Every finding on record at Exton Post Acute

Based on observations and staff interview, it was determined that the facility failed to ensure that food stored in the walk-in freezer were properly stored and labeled to prevent contamination and ensure safe storage in accordance with professional standards for food service safety in one of one kitchen areas. (Main Kitchen)Findings include:Observations in the kitchen on April 6, 2026 at 9:45 a.m., in the presence Food Service Director Employee E7 revealed the following: one bag of frozen cookie dough in a cardboard box; a bag of mixed frozen vegetables in cardboard box; one bag of frozen peas in a cardboard box; one box of frozen hamburger patties; one box of frozen turkey burgers; and one bag of frozen French toast in a cardboard box. Additional observation revealed that the above-mentioned frozen foods in the plastic bags were not sealed and the box that they were in was not closed.Observations on April 8, 2026, at 9:15 a.m., in the presence of Employee E7 revealed the following: a bag of unsealed frozen chicken nuggets; an open box of frozen hamburger patties; an unsealed bag of cookie dough.Interview with Employee E7 on April 9, 2026, at 12:51 p.m., confirmed that the above-mentioned foods observed on April 7, 2026, and April 8, 2026, were not properly stored and labeled.The above findings were conveyed with the Nursing Home Administrator (NHA) on April 9, 2026, at 2:00 p.m.The facility failed to ensure that food stored in the walk-in freezer in the main kitchen was properly stored and labeled to prevent contamination and ensure safe storage in accordance with professional standards for food service safety. 28 Pa. Code 211.6(f) Dietary services.

Based on clinical records review and staff interview, it was determined that the facility failed to develop a care plant for residents on Dialysis (A process of purifying the blood of a person whose kidneys are not working normally) in a timely manner for two of three residents reviewed (Resident 1 and 38).Findings: Review of Resident 1 admission record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis of ESRD and dependence on dialysis. A review of Resident 1 physician's order date March 11, 2026, revealed an order for dialysis every Tuesday, Thursdays, and Saturdays. A review of Resident 1 active care plan revealed care plan for dialysis was not developed until April 2, 2026. An interview was conducted with Employee 5 on April 9, 2026, at 2:30 p.m. and confirmed that Resident 1 dialysis care plan was not developed until April 2, 2026. The facility failed to ensure comprehensive dialysis care plan for Resident 1 was timely developed. A review of Resident 38's admission records dated March 11, 2026, revealed resident was admitted to the facility with diagnosis of End Stage Renal Disease (ESRD – Is the final, permanent stage of chronic kidney disease where kidneys have lost most of its function, making them unable to sustain life) and Dependence on Dialysis. A review of Resident active care plan revealed resident Dialysis care plan was not developed until April 8, 2026. An interview was conducted with Employee E5 on April 8, 2026, at 1:30 p.m. Employee E5 confirmed Resident 38's dialysis care plan was not developed until April 8, 2026. The facility failed to ensure Resident 38's comprehensive care plan for dialysis was developed timely. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one out of six residents reviewed (Resident 115).Findings Include:Review of facility policy for Care Plans, Comprehensive Person-Centered, revised March 2022, revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.Review of Resident 115's admission Minimum Data Set assessment (MDS- a mandated assessment of a resident's abilities and care needs), dated March 5, 2026, indicated the resident had no cognitive impairment, was dependent on staff for daily care needs, and had an active diagnosis of cancer, heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs), and diabetes (a chronic condition characterized by high blood sugar).Review of Resident 113's nursing progress notes revealed an entry dated March 12, 2026 at 5:17 a.m., Stating (Resdient 113) transported to (hospital) ER via EMS (Emergency Medical Services) at 5:04 a.m.Review of the hospital Discharge summary dated [DATE], revealed that the resident tested positive for C. difficile (Clostridioides difficile - a bacteria that causes severe diarrhea), was placed on special contact precautions (an infection control measure required for patients infected with bacteria spread by direct/indirect contact, such as C. difficile) and was discharged with an order for Vancomycin (an antibiotic) 125MG (milligrams) capsule, take 1 capsule by mouth 4 (four) times a day for 10 days.Review of Resident 113's progress notes revealed a provider note dated March 18, 2026 at 4:10 p.m., stating an assessment and plan for C. difficile infection - likely secondary to prolonged exposure to antibiotic use. Will discontinue systemic antibiotics in the absence of fever and leukocytosis (high white blood cell count) and urine culture (a laboratory test that indicates if urine contains an infection-causing bacteria). Start oral vancomycin.Review of Resident 113's care plan initiated on readmission on [DATE], revealed that a c-difficile care plan was not added until April 2, 2026.An interview with the Infection Preventionist on April 9, 2026 at approximately 1:30PM, revealed that when a resident develops an infection or is admitted with an infection, nursing is to notify Infection Prevention so they can initiate the appropriate care plan.The above findings were shared with the Director of Nursing on April 9, 2026 at approximately 2:15PM.28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of the facility's policy, clinical records review and resident and staff interviews, it was determined the facility failed to ensure physicians' orders were followed for two of 21 residents reviewed (Residents 1 and 38).Findings: A review of the facility's policy titled End Stage Renal Disease (ESRD - Is the final, permanent stage of chronic kidney disease where kidneys have lost most of its function, making them unable to sustain life), undated, revealed residents with ESRD will be cared for according to currently recognized standards of care. A review of Resident1's diagnosis list includes ESRD, Dependence on Dialysis (A process of purifying the blood of a person whose kidneys are not working normally), and Diabetes (A group of metabolic disorder characterized by a high blood sugar level over a prolonged period of time). A review of Resident 1's physician order dated March 11, 2026, revealed Dialysis Schedule [Name of dialysis facility] Tuesdays, Thursdays, and Saturdays. An interview with licensed nurse Employee E4 was conducted on April 9, 2026, at 2:06 p.m. Employee E4 confirmed that Resident 1 goes out for Dialysis every Tuesday, Thursday, and Saturday. Employee E4 further reported that the resident usually leaves around 7:30 a.m. and returns to the facility around 3:30 p.m. A review of Resident 1's physician order dated March 11, 2026, revealed an order of Sevelamer Carbonate (A phosphate-binding medication used to manage high blood phosphate levels in patients with chronic kidney disease on dialysis) oral tablet 800 mg. Give one tablet by mouth with meals. The medication was scheduled for 8:00 a.m., 12:00 noon, and 5:00 p.m. A review of Resident 1's March 2026 Administration Record (MAR) revealed Sevelamer medication was not administered to the resident at 12:00 noon on the following days: March 14, 17, 19, 21, 24, 26, and 28. The MAR revealed 3 on March 14 and 28, 2026, indicating hold and 5 on March 17, 19, 21, 24, 26, and 28, indicating absent from facility. A review of Resident 1's physician's order dated March 11, 2026, revealed an order of Insulin Lispro (A rapid-acting insulin) 100 unit/ml inject as per sliding scale: 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; [PHONE NUMBER] = 8 units; 351-400 = 10 units, call the physician for blood sugar below 70 and above 401 before meals and at bedtime. The blood sugar check was scheduled for 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:30 p.m. A review of Resident 1's March 2026 MAR revealed the resident's blood sugar from March 12, 2026, until March 31, 2026, ranges from 80 mg/dl- 397 mg/dl. Further March 2026 MAR review revealed Resident 1's blood sugar check was not done at 11:30 a.m., on the following dates: March 14, 17, 19, 21, 24, 26, 28, and 31. MAR revealed 3 on March 14, 17, 19, 21, 24, 26, and 31, indicating absent from facility, and 5 on March 28, indicating hold. Blood sugar check on the above-mentioned dates/times were not done, thus unable to determine if Lispro insulin medication was indicated based on the sliding scale order. Resident 1's physician's order did not reveal an order to hold Sevelamer medication and blood sugar check with Lispro sliding scale during Resident 1's dialysis days/time. A review of Resident 38's diagnosis list includes ESRD and Dependence on Dialysis, Hypertension (high blood pressure, and Depression (A mood disorder that causes a persistent feeling of sadness and loss of interest). An interview with Resident 38 was conducted on April 9, 2026, at 2:10 p.m. Resident 38 reported that their dialysis schedule is every Monday, Wednesday, and Friday. The resident further reported that pick up time was usually 6:30 a.m., and returns to the facility around 1:00 p.m. A review of Resident 38's physician order dated March 11, 2026, revealed the following orders: Amlodipine (A medication to lower high blood pressure) 10 mg, give one tablet by mouth one time daily; and Prozac (A medication to treat depression) 40 mg, give one capsule by mouth two times daily. A review of Resident's April 2026, MAR revealed that residents' 9:00 a.m., Amlodipine, and Prozac were not administered on the following dates: April 1, 3, 6, and 8. MAR review revealed 5 on April 1 and 3, 2026, indicating hold, and 3 on April 6 and 8, 2026, indicating absent from facility. A review of Resident 28's physician's order did not reveal an order to hold the Amlodipine and Prozac during dialysis day/time. An interview with the Director of Nursing (DON) was conducted on April 9, 2026, at 2:30 p.m. and confirmed that above medications were not administered because residents were out for dialysis. There were no documents indicating that Resident 1 and Resident 38 physicians were notified of the missed medications. The facility failed to ensure Resident 1's and Resident 38's medication orders were followed. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on observation, clinical records review, and resident and staff interview, it was determined the facility failed to follow the physician's order for PICC (a peripherally inserted central catheter with two lines that allows the provider to deliver more than one therapy directly into the blood stream) line care by not changing the PICC dressing within 7 days for one of two residents reviewed (Resident 26).Findings include:Review of Resident 26's admission dated March 10, 2026, revealed resident was admitted to the facility with a diagnosis of Osteomyelitis (infection to the bone) to the vertebra, lumbar region (the five largest bones L1-L5 of the vertebral column located in the lower back between the thoracic spine in the pelvis).A review of Resident 26's physician order dated March 11, 2026, revealed Ceftriaxone (antibiotic) Sodium Solution Reconstituted two grams use two grams intravenously (administered through vein) every 12 hours for infection for 100 administrations.A review of Resident 26 physicians order dates March 11, 2026, revealed change PICC transparent dressing on admission and then every 7 days; caps to be changed during dressing change one time a day every seven days.Review of Resident 26's March 2026 and April 2026 medication administration record (MAR) revealed this order was signed off and completed every seven days.Observation on April 6, 2026, at 9:30 a.m. revealed Resident 26 was seated on a chair in his room. Further observation revealed right upper arm PICC line transparent dressing halfway detached. The date on the transparent dressing was observed March 16, 2026.An interview with Resident 26 was conducted on April 6, 2026, at 9:32 a.m. Resident 26 reported that transparent dressing has not been changed since March 16, 2026.An observation conducted on April 6, 2026, at 1:30 p.m. in the presence of Employee E8 revealed that Resident 26 transparent dressing on the right arm PICC line was still halfway detached and was not changed.An interview conducted with Employee E8 on April 6, 2026, at 1:30 p.m. confirmed that Resident 26's PICC line dressing should have been changed every seven days.An interview with the Director of Nursing on April 9, 2026, at 2:30 p.m. confirmed the PICC line dressing should have been changed every seven days.The facility failed to ensure Resident 26 Physician order to change PICC line dressing was followed.28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on observations, clinical records review and interview with staff, it was determined that the facility failed to ensure fluid restriction orders for dialysis residents were followed for two of three dialysis residents reviewed. (Residents 31 and Resident 38).Findings: A review of the facility's policy titled End Stage Renal Disease (ESRD – Is the final, permanent stage of chronic kidney disease where kidneys have record lost most of its function, making them unable to sustain life), undated, revealed residents with ESRD will be cared for according to currently recognized standards of care. A review of the facility's policy titled Encouraging and Restricting Fluids, undated, revealed the following guidelines: Be accurate when recording fluid intake; Record fluid intake on the intake side of the intake and output. Record fluid intake in ml (milliliter) ; When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room; and be sure an intake and output record is maintained in the resident's room. A review of the same policy revealed that the information should be recorded in the resident's medical record: The amount (in ml) of fluid consumed by the resident during the shift. Review of Resident 31's diagnosis list includes End Stage Renal Disease (ESRD- failure of kidney function to remove toxins from blood), and dependence on renal Hemodialysis (A process of purifying the blood of a person whose kidneys are not working normally). Review of Resident 31's physician orders dated April 2,2026 revealed an order for Fluid Restriction1200ml Serve 720 ml for dietary/day Serve480 ml for Nursing/day Nursing Amount per shift: 7-3Shift= 180ml,3-11shift = 180ml,11-7shift = 120 ml. Review of Resident 31's April 2026's Medical Administration Record (MAR) reveal there was no evidence of the amount of fluid Resident 31 was receiving each shift from the date of the order on April 2, 2026. Interview with Director of Nursing on April 9, 2026, at approximately 11:55am confirmed the above findings. A review of Resident 38's diagnosis list includes ESRD and Dependence on Dialysis. A review of Resident 38's physician's order dated April 1, 2026, revealed an order for Fluid restriction 1500 ml serve 840 ml dietary/day, served 660 ml for nursing/day. Amount per shift: 7-3 shift = 270 ml, 3-11 shift = 270 ml, 11-7 shift = 120 ml. A review of Resident 38, April 2026, Medication Administration Record (MAR) revealed that the fluid amount consumed by the resident during the shift was not recorded. Observations were conducted on the following dates/times: April 6, 2026, at 1:18 p.m., April 7, 2026, at 9:20 a.m., and April 8, 2026, at 2:05 p.m. All three observations revealed that a big white cup filled with water was on the resident's bedside table. An interview with Resident 38 was conducted on April 8, 2026, at 2:05 p.m. The resident reported that staff placed a big cup of water on their bedside table. The resident further stated, It just appears. The resident was not sure how much fluid/water they were allowed to consume each day. An interview with the Director of Nursing on April 10, 2026, at 1:00 p.m., confirmed that fluid consumed by the resident every shift was not recorded. The facility failed to ensure Resident 38's ordered fluid restriction of 1500 ml/day were properly monitored and followed. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to respond to recommendations made by the consultant pharmacist during monthly medication reviewed for three of five residents reviewed. (Residents 3, 1, and 115)Findings include:Review of facility policy, titled Medication Regimen Reviews last revised July 2025 revealed that a licensed consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.the MRR includes a review of the medical record to prevent, identify, report, and resolve medication related problems.or other irregularities such as ordered without clinical indication.Review of Resident 3's admission Minimum Data Set assessment (MDS- a mandated assessment of a resident's abilities and care needs), dated January 16, 2026, revealed that the resident was cognitively intact, required extensive assistance with care needs, had an indwelling Foley catheter (a tube placed into the bladder that drains urine into an attached drainage bag) related to a neurogenic bladder (a dysfunction of the lower urinary tract caused by nerve damage), received antipsychotic medications, antidepressant medications, diuretic medications, opioid medications, and anticonvulsant medications and had a diagnoses of bipolar disorder (a chronic mental health disorder), fracture of the lower end of the right humerus (the long, upper bone of the arm) resulting from an automobile accident, and obesity.Review of Resident 3's progress notes revealed a pharmacy consultant note dated January 10, 2026, at 10:24 p.m. stated see report for complete information in monthly review.Review of Resident 3's recommendations for January 10, 2026 revealed, Resident previously had orders for Pantoprazole (a medication that decreases stomach acid) 40MG (milligrams), Tamsulosin (a medication that improves urine flow) 0.4MG, and Zolpidem (a sleep medication) 10MG. Re-evaluate if resident still needs these medications and reconcile. The provider checked the agree box for this recommendation.Review of Resident 3's physician orders and provider notes revealed the facility failed to address the recommendations of the January 2026 MRR.Revie of Resident 10's admission Minimum Data Set assessment for Resident 10 dated February 14, 2026 revealed that the resident had significant cognitive impairment, relied on assistance from staff for personal care, had a diagnosis of heart failure, hypertension, non-Alzheimer's dementia, and anxiety disorder, and received antipsychotic medications, antianxiety medications, diuretic medications, antiplatelet medications, and anticonvulsant medications.Review of Resident 10's progress notes revealed a pharmacy consultant note dated February 8, 2026 at 11:06 p.m. revealed recommendations from the MRR: 1: Resident was admitted on Lorazepam (a medication used to treat anxiety disorders) which need a supporting diagnosis to support use. Clarify the indication use of the medication; and 2: Resident is receiving Seroquel (a medication used to treat schizophrenia, bipolar disorder, and depressive episodes) but lacks an appropriate diagnosis to support its use. Clarify the indication use of the medication.Review of Resident 10's physician orders as of April 3, 2026 revealed the facility failed to address the pharmacy recommendations of the February 8, 2026 MRR.Review of Resident 10's progress notes revealed a pharmacy consultant note dated March 4, 2026 at 8:20 p.m. stating recommendationsThe facility was asked to provide the recommendation for Resident 10 on March 4, 2026 MRR. Interview with the Director of Nursing (DON) on April 9th, 2026, at approximately 1:00 p.m. confirmed they were unable to provide the recommendations from the Pharmacist of March 4, 2026.Review of Resident 115's admission MDS dated [DATE], indicated that the resident had little cognitive impairment, was dependent on staff for daily care needs, had an active diagnosis of cancer, heart failure, and diabetes, and received antidepressant medications, anticoagulant medications, antibiotic medications, diuretic medications, and insulin.Review of Resident 115's progress notes revealed a pharmacy consultant note dated March 4, 2026 at 9:33PM stating the following recommendations: Voltaren Gel (a topical gel used to relieve joint pain): Clarify order to include dose.Review of Resident 115's current physician orders revealed an active order for Voltarin Gel without a dose.Review of Resident 115's pharmacy consultant note dated March 18, 2026, at 7:34PM revealed the following recommendations: 1: Resident was admitted on Potassium chloride (a mineral that supports heart function), which need (sic) a supporting diagnosis to support use. Clarify the indication use of the medication. Review of the MRR revealed the physician agreed with the recommendation and wrote hypokalemia(a condition where low blood potassium levels cause irregular heart rhythms).Review of Resident 115's orders active as of April 8, 2026, revealed a physician's order dated March 23, 2026, for Potassium Chloride Crys ER Oral Tablet Extended Release 20MEQ, without a diagnosis listed.Interview with the DON on April 9, 2026, at approximately 2:15PM confirmed that the recommendation had not been addressed for Resident 3, 10, and 115.28 Pa Code 211.5(f) Clinical records 28 Pa Code 211.12(d)(3) Nursing Services

Based on review of facility policy, resident's clinical records, staff interviews, and observations, it was determined the facility failed to follow transmission-based precautions for one of 24 residents reviewed. (Resident 12)Findings Include:Review of facility policy Clostridioides (Clostridium) Difficile (a bacterium causing diarrhea), last revised December 2024, states, Residents with diarrhea and suspected CDI (Clostridium Difficile infection) are placed on contact precautions (measure of infection control requiring gloves and gown to be worn during patient care, as well as hand washing with soap and water) while awaiting laboratory results.Review of Resident 12's Nurse Practitioner Notes revealed that on April 6, 2026, at 9:30 a.m., the resident complained of having multiple liquid stools and an order was placed to collect a stool sample to rule out Clostridium Difficile. The Nursing Progress notes further revealed that on April 6, 2026, at 1:14 p.m., a stool sample was collected from the resident. Further review Resident 12's progress notes revealed a nursing note dated April 7, 2026, at 12:07 p.m. stating that the resident continued to experience diarrhea. On April 8, 2026, at 8:08 a.m., a Health Status note reveals that the resident was experiencing loose stools, chills, and aches. Review of physician orders for Resident 12 revealed an order for Enhanced Barrier Precautions (measure of infection control requiring gloves and gown to be worn during high contact patient care) on March 12, 2026. Further review of Resident 12's physician orders revealed no order for contact precautions.Observation of Resident 12's room on April 6, 2026 at 10:20 a.m., April 7, 2026 at 11:00 a.m., April 8, 2026 09:30 a.m. and April 9, 2026 at 11:15 a.m. and 1:00 p.m. revealed there was no signage indicating contact precautions were in place and no personal protective equipment available in Resident 12's room. Results of laboratory testing on the stool sample for Resident 12 were pending at the time of exit at 3 p.m. on April 9, 2026.Interview with facility Infection Preventionist on April 9, 2026, at 12:05 p.m. confirmed that Resident 12 was tested for c-diff and should have been on contact precautions while the results were pending. 28 Pa Code 201.18(b)(1)(3) Management 28 Pa Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of guidelines for Cardiopulmonary Resuscitation (CPR), facility's policies, staff interviews and residents' clinical and hospital records, it was determined the facility failed to ensure that code status was documented on the residents clinical record delaying the decision to provide life sustaining measures such as CPR for one of five residents reviewed (Resident CL1), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform life sustaining interventions.Findings include: Review of the American Health Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published on [DATE], revealed the AHA recommends all potential rescuers to initiate CPR unless a valid, Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. Review of facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation and Basic Life Support, dated 2001, revealed If an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, a staff member who is certified in CPR for healthcare provider/BLS (Basic Life Support) will administer CPR unless: it is known that a do not resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual; or there is obvious signs of irreversible death (e.g. Rigor mortis). If the resident's DNR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order not to administer CPR. Review of Resident CL1's emergency room hospital records dated [DATE], revealed Resident CL1 admitted for diagnosis of Acute respiratory failure with hypoxia (critical condition where the lungs cannot adequately transfer oxygen to the blood), and Atrial Fibrillation (A-fib is an irregular heartbeat). The same records revealed Code Status: Full Code. Review of Resident CL1's Encounter notes by attending physician dated [DATE], signed at 10:26 p.m., revealed Resident CL1 was admitted from the hospital with a diagnosis of Acute respiratory failure with hypoxia. The same note revealed Code Status - Full code: Patient has elected Full Code status, indicating they wish to receive all possible life-saving interventions, including CPR, defibrillation (lifesaving medical procedure that uses a controlled electrical current to stop a life-threatening, chaotic heart rhythm, allowing normal heart rhythm to restore), advanced airway management, and other aggressive treatments. Review of Resident CL1's physician's order dated [DATE], revealed an order for BIPAP (Bilevel Positive Airway Pressure - noninvasive device that helps people breathe by delivering pressurized air through a mask at two distinct pressures: high for inhalation (IPAP) and low for exhalation (EPAP). Inspiratory pressure 14, Expiratory pressure 5 at bedtime. Review of Resident CL1's nursing progress notes documented by licensed nurse Employee E4 dated February 12, 2026, at 5:10 a.m., revealed Resident noted at 0510 without signs of life. Evidence of irreversible signs of death are pulseless, no viable vital signs, and skin cool, skin color pale and grayish, pupils dilated and fixed, no chest rise or lung sound heard. Resident pronounced by this RN (registered Nurse), family notified. Review of statements obtained from the staff by the Director of Nursing the night of the incident revealed a statement by unlicensed Employee E5, I [employee's name] changed [Resident CL1] at 2:30 (a.m.) [they] rolled over for me and drank some water when I went back to change [them] at 4:45 (a.m.), that's when I realized [they were] gone and I called the nurse. Interview conducted on February 17, 2026, at 6:30 a.m. with licensed nurse Employee E4, revealed Employee E4 reported being a new nurse and employee in the facility. Employee E4 confirmed being the nurse of Resident CL1 on February 11-12, 2026, on the 11-7 shift. Employee E4 revealed that Resident CL1 was first observed at 12 midnight sleeping with BIPAP on, the resident was next observed at around 3:30 a.m., sleeping without a BIPAP mask but with a nasal cannula (flexible tube with two prongs that deliver supplemental oxygen at a low flow rate). Employee E4 reported, the resident had a habit of taking off the BIPAP mask at night. Employee E4 further revealed that before 5:00 a.m., non-licensed nursing Employee E5 called them to check the resident. Employee E4 stated, [Resident] was lying supine, normal pale color, [resident] normally pale. I checked the pulse on the wrist and neck using my two fingers, and I did not feel a pulse. I checked the code status, but it was not listed on my sheet. Then, I saw the Nursing Supervisor, Employee E3, coming, so I called her and both of us looked for the code status, which took approximately 10 minutes. Employee E4 revealed an aide was left with Resident CL1 while checking for the resident's code status, but the code status was not on the computer. Employee E4 asked Employee E3 (nursing supervisor) what to do, and Employee E3 responded to go and get the vitals. Employee E4 reported Resident's blood pressure, pulse rate and respirations were all 0, the temperature was 97.9 F (Fahrenheit) with the use of a thermometer machine on the forehead, resident was still kinda warm, fingertips were just turning blue, arms were both movable because I was able to put the blood pressure cuff. Employee E4 reported the above information was communicated with Employee E3 and the response was the DON (Director of Nursing) had been called. Employee E4 stated, I was never told to do CPR or call 911. Interview conducted with licensed nurse Employee E3 on February 17, 2026, at 7:10 a.m. revealed Employee E3 reported that on February 12, 2026, at around 5:00 a.m., Employee E4 flagged them down to come to the unit and check the resident. Employee E3 revealed Resident CL1 was gray, cheek was cool, no breath sounds, no carotid pulse (located on either side of the neck, in the soft groove between the windpipe and the large neck muscle), no radial pulse (located on the thumb side of the inner wrist, is a primary site to measure the heart rate). Employee E3 further stated that during the assessment I did not feel any warmth, eyes were closed, mouth was open, when I checked the wrist, I was still able to roll the arm, there was mottling (discoloration caused by reduced blood flow to the skin's surface) on the legs, they were off color but I'm not sure since I'm not familiar with the resident. Employee E3 reported that upon checking the computer, the resident's code status was full code, as indicated on the resident's preadmission report located under the miscellaneous section of the resident's EMR- Electronic Medical Record) dated [DATE], the DON was called. When asked by the surveyor why CPR was not initiated, Employee E3 responded, I do not do CPR to somebody that I assessed was already dead, no viable signs of life. Review of Resident CL1's physician's orders revealed no order for a code status. Interview was conducted with the DON on February 17, 2026, at 10:30 a.m. The Director of Nursing (DON) revealed the residents' code status should be reflected on the EMR (electronic medical records) in PCC (Point Click Care- electronic documentation program) below their name and on physician's orders. The DON was unable to provide an answer as to why Resident CL1's code status was not reflected in both places. The DON reported getting a call around 5:15-5:30 a.m., from Employee E3 reporting that Resident CL1 was unresponsive, was cold and ashen (color), starting to mottle, with no vitals and was last seen by the aide at 2:30 a.m. The DON reported asking for Resident CL1's code status, and Employee E3 responded, I don't know, I'm looking for the advance directive (legal documents, primarily living will and durable power of attorney for healthcare that outline your preferences for medical treatments if you become unable to communicate or make decisions). The DON reported coming to the facility around 5:50 a.m. Resident CL1's pupils were fixed and dilated. The resident was hard, ashen in color, with no vitals, the medical director was notified. The DON revealed that Employee E3 pronounced the resident dead at 5:15 a.m. Review of Resident CL1's death certificate dated February 12, 2026, revealed the following cause of death: Cardiac Arrest (abrupt, often fatal cessation of heart function, causing immediate loss of consciousness, pulse, and breathing, requiring instant CPR and defibrillation to survive), A-fib, and Respiratory Failure. Interview with Director of Nursing (DON) on February 17, 2026, at 10:30 a.m., revealed the facility did not initiate CPR despite information indicating the resident was a full code due to irreversible signs of death as mentioned in their interviews. The assessments mentioned in the interviews were not signs of irreversible death as indicated by the AHA guidelines and facility policy. On February 17, 2026, at 12:12 p.m., the Nursing Home Administrator (NHA) and Director of Nursing were informed the health and safety of facility residents were in Immediate Jeopardy due to licensed nurse staff failing to provide CPR in accordance with a resident's physician encounter note and hospital documents indicating resident was a full code. The Immediate Jeopardy template was presented to the NHA and DON at this time. The facility submitted an acceptable action plan on February 17, 2026, at 2:47 p.m. that included the following actions: A full house audit of all residents was completed to determine presence of code status and presence of a physician order; Monthly CPR drills were reviewed; Licensed staff education in CPR policy and procedures including general guidelines with focus on assessment of unresponsive residents, when to initiate CPR and identification of irreversible signs of death; Licensed staff have been taught that code status will be in PCC on the code status banner; Licensed staff have been educated in Emergency Code documentation form including the narrative of details during the code; Licensed staff have been educated in the compliance with physician orders related to the provision of CPR when indicated; Licensed staff orientation has been updated to include CPR and procedures, Emergency Code Documentation and compliance with physician order; Audit of order listing report and admission/readmission for presence of code status and corresponding order in PCC daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two month; Audit of effectiveness of licensed staff training will be conducted via questionnaires and on the spot interviews daily for seven days, three times a week for two weeks, weekly for two weeks, biweekly for two weeks then monthly for two months; and All ongoing compliance audits will be presented and reviewed at the QAPI meeting monthly for the next 6 months. The Immediate Jeopardy was lifted on February 18, 2026, at 11:32 a.m., when it was confirmed the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders and facility's policy, location of code status, and completed a Code drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical review and staff interview, it was determined that the facility failed to follow a physician's recommendations for one of five residents reviewed (Resident CL2).Findings: A review of Resident CL2's admission notes dated February 3, 2026, at 7:53 p.m., revealed the resident was admitted with a diagnosis of COVID (Coronavirus disease- A contagious disease caused by the coronavirus SARS-CoV-2), shingles (A painful, blistering skin eruption caused by the reactivation of the chickenpox virus). The resident had a fall and required rehab. The same notes revealed the resident was incontinent of bowel and bladder. A review of Resident CL2's Physical Medicine and Rehab notes dated February 5, 2026, at 9:18 p.m., revealed resident was admitted with altered mental status, COVID, Shingles, Encephalopathy (A reversible, non-structural brain dysfunction caused by systemic metabolic issues such as organ failure or infection) and BPH (Benign prostatic hyperplasia- A non-cancerous enlargement of the prostate gland caused by age related hormones changes). Plan and assessment for BPH revealed as follows: recommend monitoring urine output and PVRs (post-void residual- the amount of urine remaining in the bladder immediately after urination). A review of Resident CL2's physician orders failed to reveal an order of urine output and PVR monitoring. An interview with the Director of Nursing on February 17, 2026, at 1:00 p.m., revealed that nursing was not aware of the physiatrist's (A medical doctor who specializes in helping people regain function after surgery, a stroke, or an injury) recommendations; therefore, they were not communicated with the primary physician. The DON confirmed that the physiatrist's recommendations for urine output monitoring and PVR were not followed. The facility failed to ensure Resident CL2's Physician's recommendations for urine and PVR monitoring were followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on clinical records review and staff interview, it was determined that the facility failed to follow a blood work order in a timely manner for one of five residents reviewed (Resident CL2)Findings include: A review of Resident CL2's Nurse Practitioner's (NP) notes dated February 4, 2026, at 9:36 a.m., revealed a resident with a diagnosis of Metabolic Encephalopathy (A reversible, non-structural brain dysfunction caused by systemic metabolic issues such as organ failure or infection), and behavioral disturbances. A review of Resident CL2's physician order dated February 4, 2026, revealed an order for CBC (Complete blood count- A blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets) and CMP ( Comprehensive Metabolic Panel- A routine blood test measuring 14 different substances to evaluate kidney/liver function, blood sugar, and electrolyte imbalance) on February 5, 2026. A review of Resident CL2's February 2026 Treatment Administration Record (TAR) revealed that the order for CBC and CMP was done on February 4, 2026. A review of Resident CL2's Laboratory Results revealed that Resident CL2's CBC and CMP ordered for February 5, 2026, were not done until February 11, 2026. February 11, 2026, blood works revealed the following: WBC (white blood cell) was 16.8 (normal range 3.5-11), Creatinine was 2.86 (normal range 0.60 -1.5), and BUN (blood urea nitrogen) was 79 (normal range 8-23). A review of Resident CL2's physician's order dated February 11, 2026, revealed an order for Sodium Chloride 0.45%. Use 2 liters intravenously (administer through a vein) one time only for hydration for 1 day at 80ml/hr. x 2 liters. An interview with the Director of Nursing was conducted on February 17, 2026, at 1:00 p.m. The DON reported that the blood work order for February 5, 2026, was not put into the laboratory system and therefore was not done. The missed blood work was not identified until February 10, 2026, during an audit. The DON confirmed that the laboratory ordered for February 5, 2026, was not followed timely manner. The facility failed to ensure Resident CL2's orders for CBC and CMP were timely followed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on a review of their job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that Cardiopulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code. Findings include: Review of the job description for the NHA revealed the administrative authority, responsibility and accountability of directing the activities and programs in the center. Review of the job description for the DON revealed planning, develop, organize, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. The findings in this report identified that the facility failed to ensure that CPR was provided in accordance with the facility policy and procedures as a resident was a FULL CODE. The NHA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed. Refer to F678 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's Responsibility 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.12(d)(2)(3) Nursing Services

Based on a review of hospital and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician's order from the hospital was followed and accurately communicated to the facility's physician for one of the two residents reviewed (Resident CL1). Findings include:Clinical records review revealed Resident CL1 was admitted to the facility on [DATE] at aproximately 5:00 p.m., with the following diagnoses of falls and Atrial fibrillation (Irregular heartbeat).A review of Resident CL1's hospital record After Visit Summary dated October 16, 2025, revealed Resident CL1 was ordered and administered Warfarin (A medication that thins the blood) four milligrams (mg) in the hospital on October 16, 2025. Additional hospital records revealed that the resident had orders for Warfarin 3 milligrams and Warfarin 6 milligrams (total of 9 milligrams) on March 30, 2022. Further review revealed the resident's INR level (International Normalized Ratio- A standard blood test that measures how long it takes for your blood to clot) dated October 17, 2025, at 7:31 a.m., revealed an 8.8 result (high-a therapeutic level for a resident on moderate intensity anticoagulation should be between 2.0-3.0). The same report revealed as follows: Instructions: Please hold the Coumadin dose throughout the weekend. You need to see [name of the physician] on Monday to have your INR / Coumadin level rechecked. Please call today to make that appointment, or maybe the staff at [name of the skilled facility where the resident was admitted ] can have their medical staff doctor order the repeat blood test on Monday (October 20, 2025).A review of Resident CL1's October 2025 Medication Administration Record revealed that on Friday October 17, 2025, at 9:00 p.m., the resident was ordered and administered Warfarin 3 mg and Warfarin 6 mg, for a total dose of 9 mg.A review of the nursing progress notes dated October 17, 2025, at 11:09 p.m., revealed Resident CL1 was sent to the emergency room via 911 due to impulsive behavior, anxiety, and getting out of bed into the floor mats. Physicians and family were notified.A review of the nursing progress notes dated October 18, 2025, at 1:21 p.m., revealed that the resident's family called and informed the facility that Resident CL1 was admitted for an elevated PT/INR result.A review of the hospital records dated October 18, 2025, at 3:24 a.m., revealed Resident CL1 had an INR level of 11.2. Admitting diagnoses were multiple falls with possible fracture of the left 5th, 6th, and 7th ribs, hematoma of left lower extremity, and an elevated INR.An interview with the Director of Nursing (DON) was conducted on December 15, 2025, at 12:00 noon. The DON reported that the admitting nurse verifies orders from the hospital to the resident's physician/NP (nurse practitioner), then enters the order to the resident's electronic medical records.An interview was conducted with the NP on December 15, 2025, at 12:05 p.m. The NP confirmed they were not notified of the hospital's instruction to hold the residents' Warfarin for the weekend and ordered 9 milligrams (which was an old order from March 2022 and not 4 mg of coumadin which was the last amount prescribed on October 16, 2025 while in the hospital) of coumadin to be given the night of October 17, 2025.The above was conveyed with the DON and Nursing Home Administrator on December 15, 2025, at 1:30 p.m.The facility failed to ensure the physician's order for Warfarin medication from the hospital was followed and accurately communicated with the facility's physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on a review of facility policy, review of personnel files and interviews with staff, it was determined that the facility failed to implement their policy to screen employees according to the Older Adults Protective Services Act for one of five employees (Employee E3). Findings include: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that employee background checks would be completed. Review of Employee E3's personnel record revealed that the employee was hired on April 7, 2025. Further review of the personnel record revealed that the employee had not been a resident of Pennsylvania for the two years immediately preceding the date of application. There was no documented evidence that a federal criminal background check application had been completed. Interview with Employee E3 on June 25, 2025, at 12:00 p.m. confirmed that a federal criminal background check application had not been completed. Interview with Employee E4 on June 25, 2025, at 12:05 p.m. also confirmed that the federal criminal background check had not been completed for Employee E3. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code: 201.18 (b)(1)(e)(1) Management 28 Pa. Code: 211.10(d) Resident care policies Previously cited 1/16/25, 8/22/24

Based on review of clinical records, incident reports, policy review, and staff interviews it was determined the facility failed to ensure that one of 18 residents reviewed was free of a significant medication error, which compromised the resident's clinical condition and resulted in actual harm when the resident required a hospital admission. This is being cited as past noncompliance. (Resident R1) Findings Include: Review of facility policy titled, Reconciliation of Medications on Admission undated, revealed, the purpose of the procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Review of facility policy titled Administering Medications undated, revealed the purpose of the policy is to ensure medications are administered in a safe and timely manner, and as prescribed. Review of Resident R1's Face Sheet revealed an admitted [DATE], with medical diagnoses including fracture of the right femur (break of the thigh bone), Type 2 Diabetes Mellitus (insulin resistance and elevated blood sugar levels), Cerebral Infraction (aka: stroke), Peripheral Vascular Disease (disorder of blood vessels outside the heart), and Anemia (red blood cell deficiency). Review of Resident R1's clinical records revealed a hospital discharge summary, dated March 25, 2025, documenting a list of Resident R1's discharge medications which included Amlodipine 10mg (medication taken for blood pressure), Apixaban 5mg (milligram) (aka: Eliquis- blood thinner), Atorvastatin 80mg (cholesterol), Losartan 100mg (blood pressure, stroke, and diabetes), Loratadine 10mg (medication used to treat allergies), Metformin XR 500mg (diabetes), Trazodone 150mg (antidepressant), and Vascepa 1gr (gram) (medication used to reduce heart attack and stroke). Review of Resident R1's clinical record failed to reveal a physician's order for Apixaban 5mg. Further review of Resident R1's clinical record failed to reveal on Medication Administration Record an order for Apixaban from March 25, 2025 through April 3, 2025. Review of Resident R1's clinical records revealed physician progress note dated April 3, 2025, documenting the resident was seen due to a cold, left foot with no palpable (felt) pulse per nursing, has history of Peripheral Artery Disease, Superficial Femoral Artery disease (SFA) stenting (small wire used to increase blood or fluid flow). Resident on Eliquis but no antiplatelet (blood clot reducer) agent. Recommendation made for stat (immediate) arterial doppler. Further review of Resident R1's clinical records revealed an encounter progress note dated April 4, 2025 (1:00 a.m.) indicating Resident R1's previously ordered doppler of left lower extremity unable to be performed due to unavailable technician, transfer to hospital for further evaluation. Review of Resident R1's clinical records revealed a progress note dated April 4, 2025, at 4:40 a.m., documenting Resident R1 was admitted to the hospital for treatment of Popliteal Artery Embolism (critical vascular condition characterized by the obstruction of blood flow in the right popliteal artery, located behind the kneee, due to an embolus/blood clot which increases risk of limb loss). Review of Resident R1's clinical record including hospital discharge summary revealed Resident R1 was admitted to the hospital on April 4, 2025, with history of Coronary Artery Disease, Peripheral Artery Disease, Atrial Fibrillation, Diabetes Mellitus Type 2, who presented with cold extremity. Resident R1 was found to have a Popliteal Thrombus (blood clot in vein behind knee) and underwent a Thrombectomy (surgical procedure to remove the blood clot). Resident R1 was transitioned from Plavix (medication used to prevents platelets from forming blood clots. Used for preventing heart attacks and strokes in high-risk patients) and Aspirin to Eliquis (medication blocks a protein that helps form blood clots. Used for atrial fibrillation (irregular heartbeat) to prevent stroke) and Aspirin alone. Review of Resident R1's clinical records revealed a progress note dated April 8, 2025, at 5:58 p.m., documenting the resident was readmitted to the facility. Review of Resident R1's clinical records revealed a hospital discharge summary, dated April 8, 2025 indicating Resident R1's discharge medications including Amlodipine 10mg (medication used to manage high blood pressure), Apixaban 5mg (blood thinner), Atorvastatin 80 mg (medication used to treat cholesterol), Losartan 100mg (blood pressure, stroke, and diabetes), Loratadine 10mg (allergies), Metformin XR 500mg (medication used to control high blood sugar levels), Trazodone 150mg (antidepressant medication), Vascepa 1gr (medication to reduce risk of heart attack and stroke). Venlafaxine XR 150mg (antidepressant medication), and Oxycodone 5mg (medication used to alleviate moderate to severe pain). Review of Resident R1's clinical records revealed a progress note dated April 9, 2025, at 12:16 p.m., documenting Eliquis (Apixaban) ordered and started. Review of Resident R1's clinical records revealed a care plan initiated on April 9, 2025, documenting the resident is on anticoagulant therapy related to Atrial Fibrillation (irregular heart rhythm). Review of information dated April 9, 2025, submitted by the facility to Department of Health revealed during Resident R1's readmission review on April 9, 2025, the team identified a potential transcription error for the medication Apixaban, an anticoagulant. QAPI (Quality Assurance Performance Improvement) was initiated and concluded a transcription error occurred and Apixaban was omitted during the resident's original admission of March 25, 2025, subsequently the resident missed 10 days of this medication from March 25, 2025, through April 3, 2025. The resident was sent to the emergency room and admitted to the hospital on April 4, 2025, with a diagnosis of Popliteal Artery Embolism. Further review of the information dated April 9, 2025, submitted by the facility to the Department of Health revealed on April 11, 2025, after Director of Nursing's completed investigation, chart audits were performed for all new admissions for past 14 days to ensure accuracy of transcribed orders and compared to the hospital discharge instructions. Education was provided to professional staff to review the admission process and double check accuracy to mitigate medication errors. Review of facility records revealed witness statement dated April 11, 2025, documenting Registered Nurse, Employee E4 entered orders for the resident, she did not enter the Apixaban due to having concerns about the order. The physician's order indicated Resume 9/18/24. Employee E4 left the order to be followed up with the nurse on duty, LPN Employee E5. Employee E5 did not follow up on the order. Interview of Registered Nurse, Employee E4, on April 15, 2025, at 2:30 p.m., stated he/she was assisting Licensed Practical Nurse (LPN) Employee E5 with admissions as there were four admissions during the shift and only one nurse. Employee E4 stated there was a note on the resident's hospital discharge medication list concerning the resident's Apixaban which indicated, Apixaban 5 mg oral 2 times daily, resume 9/18/2024. Employee E4 stated he/she notified Employee E5 and informed E5 to ask about this. Per Employee E4, Employee E5 failed to follow up therefore the resident's medication was not entered into the system. Interview conducted with Nursing Home Administrator (NHA), Director of Nursing (DON), and [NAME] President of Operations (VPO) on April 15, 2025, at 2:00 p.m. when the above information was presented. The Nursing Home Administrator, Director of Nursing and [NAME] President of Operations confirmed the incident occurred, indicating that a plan of correction had already been put into place, and provided evidence of the plan of correction. Per the NHA Employee E5 was on vacation from April 9, 2025, through April 23, 2025, and was unavailable for interview. Review of facility educational documents revealed a 24-Hour Chart Check Process in-service training sheet dated April 13, 2025, containing nine nursing staff signatures. Review of facility records revealed a Medication Reconciliation Process training inservice sign in sheets dated April 14, 2025, documenting 17 nursing staff signatures and for April 15, 2025, containing 20 nursing staff, of which six are PRN (as needed), were educated via telephone and required to sign the in-service attendance sheet prior to starting their next shift. Review of facility documentation revealed a Message Blast (text message sent to staff) dated April 14, 2025, indicating for all nursing staff to note admit nurse signs on the after-visit summary (AVS- utilized for new admissions), medications reviewed with physician, note in PCC (Point Click Care- electronic medical record) 2nd nurse reviews medications AVS (after visit summary) and signs ok (to confirm order). Any unclear (questionable) orders need verified by physician as soon as possible, enter order on-hold until clarified. You need to sign education in supervisor book next time you work, please verify receipt. Review of facility records revealed a Medication Reconciliation Policy with in-services sign in sheets documenting the staff was retrained on the medication reconciliation policy. The purpose of the policy was to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Further review revealed a policy titled Administering Medications with in-service sign in sheets documenting the staff was retrained on the administering medications policy. The purpose of the policy was to ensure medications are administered in a safe, timely manner and as prescribed. Interviews conducted on April 15, 2025, approximatley 1:00 p.m and 2:00 p.m., with Employee E4, Employee E6, Employee E7, Employee E8, and Employee E9, confirmed education topics and knowledge of medication protocols as well as training for Medication Reconciliation on April 14, 2025. Review of audits conducted by the facility revealed newly admitted residents had medications verified and AVS was signed by two nurses, with no discrepancies noted. The facility failed to administer medication as ordered due to a transcription error upon initial admission for Resident R1 causing actual harm when Resident R1 was hospital for a Popliteal Artery Embolism. The deficiency is past non compliance. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(e)(1) Management 28 Pa Code 211.12(c)(d)(3) Nursing services

Based on clinical record review and staff interview, it was determined the facility failed to assist one of one (Resident 43) residents in making transportation arrangements to and from multiple orthopedic surgery appointments resulting in actual harm by causing a deterioration of the wound and being admitted to a hospital for wound washing, and failure to follow a medication order from the physician for one out 19 residents reviewed (Resident 30). Findings include: Review of Resident 43's admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated November 29, 2024, revealed the resident was admitted on [DATE], was understood, could understand others, was cognitively intact, dependent on staff for care needs, and had a fracture of lower end of right femur (thigh bone), fracture of T9-T10 vertebra (spinal cord), fracture of ribs, fracture of lower end of left radius (forearm), displaced [NAME] fracture of left tibia (lower leg), other fracture of upper and lower end of left fibula (calf bone), displaced bicondylar fracture with nonunion (knee joint), and displaced bicondylar fracture of right tibia. Review of Resident 43's physician follow-up note dated January 10, 2025, at 2:33 p.m. revealed Resident 43 was evaluated due to nursing concerns over worsening right lower extremity (RLE) wound. Further review of the follow-up note revealed Resident 43 was not able to attend (his/her) orthopedic surgery appointment on January 6, 2025, due to not being able to cover the out-of-pocket expense. Review of wound care progress note dated January 10, 2024, revealed Patient has follow-up appointment with surgeon on January 13 regarding worsening right leg surgical repair, Transportation scheduled, and payment has been confirmed by husband. Nurse Practitioner (NP) aware of same. Review of Resident 43's physician follow-up note dated January 13, 2024, revealed Resident 43 was seen for a worsening right lower extremity (RLE) wound and concern for missed orthopedic surgery appointments and an order for Bactrim [double strength] tablet 800-160 milligrams, give 1 tablet by mouth every 12 hours for bacterial infection/worsening leg wound for 7 days and oxycodone [hydrochloride] oral tablet 5 milligrams, give one tablet by mouth every 4 hours as needed for moderate to severe pain. Further review revealed [Resident 43] wished the facility worked with a different service and was also upset that (he/she) was having to do follow ups and schedule them (him/herself). Interview conducted with Resident 43 on January 13, 2024, at 10:02 a.m. reported that (he/she) has missed multiple orthopedic surgery appointments (January 13, 2025, and January 6, 2025) due to not being able to cover the out-of-pocket expense to use [medical transportation services]. Resident 43 reported [medical transportation service] is the only transportation service the facility uses. Resident 43 reported each use of [medical transportation service] cost's a minimum of $1,300. Subsequent interview with Resident 43 revealed resident is worried that (he/she) will miss additional orthopedic surgery appointments due to not being able to cover the cost. Resident 43 also reported the pain from her right lower extremity wound is intensifying, requiring staff to administer her oxycodone pain medication. Review of Resident 43's clinical record revealed a progress note dated January 15, 2025, at 5:30 p.m. indicating Per NP, patient's surgeon requesting patient be sent to [Hospital] for washout of RLE surgical wound. [Medical transportation company] transport arranged and patient left facility via ambulance. Husband and daughter updated. Interview with the Social Worker, Employee E13 on January 16, 2025, at 11:55 a.m. revealed, (he/she) was aware Resident 43 had missed multiple appointments due to the inability to cover the out-of-pocket expenses. Social Worker, Employee E13 acknowledged, (he/she) had not attempted to arrange alternative transportation options or provided Resident 43 with resources to secure (his/her) own transportation. Interview with the Director of Nursing (DON) on January 16, 2025, at 1:15 p.m. revealed the facility did not follow up with [medical transport company] to determine why Resident 43 was not transported to her orthopedic surgery appointment on January 13, 2025. A follow-up interview with the Director of Nursing (DON) on January 16, 2025, at 1:59 p.m. revealed she had contacted [medical transport company] to inquire why Resident 43 was not transported to medical appointment. The DON reported the [medical transport company] did not provide transportation due to Resident 43 inability to cover the out-of-pocket expense. She further stated that she was unaware Resident 43 could not cover this expense and that the facility will attempt to schedule virtual appointments with the resident's orthopedic surgeon in the future. The Director of Nursing (DON) confirmed the previous statements and acknowledged the facility should have assisted Resident 43 in arranging alternative transportation to resident's orthopedic surgeon appointments. The DON reported Resident 43 was admitted to the Hospital for wound treatment and did not know when Resident 43 would be returning to the facility and did not have access to Resident 43's hospital records. The facility failed to ensure Resident 43 attended the orthopedic surgical follow-up appointments by not providing alternative modes of transportation or scheduling virtual appointments causing actual harm to Resident 43 when the surgical wound deteriorated and Resident 43 needed to be hospitalized for care to the worsening wound. Review of Resident 30's diagnosis list includes Acute Respiratory Failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels) and a history of Pulmonary Embolism (blood clot that blocks and stops blood flow to an artery in the lung). Review of Resident 30's physician order dated December 17, 2024, revealed an order for Enoxaparin Sodium Injection 80 mg/0.8 ml. Inject 0.8 ml (milliliter) subcutaneously (shot given into the fatty layer of tissue beneath the skin) every 12 hours for DVT (Deep Vein Thrombosis- clot in the deep vein). The medication was ordered to be administered at 9:00 a.m., and 9:00 p.m. Review of Resident 30's January 2025, Medication Administration Record revealed from January 7, 2025, until January 15, 2025, Resident 30 was not administered the medication on the following dates and times: January 7, 2025, at 9:00 a.m., January 8, 2025, at 9:00 p.m., January 9, 2025, at 9:00 a.m., and 9:00 p.m. Review of the nursing progress notes dated January 7, 2025, at 12:36 a.m., revealed medication on order, NP aware. Review of Resident 30's nursing progress notes dated January 8, 2025, at 8:29 p.m., and January 9, 2025, at 8:20 p.m., each note revealed medication was on order with the pharmacy. Review of Resident 30's clinical records failed to reveal the physician was notified of the missed medications on the evening of January 8, 2025, and the morning and evening dose on January 9, 2025. Review of the pharmacy documentation revealed Enoxaparin medication was available in the facility for emergency use. An interview with the Director of Nursing conducted on January 16, 2024, at 10:00 a.m., failed to provide an explanation why the medication was not administered to the resident despite being available in the facility. The facility failed to ensure Resident 30's physician's medication order was followed. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

Based on review of clinical records, hospital records, and interviews with resident and staff, it was determined that the facility failed to provide adequate supervision and assistance, resulting in harm from a fall which led to hospitalization and further surgical procedures and treatments for one of the 19 residents reviewed (Resident 20). Findings include: Clinical records review revealed Resident 20 was admitted to the facility on [DATE], with a diagnosis of post-right below knee amputation, Osteomyelitis (bone infection), and left trans metatarsal (foot bone) amputation. Review of Resident 20's admission Minimum Data Set (MDS-standardized assessment tool that measures health status in long-term care residents) dated October 21, 2024, revealed the resident was cognitively intact. The same MDS assessment revealed that the resident required partial/moderate assistance with toilet transfers. Review of Resident 20's care plan developed on October 18, 2024, revealed an ADL (activities of daily living) care plan for the resident requiring assistance/dependent for ADL care with bathing, grooming, dressing, bed mobility, transfer, and toileting. An intervention initiated on October 18, 2024, revealed: Provide two persons assist with toilet transfer and toileting hygiene. Review of the nursing progress notes dated October 21, 2024, at 5:23 p.m., revealed Resident 20 was sent to the hospital post-fall. The same note revealed Resident 20 was transferring over to the toilet with the NA (nurse assistant) when he/she fell and hit the right leg causing surgical incision to open. The same note revealed There was a copious amount of bleeding, a pressure dressing applied, and then sent to the hospital for evaluation. Review of the physician's progress notes dated October 21, 2024, revealed resident was seen for an acute visit regarding a witnessed fall reported with an NA. The same note revealed the Resident stated that he/she was still having a hard time coping with the new right BKA (Below Knee Amputation) and did attempt to use the right leg with the transfer, causing him/her to land on his/her new BKA incision. The right BKA incision split open with profuse bright red blood present and actively bleeding. Pressure dressing was applied immediately and they advised nursing to send the resident to the emergency room for evaluation and repair of the open incision. Review of the hospital record section titled, History and Physical, dated October 21, 2024, revealed patient with post-BKA on October 15, 2024, was sent back to the ED (Emergency Department) after sustaining a fall during transfer from the commode, resulting in right BKA stump injury. The same note revealed, usually he/she has two staff members helping him/her but today it was only one. The BKA surgical site was reported to be open and bleeding at the rehab. The diagnosis was right BKA wound dehiscence with bleeding secondary to mechanical trauma. Review of Resident 20's hospital records, including Details of Hospital Stay dated October 29, 2024, revealed the patient was admitted and vascular surgery was consulted. The patient was sent to the OR (operating room) for BKA washout and wound vac (wound treatment that uses suction to help wounds heal) placement on October 23, 2024. Post-op, the patient had to be transfused with 1 unit of PRBC (pack red blood cell) due to a drop of the Hgb. He/she experienced acute urinary retention postoperatively requiring multiple straight catheters (A procedure that uses a flexible tube to drain urine from the bladder). The patient developed bleeding from the wound vac so he/she was given another unit of PRBC. Interview conducted with Resident 20 on January 13, 2025, at 10:30 a.m., revealed a few days after he/she was admitted to the facility, a male staff assisted him/her from the wheelchair to the toilet commode. Resident 20 reported it was always two people assisting with transfers but at that moment there was only one. The resident stated He/she thought he/she could handle me by him/herself. The resident further reported he/she lost balance during the transfer and fell hitting the right knee. Interview with the Director of Nursing (DON) conducted on January 15, 2025, at 1:00 p.m., confirmed there was only one person that transferred the resident during the fall. The facility failed to provide Resident 20 with adequate supervision and assistance during toilet transfers resulting in harm from falling including hospitalization , and undergoing additional surgical treatment complications post-surgical procedure. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

Based on review of facility's policy, observations and staff interviews, it was determined the facility failed to ensure infection control was practiced for a resident with COVID and Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of MDRO-multidrug-resistant organisms in nursing homes) were in place for residents requiring enhanced barrier precautions for seven of seven residents reviewed (Resident 8, 13, 20, 21, 30, 46, and 105). Findings include: Review of the facility's current Enhanced Barrier Precautions policy as revised by the facility dated March 2024, revealed for residents for whom EBP are indicated, EBP is employed when performing high contact resident care activities. This includes the use of gown and gloves for the use of accessing wound care (any skin opening requiring a dressing). Review of Resident 8's clinical record revealed, Resident was admitted on [DATE], with a diagnosis of Partial Traumatic Amputation of Right Foot, Level Unspecified, Subsequent Encounter (part of the foot has been severed due to an injury or trauma but not the entire foot) and Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene (condition that occurs with type 2 diabetes that develops peripheral arterial disease that leads to gangrene) Observation of Resident 8 on January 13, 2025 @ 09:41 am revealed bilateral (left and right) feet wrapped in gauze with toes open to air and post-op boots in place. Observation of Resident 8's room on all four days of the survey failed to reveal evidence of EBP signage or PPE. Review of Resident 13's clinical record revealed, Resident was admitted on [DATE], with a diagnosis of Pressure Ulcer of Sacral Region, Unspecified Stage and Unspecified Open Wound of Lower Back and Pelvis Without Penetration into Retroperitoneum, Initial Encounter (a pressure sore located on the tailbone where the exact stage of the wound is unknown, along with an open wound on the lower back and pelvis that does not extend deep enough to reach the tissue behind the abdominal lining). Interview with licensed staff Employee E7 on January 14, 2025, revealed that Resident 13 Stage 3 sacral wound had primarily healed and that dressing changes were no longer required however per clinical record wound treatment continued daily and PRN (as the need arises). Observation of Resident 13's room on all four days of the survey failed to reveal evidence of EBP signage or PPE. Clinical records review revealed Resident 20 has surgical wound to the right leg post below knee amputations. Observations conducted on January 13, 2025, at 10:00 a.m., revealed a dressing to Resident 20's right knee. Additional observation revealed absence of EBP signage/communication. There was no PPE available outside of the resident's room. Review of Resident 21's clinical record revealed, Resident was admitted on [DATE], with a diagnosis of Encounter for Other Orthopedic Aftercare (routine follow-up care by a healthcare provider after orthopedic surgery on a joint or bone) and Type 2 Diabetes Mellitus with Unspecified Complications (a diagnosis of type 2 diabetes where the specific complications are not yet identified), Resident 21 is receiving treatment for an arterial wound to second digit left foot. Observation of Resident 21 on January 13, 2025 @ 10:00 am revealed resident in bed with bilateral foam boots and left foot wrapped with Kling (stretchy -gauze material that is wrapped around a wound or injury). Observation of Resident 21's room on all four days of the survey failed to reveal evidence of EBP signage or PPE. Clinical records review revealed Resident 30 has a Gastrostomy tube (GT- A medical device used to provide nutrition to people who cannot obtain nutrition by mouth). Observation conducted on January 13, 2025, at 10:15 a.m., revealed absence of EBP signage/communication. There was no PPE available outside of the resident's room Clinical records review revealed Resident 46 has a GT. Observation conducted on January 13, 2025, at 10:30 a.m., revealed absence of EBP signage/communication. There was no PPE available outside of the resident's room. Observation of Resident 8, 13 And 21's room on all four days of the survey failed to reveal personal protective equipment located outside the room or signage indicating Resident 8,13, and 21 were on Enhanced Barrier Precautions. Interview with the Director of Nursing on January 16, 2024, at 12:30 pm confirmed that Resident 8, 13 & 21were not on Enhanced Barrier Precautions at the time of the survey despite meeting the above criteria. Clinical records review revealed Resident 105 was on transmission-based precaution for diagnosis of COVID (An infectious disease caused by SARS-CoV-2). An observation conducted on Resident 105's room on January 14, 2025, at 12:48 p.m., in the presence of licensed employee E5 revealed absence of bin/container for used PPE (personal protective equipment). Observations also revealed the following: one yellow gown on the bathroom floor, one yellow gown hanged on the toilet handrail; used glove on the bathroom floor, and two used gloves on top of the drawer. The above was discussed with the Director of Nursing on January 16, 2025, at 10:00 a.m. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24

Based on review of facility's policy, clinical records and hospital record review, and interview with resident and staff, it was determined the facility failed to report a fall to the state agency for one of 19 residents reviewed (Resident 20). Findings include: Review of facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, revealed that if resident abuse, neglect, exploitation, or theft/misappropriation is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies: The state licensing /certification agency responsible for surveying /licensing the facility; the local state ombudsman; the resident's representative; Adult protective services; Law enforcement officials; The resident's attending physician and facility director. Immediately is defined within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of Resident 20's Admission Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents) dated October 21, 2024, revealed that the resident was cognitively intact. The same MDS revealed that the resident required partial/moderate assistance with toilet transfers. A review of Resident 20's nursing progress notes dated October 21, 2024, at 5:23 p.m., revealed that the Resident was sent to the hospital post-fall. The same note revealed Resident 20 was being transfered to the toilet with assistance from the NA (nurse assistant) when Resident 20 fell and hit their right leg causing the surgical incision to reopen. A review of Resdient 20's physician's progress notes dated October 21, 2024, revealed resident was seen for an acute visit regarding a witnessed fall reported with a NA. The same note revealed that Resident 20 stated that they were still having a hard time coping with the new right BKA and did attempt to use the right leg with the transfer, causing Resdient 20 to land right into their BKA incision. The right BKA incision split open with profuse bright red blood present and actively bleeding. Pressure dressing was applied immediately and they advised nursing to send the resident to the emergency room for evaluation and repair of the open incision. Hospital record review dated October 29, 2024, revealed resident was admitted to the hospital on October 21, 2024, with diagnosis of right BKA wound dehiscence (a surgical complication in which a wound ruptures along a surgical incision) with bleeding secondary to mechanical trauma. An interview with Resident 20 conducted on January 13, 2025, at 10:30 a.m., revealed that a few days after they were admitted to the facility, a male staff assisted them from the wheelchair to the toilet commode. Resident 20 reported that it was always two people assisting with transfers but at that moment it was only one. The resident stated He/she taught he/she could handle me by him/herself The resident further reported that he lost balance during the transfer and fell hitting the right knee. A review of Resident 20's care plan developed on October 18, 2024, revealed an ADL (activities of daily living) care plan for the resident requiring assistance/dependent for ADL care with bathing, grooming, dressing, bed mobility, transfer, and toileting. An intervention initiated on October 18, 2024, revealed: Provide two persons assist with toilet transfer and toileting hygiene. An interview with the DON on January 16, 2025, at 10:00 a.m., confirmed that the incident was not reported to the state agency until January 14, 2025, after surveyor requested for the investigation of the incident. The facility failed to ensure Resident 20's fall due to failure to provide adequate assistance and supervision which led to hospitalization was reported to the state agency. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 8/22/24, 3/15/24, 5/18/23 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

Based on review of facility policy, clinical record review, hospital record review, and interviews with resident and staff, it was determined the facility failed to investigate a fall for one of 19 residents reviewed (Resident 20). Findings include: A review of facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, revealed that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated. The administrator initiates investigations. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation form. A review of Resident 20's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of post-right below knee amputation, Osteomyelitis (bone infection), and left trans metatarsal (foot bone)amputation. A review of Resident 20's Admission Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents) dated October 21, 2024, revealed that the resident was cognitively intact. The same MDS revealed that the resident required partial/moderate assistance with toilet transfers. An interview with Resident 20 conducted on January 13, 2025, at 10:30 a.m., revealed that a few days after Resdient 20 was admitted to the facility, a male staff assisted them from the wheelchair to the toilet commode. Resident 20 reported that it was always two people assisting with transfers but at that moment it was only one. The resident stated He/she taught he/she could handle me by him/herself. Resdient 20 further reported that he lost balance during the transfer and fell hitting the right knee. Resdient 20 reported that their surgical incision opened after the fall and was sent to the hospital. A review of Resident 20's care plan developed on October 18, 2024, revealed an ADL (activities of daily living) care plan for the resident requiring assistance/dependent for ADL care with bathing, grooming, dressing, bed mobility, transfer, and toileting. An intervention initiated on October 18, 2024, revealed: Provide two persons assist with toilet transfer and toileting hygiene. A review of the nursing progress notes dated October 21, 2024, at 5:23 p.m., revealed that the Resident was sent to the hospital post-fall. The same note revealed Resident was being transfered to the toilet by the NA (nurse assistant) when Resident 20 fell and hit their right leg causing the surgical incision to open. A review of the physician's progress notes dated October 21, 2024, revealed Resdient 20 was seen for an acute visit regarding a witnessed fall reported with an NA (Nursing Assistant). The same note revealed that Resident 20 stated that they were still having a hard time coping with the new right BKA (Below Knee Amputation) and did attempt to use the right leg with the transfer, causing Resident 20 to land right into their BKA incision. The right BKA incision split open with profuse bright red blood present and actively bleeding. Pressure dressing was applied immediately and then advised nursing to send the resident to the emergency room for evaluation and repair of the open incision. Review of hospital records dated October 29, 2024, revealed Resident 20 was admitted to the hospital on October 21, 2024, with diagnosis of right BKA wound dehiscence (a surgical complication in which a wound ruptures along a surgical incision) with bleeding secondary to mechanical trauma. A review of the facility's documentation revealed an incident report of Resident 20's fall that occurred on October 21, 2024, at 5:00 p.m., completed by the Director of Nursing (DON). No further investigation documents were provided to the surveyor. An interview with the DON on January 16, 2025, at 10:00 a.m., confirmed that the incident report of Resident 20's fall that occurred on October 21, 2024, was just completed on January 14, 2025, after the surveyor asked for it. The DON confirmed that the incident was not investigated, and that the perpetrator was not identified. The facility failed to ensure Resident 20's fall due to failure to provide adequate assistance and supervision which led to hospitalization was investigated. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 8/22/24, 3/15/24, 5/18/23 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 8/22/24, 4/25/24, 3/15/24, 12/19/23, 5/18/23 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 8/22/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23 28 Pa. Code 211.5(f) Clinical records Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 5/18/23 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service Previously cited 8/22/24, 6/10/24, 4/25/24, 3/15/24, 1/27/24, 12/19/23, 11/1/23, 5/18/23

Based on facility policy and procedure review, staff interview and resident record review it was determined the facility failed to complete skin assessments to monitor skin conditions and prevent pressure ulcers for one of six residents reviewed causing actual harm to Resident 1 when they developed a stage 3 pressure ulcer to the sacrum(Resident 1). Findings Include: Review of facility policy and procedure titled Skin Integrity and Wound Management revealed under practice standards the following Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Identify patient's skin integrity status and need or prevention or treatment interventions through review of all appropriate assessment information. Review of Resident 1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses of a fracture of unspecified part of neck of left femur, Lewy Bodies Dementia (affects chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood), and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of Resident 1's Admission Minimum Data Set (MDS-periodic assessment of resident needs) dated May 9, 2024, revealed the resident was at risk for developing a pressure ulcer. Review of Resident 1's Admission Braden Assessment completed on May 10, 2024, revealed the resident was at high risk for developing pressure ulcers. Review of Resident 1's baseline care plan on admission, dated May 10, 2024, revealed there was a care plan for the risk of developing pressure ulcers with an intervention of observe skin conditions with ADL care daily; report abnormalities with a date initiated of May 10, 2024. Review of Resident 1's clinical record revealed skin assessments were not completed from May 11, 2024, until June 6, 2024. Further review of the clinical record failed to reveal any progress notes of skin assessments being completed or the development of a stage 3 pressure ulcer (wound that has progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). Review of Resident 1's Initial Wound Care Consult Note completed by the wound specialist, dated June 12, 2024, revealed Resident 1 had developed two DTIs (Deep Tissue Injury- localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and one stage 3 pressure ulcer of sacral region (bottom of the spine). Interview conducted with the Wound Specialist on August 19, 2024, at 2:05 p.m. stated the facility had not completed multiple skin assessments on Resident 1 which led to the resident developing an avoidable stage 3 pressure ulcer on her sacral. Interview conducted with the Director of Nursing on August 19, 2024, at 2:15 p.m. confirmed the above information. The facility failed to monitor Resident 1's skin resulting in Resident 1 developing a stage 3 pressure ulcer to her sacral. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing service

Based on review of facility policy, clinical record, and facility documentation, it was determined that the facility failed to timely assess, monitor, and treat for suspected laundry detergent poisoning of Resident 222, resulting in actual harm of vomiting and diarrhea with a subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed. Findings include: Review of facility policy, Poisoning, effective December 1, 2006, revealed: Upon discovery of suspected poisoning, call for help and instruct staff to call 911. Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances. Review of Resident 222's July 2023 Admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment. Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee 12 dated November 17, 2023, at 1:44 a.m., indicating: Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified. Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm. Further review of nurse aide Employee 13's witness statement revealed: I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time. Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse. Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023. Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222's was found with an open laundry detergent pod. Review of Resident 222's clinical record and facility documentation revealed resident was unable to articulate if he/she ingested the contents of the laundry detergent pod due to impaired cognition and poor safety awareness. Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time Resident 222 was observed with open laundry deteregent pod and possible ingestion of the contents. Review of Resident 222's emergency room notes revealed: Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent. Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning. Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. confirmed the (nursing agency) staff failed to timely assess, monitor, and treat Resident 222 for suspected laundry detergent poisoning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on review of facility policy, clinical record, and facility documentation, it was determined that the facility failed to ensure a cognitively impaired resident's (Resident 222) environment was free from known environmental hazards including laundry detergent pods resulting in actual harm of suspected poisoning and subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed. Findings include: Review of facility policy, Poisoning, effective December 1, 2006, revealed: Upon discovery of suspected poisoning, call for help and instruct staff to call 911. Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances. Review of Resident 222's July 2023 Admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment. Review of Resident 222's clinical record revealed a nursing progress note dated November 13, 2023 (15:49 aka 3:49 p.m) indicating pt [patient] AAOx1 [Awake/Alert/Oriented x1] w/ hx [with history] of adv [advanced] dementia. steady gait, able to ambulate independently. impulsive, often wanders and tries to enter other patients' rooms. no s/s [signs/symptoms] of respiratory distress or sob [shortness of breath]. no c/o [complaints of] pain or discomfort. [resident] accepted [his/her] medications crushed with applesauce this morning. pt often refuses care. pt is grossly incontinent and often refuses incontinence care. becomes combative and agitated w/ at times. [Resident] is unable to make [resident] needs known. needs anticipated. call bell within reach. Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee E12 dated November 17, 2023, at 1:44 a.m., indicating: Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified. Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm. Further review of nurse aide Employee 13's witness statement revealed: I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time. Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse. Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023. Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222 was found with an open laundry detergent pod. Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time of Resident 222's suspected ingestion of the laundry detergent pod contents. Review of Resident 222's emergency room notes revealed: Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent. Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning. Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. when the above information was presented for staff failed to ensure a safe environment for cognitively impaired Resident 222 from ingesting laundry pod contents and timely assess, monitor, and treat suspected poisoning. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records 28 PA Code 211.10(a) Resident care policies

Based on facility's policy, clinical records, facility investigation reviews; and staff interviews, it was determined that the facility failed to follow policy and procedures for hot beverages for one resident resulting in harm of a third-degree burn (injury that involves the outer layer of the skin and part of the inner layer of the skin) for one resident reviewed (Resident 1). Findings include: Review of the facility's policy titled Guidelines for Hot Beverages, with a revision date of August 1, 2008, revealed, when serving hot liquids to patients/residents, the following should be considered: Beverages should be dispensed in a plastic or China mug; no Styrofoam cups. Observations conducted on December 18, 2023 and December 19, 2023 revealed the facility had a beverage center located on the unit, where dietary staff place carafes of coffee. Review of Resident 1's clinical record revealed diagnoses including but not limited to difficulty in walking, Hypertension (high blood pressure), type 2 Diabetes Mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time) with hyperglycemia, Major Depressive (mood disorder that causes a persistent feeling of sadness and loss of interest) disorder, Chronic Obstructive Pulmonary Disease (COPD - progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and Hypothyroidism (thyroid gland doesn't make enough thyroid hormone which may cause fatigue, weight gain, and depression). Review of Resident 1's clinical record including Medicare 5-day MDS (Minimum Data Set - assessment of resident clinical needs), dated November 9, 2023, revealed resident identified with a BIMS (Brief Interview of Mental Status) of 12 indicating resident has (mild/moderate) cognitive impairment. Review of information dated December 4, 2023, submitted by the facility on December 4, 2023, revealed that on December 1, 2023, Resident 1 requested coffee from the speech therapist, and while holding the cup, Resident 1's hand shook causing the coffee to spill on Resident 1's lap, which caused redness to [resident]'s right thigh. This event was witnessed by the speech therapist, who notified the nurse and the medical provider. The provider examined Resident 1 and applied ice to the area. Review of witness statement written by Employee E4 Speech Therapist, revealed that Resident 1 requested coffee prior to completing speech therapy exercise. Resident 1 was on a thin liquid diet. Resident 1 was observed with hot coffee via cup sips previously with no overt signs or symptoms of aspiration. The coffee was retrieved from a carafe on the unit. The coffee was served directly to Resident 1 in a Styrofoam cup which did not have a lid. When Resident 1 attempted to place the coffee cup on her table, Resident 1's hand jerked causing the coffee to spill on Resident 1's right hip and leg. Resident 1's pants were promptly removed. Resident 1 was then examined by a licensed nurse. Interview with Resident 1 on December 18, 2023 revealed, R1 stated that after he/she took a sip of his/her coffee he/she went to place the cup on his/her bedside table, resident missed the table and the coffee spilled on his/her lap, burning the leg. Review of the Wound Evaluation report dated December 14, 2023, revealed the third-degree burn to the front right trochanter (hip), was acquired in-house, and had a measurement of 6.6 x 15.4 cm (centimeters) with a total area of 67.9 cm. The wound was treated with Silvadene cream (an anti-microbial medication used to treat and prevent wound infection in patients with burns). Interview with Dietary Aide Employee E3, on December 18, 2023, at 10:58 a.m., revealed that at the time of the incident the facility did not have plastic lids for the beverage cup, therefore dietary staff used plastic wrap instead. Interview with interim Nursing Home Administrator on December 18, 2023, at 10:45 a.m., indicated the facility records food and beverage temperatures prior to service at the point of dispensation (in the kitchen). The Nursing Home Administrator indicated that the hot water used to make coffee come from a dispensing machine. The machine indicates temperature of brewing which was 190 degrees. The dietary staff add water and coffee crystals to a carafe for continue the process. Dietary staff allow the hot beverage to steep and cool before dispensing into serving cups. Further interview with Nursing Home Administrator on December 18, 2023, indicated that the dispensing machine brewing temperature was lowered to 160 degrees after the incident. Interview with Interim Nursing Home Administrator on December 18, 2023, at 12:50 p.m., confirmed the resident received a third degree burn after spilling coffee on thigh. Further interview with NHA revealed the employee who provided Resident 1 with the hot coffee was an agency employee, who will be required to complete the hot beverage training before working with residents at the facility in the future. Interview conducted with Employee E1, dietary staff on December 19, 2023, at 10:28 AM revealed food and beverage temperatures are recorded, reviewed and then are shredded at the end of the month. Further interview with Employee E1 revealed on the day of the incident, lids for Styrofoam cups could not be located. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services