Every finding on record at Ephrata Manor

Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to ensure appropriate social services were provided to ensure a safe discharge to home for one of the two residents reviewed (Resident CL1).Findings include: Review of Resident CL1 diagnosis list includes the following diagnoses: Altered mental status (Unusual changes in a person's emotional response, thinking, and behavior) and Metabolic Encephalopathy (A non-traumatic brain dysfunction caused by illnesses or chemical imbalance, resulting in altered mental status). Review of Resident CL1's admission Visit Physician Orders, dated December 4, 2025, revealed Resident is not capable of understanding rights and exercising own rights. Interview with Licensed Employee E3 was conducted on February 2, 2026, at 11:00 a.m. Employee E3 reported being the social worker (SW) assigned to Resident CL1. It was further reported that Resident CL1's emergency contact was an ex-husband who does not reside with the resident but aids with the resident's bills and finances. Employee E3 confirmed that the resident does not have a POA (Power of Attorney - A legal document that authorizes an agent to act on behalf of a principal for financial or medical matters). The residents had been deciding for themselves before hospitalization. Review of nursing progress notes revealed a note dated December 10, 2025, at 8:04 p.m., stating resident continues with frequent confusion/disorientation. Review of nursing progress notes revealed a note dated December 11, 2025, at 7:25 a.m., stating Staff report [the resident] is increasingly confused, found in the hallway carrying their purse saying they didn't know where their room was. Review of nursing progress notes revealed a note dated December 12, 2025, at 10:07 a.m., stating the resident's insurance company notified the facility of the resident's last cover date, which is December 13, 2025. A review of the Nurse Practitioner's (NP) notes dated December 12, 2025, revealed: Assessment and Plan - Dementia (A term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life) associated with alcoholism, oriented only to self. The same note revealed SLUMS (The St. Louis University Mental Status- Examination for detecting mild cognitive impairment and early dementia) done in the facility was 16 out of 30. Further note review indicated [The Resident] exhibits memory impairment and tangential (Someone whose conversation wanders off topic, bringing irrelevant details, without returning to the original point, failing to answer the question asked) thought process. Further review of the same notes revealed Resident is not capable of making sound medical decisions. There is concern regarding discharge plan as they live alone with limited support. History of Present Illness revealed [The resident] has a marked severe level of impairment, demonstrated by a SLUMS score of 16 out of 30 indicatives of dementia. [Name of insurance] gave an insurance cut, but due to concern for a safe discharge plan as they live alone in a dilapidated trailer with unsanitary living conditions, peer-to-peer was done by this provider with extension until December 17, 2025. The resident has limited support with an ex-husband who is minimally involved. Review of the social services (SS) notes revealed a note dated December 12, 2025, at 12:57 p.m., stating SS attempted to discuss discharge plans with [resident's name], though the resident presented confused, stating they had a two-story home and a manufactured home. Same note revealed [The resident] stated that ex-husband [name of ex-husband] assisted them and that ex-boyfriend [name of ex-boyfriend] was staying in the two-story home with them, the SS will continue to discuss discharge options with [resident's name]. Interview conducted with Employee E3 on January 2, 2026, at 1:00 p.m., revealed resident initially reported residing in a two-level house, then informed SS that they live in a mobile home. Employee E3 reported that the ex-husband reported concerns with the resident's home due to holes and some soft spots on the floor. The SS reported that the information, both provided by the resident and the ex-husband, was not verified by the facility. The SS reported rehab previously did home check, but not anymore. Interview with the rehab director, Employee E4, was conducted on January 2, 2026, at 1:30 p.m. Employee E4 reported that Resident CL1 was physically cleared by rehab but had cognitive impairment, making residents unsafe to go home. Employee E4 confirmed by getting mixed information between the resident, who claimed to live in a two-story house, and the ex-husband, who reported resident lives in a trailer. Employee E4 reported not doing a house check to ensure Resident CL1 will have a safe home discharge. Employee E4 stated, It's a base-to-base case, it was a quick discharge due to insurance cut, and the resident does not have anyone to drive them home. Review of Resident CL1's Physician orders revealed an order dated December 18, 2025, for Stable for discharge with support services. Social services notes dated December 19, 2025, at 4:03 p.m., revealed SS contacted the Office of Aging to report unsafe discharge for [Resident name]. SS spoke to a caseworker and provided the concerns regarding the safety/cleanliness of the home as well as the current mental status/increased confusion. Further review of Resident CL1's nursing progress notes revealed a note dated December 21, 2025, stating the resident was discharged home, accompanied by the ex-husband, despite the facility's knowledge that Resident CL1 was not safe to go home due to their impaired mental status and safety concerns at the resident's mobile home. Review of Resident CL1's Discharge summary, dated [DATE], revealed the facility arranged for homecare services with [name of home care company] for nurse, aide, and social services visit and evaluation once discharge. An interview was conducted with licensed SS Employee E5 on January 2, 2026, at 1:00 p.m. Employee E5 confirmed that there was no follow up made to the resident after being discharged on December 21, 2025. Employee E5 reported last hearing from [name of the hospital] that resident CL1 was sent back to the hospital a few days after being discharged home. The above findings were conveyed to the Nursing Home Administrator and Director of Nursing on January 2, 2026, at 2:00 p.m. The facility failed to ensure Resident CL1 was provided with all social services to ensure a safe discharge to home. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a review of the facility's policy, clinical records, and staff interview, it was determined the facility failed to monitor potential side effects of anti-psychotropic medication for one of five residents reviewed (Resident 99). Findings include: Review of the facility's policy titled Psychotropic Medications, dated March 2021, revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications to include regular review for continued need, appropriate dosage, side effects, risk, and benefits. The same policy also indicated potential adverse medication reactions and side effects will be evaluated. Review of Resident 99's physician order dated June 7, 2024, revealed an order for Quetiapine (anti-psychotic medication) 25 mg tablet, three tablets by mouth daily for delusional disorder (mental health condition in which a person cannot tell what is real from what is imagined). Anti-psychotic side effect (monitoring) 1-No side effect; 2-Confusion; 3-Sleep disturbance; 4-Hangover effect; 5-Restlessness with repetitive movements; 6-Uncontrolled muscle spasm, shaking, tremors; 7-Involuntary repetitive movements of the body; 8-Involuntary chewing motion, tongue movements; 9-Stiff neck. Review of Resident 99's physician order dated July 31, 2024, and August 17, 2024, revealed an order for Rexulti (anti-psychotic medication) 2 mg tablet take one tablet by mouth daily. Review of Resident 99's Medication Administration Record failed to reveal potential side effects for Quetiapine and Rexulti were monitored for August 2024, and September 1-19, 2024. Interview with the Director of Nursing was conducted on September 20, 2024, at 10:00 a.m. The Director of Nursing confirmed there were no documented side effects monitoring for both Quetiapine and Rexulti medication. The facility failed to ensure Resident 99 was monitored for the side effects of Quetiapine and Rexulti medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 11/3/23

Based upon review of facility policy and procedure, clinical record review and interview it was determined the facility failed to provide interventions to prevent pressure ulcers, failed to timely identify pressure ulcers and failed to provide treatment for pressure ulcers causing harm to one of two residents reviewed (Resident 40). Findings include: Review of facility policy and procedure titled Skin Integrity Program - Pressure Ulcer Prevention/Treatment Program, revised April 27, 2023, revealed Pressure Ulcer Prevention: Every resident shall have a skin risk assessment (Braden Scale) upon admission, return from hospitalization , any significant change in condition and a routine quarterly screening to be completed by a licensed nurse. Further review of this policy revealed A routine skin inspection shall be performed daily as part of their personal hygiene. Further review of this policy revealed For residents determined to be 'at risk' a plan of care shall be implemented to maintain their skin integrity. Further review of this policy revealed Pressure Ulcer Assessment and Treatment: Upon completion of the assessment, the staff shall implement an interdisciplinary plan of care. The identification of risk factors and/or clinical conditions shall be incorporated in the plan of care' A plan to promote wound healing shall be implemented (e.g., films, hydrocolloids, foams, alginates, negative pressure wound therapy), including from excess moisture and incontinence. Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of Resident 40's admission Braden Scale for Predicting Pressure Sore Risk dated June 16, 2023, revealed a score of 15. If the score is 18 or less resident is at risk for developing a pressure ulcer. Review of Resident 40's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated June 22, 2023, revealed Resident 40 required extensive assistance of two plus staff members for bed mobility (turning and repositioning while in bed). Review of Resident 40's skin evaluation report dated August 14, 2023, revealed no new skin issues. Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's clinical record revealed a Wound Healing Solutions report dated August 28, 2023, indicating resident was seen for evaluation and management for newly noted areas of skin breakdown along the left heel. Review of Wound Healing Solutions report dated August 28, 2023, revealed full-thickness wound of the left heel - 1.3 cm x 2.6 cm - wound base 100% stable eschar (dry scab, tan, brown or black in wound bed; dead tissue; black in color in wound bed), no fluctuance noted, edges adherent to the wound base, no drainage noted, periwound without erythema, induration or edema. Further review of the Wound Healing Solutions report dated August 28, 2023, revealed a treatment order to cleanse the affected area with saline solution and apply skin prep daily and PRN (as needed). Review of Resident 40's Treatment Administration Record (TAR) dated August 2023, revealed treatments to the left heel began on August 29, 2023. Further review of Resident 40's TAR failed to reveal evidence that any treatments occurred to Resident 40's left heel from August 15, 2023, when the wound was discovered until August 29, 2023. Review of Resident 40's Skin Conditions care plan revealed that a Skin Conditions care plan was not developed until August 23, 2023. Further review of Resident 40's active care plan failed to reveal evidence that a Skin Condition care plan was initiated upon admission and no interventions were put into place upon admission or prior to the development of the left heel pressure ulcer. Interview with the Director of Nursing on November 3, 2023 at 11:00 a.m. confirmed the facility did not have interventions in place prior to the development of the pressure ulcer, confirmed that no treatments were in place from August 15, 2023 until August 29, 2023 and confirmed that skin evaluations were inaccurate prior to the identification of the wound. The facility failed to prevent the occurrence of a pressure ulcer, failed to timely identify a new pressure ulcer, and failed to treat a new pressure ulcer causing harm to Resident 40. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022

Based upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12-hour annual re-training for two of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed three nurse aides received the required 12-hour annual retraining. Further review of the staffing records and inservice documentation revealed two of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator and DON on November 3, 2023, at 11:27 a.m. confirmed that the nurse aides did not receive the required in-service retraining within the appropriate timeframe. 28 Pa. Code 201.20(a)(c) Staff Development

Based upon clinical record review and staff interview, it was determined the facility failed to ensure that a clinical rationale was provided by residents' physician for not performing a Gradual Dose Reduction of an antipsychotic medication and failed to provide a clinical rationale for the continued use beyond 14 days of an as needed anti-anxiety medication for two of five residents reviewed (Resident 38 and Resident 79). Findings include: Review of Resident 38's physician's orders included an order dated December 27, 2022, for Lorazepam (anti-anxiety medication) 0.5 milligrams one tablet by mouth as needed every six hours for anxiety. Review of Resident 38's clinical record revealed a Note to Attending Physician/Prescriber from the consultant pharmacist dated August 11, 2023, with a recommendation to evaluate the use of prn (as needed) Lorazepam. The note indicated that prn psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the prn order. Review of the physician/prescriber response dated August 21, 2023, indicated to cont.[continue] as ordered. Further review of the clinical record failed to reveal evidence that a clinical rationale or duration was provided as recommended by the pharmacist for the PRN use of Lorazepam. Review of Resident 79's clinical record revealed notes to Attending Physician/Prescriber from the facility pharmacist. Further review of Resident 79's clinical record revealed the facility pharmacist was recommending a Gradual Dose Reduction (GDR) of Resident 79's Seroquel (antipsychotic medication). Review of the physician response to facility pharmacist revealed a note continue as ordered. Further review of the physician response to facility pharmacist failed to reveal a clinical rationale for not performing a GDR as requested by the pharmacist. Further review of Resident 79's clinical record revealed notes to Attending Physician/Prescriber from the facility pharmacist. Further review of Resident 79's clinical record revealed the facility pharmacist indicated that PRN psychotropic orders cannot exceed 14 days. The pharmacist was requesting a clinical rationale for the continued use of PRN Lorazepam beyond the 14 days. Review of the physician response to the PRN Lorazepam request was continue with PRN Ativan. Further review of the clinical record failed to reveal evidence that a clinical rationale was provided as requested by the pharmacist for the PRN use of Lorazepam. Interview with Director of Nursing on November 30, 2023, at 11:15 a.m. confirmed that the physician failed to provide clinical rationales as requested by the facility pharmacist for the continued use of Seroquel and Lorazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/2022

Based upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for three of five staffing records reviewed. Findings include: Review of staffing records and performance reviews revealed three staff members did not have annual performance reviews performed within the appropriate timeframe. Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 3, 2023, at 11:27 a.m. confirmed staff performance reviews were not completed timely. Per the DON a performance plan has been made to catch up on past due staff performance reviews. 28 Pa. Code 201.20(a)(c) Staff Development FACILITY

Based upon clinical record review and interview it was determined the facility failed to develop a comprehensive care plan for prevention and treatment of pressure ulcers for one of 22 residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of Resident 40's admission Braden Scale for Predicting Pressure Sore Risk dated June 16, 2023, revealed a score of 15. If the score is 18 or less resident is at risk for developing a pressure ulcer. Review of Resident 40's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated June 22, 2023, revealed Resident 40 required extensive assistance of two plus staff members for bed mobility (turning and repositioning while in bed). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's active care plan failed to reveal evidence that a skin care plan was implemented prior to August 15, 2023, the date upon which Resident 40's pressure ulcer was identified. Interview with the Director of Nursing on November 3, 2023, at 11:00 a.m. confirmed that no care plan was in place prior to the development of Resident 40's pressure ulcer. The facility failed to provide a care plan with interventions for the prevention and/or treatment of Resident 40's pressure ulcer. 28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022

Based on clinical record review and interviews with staff, it was determined that the facility failed to complete a Quarterly MDS assessment at least every three months as required for one of eight residents reviewed (Resident 100). Findings include: Review of Resident 100's MDS (Minimum Data Set - a mandatory periodic assessment) assessments revealed that the resident had an Admission MDS assessment completed on May 29, 2023. Continued review revealed that no further MDS assessments had been completed for Resident 100 since May 29, 2023. Interview on November 3. 2023, at 10:20 a.m. with Employee E3, Registered Nurse Assessment Coordinator, confirmed that Resident 100 had not had an MDS assessment since her admission in May 2023. Employee E3 could not provide an explanation as to why no additional assessments were performed for Resident 100. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.5(h) Clinical records

Based upon clinical record review and interview it was determined the facility failed to notify resident's physician regarding the development of a pressure ulcer for one of two residents reviewed (Resident 40). Findings include: Review of Resident 40's diagnosis list revealed diagnoses including Alzheimer's disease (irreversible progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Peripheral Vascular Disease (poor circulation of the extremities). Review of facility's Skin/Wound Tracking Report revealed on August 15, 2023, the facility identified an open left heel wound, unstageable with slough measuring 1.3 centimeters (cm) x 2.6 cm. Review of Resident 40's clinical record revealed a Wound Healing Solutions report dated August 28, 2023, indicating resident was seen for evaluation and management for newly noted areas of skin breakdown along the left heel. Review of Wound Healing Solutions report dated August 28, 2023, revealed full-thickness wound of the left heel - 1.3 cm x 2.6 cm - wound base 100% stable eschar (dry scab, tan, brown or black in wound bed; dead tissue; black in color in wound bed), no fluctuance noted, edges adherent to the wound base, no drainage noted, periwound without erythema, induration or edema. Review of Resident 40's clinical record failed to reveal evidence Resident 40's physician was notified of the development of Resident 40's left heel pressure ulcer. Interview with the Director of Nursing on November 3, 2023, at 11:00 a.m. confirmed Resident 40's physician was not notified of Resident 40's change in condition. The facility failed to notify resident's physician of a change in condition. 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services Previously cited 12/16/2022

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents did not receive psychotropoic medications unless necessary and that non-pharmacological interventions were attempted before the use of a PRN (as needed) psychotropic medication for two of five residents reviewed (Residents 88 and 90). Findings include: Review of facility policy Psychotropic Medications, reviewed March 2021, revealed that residents do not receive psychotropic medications pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the medical record. Non-pharmacological interventions (such as behavioral interventions) are considered and used/care planned when indicated, instead of, or in addition to, medication to assist in the allevation of target behaviors. Review of Resident 88's admission MDS (Minimum Data Set - periodic assessment of resident needs) of March 28, 2022, included diagnoses of CVA (cerebrovascular accident - stroke) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Review of Resident 88's physican's order dated April 20, 2022, reveale an order for Hydroxyzine HCl (medication used to treat anxiety) 25 milligrams one tablet every six hours as needed for anxiety. Review of Resident 88's September 2022 Medication Administration Record (MAR) revealed that PRN Hydroxyzine HCl was administered 18 times. Further review of the clinical record failed to reveal behaviors documented prior to the administration on 15 of 18 occasions. Review of the October 2022 MAR revealed that Hydroxyzine HCL was administered eight times. Further review of the clinical record failed to reveal behaviors documented prior to the administration on six of eight occasions. Review of Resident 88's physician's order dated August 9, 2022, revealed an order for Trazodone (antidepressant medication used to treat sleep disorders) 50 milligrams 0.5 tablet at bedtime as needed for insomnia. Review of Resident 88's September 2022 MAR revealed that PRN Trazodone was administered 17 times. Review of the clinical record revealed no documented evidence that alternate interventions were attempted prior to administration on 14 of 17 occasions. Review of Resident 88's October 2022 MAR revealed that PRNTrazodone was administered 10 times. Review of the clinical record failed to reveal documented evidence that alternate interventions were attempted prior to administration on 8 of 10 occasions. Interview with the Director of Nursing on December 16, 2022, at 1:30 p.m. confirmed that the reasons for the use of the PRN Hydroxyzine were not documented and non-pharmacological interventions were not documented for the use of PRN Trazodone for Resident 88. Review of Resident 90's diagnosis list revealed Alzheimer's Disease (An irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Dementia (A term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) Review of Resident 90's physician's order dated July 23, 2022, revealed an order for Ativan (A medication to treat anxiety) 0.5 mg, give half a tab (.25mg) every four hours as needed for anxiety, restlessness, and agitation. Review of the August 2022, MAR revealed that Resident 90 was administered the PRN Ativan nine times for increased anxiety. Clinical records revealed no documented evidence that an alternative behavior intervention was attempted before the medication administration. Interview with the Director of Nursing was conducted on December 16, 2022, at 12:30 p.m., and confirmed nondrug intervention was not provided before administering PRN Ativan to Resident 90. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review and staff interview, it was determined that the facility failed to ensure that irregularities from the monthly drug regimen review were acted upon by a physician for one of five residents reviewed (Resident 45). Findings include: Review of Resident 45's clinical record revealed that a MRR (Medication Record Review) was completed on June 10, 2022, with a recommendation to evaluate the current dose of Buspar (medication to treat anxiety) and consider a dose reduction. Further review of the clinical record revealed no evidence that the recommendation was acted upon by the physician until a MRR completed on August 17, 2022, revealed a recommendation to address Buspar again. An interview with the Director of Nursing on December 16, 2022, at 9:35 a.m. confirmed that the recommendation was not addressed by the physician until the MRR of August 17, 2022. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were provided nursing and related services to maintain the highest practicable physical, mental, and psychosocial well being as evidenced by a resident who had the same dressing on their calf for twenty-seven days, without assessment or treatment. (Resident #11). Findings include: The facility policy entitled Skin Integrity Program: Pressure Ulcer Prevention/Treatment Program, with a revision date of February 2009, states under the section 2 (B) Pressure Ulcer Prevention: A routine skin inspection will be performed daily as part of personal hygiene. Section 2(C) states for residents At Risk, a plan of care shall be implemented to maintain their skin integrity. Review of the policy section titled Skin Care Procedures for Wound Types and Suggested Treatments states that the attending physician must be notified of any of the following events and treatment initiated. The events listed are, abrasions, lacerations, skin tears, rashes, pressure ulcers, venous stasis ulcers, arterial ulcers, intact heel blisters, diabetic ulcers, excoriation/MASD (moisture associated skin damage). Review of Resident R#11's clinical record indicates Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED].). Review of Resident R11's care plan indicated impaired skin integrity listed as a problem, initiated on July 12, 2016, and mentions a scab on right calf. The care plan also noted that TEDS stockings (stockings designed and worn to support the leg, to help stop blood clots from forming), were used by the resident with an intervention to check skin for redness/irritation. Review of Resident #11's Minimum Data Set (MDS) (periodic assessment of resident's needs) dated February 18, 2019, indicated that the resident was a two+ assist for bed mobility, transfers and toileting. Resident #11 was an extensive assist for bathing, personal hygiene, and dressing. Resident #11 has a brief interview for mental status (BIMS) of three out of 15, indicating resident was severely cognitively impacted. Review of Resident #11's MDS dated [DATE], under skin condition section documentation reveals no wounds or ulcerations. Review of clinical record for Resident #11 on February 20, 2020, revealed an Alert Charting Flowsheet: Skin Infection R/O with a date of February 2, 2020, and Treatment Administration Record Report (TAR) dated February 5, 2020 for a right posterior calf scab/wound. Documentation provided by the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) related to the specifics concerning the right posterior calf wound included a Skin Conditions of Unknown Origins Investigation dated June 11, 2019, which revealed an open area on Resident #11's right posterior calf open area, measuring 2 cm x 1.9 cm. Also included in investigation documentation was an Incident/Accident Report dated June 11, 2019 at 4:00 a.m., which stated that the nursing assistant (NA) assigned to Resident #11 reported to the Licensed Nurse that an outdated dressing (a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm) to right posterior calf, labeled May 15, 2019 was removed and a 2 cm x 1.9 cm. area was discovered, area red, blanchable, odor and moderate serous drainage noted. Review of Resident #11's physician's orders [REDACTED]. No documented evidence the physician was notified, of the right posterior calf wound when the dressing was applied on May 15, 2019. Review of Resident #11's Bath and Skin Report documentation revealed on May 22, 2019, Resident #11 received a shower with no noted skin problems, on May 29, 2019 a bed bath was given with skin problem documented as none, and on June 5, 2019 a shower was given with skin problem documented as none. Review of Skin-Wound Progress Report dated June 11-24, 2019, for a right posterior calf wound revealed a healing pattern. A Skin-Wound Progress Report dated July 27, 2019 for a right posterior calf irregular skin mole documented as healed on August 29, 2019. No evidence of Skin-Wound Progress Report for May 15, 2019, when the dressing was applied. Interview with Director of Nursing and Assistant Director of Nursing on February 21, 2020, at 12:30 p.m., confirmed there was no explanation for the dressing being applied on May 15, 2019, who applied the dressing, why it was applied, and why the dressing remained in place for 27 days, unmonitored and unchanged, and with no reassessment of the area. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.5(f)(h) Clinical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, resident interview, and staff interview it was determined that the facility failed to ensure that dental services were provided in a timely manner for one of one resident reviewed (Resident #92). Findings include: Review of their clinical record revealed that Resident #92 was diagnosed with [REDACTED]. Interview with Resident #92 on February 09, 2020, at approximately 12:48 p.m. revealed a missing partial upper denture. During the interview resident indicated that dental services were requested to replace the missing partial denture. Resident #92 indicated that the missing partial denture has been missing for several months but has only seen dental personnel once to address missing denture. Review of Resident #92's clinical record revealed a care plan meeting progress note dated February 19, 2019, indicating, (Resident) asked about getting partial, MSW checked and request was sent on 1/11/19 to in house dentist. Awaiting visit. Review of Resident #92's clinical record revealed a dental consult dated February 28, 2019 which indicated, dentition as charted with light plaque. Pt (patient) reports upper partial is missing for approx. 3 months. Will submit MAPA (medical assistance application for coverage) for replacement and schedule for [MEDICATION NAME] (cleaning) q6mos (every 6 months). Further review of Resident #92's clinical record revealed a dental consult dated December 16, 2019 which failed to indicate status of partial denture replacement process. Continued review of Resident #92's clinical record revealed a dental consult dated February 19, 2020 indicating, (Resident) was seen on request. Would like to have a flipper appliance made to replace tooth #8. A pre-authorization for this will be submitted. Will proceed with approval. Interview on February 21, 2020 at approximately 11:25 a.m. with non- licensed Employee E3 revealed the facility is anticipating paying for the partial denture replacement. Employee E3 also stated that Resident #92 has a dental appointment for March 2020, at the personal request of resident. Employee E3 stated that staff are unable to identify reason for delay in acquiring replacement. Interview on February 21, 2020, at approximately 11:55 a.m., with the Director of Nursing (DON), when the above information was presented, and DON also indicated that nursing reviews the consults and provides the follow ups including scheduling additional appointments. 28 Pa Code 211.15(d)(1)(3) Nursing Services 28 Pa Code 211.15(a) Dental services

Based on review of the facility's staff education records and interview with staff, it was determined that the facility failed to complete performance reviews annually based on the nurse aide's hire date for two out of five nurse aides (Employee E4, and Employee E5). Findings include: Review of facility's nurse aide education revealed that Employee E4's date of hire was May 8, 2012. Further review of Employee E4's facility file revealed annual performance review was conducted on February 9, 2020 but no performance review conducted in proximity to hire date of May 8th in the year of 2019. Review of Employee E5's facility education documentation revealed a hire date of October 8, 2002. Review of Employee E5's nurse aide performance evaluation for year of 2019 revealed a review was conducted on February 18, 2019. Interview occurred on February 20, 2020 at approximately 11:33 a.m. with the Nursing Home Administrator and Director of Nursing when the above information was presented. 28 Pa Code 201.20(a)(c) Staff development

Based on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to accurately assess and provide adequate supervision related to an elopement for one of 22 residents reviewed (Resident #75). Findings include: A review of the facility's policy titled Elopement Prevention Program, Location of Missing Resident, with the last revision date of September 6, 2019, revealed that as part of the pre-admission and admission procedures, and ongoing assessments, staff shall establish the resident's risk of wandering or elopement. Further review of the same policy revealed that all residents at risk for elopement shall be identified as such on the resident care plan so staff can be alerted to their needs for support and supervision. In addition, the resident's care plan shall list all interventions that are used to prevent an elopement from happening. A review of Resident #75's clinical record [DIAGNOSES REDACTED].). A review of Resident #75's Admission Assessment form completed on December 11, 2019, revealed that the resident was awake and oriented only to person. Further review of the same admission assessment form revealed that the resident was independently mobile with, or without, an assistive device. A review of the physician orders [REDACTED].#75. A review of the facility documentation, Incident/Accident Report, and Elopement Investigation revealed that on December 13, 2019, at 4:40 p.m., Resident #75 was found on the Personal Care (PC) area (residences that provide shelter, meals, supervision, and assistance for older people who are unable to care for themselves but do not need nursing home). An observation of the facility layout during the facility tour on February 18, 2020, revealed that Personal Care was located on the ground floor, left side of the same building where Resident #75 was residing. A review of the facility documentation, a written statement from Employee E6, completed on December 13, 2029, at 4:40 p.m., revealed that a physical therapist, Employee E7, reported that a coworker, Employee E8, was with Resident #75 in the therapy room on December 13, 2019. Resident #75 was taken to the facility chapel by Employee E8 for an activity because she/he had to leave early due to a family emergency. An interview with Employee E7 on February 21, 2020, at 11:00 a.m., confirmed that on December 13, 2019, Employee E8 took Resident #75 to the facility chapel for an activity before she/he left for the day. Employee E7 further stated that they can leave residents in the chapel if an activity was going on, but would inform the staff in the chapel. Employee E7 does not know if Employee E8 informed any staff in the chapel that Resident #75 was left in the chapel to participate with the activities. The facility documentation review revealed no documented statement from Employee E8. Employee E8 was not available for an interview by the surveyor. A review of the facility documentation, a written statement of Employee E9 completed on December 13, 2019, revealed that when the chapel program was over, Employee E9 saw a woman (believed to be Resident #75) with a gait belt (belt used to assist with walking) on in the chapel. Employee E9 was taking other residents back to the unit and when she/he returned, Resident #75 was no longer in the chapel and was later found walking with a nursing assistant in the Personal Care (PC) hall. Employee E9 further stated in their statement that she/ he learned from the occupational therapist (OT) assistant that Resident #75 walked over to PC following the crowd. A review of the Admission Assessment Elopement Risk completed upon admission on December 11, 2019, revealed that Resident #75 only scored a one which indicated that Resident #75 was not an elopement risk. Further review of the same assessment revealed that the facility failed to accurately assess Resident #75 elopement risk by not checking potential risk letter C which indicated not oriented to the surrounding and letter D which indicated admission and room change in the last week. Potential risk letter A for [DIAGNOSES REDACTED].#75 was an elopement risk and an elopement precaution should have been initiated. A review of Resident #75's care plan revealed that the Elopement care plan was not initiated until December 13, 2019, after the incident where Resident #75 was left in the chapel and followed the crowd which ended with Resident #75 in the Personal Care area of the building. An interview with the Director of Nursing (DON) on February 21, 2020, at 11:30 a.m., confirmed that Resident #75's elopement assessment was not completed accurately which resulted in a delay in the development of an elopement care plan. The facility failed to accurately assess elopement risk and provide adequate supervision for Resident #75. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c) Resident care policies

Based on observation and review of facility policy, it was determined that the facility failed to ensure that food was distributed in accordance with professional standards for one of two dining rooms observed. (2nd floor dining room) Findings include: Review of facility policy titled General Food Preparation and Handling with revision date of (MONTH) 2013 revealed as Number 19 Any item or food that is dropped on the floor must be discarded if it cannot be properly sanitized. Observation of dining service on (MONTH) 13, (YEAR) at approximately 12:34 p.m. on the 2nd floor dining room revealed Employee E5, dropped a covering lid for a plate on the floor, nursing aide picked up the lid placing it back on the top of tray line which was subsequently used to cover next lunch plate. Interview with Employee E3, Dietary Manager on (MONTH) 13, (YEAR) at approximately 12:46 p.m. confirmed the lid should have been sanitizer before use. 28 Pa. Code 211.6(d) Dietary services.

Based on clinical review, review of facility's Medication Pass Competency, review of manufacturer's instructions, and staff interview, it was determined that the facility failed to ensure professional standards of practice with respiratory care for 1 of 23 residents (Resident R210). Findings include: Review of facility's Medication Pass Competency which must be signed off for each licensed nurse administering medications per the Director of Nursing, states, proper administration of dose inhalers includes rinsing mouth after administration of inhaler and cleaning of mouthpiece with alcohol wipe after use. Review of manufacturer's instructions for [MEDICATION NAME] inhaler usage reveals mouth should be rinsed after each dose and mouth piece cleaned. Observation conducted on (MONTH) 13,2018 at approximately 4:06 p.m. on the second floor nursing unit revealed licensed nurse, Employee E8 gave resident, R210 the [MEDICATION NAME] inhaler and instructed the resident to take a puff. After the resident complied, licensed nurse, Employee E8 recapped inhaler and placed in medication cart drawer without cleaning mouthpiece as reflected in facility's Medication Pass Competency as well as manufacturer's instructions. Resident, R210, who was seated in a wheel chair was then wheeled into the dining room for dinner without having their mouth rinsed as per facility's Medication Pass Competency and manufacturer's instructions. Interview with the Director of Nursing and Administrator on (MONTH) 16, (YEAR) at approximately 1:30 p.m. confirmed that licensed nurse, Employee E8 did not follow the facility's Medication Pass Competency or the manufacturer's instructions. 28 Pa code 211.12 (c) (d) (1)(2)(5) Nursing services Previously cited 1/25/2017; 02/12/2016

Based on clinical record reviews, and staff interviews, it was determined the facility failed to ensure that care plans were developed and updated to reflect individual needs for one of 23 residents reviewed (Resident R94). Findings include: Review of Resident R94's clinical record revealed that Resident R94 was admitted to the facility on (MONTH) 15, (YEAR). Review of Resident R94's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident R94's Admission MDS (Minimum Data Set - Periodic assessment of resident needs) of (MONTH) 5, (YEAR) revealed Section title Cognition Patterns was BIMS (Brief Interview of mental Status) score of 15 of 15. Resident R94's BIMS score indicated cognition was intact. Review of the facility Protocol titled At Risk for Suicide failed to reveal that a care plan was initiated or reviewed after suicidal statement made by resident. Review of Resident R94's active plan of care failed to reveal goal for suicide prevention or that suicidal interventions were put into place to address the suicidal statements voiced by Resident 94 on (MONTH) 27, (YEAR). Interview with Nursing Home Administrator and Director of Nursing on (MONTH) 16, (YEAR) at approximately 12:30 p.m. confirmed a care plan was not developed for Resident R94 after statements of suicidal ideation on (MONTH) 27, (YEAR). 28 Pa. Code: 211.5 (f) Clinical records Previously cited 1/25/2017. 28 Pa. Code: 211.12 (c)(d)(1)(5) Nursing services. Previously cited 1/25/2017; 02/12/2016

Based on clinical record review, staff interview and facility policy, it was determined that the facility failed to notify the resident's physician of a resident's fall incident with injury (Resident R95) and suicidal statements (Resident R49 and Resident 94) for three of 23 residents reviewed (Resident 49, Resident 94 and Resident R95). Findings include: Review of facility policy titled Suicide Measures revealed that charge nurse will notify 1). Attending physician 2). Director of Nursing 3). Family/Responsible party 4). Administrator. Review of Resident R49 clinical record revealed that the resident was admitted to facility on (MONTH) 8, (YEAR). Review of Resident R49's clinical record revealed [DIAGNOSES REDACTED]. (Reflux disease), Chronic Pain, Localized [MEDICAL CONDITION] (Swelling), Nonrheumatic [DIAGNOSES REDACTED] (abnormal narrowing in a blood vessel), Depression (Loss of interest in pleasurable activities), [MEDICAL CONDITION] (enlargement of the prostate). Review Resident R49's clinical record revealed a facility protocol titled At Risk for Suicide initiated on (MONTH) 17, (YEAR) indicated resident stated just wanted to end it, maybe stop eating. Further review of Protocol titled At Risk for Suicide failed to reveal notification on (MONTH) 17, (YEAR) to the resident's physician, Director of Nursing, or Nursing Home Administrator of the resident risk of suicide. Review of Resident R49's physcian's notes revealed that the nurse practitioner assessed Resident 49 on (MONTH) 19, (YEAR) but there was no documentation regarding the resident suicidal ideation. Review of Resident R94's clinical record revealed that Resident R94 was admitted to the facility (MONTH) 15, 2019 with the [DIAGNOSES REDACTED].(Elevated blood pressure); Pleural Effusion (buildup of fluid in area between the lungs and the chest cavity); Hypo-osmolality and [MEDICAL CONDITION] (low sodium level in the blood); Vitamin B deficiency; Radiculopathy of Lumbar region (nerves that do not work properly in lower back); Retention of Urine; History [MEDICAL CONDITION] (Infection in blood); Dysphagia (Difficulty swallowing); [MEDICAL CONDITION] (poor circulation in extremities); and Adult failure to thrive. Review of Resident R94's clinical notes dated (MONTH) 27, (YEAR) revealed that the resident stated, use watch to slit my wrists. Review of Alert Charting Flowsheet documentation initiated on (MONTH) 28, (YEAR) revealed alert charting for hallucinations as well as negative statements. Review of facility protocol titled At risk for Suicide revealed resident's statement of use watch to slit my wrists. Further review of At Risk for Suicide Protocol revealed that resident expressed Anxiety, Hopelessness and change in ADLs (Activities of Daily Living). There was no documented evidence that the resident's physcian, Director of Nursing, family member, or Nursing Home Administrator were notified of the resident suicidal statement. Interview with Nursing Home administrator and Director of Nursing on (MONTH) 16, (YEAR) at approximately 12:30 P.M confirmed attending physician was not notified for Residents R49 and R94 after statements of suicidal ideation Review of Resident R95 revealed [DIAGNOSES REDACTED]. Review of the facility fall investigation completed on (MONTH) 4, (YEAR) at approximately 1:00 a.m. revealed that Resident 95, with assessed with [REDACTED]. Resident R95 was found on floor in room at 1:00 a.m. Facility investigation revealed that the resident sustained [REDACTED]. There was no documented evidence of notification the resident's physician. A Physician's notification form was filled out, but per Director of Nursing it was given to Nurse Practitioner when she came in the next morning. There was no documentation indicating when or what time the Nurse Practitioner came in to see the resident. Review of Resident R95 clinical record revealed no evidence that Resident R95 was seen by the physician. Review of a physician's notification form dated (MONTH) 5, (YEAR) ( one day post fall. incident) at approximately 6:00 p.m. revealed a physcian's order for the resident to be transfer to the hospital for left sided weakness. Review of hospital admission documentation revealed that on (MONTH) 5, (YEAR) at 7:11 p.m. resident was brought into emergency room with generalized weakness, pale coloring, and laceration and swelling to forehead. Review of hospital documentation dated (MONTH) 5, (YEAR) at approximately 10:00 p.m. upon readmission to the facility revealed instructions on management of closed head injury. The aforementioned findings were discussed with the Director of Nursing and Administrator on (MONTH) 16, (YEAR) at approximately 1:30 p.m. 28 Pa code 211.12 (c) (d) (1)(2)(5) Nursing services Previously cited 1/25/2017; 02/12/2016

Based on observations and staff interview, it was determined that the facility failed to treat 6 of 23 residents in a dignified manner during dining observations and medication administration (Resident R32, R36, R72, R100, R101, R160). Findings include: Observation of lunch meal on (MONTH) 13, (YEAR) at approximately 12:04 p.m. revealed Employee E5, non licensed nursing staff announced to dining hall attendants and residents that Resident R72 needs meal as tablemate was already served. Employee E5, announced the need for meal in this manner three times. Additonal observation of meal service on (MONTH) 13, (YEAR) at approximately 12:23 p.m., revealed Employee E6, non licensed nursing staff, called Resident R101 girlie; Sweetie; and love when addressing resident. Further observation of same meal service revealed Employee E6, non licensed nursing staff addressed Resident R100 as Sweetie. Review of care plans for Resident R101 and Resident R100 failed to reveal a care plan indicating that residents' preference of alternative names. Interview with Nursing Home Administrator and Director of Nursing on (MONTH) 16, (YEAR) at approximately 12:30 p.m. confirmed Employees E5 and E6 did not ensure dignity for residents. Review of Resident R36 current physician's orders [REDACTED]. Interview with licensed nurse Employee E7 (MONTH) 14, (YEAR) at approximately 9:40 a.m. confirmed the injection mixture observed was of a insulin mixture. Review of Resident R32 current physician's orders [REDACTED]. Observation of the 1st floor South Hall, on (MONTH) 14, (YEAR) at approximately 11:18 a.m., revealed licensed nurse, Employee E7 administered an injection into the abdomen of Resident R32 in the presence of 11 other residents. Further observations on (MONTH) 13, (YEAR), at approximately 12:20 p.m. revealed license nurse, Employee E4 sitting with three residents at a square table. Employee E4 spoke loudly across the table to Resident R160 and asked if the food was in the center of the mouth or at the side. When Resident R160 responded Employee E4 abruptly stated I am done here and walked away. Residents at the table appeared puzzled and shrugged there shoulders. Interview with the Director of Nursing and the Administrator on (MONTH) 16, (YEAR) at approximately 1:30 p.m. confirmed that privacy was not privided for residents during medication pass. The facility failed to ensure dignity and privacy for residents during dining and medication administration. 28 Pa Code: 201.29(j) Resident's rights Previously cited 1/25/2017

Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure that one of three residents reviewed was free from neglect during toileting which resulted in actual harm to the resident when the resident sustained [REDACTED]. Finding include: Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set assessment (MDS- periodic assessment of resident needs) completed on November 30, 2016, revealed that the resident was assessed with [REDACTED]. Further review of Section G Functional Status, G0110 Activities of Daily Living Assistance, revealed that the resident required extensive assistance for transferring and hygiene with one person physical assist and extensive assistance of one person for toileting. Section G0300 Balance During Transition was assessed as not steady and only able to stabilize with staff assistance for moving from a seated to a standing position, and for moving on and off the toilet. Review of the resident's care plan developed October 7, 2016, revealed that the resident was identified at risk for falls in relation to anxiety and deconditioning from hospitalization , and generalized weakness. Interventions included to monitor the resident for steadiness and balance and to follow the Transfer Lift Form. Review of the resident's Transfer and Lift Form for functional transfer status (which is used to develop the resident's care plan) dated October 7, 2016, identified the resident as ambulating with the assistance of one staff with a gait belt (a belt use to assist in the transfer and ambulation of a resident for safety), transfer assistance of one staff and listed special considerations as may not be left alone in the bathroom. Review of the fall investigation from a fall sustained by Resident CL1 on January 29, 2017, at 6:16 p.m. revealed a statement obtained from the nursing assistant assigned to Resident CL1 that indicated the resident was walked to the bathroom with a walker and a gait belt, and the, Resident sat down and was out of breath. The nursing assistant went to get help to assist the resident back to bed. The statement indicated, On our way back to the room we heard him fall on the floor before he fell he acted very weak and short of breath. Review of the nursing documentation dated January 29, 2017, titled, Alert Charting Flowsheet: Head Injury, revealed that the resident sustained [REDACTED]. The resident had an acute illness of pneumonia and was showing signs and symptoms of weakness. Review of the hospital history and physical dated January 29, 2017, revealed an anterior nasal bone fracture bilaterally (both sides), with minor displacement of the right sided fractures and overlying soft tissue swelling. Further review of the hospital documentation noted that the wound located on the nasal bridge measured approximately 1 centimeter and was Y-shaped requiring four sutures. Review of the facility findings of the fall investigation revealed that the facility substantiated that neglect did occur by the nursing assistant failing to call for assistance while the resident was in the bathroom which resulted in the resident sustaining bilateral nasal bone fractures requiring transfer to the emergency room and hospitalization . The facility failed to ensure that Resident CL1 was free of neglect by leaving the resident unattended while in the bathroom which resulted in the resident falling to the floor and actual harm by sustaining a laceration and fractures of the nasal bone. 42 CFR 483.12(a)(1) Prohibit Mistreatment/Neglect/Misappropriation Previously cited 01/25/17 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 6/16/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 01/25/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/12/16, 06/06/16, 07/26/16, 01/25/17

Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure the residents received proper supervision during toileting for one of three residents reviewed which resulted in actual harm when the resident sustained [REDACTED]. Finding include: Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set assessment (MDS- periodic assessment of resident needs) completed on November 30, 2016, revealed that the resident was assessed with [REDACTED]. Further review of Section G Functional Status, G0110 Activities of Daily Living (ADL) Assistance, revealed that the resident required extensive assistance for transferring and hygiene with one person physical assist and extensive assistance for toileting of one person. Section G0300, Balance During Transitions and Walking, was assessed as not steady and only able to stabilized with staff assistance for moving from a seated to a standing position and for moving on and off the toilet. Review of the resident's care plan developed October 7, 2016, revealed that the resident was identified at risk for falls in relation to anxiety and deconditioning from hospitalization , and generalized weakness. Interventions included to monitor the resident for steadiness and balance and to follow the Transfer Lift Form. Review of the resident's Transfer and Lift Form for functional transfer status (used to develop the residents care plan) dated October 7, 2016, identified the resident as ambulating with the assist of one staff with a gait belt (a belt use to assist in the transfer and ambulation of a resident for safety), transfers assist of one staff and listed special considerations as may not be left alone in the bathroom. Review of the fall investigation from a fall sustained by Resident CL1 on January 29, 2017, at 6:16 p.m. revealed a statement obtained from the nursing assistant assigned to Resident CL1 indicating that the resident was walked to the bathroom with a walker and a gait belt and the Resident sat down and was out of breath. The nursing assistant went to get help to assist the resident back to bed. The statement indicated, On our way back to the room we heard him fall on the floor before he fell he acted very weak and short of breath. Review of the nursing documentation dated January 29, 2017, titled, Alert Charting Flowsheet: Head Injury, revealed that the resident sustained [REDACTED]. The resident had an acute illness of pneumonia and was showing signs and symptoms of weakness. Review of the hospital history and physical dated January 29, 2017, revealed an anterior nasal bone fracture bilaterally (both sides), with minor displacement of the right sided fractures and overlying soft tissue swelling. Further review of the hospital documentation noted that the wound located on the nasal bridge measured approximately one centimeter and was Y-shaped requiring four sutures. Review of the facility findings of the fall investigation revealed that the resident was care planned to not be left unattended in the bathroom and the resident became weak in relation to the [DIAGNOSES REDACTED]. The fall investigation noted that the resident's plan of care was not followed. The facility failed to ensure that Resident CL1 was supervised during toilet use which resulted in actual harm when the resident fell to the floor, and sustained a hematoma to the nose, bilateral nasal bone fractures and a laceration to the nose requiring sutures. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 01/25/17 28 Pa. Code 201.18(b)(1) Management Previously cited 6/16/16 28 Pa. Code 211.11(d) Resident care plan Previously cited 01/25/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 02/12/16, 06/06/16, 07/26/16, 01/25/17

Based on review of clinical records, facility policies and procedures, facility documentation and hospital records and staff interviews, it was determined that the facility failed to correctly administer medications in accordance with the physician's orders for one of three residents reviewed resulting in a significant medication error and actual harm to Resident R1. Findings include: Review of the facility policy entitled, Drug Error, reviewed January 28, 2016, indicated that all significant drug errors shall be reported to the attending physician immediately. The facility's definition of a significant drug error was described as: unintended, undesirable and unexpected effects of prescribed medication that require discontinuing the medication or modifying the dose; requiring initial or prolonged hospitalization ; resulting in disability; requiring treatment with a prescription medication and are life threatening or result in death. Review of facility policy entitled, Medication Errors and Adverse Reactions, reviewed January 28, 2016, indicated that medication errors and adverse drug reactions must be reported to the resident's attending physician. Procedure Step 1 proceeded for facility to immediately report to the resident's attending physician those adverse drug reactions and medication errors with adverse clinical consequences. Step 2 proceeded for nursing to immediately implement and follow physician's orders. Step 3 proceeded for nursing to document the medication error on the, Incident Report: Medication/Treatment Error form which was to include the name; date and time that the physician was contacted and any accompanying orders or other information. Finally, Step 5 proceeded for the Medical Director and the consultant pharmacist to be informed of all medication errors and adverse reactions. Review of Resident R1's physician's note, dated April 27, 2016, indicated the resident had [DIAGNOSES REDACTED]. progressive condition where the heart muscle weakens and cannot pump blood efficiently and fluid accumulates in the lungs and other parts of the body), severe [DIAGNOSES REDACTED] (narrowing of the aortic valve which can limit amount of blood that can reach the body), [MEDICAL CONDITION] (accumulation of fluid), [MEDICAL CONDITION] (a condition that results from insufficient red blood cells or hemoglobin in the the blood), hypertension (blood moves through your arteries at a higher pressure than normal) and Diabetes Mellitus Type II ( a metabolic disorder characterized by high blood sugar in the context of insulin resistance and relative lack of insulin). Review of the physician's orders for Resident R1 for April 2016, included the diuretic (promotes the production of urine, sometimes called a water pill) medication [MEDICATION NAME] (a medication used for the prevention/treatment of [REDACTED].) conditions associated with [MEDICAL CONDITION], including [MEDICAL CONDITION]) 2.5 milligrams, one tablet in the morning on Monday and Thursday and the diuretic medication [MEDICATION NAME] 100 milligrams, one tablet in the morning and evening. Review of a facsimile physician's order regarding Resident R1 from the facility to the [MEDICAL CONDITIONS] clinic dated April 22, 2016, revealed a request for the collection of a basic metabolic panel (BMP - a blood test that measures the sugar level, electrolyte, fluid balance and kidney function) to be checked in two weeks. Review of the BMP laboratory results, which was collected and received by the [MEDICAL CONDITION] clinic on May 6, 2016, documented that critical results were telephoned to the facility's Licensed Nursing Staff, Employee E2, on May 6, 2016 at 10:10 a.m. Review of Resident R1's BMP laboratory results from May 6, 2016, listed critical results as follows: 116 mg/dL (milligrams per deciliter) for blood urea nitrogen (BUN- measures kidney function with a normal range reference values of 7-26 mg/dL) and 4.70 mg/dL for Creatinine (measures kidney function with a normal range reference values of 0.60-1.20 mg/dL). Review of a facsimile notification dated May 6, 2016, revealed that Employee E2 alerted the resident's attending physician's office to review the critical BUN and Creatinine lab results that were received on May 6, 2016. In response to this notification, the attending physician's Certified Registered Nurse Practitioner (CRNP) ordered the facility to obtain a BMP on May 9, 2016, and to consult with nephrology (a speciality of medicine that treats kidney problems) and evaluate and treat if the family was agreeable. Review of Resident R1's April 2016, Medication Administration Record, [REDACTED]. Review of the facility facsimile physician's order dated May 9, 2016, and authorized by the CRNP, directed the facility to notify both the [MEDICAL CONDITION] clinic and the nephrology specialists of the Creatinine 4.80 mg/dL and critical level BUN laboratory result of 126 mg/dL, which was received by the laboratory, on May 9, 2016 at 8:03 a.m., and called to the facility, on May 9, 2016 at 9:35 a.m. A subsequent facsimile physician's order dated May 9, 2016 at 2:08 p.m., revealed an order from the CRNP to the facility to send the resident to the hospital. Review of hospital emergency care documentation (history and physical) dated May 9, 2016, indicated that the resident presented to the hospital due to abnormal BUN and Creatinine levels. The hospital documentation further indicated that the resident, had been on [MEDICATION NAME] 100 milligrams twice a day as well as [MEDICATION NAME] 2.5 milligrams daily since April 18, 2016, and that the resident should have been on [MEDICATION NAME] twice weekly. The hospital documentation assessed the resident with, Acute Kidney Injury (sudden and dramatic loss of kidney function that develops rapidly, often in just a few days) in the setting of [MEDICATION NAME] on a daily use with concurrent [MEDICATION NAME]. Review of the Hypertensive and Kidney Specialist notes, dated May 10, 2016, indicated that this specialty consultation was ordered secondary to the resident's acute [MEDICAL CONDITION] which was described as hemodynamic (fluid dynamics of blood flow in nature with increased diuretic dose.) Documentation further indicated that the resident's blood pressure medication was being held due to low blood pressure and significant azotemia (higher than normal blood level of urea (waste product produced by body after breaking down protein) likely from intravascular volume depletion (volume of blood in circulatory system) and if the kidneys do not improve, enroll the assistance of palliative care (the treatment and relief of mental and physical pain without curing the causes). Review of the hospital discharge documentation dated May 17, 2016, revealed that the resident was being transferred to the facility secondary to discharge [DIAGNOSES REDACTED]. Review of the attending physician's note for Resident R1 dated May 17, 2016, documented that Resident R1 was readmitted to the facility following a transfer out of the facility secondary to Acute Kidney Injury with underlying Stage III-IV [MEDICAL CONDITION] and hypovolemia (decreased volume of circulating blood in the body) from treatment of [REDACTED]. Review of the attending physician's consultation request, dated June 1, 2016, for Resident R1's follow up with the Hypertension and Kidney Specialists, resulted in a recommendation from the specialist for the resident to be reviewed for the provision of hospice care (care designed to give supportive care during the final phase of a terminal illness and focus on comfort and quality of life) versus palliative care. During an interview on June 4, 2016 at approximately 1:00 p.m., the Director of Nursing indicated that the facility had not yet responded to the recommendations received from the resident's Hypertension and Kidney Specialist dated June 1, 2016, to review with the resident and the resident's family the consideration for palliative or hospice care. Interview with Licensed Nursing Staff, Employee E1, on June 4, 2016 at approximately 10:00 a.m., revealed that the facility had transitioned in April 2016, to a comprehensive medication administration and management software program. Employee E1 further indicated that prior to the implementation of the new pharmacy software, several licensed staff were responsible for manually integrating approximately 2,000 medications into this pharmacy software. Employee E1 revealed that the significant medication error was known to have occurred at the transcribing stage when Licensed Nursing Staff, Employee E6, failed to read and transcribe the medication order correctly and place it into the new pharmacy software. Review of the facility's investigation entitled, Medication/Treatment Error form, dated May 6, 2016, revealed that there was no documented evidence that the facility notified the resident's attending physician of this significant medication error at the time of discovery. In addition, this report was not reviewed by the Medical Director or the consultant pharmacist, as evidenced by the absence of their signatures on this report, in Part II entitled, Reviewing Signatures. Interview conducted with the Nursing Home Administrator and the Director of Nursing on June 4, 2016 at approximately 1:00 p.m., confirmed that a significant medication error occurred for Resident R1 as a result of a transcription error for the resident's [MEDICATION NAME] on the Medication Administration Record [REDACTED]. Additionally, the Nursing Home Administrator and the Director of Nursing confirmed on June 4, 2016 at approximately 1:00 p.m., that this medication error consequently resulted in Resident R1's critical and elevated laboratory values of a BUN and Creatinine on May 6, 2016, and May 9, 2016. The facility was unable to explain why there was no clinical collaboration between the Certified Registered Nurse Practitioner and Resident R1's attending physician, who is also the Medical Director, regarding the management of the resident when this medication error became known on May 6, 2016. Interview with the Director of Nursing on June 6, 2016 at approximately 3:00 p.m., confirmed that the facility investigation failed to provide documentation that the facility's Medical Director, who is also Resident R1's attending physician, was notified on May 6, 2016, of the discovery of this significant medication error. The Director of Nursing confirmed during a telephone interview on June 6, 2016 at approximately 3:00 p.m., that there was no evidence that the facility utilized their Medical Director for the collaboration, management and care of this resident when the significant medication error was initially detected by an abnormal lab result dated May 6, 2016, The facility failed to ensure that a physician ordered medication, [MEDICATION NAME], was transcribed correctly into the medication administration and management software program. The facility failed to follow policies and procedures regarding the discovery of a significant medication error by not immediately notifying the resident's attending physician and/or the Medical Director of this error which resulted in actual harm to a resident requiring transfer and subsequent admission to the hospital for treatment of [REDACTED]. 28 Pa. Code: 201.18(b)(1)(2)(e)(1) Management 28 Pa. Code 211.2(d)(1) Physician services 28 Pa. Code 211.5(f) Clinical records Previously cited 02/12/2016, 01/23/2015 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Previously cited 02/12/2016, 01/23/2015 28 Pa. Code 211.12(d)(2)(3) Nursing services

Based on review of the clinical record, review of facility policy and a reportable event, observation and staff interview, it was determined that the facility failed to ensure the safety of a resident during the administration of a warm compress for one of one resident reviewed, resulting in actual harm to the resident (Resident A1). Findings include: Review of Resident A1's wound care consultation dated April 5, 2013, revealed [DIAGNOSES REDACTED]. The resident was assessed during the evaluation as oriented to person, time and place. Review of an electronic event report submitted to the State Agency on April 7, 2013, revealed that on April 7, 2013, at 2:00 a.m., Resident A1 was found with blisters on the left hand's index and middle fingers. The resident reported that during the night, a warm compress was applied to his neck and the temperature was too warm. The resident placed his fingers between the compress and his neck. Further review of the event report noted that the resident developed blisters on the left hand fingers and upon evaluation by the licensed staff, the resident's fingers were found with swelling inside the blisters that had increased to the point where the fingertips were blue and the tissue color of the fingers was impaired. Review of the facility's investigation dated April 7, 2013, revealed that the resident stated during the interview that the nursing assistant placed a compress on the back of his neck that was heated in the microwave. The compress became too hot and he placed his left hand behind his head between the skin and the compress. He did not feel any heat on the fingers and did not realize the blisters on the fingers were there until the next morning. Review of the facility's policy for warm compresses, indicated that a compress is a piece of gauze dressing moistened in a prescribed warmed solution. It noted that the heat from the warm compress dissipates quickly and to maintain a constant temperature, the compress is to be change often. There was no procedure in place to instruct the nursing staff on the temperature of the water or the method to moisten the gauze dressing before application to a resident. There was no direction for the length of time for the application of a compress to be placed on a resident. Review of statements obtained during the facility's investigation from the nursing assistant, Employee E3, related that it was confirmed that under the direction of a licensed staff, Employee E2, the nursing assistant, Employee E3, obtained wet washcloths and heated the washcloths for approximately 1 minute and 30 seconds in the microwave and placed it behind the resident's neck. The resident stated that the wet compress was too warm and a second towel was placed behind the resident's neck. Review of facility policies and interview with the Director of Nursing, related that the facility had no procedures or policies to heat compresses in the microwave. Review of the skin progress report dated April 7, 2013, revealed that a blister measuring 7.0 cm (centimeters) by 4.0 cm was identified on the resident's left middle finger and a second blister measuring 6.5 cm by 4.0 cm was identified on the left index finger. Review of nursing documentation dated April 7, 2013, revealed that the physician was notified of the blisters found on the resident's fingers and that the fingers were becoming cyanotic at the finger tips ( blueness of the skin due to tissues near the skin surface being low in oxygen). An order was obtained to transfer the resident to the hospital for evaluation. The resident returned to the facility on [DATE], at 6:10 p.m., with physician's orders [REDACTED]. Further review of nursing documentation dated April 9, 2013, at 7:33 a.m., revealed that during wound treatment to the fingers, the finger nail of the middle finger came off with a small amount of bleeding noted. Observations conducted with licensed nurse, Employee E1, on April 10, 2013, at 11:00 a.m., during wound treatment to Resident A1's left hand fingers, revealed two open areas on the index fingers of the left hand as well as a redden area between these two open areas. The nail on this finger was black and blue in color. The middle finger of the left hand was observed with one open area and there was no nail present on this finger. Licensed nurse, Employee E1, administering the treatment to the fingers confirmed that the open areas, redness, discoloration of the nail of the index finger and the absence of the nail on the middle fingers were a result of the injury that occurred when the warm compress was placed on the resident. The facility failed to develop proper procedures on the application of warm compresses to prevent injury and failed to monitor the resident after the application of heated washcloths, resulting in actual harm to Resident A1. 28 Pa Code: 201.14(a) Responsibility of licensee Previously cited 1/25/2013 28 Pa Code: 201.18(b)(1)(3) Management Previously cited 2/29/12, 1/25/2013 29 Pa Code: 211.10(d) Resident care policies Previously cited 2/29/12, 1/25/2013 29 Pa Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 2/29/12, 1/25/2013

Based on the review of facility policies and procedures, clinical record review, review of facility documentation, staff interview and observations, it was determined that the facility failed to follow the physician's orders [REDACTED]. Findings include: Review of the facility's policy and procedure for the application of a warm, moist compress revealed that a moist compress was a piece of gauze dressing moistened in a prescribed warmed solution. A timer, clock or watch was to be provided for the resident to alert the nurse when the time of the application was up; the resident was not to move the compress or place hands on the site. It noted that the heat from the warm compress dissipated quickly and to maintain a constant temperature, the compress had to be changed often. The policy outlined that one of the disadvantages of moist heat application was that the prolonged exposure could cause maceration of the skin (Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected with bacteria or fungi.). Moist heat creates a greater risk [MEDICAL CONDITION] the skin because moisture conducts heat. The policy did not instruct the nursing staff to microwave a compress. Review of Resident A1's April 2013, physician's orders [REDACTED]. Review of nursing documentation dated April 4, 2013, during the 11:00 p.m. to 7:00 a.m.shift, indicated that Resident A1 was alert and oriented. On April 7, 2013, at 2:59 p.m., the nurses' notes indicated that the resident was identified with blisters on the left hand, on the second and third digits (fingers). Review of the skin report dated April 7, 2013, revealed that Resident A1's left hand was assessed with [REDACTED]. The blister on the left hand index finger measured 6.5 cm (centimeters) by 4.0 cm. The blister on the middle finger measured 7.0 cm by 4.0 cm. Nurses notes dated April 7, 2013 at 2:59 p.m. related physician notified at 2:20 p.m. that fingers were becoming cyanotic ( blueness of the skin due to tissues near the skin surface being low in oxygen at the finger tips). Review of physician orders [REDACTED]. Nurses notes dated April 7, 2013 related the resident returned from the hospital at 6:10 p.m. Review of nursing documentation dated April 9, 2013, revealed that during wound treatment to the fingers, the finger nail of the middle finger came off with a small amount of bleeding noted. Review of the facility investigation report of the blisters identified on Resident A1, revealed that the resident stated during an interview that the nursing assistant had placed a compress on his neck that was heated in the microwave. The compress became too hot and he placed his left hand behind his head between the skin and the compress. He did not feel any heat on the fingers and did not realize there were blisters on the fingers until the next morning. Review of the nursing assistant statement obtained during the facility's investigation, revealed that the nursing assistant was directed by licensed nurse, Employee E2, to wrap washcloths in a towel and use it as a warm compress. The compress was heated for approximately one minute and 30 seconds in the microwave prior to being applied, by the nursing assistant, to the resident's neck. Review of the physician's notification sheet dated April 2, 2013, related that the resident requested hot packs to the hip and neck. The physician's orders [REDACTED]. There was no order obtained for the application of a warm compress to the resident's neck. Observations conducted with licensed nurse, Employee E1, on April 10, 2013, at 11:00 a.m., during wound treatment to Resident A1's left hand fingers, revealed two open areas on the index finger of the left hand, as well as a redden area between these two open areas. The nail on this finger was black and blue in color. The middle finger of the left hand was observed with one open area and there was no nail present on this finger. Employee E1, administering the treatment to the fingers, confirmed that the open areas, redness, discoloration of the nail of the index finger and the absence of the nail on the middle fingers, were a result of the injury that occurred when the warm compress was placed on the resident. The facility failed to follow the physician's orders [REDACTED]. 28 Pa Code: 201.14(a) Responsibility of licensee Previously cited 1/25/2013 28 Pa Code: 201.18(b)(1)(3) Management Previously cited 2/29/12, 1/25/2013 29 Pa Code: 211.10(d) Resident care policies Previously cited 2/29/12, 1/25/2013 29 Pa Code: 211.12(d)(1)(3)(5) Nursing services Previously cited 2/29/12, 1/25/2013

Based on clinical record review, facility documentation an, staff interview, it was determined that the facility failed to adequately supervise and provide care to prevent accidents resulting in actual harm to one of 24 residents reviewed (Resident: G16). Findings include: A review of resident G16s [DIAGNOSES REDACTED]. A review of physician orders [REDACTED]. Review of the significant change Minimum Data Set (MDS)- periodic assessment of resident needs) dated October 10, 2012 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Further review of the assessment showed that the resident needed extensive assistance when transferring from one surface to another. Review of nurses notes dated October 19, 2012 at 10:30 p.m. stated " CNA approached me and at 8:00 p.m. and stated that resident bumped his leg and that it was bleeding. I gathered some dressing and supplies and entered the resident's room and found the resident sitting on his bed with CNA kneeling on the floor applying pressure to right calf with a towel. There was a large amount of blood on the floor and on the towel. MD was notified and a VTO (Verbal Telephone Order) was obtained at 8:20 p.m. to send resident to ER for further evaluation" A nursing note dated October 19 2012 at 10:30 p.m. revealed that the resident was sent to emergency room via ambulance at 9:00 p.m. Review of individual staff statements obtained during the facilities investigation revealed that as the resident ascended from the chair the resident grazed their leg on the edge of the folded up foot pedal of the wheelchair, the residents leg immediately began to bleed large amounts of blood and fluid. The resident sat down on the side of the bed and states " that burned like hell " . A review of Resident G16s Skin-Wound Progress Report dated October 20, 2012 revealed the resident had a skin tear of the right calf that measured 17 centimeter in length and 4 centimeters in width that was covered with steri-strips with a heavy amount of exudate (fluids, cells or other substances that have been discharged from cells or blood vessels through small openings). Interview with the DON on January 25, 2013 confirmed that the resident was being transferred by a CNA (nursing assistant) alone from the wheel chair to the bed. The resident was not transferred with the assistance of two staff member as outlined in the resident's plan of care. The facility failed to ensure the safe transfer of the resident from the wheelchair to the bed resulting in actual harm to resident G16 resulting in transfer to the hospital for treatment and sustaining a large skin tear. 28 PA Code: 201.14(a) Responsibility of licensee Previously cited 2/29/2012 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 2/29/2012 28 Pa. Code 211.10(d) Resident care policies Previously cited 2/29/2012 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/29/2012 28 Pa. Code 211.12(d)(3) Nursing services