signed by the resident's son on [DATE], and by the physician on [DATE]. The Director of Social Services confirmed that the resident's change in code status from Full Code to DNR was not implemented after the physician signed the DNR order. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.5 (f)(i) Medical records. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 211.10 (c)(d) Resident care policies.

Based on a review of clinical records, select facility policy, investigative documentation provided by the facility, and interviews with facility staff, it was determined the facility failed to protect one of five sampled residents (Resident 3) from neglect by not implementing the individualized care plan intervention of a mechanical lift for all transfers, resulting in actual harm in the form of a spiral fracture of the left tibia. This deficiency is cited as past noncompliance Findings include: A review of a facility policy titled Abuse, Neglect, and Exploitation, last reviewed by the facility on February 19, 2025, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse and neglect. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that include 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) and osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down). A review of Resident 3's individualized care plan revealed she has an activities of daily life (ADL) self-care performance deficit related to dementia initiated on June 6, 2025. Interventions implemented to assist Resident 3 with her goal to improve her level of functioning through the review period include transfers with the assistance of two staff with the Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility between surfaces like beds, chairs, or wheelchairs) implemented on June 6, 2025. A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 12, 2025, documented that Resident 3 was severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). A review of a Task List Report (a report that indicates the date when interventions were added to the Kardex, a quick reference for staff that includes a summary of resident required care information) revealed Resident 3 was to be transferred with the assistance of two (employees) for all transfers and the Hoyer lift was initiated on June 5, 2025. A progress note dated June 24, 2025, at 3:32 PM indicated Employee 1, a licensed practical nurse (LPN), went into Resident 3's room to administer morning medications around 8:20 AM. Employee 1, LPN, indicated when the employee raised the head of the resident's bed, Resident 3 began yelling, My leg is hurting. Don't touch it!. Upon examination, red discoloration and swelling were noted on the inner lower left leg. An X-ray ordered by the Certified Registered Nurse Practitioner (CRNP) confirmed a nondisplaced spiral fracture across the distal left tibia (A twist type break in the lower part of the left shin bone near the ankle. The broken bone pieces are still lined up correctly and have not shifted out of position). A review of the documentation survey report dated June 2025 revealed Employee 2, agency nurse aide (NA), transferred the resident to bed on June 23, 2025, during the 3 to 11 nursing shift. A facility-provided investigative document dated June 25, 2025, revealed Employee 2, an agency nurse aide (NA), indicated that Resident 3 was in her chair at 4:00 PM when she arrived (on June 23, 2025). The document indicated Employee 2, Agency NA, was questioned about how she transferred Resident 3 into her bed that evening. Employee 2, Agency NA, stated, Nobody helped. I put her arms around me and put her back to bed myself. A review of the facility provided investigative witness statements that revealed no other employees were aware of any falls, improper transfers, injuries, or distress related to Resident 3 from June 23, 2025, through June 24, 2025, until 8:20 AM. A physician's order for acetaminophen oral tablet 500 mg with directions to give by mouth three times a day related to fracture was initiated on June 24, 2025. A review of Resident 3's Medication Administration Record dated June 2025 revealed the resident received Acetaminophen 325 mg at 8:30 AM for a pain level of three out of ten on June 24, 2025, and received Acetaminophen 500 mg three times a day from June 24, 2025, at 9:00 PM through July 8, 2025. A subsequent orthopedic consult report dated June 27, 2025, indicated Resident 3's left leg presented with redness and tenderness. The consultation indicated a diagnosis of a left tibial shaft fracture requiring non-weight bearing precautions, daily skin inspections to the left leg, a CAM boot (a device used to immobilize and protect the foot and ankle after an injury or surgery) for 6 to 12 weeks to the left leg, and a follow-up appointment in 4-6 weeks. During an interview conducted on July 8, 2025, at 9:55 AM, Employee 1 (Licensed Practical Nurse) confirmed that she first observed Resident 3 complaining of leg pain on June 24, 2025, at approximately 8:30 AM. Employee 1 stated that Resident 3's lower left leg appeared red and swollen. Employee 1 further explained that when she asked Resident 3 what had happened, the resident replied that the girl with the band on her head had hurt her. Employee 1 also reported that she had last provided care to Resident 3 the previous day, June 23, 2025, at approximately 3:15 PM, at which time the resident was seated in her chair in her room and showed no signs of pain or distress. During a telephone interview on July 8, 2025, at 12:07 PM, Employee 2 (Agency Nurse Aide) confirmed that she transferred Resident 3 by herself on June 23, 2025. Employee 2 stated that she was not familiar with Resident 3's specific care needs and was unaware that the resident's care plan required all transfers to be performed with two staff members and the use of a mechanical lift. Employee 2 also indicated that she did not know how to access resident care plan interventions in the facility's system and was unaware that Resident 3's leg had been injured. Employee 2 confirmed she was assigned to Resident 3's hallway from June 23, 2025, at approximately 4:00 PM until the end of her shift on June 24, 2025, at 7:00 AM. A review of Employee 2's personnel file showed that she had signed an attestation on April 27, 2025, acknowledging that she received the facility's orientation, which included training on the facility's abuse and neglect policy, safe transfer and lift procedures, and the use of the electronic health record system. During an interview on July 8, 2025, at approximately 12:45 PM, the Director of Nursing confirmed that the facility's investigation determined that Employee 2 failed to follow Resident 3's care plan, which required assistance from two staff and the use of a mechanical lift for all transfers. This failure resulted in serious physical injury in the form of a spiral fracture of the tibia. The Director of Nursing stated that Employee 2 was immediately removed from the staffing schedule and placed on the facility's do not return list for agency staff. This deficient practice resulted in actual harm and is cited as past noncompliance. Corrective actions implemented by the facility included: Per physician, the resident was ordered an X-ray of the left lower extremity. It was determined the resident has a spiral fracture of the left tibia. The resident's chart was reviewed for transfer status orders, transfer status in tasks, care plan, and the Kardex. No other residents were affected. All residents' charts were reviewed to confirm current transfer status orders matched care plan interventions and Kardex summaries All new admission charts will be audited for transfer status orders, transfer status on care plans, tasks, and Kardex. Education on abuse, neglect prevention, transfer procedures, and proper use of the Kardex was provided to all clinical staff, including agency staff. The Director of Nursing or designee performs random audits of caregivers once a week for four weeks, then every two weeks for two months, to ensure care provided matches each resident's individualized care plan. Audit results are reviewed during quality assurance and performance improvement meetings for further action as needed. The facility's compliance date for correction of this deficient practice was June 30, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, the facility's abuse prohibition policy, select investigative reports, and interviews with staff and residents, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with assistance of two-persons as planned to ensure safety and prevent major injuries, fractures to the left distal femur and right distal tibial, for one resident, Resident 2, out of eight sampled residents for abuse prohibition. Findings include: Review of the facility's policy entitled Abuse, Neglect, and Exploitation that last revised by the facility on January 1, 2024, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility would deploy trained and qualified registered, licensed, and certified staff on each shift and assure that the staff assigned have knowledge of the individual residents' care needs and behavior symptoms. Review of Resident 2's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses to include unspecified intellectual disabilities (neurodevelopmental condition that develops in childhood and affects one's capacity to learn and retain new information, and it also affects everyday behavior such as social skills and hygiene routines. Individuals with this condition experience significant limitations with intellectual functioning and developing adaptive skills like social and life skills) liver disease (is a broad term to describe damage to the liver), anxiety disorder, and abnormalities of gait (walking pattern) and mobility. Review of Resident 2's Quarterly MDS assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 29, 2024, revealed the resident had a BIMS score of 3 (Brief Interview for Mental Status is a tool used to evaluate cognitive impairment and assist with dementia diagnosis. A score of 0-7 equates to severe cognitive impairment). Review of Resident 2's current comprehensive person-centered care plan, initiated on July 1, 2022, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to intellectual disabilities, history of falls, and a history of seizures. Planned resident centered interventions revealed he required two-staff participation with bed mobility to reposition and to turn in bed, and also required two-staff participation for bathing/showering and dressing, bed mobility, transfers, toileting and hygiene. Additionally, the resident's cognition and communication care plan indicated the resident had impaired cognition but is able to respond yes or no to simple questions when asked. A review of a nurses note completed by Employee 1, a Licensed Practical Nurse (LPN), dated September 7, 2024, at 7:05 PM, revealed Resident 2 was yelling out in pain when rolled to the left side on his hip area and when his left leg is lifted. On call CRNP (certified registered nurse practitioner) was made aware and new orders were obtained for a STAT x-ray (immediate) of the left hip and leg. The resident's responsible party (RP) was made aware. The X-ray was completed at 11:30 PM. A review of the x-ray results dated September 8, 2024, at 4:41 AM, revealed the resident had sustained an acute displaced comminuted fracture (fractures caused by severe trauma) to the distal femur (thighbone that occur just above the knee joint), and the on-call physician was notified, and the resident was transferred to the hospital. A review of an investigative report provided by the facility, completed by Employee 1, a Licensed Practical Nurse (LPN), dated September 8, 2024, at 4:41 AM, in response to the resident's pain and unknown injury indicated the x-ray results of Resident 2's left femur/knee were received, and impression read acute displaced comminuted (result of trauma or force to an area) distal femoral fractures with no witnessed to report. Immediate actions were to notify the on-call physician with new orders noted to send resident to the emergency room (ER) for evaluation and treatment. The responsible party (RP) was aware and in agreement with the treatment. A review of the facility's investigation revealed a witness statement completed by Employee 2, a Nurse Aide (NA), dated September 8, 2024, no time indicated, indicated Employee 2, last saw the resident during last rounds and was laying in bed around 6:00 PM on September 7, 2024. A co-worker, Employee 3, a NA and I changed the resident, and I didn't witness any fall or abuse. Additionally, during a staff interview conducted by the facility's Director of Nursing, on September 8, 2024, no time indicated, Employee 2 stated she provided care to Resident 2 at approximately 8:30 AM on September 7, 2024, with NA Employee 3 present to help her. Employee 3 noticed his leg was not right, so she got the nurse, Employee 1, LPN. (Employee 1 did not confirm she evaluated the resident at this time as per statements) Employee 2 stated the next time she provided care to the resident was at 2:00 PM, with Employee 3 on September 7, 2024. Employee 2 stated the resident seemed to be in pain when care was rendered. Employee 2 stated that at 4:00 PM, she and Employee 3 were providing care to the resident and they asked Employee 1, LPN to evaluate his leg, the nursing supervisor was also notified at this time. A review of a witness statement completed by Employee 3, a NA, no date or time noted on the statement, revealed around 1:45 PM on September 7, 2024, her co-worker Employee 2 NA asked her to assist her to provide care to Resident 2, Employee 2 NA, informed her something seemed to be wrong with the resident's leg, when Employee 2 moved his leg he cried out in pain. Employee 3 followed Employee 2 into the room, and Employee 2 started to push him towards Employee 3 in order to change his brief and he cried out in pain. Employee 3 told Employee 2 to call the nurse and the nurse came into the room and she was informed of the resident's pain. A review of statements obtained during a verbal interview conducted by the DON and signed by Employee 3 on September 9, 2024, no time indicated, regarding September 7, 2024, revealed a statement that read The first time I assisted to help change Resident 2 was at approximately 2:00 PM, with Employee 2. Employee 2 came to me and said, can you come help me with Resident 2, I think there is something wrong with his leg. They did not see Employee 1 right away but did get her and Employee 1, LPN evaluated the resident, Employee 3 stated I did not care for or help care for him for the rest of the night. Further review of a witness statement completed by Employee 4, a LPN, in response to the concern for Resident 2 from September 7, 2024, (verbal statement obtained by telephone, not dated as to when obtained) revealed she was made aware by Employee 2, NA when the resident was moved to the left side he yelled out in pain. Employee 4 stated she went in to assess the resident and when she picked up his left leg by the calf area he yelled out in pain. Employee 4 made the on-call physician aware and a STAT (immediate) x-ray (are used to generate images of tissues and structures inside the body, an image will be formed that represents the shadows formed by the objects inside of the body) was ordered and awaiting results at this time 11:26 PM. Employee 4 indicated she was his nurse on 3-11 PM shift on September 6, 2024, and there were no signs or symptoms of pain or discomfort. A review of the emergency department nursing progress notes dated September 8, 2024, at 6:11 AM, indicated that Resident 2 was mostly non-verbal with minimal short verbal responses and the note indicated the resident was questioned regarding his leg injury. The resident was asked if he fell out of bed at the nursing facility and he responded yeah. The resident was asked a second time to confirm, and he once again stated yeah, when asked if he fell out of bed at the nursing facility. A review of the emergency department documentation dated September 8, 2024, at 11:30AM revealed the resident sustained a left distal femur fracture and a right distal tibial fracture. During on-site survey conducted on October 1, 2024, a phone call was placed at 1:30 PM, to Employee 3 to gather additional details related to the incident that occurred September 7, 2024. However, Employee 3 did not return the phone call. There was no documented evidence or confirmation that Employee 3, NA assisted Employee 2 NA with Resident 2's care at 8:30 AM on September 7, 2024 as indicated by Employee 2. There was also no documented evidence or confirmation that Employee 1 LPN was made aware of the concerns of Resident 2's leg not being right at 8:30 AM on September 7, 2024, as per statement from Employee 2, NA. There was no documented evidence to determine that Employee 2 utilized the proper assistance of two staff members to provide care to Resident 2 at 8:30 AM. Employee 2 indicated she cared for the resident at 8:30 AM assisted by Employee 3 however Employee 3 stated she only assisted Employee 2 to care for resident at 2:00PM. During an interview with the nursing home administrator (NHA) and DON on October 1, 2024, at 2:00 PM, it was reported the facility's investigation process revealed that Employee 2 failed to consistently provide assistance of two persons with bed mobility as planned for Resident 2 to maintain safety and deter injury. Additionally, it was confirmed that Employee 2 neglected to fulfill duties required to safely render care to Resident 2 that resulted in a left distal femur fracture and a right distal tibial fracture causing the resident pain and discomfort. The facility failed to ensure that Resident 2 was provided the services necessary to avoid serious physical harm by ensuring that Employee 2 consistently provided care to the resident with the assistance of another staff member as planned. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on review of clinical records, select facility policy and investigative reports and staff interview, it was determined that the facility failed to ensure that at least three residents (Residents 7, 22, 61) were free from physical and verbal abuse and resultant serious physical injury, a [MEDICAL CONDITION], for one resident (Resident 61) perpetrated by one resident (Resident CR1) out of seven sampled residents. Findings include: A review of the facility's current policy entitled Abuse Prohibition and Protection Policy dated (MONTH) 2019, revealed that it is the policy of the facility that all residents have the right to be free from verbal, sexual, physical and mental abuse. Residents must not be subjected to abuse by anyone, including, but not limited to: facility staff, other residents, consultants, contractors and volunteers, etc. Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse is defined as hitting, slapping, pinching and kicking. Verbal abuse is defined as the oral, written or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, regardless of age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to; threats of harm; saying things to frighten residents. Further review of the aforementioned policy revealed the facility will thoroughly investigate all reports of suspected or alleged abuse. The facility shall notify the Department of Health, Department of Aging and Area Agency on Aging, Adult Protective Services, local law enforcement and licensing agencies depending on the circumstances of the allegation or actual event in compliance with Federal and State regulations and the Elder Justice Act. A review of the clinical record revealed that Resident CR1 was admitted to the facility on (MONTH) 28, (YEAR). The resident had [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated (MONTH) 6, 2019, revealed that the resident's was cognition was intact. A review of the resident's care plan dated (MONTH) 14, 2019, revealed the resident had the potential to exhibit behaviors at times as evidenced by agitation with peers and/or staff and had a [DIAGNOSES REDACTED]. Care plan interventions, dated and revised on (MONTH) 17, 2019, included to consult behavioral health for added psychosocial support, move resident to less populated area if found agitated with peers, separate from peers if physically aggressive, if entering a room other than his, offer redirection and reorientation, provide emotional support, redirect resident from other residents who are loud or behavioral, provide medications as per MD order and provide 1 to 1 and/or offer emotional support as needed if exhibiting signs/symptoms of [MEDICAL CONDITION]. A review of a nursing documentation dated from (MONTH) 6, (YEAR) through (MONTH) 6, 2019, revealed documented behaviors of verbal and physical outbursts displayed by Resident CR1: holding another resident's wheel hair handle with one hand and his other hand in fist and saying 'I'm going to hit you; approached another resident and kicked him in the shin, no injuries; screaming at another resident and threatening to hit the other resident with his fist; yelling at a resident to shut up in sun room; threw a cup of water on CNA (certified nurse aide) while providing care to room mate; at nurses station stated I'm going to kill that son of a [***] referring to another resident; yelling and using foul language toward another resident (his room mate) in dining room; leaving dining room had a verbal outburst at another resident threatening to beat him up; staff observed striking another resident for entering his room-feels he has the right to hit this resident since he was entering his room without permission; in dining stated to another resident (his roommate) 'I'll kick your f--king ass; verbal altercation with another resident (roommate); came out of hallway and was cursing at resident from 227A and then proceeded to kick and punch this resident; another verbal altercation with roommate-pushed door at roommate and threw a cup at him; another verbal altercation with room mate outside during smoke break; resident denies any mal intent, but admits to a quick trigger when angry; .grabbed another resident's shirt and pulled resident to floor in common area while getting ready for dinner. Similar instances of verbally and physically abusive behaviors directed at other facility residents were documented in the resident's clinical record by nursing and social services staff on 18 occasions during the above referenced time period. A review of a nurses' note dated (MONTH) 6, (YEAR), at 10:47 p.m. and an Incident/Accident report dated (MONTH) 6, (YEAR), at 10:13 p.m. revealed that the licensed practical nurse (LPN-Employee 1) heard a commotion in the dayroom. The nurse found Resident CR1 holding another resident's (not identified in the report) wheelchair, with one hand and other hand in a fist, saying I'm going to hit you. At 10:47 p.m. on (MONTH) 6, (YEAR), Employee 1 documented that Resident CR1 approached the other resident (not identified) and kicked him in the left shin with no injuries noted. Further review of the investigative report revealed Resident CR1 stated that f--ker won't shut up. He starts every day, I am sick of his s--t .I'll kick his ass. Review of an attached witness statement (a description of the event/incident by staff) by Employee 2 (NA-nurse aide) revealed that as she was pulling Resident CR1 away from the other resident, Resident CR1 kicked that resident in the left shin. Further review of the facility's investigate report revealed that the incident was not reported, as a reportable event, to the State Survey Agency and a Pennsylvania Bulletin PB22 (a state mandated report form for investigation of alleged abuse, neglect and misappropriation) was not initiated as required by the facility policy and regulatory requirements. A review of a nurses' note dated (MONTH) 15, 2019, at 1:20 p.m. and an Incident/Accident report dated (MONTH) 15, 2019, revealed that Employee 3 (LPN) noted that Resident 7 was wandering as per his norm and wandered into another resident's room (Resident CR1's room) when the other resident (Resident CR1) became angry and struck Resident 7 in the head and in the shoulder - no injuries. Further description of the incident noted that Resident CR1 had increased negative and aggressive behaviors and that the resident was to have a psych evaluation and stop sign added to resident's door. Further review of the facility's investigate report revealed that the incident was not reported, as a reportable event, to the State Survey Agency and an investigation (Pennsylvania Bulletin PB22) was not initiated. A review of a nurses' note dated (MONTH) 31, 2019, at 5:00 p.m., an Incident/Accident report dated (MONTH) 15, 2019, and facility submitted investigative report dated (MONTH) 1, 2019, revealed that Employee 4 (RN - registered nurse) noted that Resident CR1 came out into hallway and was cursing at resident (Resident 22) and then proceeded to kick and punch this resident making direct contact. Resident CR1 proceeded downstairs to smoke break. This writer went out to inform him his room was being changed. Explained he was the aggressor of the event and his room was being changed when he proceeded to swing arm and curse at this writer. Further review of the investigation revealed that Resident CR1 hit Resident 22 in the face and kicked him in the leg. Resident 22 sustained a small scratch to left cheek area. Interventions at the time included room change, CRNP (certified registered nurse practitioner) evaluation today and lab tests and hall monitoring in area around new room during 3:00 p.m. to 11:00 p.m. shift. A review of information dated (MONTH) 8, 2019, submitted by the facility revealed that Resident 61 was pulled out of her wheelchair by another resident (Resident CR1). He (Resident CR1) grabbed her shirt which caused her to fall out of her wheel chair. This happened prior to 6 PM meal time. She wanted to stay in dining room and eat dinner ,but later complained of pain and staff noted increased grimace with position changes. X-ray was obtained and acute left hip fx was noted. Follow Up - 911 was called for Resident CR1 to be sent to crisis. however he refused to go and is kept 1:1 by staff whenever out of room right now. Resident 61 is in process of being transported to hospital for treatment of [REDACTED]. The facility reported that the police investigation and APS investigation ongoing. Physician and psych services have ordered 302 crisis placement for Resident CR1 as he was deemed unsafe at this time. If they should deem him safe to return facility will follow recommendation of psych service and medical director for safety intervention. A review of a nurses' note dated (MONTH) 6, 2019, at 7:00 p.m., an Incident/Accident report dated (MONTH) 6, 2019, and a PB22 (investigative report) dated (MONTH) 6, 2019, revealed that Employee 4 (RN) documented that resident (Resident CR1) was involved in resident to resident altercation where resident (CR1) grabbed another resident's (Resident 61) shirt and pulled the resident to the floor (Resident 61). A review of a portable x-ray dated (MONTH) 6, 2019, indicated that Resident 61's suffered an acute left intertrochanteric (a type of [MEDICAL CONDITION] that occurs in the upper part of the thigh bone) [MEDICAL CONDITION] during the physical altercation with Resident CR1. As the result of the incident of physical abuse of Resident 61 on (MONTH) 6, 2019, Resident (CR1) was placed on 1 to 1 supervision at which time he got into a verbal altercation with another resident while passing. Resident (CR1) was redirected and assisted back to nursing unit where he was yelling and lashing out at staff members and had moments of crying. Further review of the nurses' note indicated multiple attempts were made to redirect resident's behaviors and verbal outbursts at different times with different staff members. Resident continues in 1 to 1. MD and responsible party made aware, will continue to monitor. At 7:16 p.m. on (MONTH) 6, 2019, Employee 6 (LPN), noted new orders received to send Resident CR1 to hospital Crisis for evaluation due to sudden onset of behavioral and mentation status changes. At 7:58 p.m. Employee 7 (RN) informed that transport agency refusing to transport resident to Crisis center at this time, as resident is alert and oriented times four and refusing to go. Transport agency feels resident answered their questions appropriately and at this time refusing to transfer resident at this time. The facility failed to follow their abuse policy in response instances of resident to resident abuse on (MONTH) 6, (YEAR) and (MONTH) 15, 2019. The facility failed to prevent the physical abuse of Resident 61 resulting in serious injury and failed to prevent the physical and verbal abuse of other residents in the facility perpetrated by Resident CR1. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/26/19 28 Pa. Code 211.10(d) Resident care policies. Previously cited 4/26/19 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services. Previously cited 6/21/19, 4/26/19 28 Pa Code 201.29(a)(c)(d) Resident rights.

Based on a review of clinical records, resident incident reports and information submitted by the facility and staff interviews, it was determined that the facility failed to provide sufficient staff assistance during resident care necessary to prevent an accident resulting in a fractured lower leg for one resident out of five residents reviewed (Resident 1). Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on (MONTH) 25, 1988, with [DIAGNOSES 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) 17, (YEAR), revealed that the resident was severely cognitively impaired and required extensive assistance with two persons for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). A review of information dated (MONTH) 7, (YEAR), submitted by the facility revealed that Resident 1 had a fall from bed. CNA (nurse aide) was providing care for incontinent BM (bowel movement). While changing the resident he had spastic movement and witnessed roll off of the right side of the bed onto fall mat. According to this submitted information the resident had a noted skin tear to the right leg and x-rays revealed a fractured right lower leg. A review of the resident's care plan, initially dated (MONTH) 4, 2010, revealed a problematic area of the resident's total dependency on staff for his care needs with a care planned intervention for the assist of two attendants (staff) for bed mobility. An additional care planned problem area, initially dated (MONTH) 20, (YEAR), was that the resident was at risk for falls. The resident's care plan was revised on (MONTH) 8, (YEAR), after the resident fell from bed on (MONTH) 7, (YEAR), again noting that the resident was at risk for falls. A nurses' note dated (MONTH) 7, (YEAR), at 7:30 PM indicated that the floor (nurse) aide reported that Resident 1 fell out of bed and landed on the floor mat during PM (evening) care. The resident is non-verbal and was unable to describe events. The floor aide denied that the resident hit his head. The resident sustained [REDACTED]. Nursing documentation dated (MONTH) 7, (YEAR), at 8:40 PM indicated that the licensed nurse assessment of the resident noted a bump/swelling to Resident 1's right shin area. The resident exhibited signs of pain to this area. The physician was contacted at that time and a stat (immediate) x-ray of the resident's right lower leg was ordered. The results from the x-ray dated (MONTH) 7, (YEAR), at 9:00 PM revealed a spiral fracture (a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone. The spiral fractures often occur when the body is in motion while one extremity is planted) of the midshaft of the right tibia (the bigger of the two lower leg bones) A review of a resident incident report dated (MONTH) 7, (YEAR), at 6:50 PM revealed that Employee 1 (nurse aide) was providing incontinence care to Resident 1 and the resident fell from bed. Review of an attached witness statement (a description of the event/incident by staff) signed by Employee 1, indicated that Resident 1 needed a brief change after a bowel movement. I noticed BM (feces) on his sheets. I changed his linen. His fall mats are on both sides of his bed. He was restless and he rolled off the bed. He pushed his bump pads ( raised pads placed on the sides of the bed to define the perimeter of the bed) off the bed. I called for help. He was on the fall mats. During an interview (MONTH) 19, (YEAR), at 5:30 PM Employee 1 stated that she had decided the level of assistance that this resident required during care on the evening of (MONTH) 7, (YEAR), at the time she provided his care. Employee 1 stated that at times the resident requires one staff for assistance with bed mobility and personal care and at other times the resident requires the assisstance of two staff. An interview with Director of Nursing (DON) on (MONTH) 19, (YEAR), at approximately 7:00 PM confirmed that Resident 1 was assessed to require and care planned for the assistance of two staff members with activities of daily living, as well as, having a history of spastic movements, of which the facility was aware. The DON further confirmed that Employee 1 had provided the resident's personal care by herself, without the assistance of another staff member, resulting in the resident's fall from bed and fractured lower leg. 483.25(d)(1)(2) Free of Accident hazards/Supervision/Devices Previously cited 10/3/17, 4/21/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 4/21/17 28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services Previously cited 5/18/18, 10/3/17, 6/8/17, 4/21/17

Based on review of clinical records and facility incident investigations and staff and resident interviews, it was revealed that the facility to maintain a safe environment, that was free of potential accident hazards for a resident with a history of falls and known unsafe behaviors, which resulted in a fall and fractured lower leg for one resident ( Resident A1) out of nine reviewed. Findings include: A review of Resident A1's initial plan of care dated January 13, 2017, revealed that the resident was identified at risk for falls related to a new environment upon the resident's admission to the facility on [DATE], and the resident's use of mood altering medications. The resident's comprehensive plan of care, most recently revised by the facility on August 12, 2017, revealed that the resident continued to be at risk for falls with planned interventions consisting of non-skid footwear, bed in low position, use of a bedside commode, alarms to the resident's bed and chair and a call bell sensor alarm (safety devices that emit an audible alarm when the resident attempts unassisted transfers from the bed or chair). A review of the resident's MDS Assessment (Minimum Data Set Assessment - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 2, 2017, revealed that the resident required extensive assistance of one staff member for toileting and transfers, utilized a bedside commode and required limited assistance of one person for ambulating in her room with the use of a walker. This was a decline in transfer status from the prior MDS assessment dated [DATE], when the resident required limited assistance with transfers. A review of the resident's Quarterly Minimum Data Set, dated dated dated [DATE], revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) was a 11 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the resident's clinical record revealed that on August 3, 2017, the resident was receiving antibiotic therapy for a urinary tract infection and had been showing increased signs of confusion. Nursing noted that the resident was ambulating in her room without supervision or the use of the walker. The resident was described as angry with the use of the alarms to her bed and chair. A review of nursing progress notes revealed that on August 5, 2017, the resident was non-complaint with the use of the alarms and with ambulating unassisted in her room. Nursing staff identified that the resident was shutting her alarms off prior to attempting to transfer or stand unassisted. When nursing instructed the resident to call for assistance, the resident expressed understanding, but remained non-compliant. Nursing progress notes dated August 7, 2017, revealed that the resident continued to be non-complaint with the alarms and self-transferring (without staff assistance). The resident was utilizing a call bell sensor light activation system, which activated a nurse call light when the resident attempted to transfer herself without staff assistance. A review of physician's progress notes revealed that the resident's Lasix (a diuretic medication used to remove excess fluid from the body) was increased to 20 mg twice daily on August 10, 2017. Nursing progress notes dated August 12, 2017, and timed 5:15 PM indicated that the resident sustained [REDACTED]. The resident denied hitting her head, but stated that she had hit her head when she fell earlier that day. The facility placed the resident on neurochecks (a brief neurological assessment to evaluate level of consciousness and orientation), in response to the unwitnessed fall, which the resident reported had occurred earlier that day prior to the current fall. Nursing progress notes later that same date, 7:28 PM on August 12, 2017, revealed that the resident was found on the floor of her room. The resident stated that she stood and slipped. The staff noted that the non-skid material on the slipper socks the resident was wearing was worn, which decreased their effectiveness as a fall prevention intervention. On August 13, 2017, nursing noted that the resident was found ambulating by herself to the bathroom during the 11 PM to 7 AM shift. The resident's gait was described as unsteady. The interdisciplinary team assessed the resident's falls on August 14, 2017, and the plan was to remind the resident again to ring for staff assistance. According to nursing progress notes, the resident was found ambulating in her room unassisted attempting to go into the bathroom on August 17, 2017. A review of nursing progress notes dated August 26, 2017, revealed that at 6:45 AM the resident was found on the floor between her bed and her roommate's bed, on the floor mat, which had been positioned next to her roommates bed. The resident's bed activating alarm was not sounding because the resident had turned it off, but her call light was sounding . The resident stated that she had gotten up and out of bed to check on her roommate and tripped over her roommate's fall prevention mat. Resident 1 sustained a displaced (bone snaps into two or more parts and moves so that the two ends are not lined up straight) comminuted fracture (break or splinter of the bone into more than two fragments) of the middle and distal (situated away from the center of the body) shaft of the right fibula (the outer calf bone and usually smaller of the two bones between the knee and the ankle). A review of the facility's investigation into the incident dated August 26, 2017 revealed that Employee 1 (LPN, licensed practical nurse) noted that staff had last seen resident lying in bed at 6:10 AM on August 26, 2017. Employee 1 noted that the resident was not sleeping at that time, because her new roommate was yelling all night keeping her awake. When interviewed on October 3, 2017 at 2:15 p.m., the resident recalled that when she broke her leg she had tripped on her roommate's fall mat after getting out of bed to see if she could stop her roommate from calling out. When interviewed on October 3, 2017 at 2:45 p.m., the Director of Nursing Services confirmed that a Respite resident (a short term admission of a resident to provide relief to the resident's usual home care givers) had been placed Resident 1's prior to the incident on August 26, 2017. A fall mat had been utilized as a safety intervention to prevent falls with injury for the Respite resident. The facility was aware of the resident's unsafe behaviors and non-compliance with safety alarms as evidenced by her repeated attempts to self-transfer and turning off her alarms as well as the recent decline in transfer abilities and increase in diuretic medication, which may increase the resident's toileting needs. However, the facility failed to ensure that the resident's environment and room surroundings were free of accident and tripping hazards (fall mats) to prevent this fall with serious injury. 483.25(d) Accidents. Previously cited:4/21/17. 28 Pa. Code: 211.12(a)(c)(d)(2)(3)(5) Nursing Services. Previously Cited: 6/8/17,4/21/17 28 Pa. Code: 207.2(a)Administrator's Responsibility 4/21/17,10/19/16

Based on a review of clinical records and select facility policies and procedures, resident and staff interview, it was determined that the facility failed to implement procedures to ensure consistent monitoring and timely assessment of skin integrity to prevent pressure sore development and failed to consistently provide care to promote healing of pressure sores for one resident out of three sampled (Resident 83). Findings include: According to the facility's current procedure entitled Skin Integrity Guideline the purpose of this procedure is to provide a comprehensive approach for monitoring skin conditions, to decrease pressure ulcer and/or wound formation by identifying those patients/residents who are at risk and implementing appropriate interventions to promote healing of wounds of any etiology, whether admitted or acquired. If a resident is identified at risk, interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. If there is a decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness and implemented as indicated by the individualized plan of care. The residents will be observed daily by the Nurse Aide for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. The changes will be reported to the licensed nurse and documented. The resident would be repositioned every two hours, or as needed and tolerated taking into consideration the resident tolerance, choice, tissue tolerance and current condition of skin. Indicate frequency in the individualized plan of care. A positioning schedule will be initiated to meet the individual needs and minimize concentrated pressure to skin as indicated by the resident. There will be minimal linen under prone skin areas and per individualized plan of care. A review of the clinical record revealed that Resident 83 was readmitted to the facility on [DATE], following a bilateral amputation of his lower extremities related to severe [MEDICAL CONDITION] (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and diabetes mellitus (disease that result in too much sugar in the blood, or high blood glucose). A Significant Change Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 27, 2017, revealed that the resident was cognitively intact and required extensive assistance of two for most activities of daily living including bed mobility, transfers, dressing, toilet use and personal hygiene. The assessment also noted that the resident had functional limitations to upper and lower extremities. A review of the resident's clinical record revealed that the resident utilized sensor pad alarms in bed and in the wheelchair due to poor trunk control and increased risk of falling. Review of the resident's current comprehensive plan of care, which was initiated on June 30, 2015, revealed that the resident had altered skin integrity related to non-pressure and pressure related issues. Plan interventions included conducting weekly skin inspections, turning and repositioning every two hours as tolerated, providing a pressure reducing wheelchair cushion and pressure reduction/relieving specialty mattress, skin assessment per facility policy and treatments as ordered. The resident's plan of care also included the problem of physical functioning deficit related to self care impairment, mobility impairment, initiated on June 30, 2015, with interventions to inspect the resident's skin with care and report reddened areas, rashes, bruising, or open areas to the charge nurse and to transfer the resident with assistance of two and use of the Marisa lift (mechanical lift). A review of the resident's weekly skin inspection record dated October 21, 2015, indicated that the only area of skin impairment identified at that time were blisters on the resident's left lower abdomen. The resident had a physician's orders [REDACTED]. However, there was no documentation to verify that staff applied this preventative treatment on October 21, 2015. According to nursing documentation on October 23, 2015, at 9:35 AM, staff observed that the resident had area on his coccyx measuring 1 cm (centimeter) x 1.4 cm x less than 0.1 cm, which was unstageable with 100% slough (Slough is typically a white/yellow color made up of dead cells that may be related to the end of the [MEDICAL CONDITION] stage in the healing process and for healing to take place it is advised that slough is removed). The surrounding area was light red and blanchable (loses all redness when pressed). A physician ordered treatment was obtained on October 23, 2015, to cleanse the wound on the coccyx with normal saline, pat dry, apply Santyl (product that breaks down dead/damaged tissue) to the wound bed, skin prep to the surrounding tissue and cover with Allevyn (speciality dressing for wounds to support moist wound healing) every shift. The resident, a relatively new bilateral [MEDICAL CONDITION], was instructed to use the siderails for positioning off the area. A therapy screen for positioning and cushion was requested. Review of wound tracking records dated October 23, 2015, revealed that this area was identified as a pressure sore on the coccyx measuring 1.0 cm x 1.4 cm x 0.1 cm; which was a Stage III (full thickness tissue loss which may expose fat) with 100 % slough. Review of a corresponding incident investigation related to the discovery of the pressure sore dated October 23, 2015, indicated that the resident was discovered to have a pressure sore while Employee 1, a Nurse Aide, was providing care to the resident. A written statement provided by Employee 1 dated 9/22/15 (which was an error for 10/23/15) revealed that she worked the 8:00 AM-3:00 PM shift (10/23/15) and at 9:45 AM, while providing care to the resident the resident stated that he was in pain all night and that his buttocks were hurting him from laying on it (buttock). Employee 1 found the open wound on his buttock and notified the nurse. A written statement provided by Employee 2, a Nurse Aide revealed that while she worked the 7:00 AM-3:00 PM shift on October 21, 2015, she noticed a reddened area on the resident's coccyx, which looked like it was starting to open. Employee 2 noted that she mentioned it to the resident and he said they (the facility) knew about it and that it was bothering him. (This written statement was provided to the facility on [DATE]). A written statement provided by Employee 3, a Licensed Practical Nurse, revealed that she worked a double shift on October 22, 2015 (Wednesday) and on October 23, 2015 (Thursday) on the 7 AM to 3 PM shift. She applied the prescribed antifungal cream to the resident's buttocks. Employee 3 noted that the appearance of the resident's buttocks were unchanged. Employee 3 described the appearance of the resident's buttocks as a red fungal like area to the inner buttocks, but no open area. Employee 3 also indicated that Employee 2 did not report any change to the area. Employee 2 further indicated that the resident did not complain of any pain or discomfort in the area. (This written statement was provided to the facility on [DATE]). A written statement provided by Employee 4, a Nurse Aide, indicated that the resident usually does not have a bowel movement on the 11:00 PM- 7:00 AM shift and that he has a suprapubic catheter (surgically implanted tube to drain urine). Employee 4 noted that unless the resident has a bowel movement she would not open his brief and that she would just reposition him. (This written statement was provided to the facility on [DATE]). Upon review of the resident's bowel records it was revealed that the resident did not have a bowel movement on October 19, 20, or 21, 2015. The resident had a bowel movement on October 22, 2015 and October 23, 2015. There was no evidence that licensed nursing staff had assessed the resident's buttock when Nurse Aide (Employee 2) observed the reddened area on the resident's coccyx that the employee described as looking like it was going to open. Employee 2 failed to implement the facility's skin guideline procedures regarding notifying the Licensed Nurse of this finding. There was no documented evidence available for review during the survey of any assessment of the resident's fungal-like area on the buttocks, which Employee 3 noted were present. A review of records from the wound care physician revealed that this physician debrided the pressure sore on October 26, 2015. Review of a subsequent wound tracking record dated October 27, 2015, indicated that the resident was discovered with a new Pressure Ulcer on the Sacrum, which had 50% granulation (new healing tissue) and 50% necrosis (dead tissue). Review of this wound tracking record incorrectly identified this pressure sore as a Stage II pressure area (The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost. The wound may be shallow and pinkish or red. The wound may look like a fluid-filled blister or a ruptured blister). The resident was also identified with two open areas on the scrotum measuring 1 x 1 cm and 1 x 1.5 cm on this same date (no Stage or description other than the size were available for review at the time of the survey). According to a general note dated October 27, 2015, at approximately 2:00 PM, the sensor pad alarms were discontinued at that time secondary to being preventative or causative in nature to the resident's sacral ulcers. There was no evidence that the facility had consistently monitored the resident's use of the particular safety alarm in an effort to prevent pressure sore development for this resident who was identified at risk for skin breakdown. Review of the resident's Treatment Administration Records for October 2015, revealed the physician's orders [REDACTED]. The treatment administration record did not reflect completion of this treatment on the night shift on October 23, 2015. This physician's orders [REDACTED]. A treatment change order was obtained on October 26, 2015, to cleanse the area on the coccyx with normal saline solution, pat dry, apply hydrogel and Allevyn dressing daily and as needed, which was to be discontinued on October 27, 2017. There was no documented evidence that this treatment was performed on October 26, 2015. Another physician's orders [REDACTED]. It was to be discontinued on October 28, 2015. There was no documentation to verify that this treatment was completed on October 27, 2015. This same treatment was re-ordered on October 28, 2015, which was to be discontinued on October 29, 2015. There was no documentation to verify that this treatment was completed on October 28, 2015. An attempt was made to observe the resident's pressure sore on October 29, 2015, at approximately 1:00 PM. The resident however, stated in an interview at that time that he did not want anyone else looking at these pressure sores. When asked how often he is repositioned the resident stated every four hours. There was no documented evidence that the nurse aides consistently and effectively performed daily skin checks to monitor for changes and reddened/open areas and had notified the licensed nurse of any areas of skin impairment. There was a lack of evidence that all skin impairments were accurately identified and documented and a lack of documented evidence that physician ordered treatments were performed consistently. 28 Pa. Code 211.10(a)(c)(d) Resident care policies Previously cited 4/2/15, 5/18/15, 6/19/15, 7/31/15 28 Pa Code 211.5 (f)(h)Clinical records. Previously cited: 4/2/15. 28 Pa Code 211.12 (a)(c)(d)(1)(5)Nursing services. Previously cited: 4/2/15, 5/18/15, 6/19/15, 7/31/15

Based on a review of clinical records and select facility policy, observation and staff and resident interview, it was determined that the facility failed to monitor the adequacy of one resident's fluid intake and timely identify and act upon risk factors for dehydration (Resident 68) and provide necessary services to promote adequate hydration of residents including Residents 37, 3, 96, 26, 85, 13, 93, 52 and 109 out of 14 sampled residents. Findings include: Review of the facility protocol for Intake & Output (I & O) indicated that the following residents are placed on Intake and Output to monitor fluid balance: Residents receiving TPN/IV Therapy Residents receiving [MEDICAL TREATMENT] Residents on Fluid Restriction Residents with specific MD orders for intake and output Residents that trigger a Sentinel event of Dehydration until resolved either by lab work or no clinical signs of dehydration. Upon initiation of eternal feedings for the first 2 weeks Output only for residents with indwelling foley catheters At nursing discretion, based upon clinical evaluation (including but not limited to persistent diarrhea/vomiting, heavily exudating wounds, fever. A review of the clinical record revealed that Resident 68 had diagnoses, which included hypertension, [MEDICAL CONDITION] ([MEDICAL CONDITION] - a bacterium which infects and can make humans ill, Symptoms can range from diarrhea to serious and potentially fatal inflammation of the colon) and [MEDICAL CONDITION] (a condition in which the heart does not pump blood adequately through the body, resulting in fluid retention sometimes requiring the use of diuretics). Review of Resident 68's care plan revealed the problem of [MEDICAL CONDITION] was identified on April 7, 2015, with approaches that the facility would administer antibiotics and treatment as ordered and provide adequate nutrition. However, the resident's plan of care failed to indicate that the facility planned to monitor the adequacy of the resident's hydration status due to the resident's risk factor of [MEDICAL CONDITION] infection. Review of laboratory test results dated April 7, 2015, indicated that the resident was positive for [MEDICAL CONDITION] and placed on antibiotic therapy as treatment. Nurses Notes from April 7, 2015 to April 17, 2015 indicated that the resident was receiving antibiotic therapy during this time. A nurse's note dated April 20, 2015 at 6:01 a.m., indicated that the resident had an increased temperature and three episodes of loose stools. Nursing called the physician and the physician prescribed antibiotic therapy for 10 more days. The resident's antibiotic therapy was completed on April 30, 2015. A nurse's note dated May 4, 2015, at 12:44 p.m., indicated that the Nurse Practitioner had seen the resident and ordered that a stool sample be obtained to test for [MEDICAL CONDITION]. Nurses notes dated May 4, 2015, to May 7, 2015, indicated that a stool sample was unable to be obtained. A nurse's note on May 7, 2015, at 9:02 a.m., indicated that the Nurse Practitioner re-ordered a a stool for [MEDICAL CONDITION] because the resident continued to have loose stools. The stool sample was not collected for testing until May 10, 2015, at 5:15 a.m. A nurse's note dated May 7, 2015, at 4:05 p.m., indicated that the resident complained of nausea and was dry heaving at times. There was no documentation in the resident's clinical record from May 7, 2015 at 4:05 p.m., to May 10, 2015 at 3:42 p.m., regarding the status of the resident's nausea or vomiting aside from an entry on May 10, 2015 at 3:42 p.m., which indicated that the resident continued to complain about nausea. A review of Resident 68's lab studies results revealed that on May 10, 2015, the resident's test for [MEDICAL CONDITION] was positive. The resident was confirmed with [MEDICAL CONDITION] infection on April 7, 2015, and May 10, 2015, had episodes of loose stools, fever, antibiotic therapy through April 30, 2015, and complaints of nausea. There was no indication that the facility had instituted intake and output monitoring in response to the resident's risk factors for dehydration. Lab studies dated April 28, 2015, indicated that the resident's BUN was 11 (normal 7-25 mg/dl) and Creatinine was .89 (normal .60-1.30) (lab indicators of hydration status, dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio). A review of Resident 68's meal consumption revealed that on May 7, 2015, the resident had no meal intake and there was no documentation of the resident's fluid intake. On May 8, 2015, the resident consumed 25 % of her dinner and her evening snack with no documentation of fluid intake. On May 9, 2015, the resident consumed 50% of breakfast and 25% of lunch and no documentation of fluid intake. On May 10, 2015, and May 11, 2015, the resident had no meal intake and no documented evidence of fluid intake. There was no documented evidence in the clinical record that the facility identified the resident's decreased meal intake nor evidence the that facility had evaluated the adequacy of the resident's fluid intake. The Nurse Practioner ordered stat (immediate) laboratory blood testing for the resident on May 11, 2015. A Nurse Practioner note dated May 11, 2015 indicated that the resident's lips appeared dry and skin turgor was decreased (signs of dehydration). The results of the resident's lab studies dated May 11, 2015, revealed that the resident's BUN and creatinine levels had increased; BUN was 48 mg/dl and creatinine was 3.6 mg/dl. The resident's Glomerular filtration rate (GFR: Moderate or severe dehydration affects the kidney function negatively and can result in a lower GFR test result) was was 12 (ml/min/1.73sq.m), which indicated acute kidney failure. Interview with the Nurse Practioner on May 18, 2015, at 11:15 a.m., revealed that she saw the resident on May 11, 2015, because the resident's family had brought to the facility's attention that the resident "wasn't looking good." She confirmed that the resident displayed dry lips and poor skin turgor and confirmed that she sent the resident to the hospital because of the resident's acute kidney failure and need for hydration. A review of hospital records revealed that in the ER the resident was found to be dehydrated and IV (intravenous) fluids were started. The hospital history and physical reported dated May 11, 2015, indicated that the impression was acute kidney injury, likely secondary to dehydration and dizziness likely secondary to dehydration. The plan was to continue to check urine studies and give the resident gentle hydration and follow up the resident's kidney function. Interview with the Administrator and Director of Nursing on May 18, 2015 at approximately 12:45 p.m., failed to provide evidence that the facility had identified the resident's declining condition and confirmed that the resident's family had brought the resident's change in condition to the facility's attention prompting evaluation by the Nurse Practitioner. The NHA and DON were unable to provide evidence that the facility had identified and acted upon the resident's decreased oral intake and had timely assessed the resident's hydration status and developed and implemented sufficient measures to increase the resident's fluid intake and maintain adequate hydration status. Further review of the resident's clinical record revealed a Nutrition Note dated May 12, 2015, at 10:57 AM (the resident was hospitalized at this time) that indicated an assessment reference date of May 11, 2015, noting the resident's height (68") and weight (91 lbs) and noted "no significant change over 30, 180 days. Regular diet with small portions, provided as ordered. Resident was admitted to the hospital." The dietitian failed to identify the resident's decreased intake and compromised hydration status. A tour of the facility's second and third floors conducted on March 18, 2015, from 9 a.m. through 10 a.m. revealed the following: at 9:21 a.m. in room [ROOM NUMBER]-B (Resident 37) there was no water/ice observed for the resident at 9:27 a.m. in room [ROOM NUMBER]-A (Resident 3) there was no water available in the room for the resident. Interview with the resident at this time revealed that the resident stated " they usually give water on 2nd shift (3:00- 11:00 p.m.), other times you have to ask for it " at 9:32 a.m. in room [ROOM NUMBER]-B (Resident 96 there was a styrofoam cup with lid on resident's tray table, but there was no straw present to assist the resident in drinking. at 9:34 a.m. in room [ROOM NUMBER]-A (Resident 26) there was no water observed in the room. at 9:37 a.m. in room [ROOM NUMBER]-B (Resident 85) there was a cup of warm water observed, which was almost empty. The resident stated during interview that "they only fill water cup once a day." at 9:40 a.m. in room [ROOM NUMBER]-B (Resident 13) there was no cup of water observed at this resident's bedside. at 9:41 a.m. - in room [ROOM NUMBER], beds A & B (Residents 93 & 52) no water was observed in the room for either resident. at 9:42 a.m. - in room [ROOM NUMBER]-A: (Resident 109) There was a cup of warm water with a coffee stain on the lid. Interview with the resident at this time revealed that the resident stated that this cup of water was from the previous day. When asked if fresh water was provided on a regular basis the resident replied " I have to ask for everything. " Interview with the Administrator and Director of Nursing on May 18, 2015 at approximately 12:15 p.m., failed to explain why these residents did not fresh water available to them. The NHA and DON confirmed that staff should pass fresh water each shift 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 4/2/15 28 Pa Code 211.10 (a)(d) Resident care policies Previously cited 4/2/15 28 Pa Code 211.6 (d) Dietary services Previously cited 4/2/15 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited 4/2/15 28 Pa. Code 211.11(c) Resident care plan Previously cited 4/2/15

Based on observation, review of the clinical record, staff interviews and review of an investigative report and an Event report submitted to the State Survey Agency, it was determined that the facility failed to consistently provide adaptive eating/drinking equipment as prescribed for one of 24 residents sampled (Resident 17). The Findings include: A review of the clinical record of Resident 17 revealed that the resident had [DIAGNOSES REDACTED]. It develops gradually, often starting with a barely noticeable tremor in just one hand). A review of a quarterly Minimum Data Set Assessment (MDS - standardized assessment completed at specific intervals to define resident care needs) dated April 23, 2012 revealed that the resident required staff assistance with activities of daily living to include set up help with eating/drinking. A review of physician orders [REDACTED]. A review of an investigative report and an Event Report submitted to the State Survey Agency dated April 22, 2012 at 6:00 p.m., revealed that the resident was seated in the sunroom for dinner and spilled hot coffee on both the right and left thigh areas of both lower extremities. The right thigh burn measurements were: right upper thigh measuring 9 centimeters (cm) x 15 cm with two areas of peeling skin measuring; 1.) 3 cm x 2 cm and the 2.) measuring 10 cm x 2 cm. The left thigh upper [MEDICAL CONDITION] 8 cm x 6 cm with an area of peeled skin measuring 3 cm x 2 cm. According to the facility's investigative report and Event Report, the resident was to utilize a covered lid on the coffee cup at mealtimes. However, a nursing assistant poured several cups of hot coffee and hot water for residents, placed them on the end of the table where Resident 17 was seated and then left the area to obtain condiments. Resident 17 then reached over and grabbed a cup of hot coffee, spilling the hot liquid on his thighs. The temperature taken by the dietary department of the coffee at the time of the incident was 180 degrees Farenheit. The facility's investigative report noted that the resident's hand were "shaky." physician progress notes [REDACTED]. Observation of the burn areas on May 9, 2012, revealed the following: 1.) right posterior thigh measuring 4.0 cm x 2.0 cm with yellow slough (wound bed with skin tissue peeling off exposing exudate) with a dark center measuring 2.2 cm x 1.2 cm. 2.) right posterior thigh measuring 1.0 cm x 4.0 cm with 100 percent of yellow slough. 3.) upper posterior right thigh area measuring 1 cm x 0.4 cm with 100 percent of yellow slough. 4.) right posterior thigh area measuring 0.8 cm x 0.8 cm with red wound bed. 1.) right inner thigh area measuring 3.6 cm x 2.4 cm with 100 percent of yellow slough (distal aspect) 2.) right inner thigh (proximal) 1.2 cm x 2.6 cm with yellow slough. 3.) .6 cm x 1.0 cm scabbed, peeling area distally. Left inner thigh measuring 3.2 cm x 1 cm with yellow slough. Observation of the breakfast meal service on May 9, 2012, revealed Resident 17 seated in the dining area attempting to eat scrambled eggs with a regular fork. There was no evidence that the resident had a curved fork as ordered by the physician for mealtimes. The mug for coffee had a white lid on it, which did not fit properly (there was no liquid in the cup at the time). The resident was observed having difficulty getting the food from the plate into his mouth. Interview with the Director of Nursing Services on May 9, 2012 at approximately 1:00 p.m., confirmed that the resident was to have a lid on the mug that would secure the hot liquids at all times. The lid was not present when the resident sustained [REDACTED]. 28 Pa. Code 211.12 (a)(d)(3)(5) Nursing services. Continuing deficiency cited 4/19/12 Previously cited 4/15/11

Based on review of clinical records, select facility policy, and resident incident/accident reports and staff interview, it was determined that the facility failed to provide timely and sufficient staff supervision based on the resident's individual safety needs to prevent an fall with injury for one of eight residents sampled (Resident 113). Findings include: A review of the facility policy for Falls Management Clinical Guidelines, last reviewed by the facility January 2012, revealed that following a resident's fall, appropriate interventions are implemented. A review of the clinical record revealed that Resident 113 was admitted to the facility September 13, 2011, with a history of a fall with a hip fracture prior to admission, abnormality of gait, muscle weakness, dementia (a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) and psychosis (a loss of contact with reality, usually including false beliefs about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations)), had a supra-pubic catheter (a plastic tube inserted directly into the bladder, through the skin, to drain urine from the bladder into a bag) and was frequently incontinent of bowel. A review of recapped monthly physician's orders dated December 30, 2011, included Risperdal (an antipsychotic medication) 0.5 mg by mouth, two times a day and Seroquel XL (an extended release, antipsychotic medication) 50 mg by mouth every day. A review of a quarterly Minimum Data Set assessment (MDS - a standardized assessment completed at specific intervals to identify resident care needs) dated March 13, 2012, revealed that Resident 113 was severely cognitively impaired (highly impaired thought processing), required assistance for transfers and ambulation, and his balance during transitions (from one position to another) was not steady. The resident was only able to stabilize with human assistance for moving from a seated to a standing position, walking, turning around, moving on and off the toilet and surface to surface transfer; transfer between bed and chair or wheelchair. A review of the resident care plan for physical functioning decline due to dementia, unsteady gait, anxiety and status [REDACTED]. A review of the resident's care plan to address the resident's high risk for falls initiated September 21, 2012, revealed interventions to prevent falls including the resident's bed in the lowest position when not providing care, call light and personal items available and in easy reach, non-skid socks to be worn every shift, bed sensor pad alarm, an afternoon nap, offer a snack prior to nap, alarming Velcro belt when in wheelchair and Dycem (a non skid material applied to a surface to prevent slipping) to wheelchair seat. A review of an incident/accident investigation dated December 3, 2011, at 4 AM, revealed Resident 113 was seated in his wheelchair and was found on the floor in the hallway. The facility's investigation indicated that the resident had dementia, confusion and is severely impaired, has impaired safety awareness and judgement. The resident propels self about in the wheelchair without any clear direction. New interventions to prevent recurrent falls included safety cues/reinforcement reminder, re-orient resident to the time of day and what he should be possibly doing, provide resident with his own clock that he could read and understand. An incident/accident report dated January 2, 2012, at 2:49 PM, revealed that Resident 113 had an unwitnessed fall from the bed with no injuries. New interventions planned by the facility to prevent falls, was to place bilateral fall mats to both sides of the bed. A review of physician's orders dated February 10, 2012, revealed an order for [REDACTED]. A review of the nurses' notes dated between January 19, 2012, and February 13, 2012, revealed that Resident 113 had multiple instances of agitated, unsafe behaviors including releasing the safety belt, attempting to self rise from his wheelchair and self ambulating into other resident's rooms, and also repeated attempts at self rising from his bed. A review of a nursing note and a physician's orders dated February 15, 2012, at 5 PM, revealed that the psychiatrist visited the resident and made a medication adjustment, increasing the resident's Seroquel XR to 100 mg by mouth at bedtime and to add Depakote sprinkles (an anti-seizure medication sometimes used to treat behavioral symptoms) 125 mg, twice a day, and discontinue Risperdal 0.5 mg by mouth at bedtime. A review of an incident/accident report dated February 25, 2012 at 8:20 AM revealed that the resident's alarm was sounding, a nurse aide found him on the floor in front of the bathroom. The facility's investigation revealed that he had been last seen in his bed by staff. He did not have non-skid socks on at the time of the fall, a planned fall intervention. New interventions to prevent falls by planned by the facility again included non-skid socks, to be worn at all times, and the addition of a three day bowel diary for potential scheduled toileting plan. However, during an interview on April 19, 2012 at 12:30 PM the Director of Nursing (DON) confirmed that Resident 113 did not have the cognitive ability to participate in a toileting plan. A review of nurses' notes dated February 29, 2012 and March 1, 2012 revealed that Resident 113 had increased behaviors, wandering from room to room attempting to self transfer. A review of the behavior intervention monthly monitoring form for March 2012 revealed that the resident displayed behaviors of wandering into others rooms. The behavior was documented as occurring daily between March 1, 2012 and March 15, 2012. The facility attempted multiple interventions. One to one supervision of the resident was listed as a possible intervention choice, but was not as utilized during this time period. A review of physician's orders dated March 1, 2012 revealed an increase in Depakote 125 mg by mouth twice a day, and now 250 mg at bedtime and on March 2, 2012 to increase the Seroquel to 200 mg at bedtime and Depakote 250 mg to three times a day. Following these medication changes, nursing documentation from March 1, 2012, to March 18, 2012, revealed the resident continued with multiple attempts to self-rise from the wheelchair and agitated behaviors. A physician's order dated March 18, 2012, prescribed an increase in Seroquel to 300 mg at bedtime. Subsequent to this medication increase, a review of nursing documentation revealed that the resident's agitated behaviors continued. On March 20, 2012, the nurses' notes revealed that while assisting Resident 113 back to bed he struck at a nurse aide and was cursing. As the result of this incident, nurses notes indicated that one to one staff supervision was provided with some effect. A review of an incident/accident report dated March 21, 2012, at 3:10 PM, revealed that the resident was found on the floor of the hallway, in front of his wheelchair and his safety alarm was sounding. New interventions implemented by the facility as the result of this fall were the use of hipsters (padding to be worn to protect the hips in the event of a fall) to be worn at all times. A review of nurses' notes dated March 28, 2012, entered at 12:36 PM, revealed that the resident's attending physician visited the resident at 10 AM. During an interview on April 19, 2012, at 12:30 PM, the DON stated that on March 28, 2012, Resident 113 was returned to bed after breakfast. The nurse on duty went into Resident 113's room with the attending physician then left the room. The physician woke the resident during this visit. There were no other staff present while the physician examined him. A review of an incident/accident report dated March 28, 2012, at 10:30 AM, revealed that Resident 113 was observed by the facility housekeeping director, ambulating towards his door and fell . The nursing documentation dated March 28, 2012, also entered at 12:36 AM, noted that at 10:30 AM, "the resident got himself out of bed and was ambulating near doorway. Alarm sounding, by the time someone reached his room, resident had fallen." The facility's investigation into this fall noted that the resident was wearing hipsters and anti -skid socks at the time of the fall and he has poor safety awareness. He recently had his psychoactive medication increased on March 18, 2012. The physician was contacted on March 28, 2012, and x-rays were ordered and completed at the facility. The x-ray results revealed an acute hip fracture with displaced right femoral neck fracture and the resident was admitted to the hospital for surgical repair on March 28, 2012. The resident was readmitted to the facility on [DATE], at 2:50 PM. Nursing notes dated April 3, 2012, at 6:30 PM, revealed that Resident 113 pulled his supra-pubic catheter out and nursing reinserted the catheter. A review of an incident/accident report dated April 3, 2012, at 8 PM, revealed he was found on the floor beside his bed. The new intervention planned to prevent future falls was 1:1 supervision. On April 4, 2012, at 1:56 PM, the resident's room was changed to 312, to be closer to the nurses station. During an interview April 19, 2012, at 10:30 AM, Employee 3 (nurse aide) stated that before his fall with the hip fracture, Resident 113 was constantly removing his alarmed seat belt, standing up and attempting to ambulate. She further confirmed that prior to the March 28, 2012, fall, there was no extra supervision provided to this resident in response to his behaviors. During an interview April 19, 2012, at 12:30 PM, the DON confirmed that Resident 113 had documented unsafe behaviors and multiple falls, but a plan to provide increased supervision in response to his unsafe acts was not developed and implemented as fall prevention intervention until after his fall with a fractured hip on March 28, 2012. The facility did not plan and provide increased supervision to the resident until he pulled out his supra-pubic catheter, displayed another unsafe transfer from bed and fell to the floor on April 3, 2012. 28 Pa Code 211.10 (a)(d) Resident care policies previously cited 4/15/11 28 Pa Code 211.11(d) Resident care plans previously cited 4/15/11 28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services previously cited 4/15/11

Based on review of clinical records and select facility policy and staff interview it was determined that the facility failed to accurately and timely assess and monitor pressure sores and consistently provide treatment and services to prevent worsening of pressure sores for one resident (Resident CR1) out of 22 sampled residents. Findings include: Review of the facility Clinical Guideline Skin Integrity reviewed by the facility March 2011, revealed that the facility was to provide a systemic approach and monitoring process for skin and to identify those residents who are at risk and developing interventions. If identified risk is present the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. The Wound Evaluation Flow Sheet is to be completed for each pressure and non-pressure wound. The accuracy and thoroughness of the Flow Sheet will assist in identifying risks and appropriately establishing a Plan of Care. Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Clinical Health Status (assessment completed by nursing upon admission) dated March 25, 2011, at 2:35 p.m., revealed that the resident was alert and had no memory problems. Skin conditions were noted, which included a left below knee amputation (described as left stump with staples); a right second toe top (described as necrotic); a right great toe (described as top necrotic); a bruise on the right lower leg (no description noted); a Stage II area to the right buttock (no description noted); and a Stage II area to the coccyx (no description noted). A Braden Scale for Predicting Sore Risk noted that the resident scored a fourteen, which would be indicative of moderate risk for pressure sores. Review of the resident's initial care plan dated March 29, 2011 (four days after admission), noted that the resident was admitted with actual pressure ulcers (on the coccyx and right buttock). Interventions included to conduct weekly skin inspections, heel boot to the right lower extremity, nutritional and hydration support, pressure reducing wheelchair cushion, pressure reduction/specialty mattress, turning and repositioning schedule per assessment (no specific recommendations were noted despite the resident being status [REDACTED]. Review of the resident's March 2011 treatment record (TAR) revealed that the Stage II areas on the coccyx and right buttock were to be cleansed with normal saline solution, Safegel (a wound healing preparation) was to be applied, and covered with an ABD Pad three times per day (6:00 a.m., 2:00 p.m., and 8:00 p.m.). There was no documented evidence that the treatments to either area were completed on March 27 at 2:00 p.m., or March 28 at 8:00 p.m.. Also, there was no documented evidence that the treatment to the resident's right buttock was completed on March 28, 2011, at 6:00 a.m. The March 2011 TAR also noted that the staples to the resident's left stump were to be monitored for signs and symptoms of infection every shift. There was no documented evidence that this was done on March 27, 2011, on the dayshift. Treatment to the left stump included to apply dry dressing (ABD) to stump site, wrap with Kling (gauze) and Ace wrap daily and as needed. It was noted that this was done once daily on the day shift from March 26, 2011, through March 31, 2011. There was no documented evidence that this treatment was performed on an as needed basis, despite the need to monitor the staples to the left stump three times per day. Review of the resident's Wound Evaluation Flow Sheets revealed that on the date of admission, March 25, 2011, the Stage II area on the right buttock measured 4 cm x 3 cm. On March 31, 2011, (six days later) it was noted that the area was now unstageable with no size noted. Yellow slough (necrotic tissue) to the bed of the wound with pink edges and yellow drainage was noted. A physician order [REDACTED]. On April 5, 2011, the wound measured 6 cm x 4 cm with a scant amount of yellow exudate (drainage). The Wound Evaluation Flow Sheet for the pressure ulcer on the coccyx revealed that on March 25, 2011, the area measured 3 cm x 1 cm. Physician orders [REDACTED]. On March 31, 2011, the area was described as a 3 cm x 1 cm unstageable with yellow slough type tissue to the wound and yellow drainage. Physician orders [REDACTED]. The Wound Evaluation Flow Sheet for the back of the resident's right lower leg noted a bruise on March 25, 2011. No description of the bruise was noted. On March 31, 2011, it was noted that the border of the bruise remained ecchymotic noted to have yellow slough type tissue within remains closed. On April 5, 2011, it was noted that the area was now vascular (no explanation for the determination was noted). There was no size noted, moderate exudate was noted, the wound bed was painful, slough was present and noted to be fifty percent necrotic. A physician's orders [REDACTED]. On April 5, 2011, the physician ordered to cleanse the right posterior calf with normal saline solution, apply [MEDICATION NAME] (antibacterial agent) Cream twice daily and cover with dry dressing. The resident was sent for a wound consult on April 6, 2011. On April 7, 2011, a physician order [REDACTED]. A physician order [REDACTED]. The Wound Evaluation Flow Sheet for the surgical wound of the left stump dated, March 25, 2011, noted that the resident had staples (no other description was noted). On March 26, 2011, it was noted that there was a small amount of dark brown exudate and the periwound area was discolored purplish. The old dressing was removed with a small amount of brown dried drainage. On April 7, 2011 (twelve days later), it was noted that all staples, but two were removed. The incision was open on both sides of the stump with some yellow tissue to the wound bed. Dark black tissue was noted to be surrounding the incision. A physician order [REDACTED]. Interview with the Assistant Director of Nursing/Wound Care Nurse on April 13, 2011, at 1:00 p.m., failed to provide documented evidence that the resident's pressure ulcers/wounds were accurately and timely assessed and consistently and adequately monitored to ensure prompt and sufficient treatment measures were instituted to prevent worsening of the resident's pressure ulcers. 28 Pa Code 211.11 (c)(e) Resident care plan previously cited 5/28/10 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services previously cited deficiency 3/31/11, 5/28/10

Based on review of clinical records and select facility policy, and staff interview it was determined that the facility failed to monitor and assess the adequacy of fluid intake and implement timely interventions to prevent dehydration for one resident out of 22 sampled(Resident 30). Findings include: Review of the facility Protocol for I &O (input and output) last reviewed March 2011, indicated that residents are placed on Intake and Output, to monitor fluid balance at nursing discretion, based upon clinical evaluation (included but not limited to: persistent diarrhea/vomiting, heavily exudating wounds, and fever). If a resident does not meet their daily fluid needs in three consecutive days the physician will be notified. Nursing will assess the resident for dehydration. Hydration interventions will be put in place according to residents status and diet/liquid order. Possible interventions may include: 120 cc of extra fluids with meds or meals, beverage preferences, and popsicles. Clinical record review revealed that Resident 30 was admitted to the facility on [DATE], and had diagnoses, which included Alzheimer disease, [MEDICAL CONDITION] with [MEDICAL CONDITION], and diabetes mellitus. Review of an admission Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required staff assistance for all activities of daily living. An admission Nutritional Screening and assessment dated [DATE], noted that the resident received a mechanical soft carbohydrate controlled, no salt packet diet, and had a varied intake of 33 to 63% of meals. On February 2, 2011, the resident's BUN level (can be elevated with decreased fluid intake) was 18 mg/dl (within normal limits). The resident's daily fluid needs was estimated as 2160 ccs of fluid per day as per the resident's admission Nutritional Screening and assessment dated [DATE]. A nutrition note dated February 15, 2011, noted that the resident's oral intake averaged 57% over the past seven days. It was noted that the resident refuses meals/alternate foods at times. The resident's weight was 181.6 pounds, which represented a weight loss of six pounds (three percent) from admission (admission weight was 187.4 pounds). A recommendation was made to discontinue therapeutic diet restrictions and also a recommendation for Two Calorie Supplement 90 cc twice daily for extra protein and calories. A nutrition note dated, February 18, 2011, noted that the resident was on a mechanical soft diet with poor oral intake. A recommendation was made to increase the Two calorie supplement to three times per day and a house supplement to twice daily. Further review of the clinical record revealed no documented evidence that the facility addressed the effect of the resident's decreased oral intake on the resident's hydration status. There was no documented evidence that the facility evaluated the need to monitor the resident's intake and output in an attempt to timely intervene to prevent dehydration. Review of a hospital Discharge Summary dated February 26, 2011, noted that the resident was admitted to the hospital on February 20, 2011, with a [DIAGNOSES REDACTED]. On February 25, 2011, the resident's BUN level was 37 mg/dl (noted to be elevated, but improved since hospital admission and the provision of fluids). Interview with the director of nursing on April 14, 2011, at 1:30 p.m., confirmed that there was no documented evidence that the resident's fluid intake and output was monitored and evaluated in an attempt to prevent the resident from developing dehydration. The DON confirmed that the facility's I &O policy did not specifically address residents with decreased appetites who may be at risk for dehydration. 483.25(j) Hydration Previously cited 5/28/10 28 Pa Code 211.10 (a)(d) Resident care policies Previously cited 5/28/10 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) previously cited 03/31/11, 5/28/10