Every finding on record at Fox Subacute at Mechanicsburg

Based on facility policy review, contact precaution review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for two of three residents reviewed on contact precautions (Residents 1 and 2).Findings Include: Review of facility policy, titled Wound Care and Infection Control: General Policy with a reviewed date of September 23, 2025, read, in part, Purpose: Guide clinical staff providing care for resident wounds in processes necessary to prevent the spread of disease and infection. Clinical staff providing wound care adhere to foundational infection prevention guidelines during these processes. Hand hygiene is performed before wound procedure and gloves and gowns are donned. PPE (personal protective equipment) is removed and hand hygiene is performed directly after the procedure. Review of Resident 1's clinical record revealed diagnoses that included pressure ulcer of left heel stage 4 (an injury to the skin and/or underlying tissue caused by prolonged pressure), pressure ulcer of sacral region stage 4, and tracheostomy status (a surgical opening created in the neck into the trachea to assist with breathing). Review of Resident 1's comprehensive care plan revealed a focus area that read, in part, Resident is at risk for infection, contact precautions: colonization (presence and multiplication of microorganisms without causing disease, symptoms, or an immune response) with an intervention for Please use PPE (gowns, gloves, and mask/goggles if splashes are anticipated) while in room, sanitize with alcohol based hand rub after care has been given and before leaving the room, initiated on August 29, 2025. Observation outside of Resident 1 and 2's room on August 19, 2026, at 1:18 PM, revealed a sign that read, in part, Contact Precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Observation of Employee 1 (Licensed Practical Nurse) on August 19, 2026, at 1:30 PM, revealed she entered Resident 1's room to perform a wound dressing change to his left heel. She did not don a gown or bring alcohol-based hand rub into the room. Observation of Employee 1 on August 19, 2026, at 1:33 PM, revealed she changed her gloves and did not perform any hand hygiene in between glove changes. Observation of Employee 1 on August 19, 2026, at 1:36 PM, revealed she changed her gloves and did not perform any hand hygiene in between glove changes During an interview with Employee 1 on August 19, 2026, at 1:38 PM, the surveyor questioned if she knew to wear a gown when performing direct patient care and she replied I forgot about that. The surveyor also revealed concern with the lack of hand hygiene between glove changes. Observation of Employee 1 on August 19, 2026, at 1:39 PM, revealed she doffed her gloves into a biohazard bag and did not perform hand hygiene. Employee 1 then exited the room and went to biohazard closet and punched in the code to the door without performing hand hygiene. During an interview with the Director of Nursing (DON) on August 19, 2026, at 1:58 PM, she revealed her expectation that staff would wear gowns when performing direct patient care for residents on contact precautions, and she would expect hand hygiene between glove changes, prior to exiting a room after care, and prior to touching other surfaces. Review of Resident 2's clinical record revealed diagnoses that included dependence on respirator (ventilator) status (the inability to breathe independently and requires long-term mechanical ventilation), gastrostomy status (refers to the presence of an artificial opening in the stomach for feeding patients who cannot ingest food orally), and tracheostomy status. Review of Resident 2's comprehensive care plan revealed a focus area that read, in part, Resident is at risk for infection, contact precautions: colonization with an intervention for Please use PPE (gowns, gloves, and mask/goggles if splashes are anticipated) while in room, sanitize with alcohol based hand rub after care has been given and before leaving the room, initiated on December 31, 2025. Observation of Employee 1 on August 19, 2026, at 1:18 PM, revealed she entered Resident 2's room to provide direct patient care for his tracheostomy and did not don a gown. Observation of Employee 2 (Nurse Aide) on August 19, 2026, at 1:23 PM, revealed she entered Resident 2's room to provide direct patient care to answer his call bell and did not don a gown. During an interview with the DON on August 19, 2026, at 1:58 PM, she revealed her expectation that staff would wear gowns when performing direct patient care for residents on contact precautions. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance during incontinence care and linen change for one of seven residents reviewed (Resident 1), which resulted in actual harm as evidenced by Resident 1 falling out of bed resulting in a fracture of the right superior pubic ramus. Findings Include: Review of facility policy, titled Accidents, reviewed December 31, 2025, revealed The facility will ensure that: The resident environment remains as free of accident hazards as is possible. Each resident receives adequate supervision and assistance devices to prevent accidents. An accident is an unexpected, unintended event that can cause a resident bodily injury. Review of Resident 1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses that included functional quadriplegia (the complete inability to move the limbs or walk due to severe physical frailty or disability from an underlying medical condition, without any direct structural injury or damage to the brain or spinal cord), anoxic brain damage (a serious injury that happens when the brain gets no oxygen), and persistent vegetative state (a severe neurological condition where a person with major brain damage is awake and has sleep-wake cycles, but shows no signs of awareness or cognitive function). Further review of Resident 1's clinical record revealed that she had a gastrostomy tube (G-tube - a flexible medical tube placed through the belly wall directly into the stomach. It supplies food, liquids, and medicines when a person cannot eat enough by mouth), a tracheostomy (a surgically made hole in the front of the neck and into the windpipe [trachea]), and that she was dependent on a ventilator (mechanical machine to breathe). On August 4, 2026, Resident 1's weight was documented as 204.8 pounds Review of Resident 1's task history revealed she was a 1-person assist for bed mobility, entered February 24, 2025 by Employee 1 (Director of Therapy), and entered again on June 16, 2026, by Employee 2 (RNAC-Registered Nurse Assessment Coordinator). Review of Resident 1's most recent physical therapy discharge summary, signed August 18, 2025, revealed Resident 1 was dependent for bed mobility, to include rolling left and right, sit to lying, and lying to sitting on side of bed. Review of Resident 1's care plan revealed she was dependent for functional activities, dated December 2, 2025. Review of Resident 1's physician orders revealed an order, dated June 2, 2026, for 1-person assist with bed mobility. Review of Resident 1's current Kardex revealed she was 1-person assist with bed mobility. Review of Resident 1's quarterly minimum data set assessment (MDS - assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), dated May 26, 2026, revealed that in section GG, Resident 1 was coded as being dependent for rolling left and right. Being dependent means the Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of facility reported incident revealed that on August 6, 2026, Employee 3 was performing care on Resident 1. The report stated that Employee 3 slid resident toward herself and rolled Resident 1 away from herself to clean Resident 1's bottom. Employee 3 tucked new linens and a brief under Resident 1 and was just about to roll Resident 1 onto her back when she had a sudden and forceful cough that caused her body to spasm and jerk forward. Employee 3 attempted to reach and grab a hold of Resident 1 but the weight of Resident 1's body and the forceful spasm was too much for Employee 3 to hold onto. Resident 1 rolled off the side of the bed and onto the floor. Coughing while having a trach and on a ventilator is common and usually happens due to mucus, tube movement, or dry air. Thick secretions or pooling of mucus triggers a natural reflex to clear the airway. In addition, ventilator hoses or the trach tube itself can tug on the windpipe and cause sudden coughing. Review of Resident 1's incident report, dated August 6, 2026, revealed that at approximately 2:40 PM, the nurse was called to the room by the nurse aide due to the Resident being on the floor. No bruising or swelling was noted. Passive range of motion revealed no pain. The provider was made aware who gave an order to transfer the Resident to the hospital for evaluation. Review of Resident 1's hospital records revealed that Resident 1 was found with a mildly displaced acute fracture of the right superior pubic ramus (a type of crack or break in a person's pelvis). Review of Employee 3's witness statement for Resident 1's incident on August 6, 2026, revealed that Employee 3 was cleaning and changing Resident 1 in her room. Employee 3 had Resident 1 turned over to clean her and put clean linen on her bed and a clean brief on her. When Employee 3 went to grab Resident 1 to turn her back over, Resident 1 started coughing and jerked her body and rolled off the bed before Employee 3 could grab her. Employee 3 immediately called for help and for the nurse. During an interview with Employee 3 on August 17, 2026, at 2:05 PM, she stated that she was familiar with Resident 1's care and often cares for her. She stated that Resident 1 was unable to hold herself over onto her side, so she holds her with one hand and performs her care with the other hand. She stated Resident 1 was rolled away from her and right when she was getting ready to roll Resident 1 onto her back, Resident 1 started coughing and before she could grab her, Resident 1 bounced off the bed. Employee 3 further stated that she has never had an issue in the past doing Resident 1's care by herself. During an interview with Employee 1 (Director of Therapy) on August 17, 2026, at 2:20 PM, she was asked to define what bed mobility means. She stated that bed mobility is the ability to roll a resident or to help them scoot in bed. She stated when a resident is admitted , a therapy evaluation is completed to determine the level of assist the resident requires. She stated that just because a resident cannot physically help with a task does not mean they have to be more than a 1-person assist. She stated that the nurse aides communicate with therapy staff for any changes in a resident's condition or status. If a nurse aide is having trouble performing care with one assist, they will notify therapy. She stated they are also to use their own judgement and if they are having difficulty performing care on a resident who is a 1-person assist, they should ask for help. Employee 1 stated that dependent for functional abilities means a resident is unable to feed or wash themselves or provide any of their own hygiene. Employee 1 stated that therapy does not determine the care part required of a resident, they simply determine the assist needed for bed mobility to be able to roll them from side to side. She stated therapy would need to be in the room with every nurse aide to see what their abilities are in order to determine a resident's care assist level. She stated they set the initial order for bed mobility and then the nurse aides will communicate with therapy if more help is needed. She stated it is not solely therapy's assessment but rather a whole team effort to determine a resident's care assistance level. During an interview with the Director of Nursing (DON), on August 17, 2026, at 2:36 PM, she stated that a resident's assist level is determined by therapy and if therapy determines they are an assist of one, that is what they go by. She stated that if staff are unable to do a resident's care with 1-person assist, they are to ask for help. She stated that they have no specific evaluation or assessment for hygiene and incontinence care, but if a staff member needs more assistance, they are to ask for help and to notify the DON and therapy. In an email correspondence from the DON on August 18, 2026, at 10:50 AM, she stated that a resident's assessment to determine the number of assists needed for a resident's care coincides with the therapy evaluation for bed mobility. She stated there is no specified clinical tool for assessing the number of people required to complete a bath or a brief change and that nurses and aides provide their best clinical judgement when caring for a resident and if extra help is required, they are educated and instructed to ask for assistance. The facility failed to provide adequate supervision and assistance to prevent falls. Resident 1 was being provided incontinence care and linen change with only one-person assisting. Resident 1 rolled out of bed which resulted in harm, as evidenced by a mildly displaced acute fracture of the right superior pubic ramus. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, facility document review, and staff interview, it was determined that the facility failed to document a resident's fall in their clinical record for one of three falls reviewed (Resident 1). Findings Include: Review of facility policy, titled Incidents and Accidents Document, updated November 28, 2018, revealed The occurrence of an incident will be recorded in the resident's clinical record. Review of Resident 1's clinical record revealed diagnoses that included functional quadriplegia (the complete inability to move the limbs or walk due to severe physical frailty or disability from an underlying medical condition, without any direct structural injury or damage to the brain or spinal cord), anoxic brain damage (a serious injury that happens when the brain gets no oxygen), and persistent vegetative state (a severe neurological condition where a person with major brain damage is awake and has sleep-wake cycles, but shows no signs of awareness or cognitive function). Review of Resident 1's incident report, dated August 6, 2026, revealed that Resident 1 had a fall out of bed on this date and was transferred to the hospital. Further review of the incident report revealed that at the bottom of the form, it read Privileged and Confidential-Not part of the Medical Record. Review of Resident 1's clinical record revealed no progress note regarding Resident 1's fall, to include a nursing assessment after the fall. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on August 17, 2026, at 3:45 PM, they confirmed that the incident report is not part of the resident's clinical record. The NHA further stated that there should have been a progress note in Resident 1's clinical record about the fall. 28 Pa Code 211.5(f)(ii)(iii) Medical records.

Based on clinical record review and staff interview, it was determined that the facility failed to discuss the risks/benefits and obtain consent for psychotropic medications for two of two resident records reviewed (Residents 48 and 49).Findings include: Review of Resident 48's clinical record revealed diagnoses that included major depressive disorder severe with psychotic features (a severe form of depression characterized by the presence of psychotic symptoms, such as hallucinations or delusions, alongside typical depressive symptoms) and generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things). Review of Resident 48's physician's orders revealed the use of quetiapine (an antipsychotic medication) with an ordered date of April 15, 2025; and lorazepam (an antianxiety medication) with an ordered date of October 17, 2025. Review of Resident 48's physician order history revealed that he had been on these types of medications since January 24, 2025. Review of Resident 48's clinical record revealed a Psychotropic Medication Treatment Consent, which indicated that Resident 48 was being treated for Tracheotomy/Brain Damage and the medications being used line was blank. The consent was signed by Resident 48's Representative on September 9, 2024. Further review of Resident 48's clinical record failed to reveal any documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the antipsychotic and antianxiety medications, including side effects and other adverse reactions. Review of Resident 49's clinical record revealed diagnoses that included schizoaffective disorder bipolar type (schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania; bipolar type includes bouts of hypomania or mania and sometimes major depression), generalized anxiety disorder, and major depressive disorder. Review of Resident 49's physician's orders revealed the use of olanzapine (an antipsychotic medication) with an ordered date of March 5, 2024; buspirone (an antianxiety medication) with an ordered date of October 23, 2025; and escitalopram (an antidepressant medication) with an ordered date of July 30, 2025. Review of Resident 49's clinical record revealed a Psychotropic Medication Treatment Consent, which revealed that the condition Resident 49 was being treated for and the medications being used were blank. The consent was signed by Resident 49's Representative on July 16, 2021. Further review of Resident 49's clinical record failed to reveal any documentation of the facility providing education to Resident 49 or his Representative of the risks and benefits associated with the use of the antipsychotic, antianxiety, or antidepressant medications, including side effects and other adverse reactions. During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on January 22, 2026, at 11:20 AM, the NHA indicated that the facility practice was to have the Resident or their Representative sign the Psychotropic Medication Treatment Consent as part of the admission process to the facility. He further indicated that the facility practice was not to get another consent signed. He said that staff would review with a Resident's Representative any medication changes and would document this discussion in the progress notes. As of January 22, 2026, at 1:15 PM, the facility had not provided any additional information to indicate that Resident 48's and 49's Representatives had been informed of the risks and benefits associated with the use of their ordered psychotropic medications, including side effects and other adverse reactions, at time of admission to the facility or when medication/treatment changes occurred. 28 Pa. Code 201.29 Resident rights.

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were reviewed and responded to by the attending physician or prescriber for three of six residents reviewed (Residents 3, 6, and 15).Findings include:Review of facility policy, titled Medication Regimen Review (Monthly Report), without revision date, revealed, Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of Resident 3's clinical record revealed diagnoses that included heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs, causing symptoms like shortness of breath, fatigue, and swelling; often from underlying issues like high blood pressure or coronary artery disease) and respiratory failure (a serious condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide).Review of Resident 3's medical record revealed a recommendation made on December 10, 2025, by the consultant pharmacist to add additional monitoring for Resident 3's anticonvulsant medication. Further review of the document revealed that it was signed by a nurse along with the statement, added to order, with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity. Review of Resident 6's clinical record revealed diagnoses that included heart failure and respiratory failure.Review of Resident 6's medical record revealed a recommendation made on October 17, 2025, by the consultant pharmacist to either add limit of 14 days to Resident 6's PRN (as needed) antianxiety medication or provide a rationale for extending the order and indicate a duration for the order. Further review of the document revealed that it was signed by a nurse along with the statement, 14-day added to order, with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity. Review of Resident 15's clinical record revealed diagnoses that included fracture of first thoracic vertebra (a break in the first thoracic vertebra, located at the top of the mid-back, often caused by significant trauma like car accidents or falls, and can lead to severe neck/back pain, potential spinal cord injury, hand weakness/numbness, and even quadriplegia if nerves are damaged) and respiratory failure.Review of Resident 15's medical record revealed a recommendation made on December 10, 2025, by the consultant pharmacist to add additional monitoring for Resident 15's antipsychotic medication. Further review of the document revealed that it was signed by a nurse along with the statement, AIMS (Abnormal Involuntary Movement Scale- a scale to assess severity of involuntary facial movements in patients taking certain medications), with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity. Interview with the Director of Nursing on January 22, 2026, at 10:45 AM, revealed that they would expect the regulation to be followed. 28 Pa. Code 211.10(c) Resident care policies.

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for two of 12 residents reviewed (Residents 1 and 4).Findings include:Review of facility policy, titled Care Plan and Conference, last reviewed December 31, 2025, read, in part, Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes. Procedure: Ongoing communication between nursing and the Registered Nurse Assessment Coordinator will occur with any change in resident condition.Review of Resident 1's clinical record revealed diagnoses that included chronic respiratory failure (lungs cannot get enough oxygen into the blood or remove enough carbon dioxide) and dependence on a respirator (unable to breath independently and relies on a machine for life sustaining respiration).Review of Resident 1's physician orders revealed an order for trach type and size: # 8 Portex, with a start date of March 19, 2025.Review of Resident 1's comprehensive plan of care revealed a care area for ineffective airway clearance related to disease process with vent support as needed and trach. Trach type and size: 7 XLT-D cuffed.Interview on January 22, 2026 at 10:46 AM, with the Nursing Home Administrator and Director of Nursing (DON) revealed Resident 1's trach size and type changed and her care plan was not updated. The DON stated she would expect care plans to be updated timely.Review of Resident 4's clinical record revealed diagnoses that included chronic respiratory failure and hypertension (persistent high blood pressure). Review of Resident 4's clinical record revealed he had an unwitnessed fall on September 24, 2025. Review of Resident 4's fall report from September 24, 2025, revealed an intervention to place bilateral fall mats on either side of his bed. Review of Resident 4's comprehensive care plan revealed a focus area for At risk for falls with an intervention for bilateral fall mats - ensure placement every shift, last revised October 21, 2025. Observation in Resident 4's room on January 20, 2026, at 11:03 AM; and January 21, 2026, at 12:58 PM, failed to reveal bilateral fall mats. Interview with Employee 4 (Housekeeper) on January 21, 2026, at 12:58 PM, revealed she hasn't seen any fall mats in the Resident's room. During an interview with the DON on January 21, 2026, at 1:03 PM, she revealed the fall mats had previously been reviewed and discontinued. Follow up interview with the DON on January 22, 2026, at 11:27 AM, revealed the fall mats were reviewed and discontinued around the time of his most recent hospitalization in November 2025, and she would expect his care plan to be updated. The DON stated she would expect care plans to be updated timely.28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.11(d)(3)(5) Nursing services

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of three residents observed during medication administration pass (Resident 46).Findings include: Review of facility policy, titled Medication Administration, dated November 30, 2025, with a last review date of December 31, 2025, revealed, in part, that gastrostomy tube [a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach] placement will be confirmed by auscultation with air prior to medication administration. Review of Resident 46's clinical record revealed diagnoses that included acute and chronic respiratory failure with hypoxia (the inability of the respiratory system to meet the oxygenation requirements of the body, dependence on a ventilator, and presence of gastrostomy tube. Review of Resident 46's physician orders revealed an order for Confirmation of feeding tube placement to be done prior to every instillation of tube feeding, medications, water, ect. every shift. Confirm placement per policy, dated January 8, 2026. During a medication administration observation for Resident 46 on January 22, 2026, at 8:45 AM, Employee 3 (Registered Nurse) was observed to administer Resident 46's medications through the Resident's gastrostomy. Employee 3 failed to confirm placement of the gastrostomy tube prior to administering the medications. During a staff interview with Employee 3 on January 22, 2026, at 8:55 AM, Employee 3 indicated that the facility used to have a policy in place that indicated gastrostomy tube placement was to be verified before medication administration, but Employee 3 believed that was no longer in effect. During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on January 22, 2026, at 11:39 AM, the DON confirmed that Employee 3 should have verified Resident 46's gastrostomy tube placement before administering the medications. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 4).Findings include:Review of facility policy, titled Wound Care and Pressure Ulcer Care last reviewed December 31, 2025, read, in part, Purpose: To manage wounds and or pressure ulcers and promote patient comfort. Check the doctor's order for specific wound care and medication instructions.Review of Resident 4's clinical record revealed diagnoses that included pressure ulcer of other site, stage 3 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), chronic respiratory failure (lungs cannot get enough oxygen into the blood or remove enough carbon dioxide), and hypertension (high blood pressure). Review of facility documents, titled Wound Evaluation & Management Summary dated October 27, 2025; November 7, 2025; November 10, 2025; December 1, 2025; December 8, 2025; December 19, 2025; December 22, 2025; January 5, 2026; January 12, 2026; and January 19, 2026; note Specific to visit recommendations: Dietician consult, vitamin C 500 mg BID (twice daily).Review of dietitian notes, titled Weekly Wound Meeting dated October 28, 2025; November 13, 2025; December 2, 2025; December 9, 2025; December 19, 2025; December 23, 2025; January 6, 2026; and January 13, 2026; note Resident 4 is taking vitamin C as an intervention for wound healing.Review of Resident 4's physician orders revealed an order for Ascorbic Acid (Vitamin C) Oral Tablet 500 MG, Give 500 mg two times a day for wounds, with a start date of September 18, 2025, and a discontinued date of October 6, 2025.During an interview with the Director of Nursing on January 22, 2026, at 12:26 PM, she revealed the vitamin C order for Resident 4 was discontinued when he went to the hospital on October 5, 2025, and never got reentered when he returned. She further revealed the order should have been reinstated when he returned from the hospital as it was still recommended by the wound doctor, and she would expect physician recommendations to be implemented. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.11(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to label medications properly and failed to discard expired medications in one of two medication rooms observed (First Floor Medication Room).Findings include: Review of facility policy, titled Pharmacy Services, dated November 28, 2018, with a last review date of December 31, 2025, revealed, in part, All opened multi-dose vials will be dated at the time that they are opened. Review of tuberculin skin testing solution information revealed that tuberculin skin testing solution expires 30 days after the initial puncture into the vial. Observation of the First Floor Medication Room with Employee 1 on January 21, 2026, at 8:54 AM, revealed two opened vials of tuberculin skin testing solution. One bottle had no open date noted and the other vial was dated December 4, 2025. During a staff interview with the Director of Nursing (DON) and the Assistant Director of Nursing on January 21, 2026, at 9:20 AM, the DON acknowledged multi-dose vials should be dated when opened and confirmed that the tuberculin skin testing solution vial dated with an open date of December 4, 2025, was expired and should have been discarded. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3) Nursing services.

Based on observation and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the administration of medications for one of three residents observed during medication administration observation (Resident 33).Findings include: Observation of Resident 33's medication administration by Employee 2 on January 21, 2026, at 10:05 AM, revealed Employee 2 donned her gown and gloves upon entering Resident 33's room. Employee 2 sat Resident 33's cups of prepared medications down on the heating unit. Employee 2 was then observed to use both of her gloved hands to pick the fall mat up off the floor on the left side of the bed and lean it against the wall. Employee 2 then placed Resident 33's cups of prepared medications on top of the upright fall mat that she had placed against the wall. Employee 2 then proceeded to administer Resident 33's medications via her gastrostomy tube (a flexible feeding tube placed through the abdominal wall and into the stomach, which allows nutrition to be placed directly into the stomach). During the continued process of administering Resident 33's medications, Employee 2 was also noted to be holding the end of the tube feeding administration tubing that connects directly to the gastrostomy tube inside her left gloved hand. During an immediate staff interview with Employee 2 on January 21, 2026, at approximately 10:20 AM, Employee 2 confirmed that she had used her gloves to touch the fall mat that was on the floor and proceeded to administer the medications. Employee 2 acknowledged that she should have removed her gloves, cleansed her hands, and applied clean gloves. During a staff interview with the Nursing Home Administrator and Director of Nursing on January 21, 2026, at 1:24 PM, they both confirmed that Employee 2 should have removed her gloves, cleansed her hands, and applied clean gloves prior to administering Resident 33's medications through the gastrostomy tube. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Controlled Drugs, Accountability and Responsibility, updated November 30, 2018, revealed The Controlled Drug Record, specific to the drug being administered, is to be signed by the nurse at the time the drug is given to avoid medication errors and discrepancies. Review of Resident 1's clinical record revealed diagnoses that included quadriplegia (paralysis of all four limbs) and hypotension (low blood pressure). Review of Resident 1's physician orders revealed an order for oxycodone (narcotic pain medication), 2.5 mg (milligrams) every four hours as needed for moderate pain and oxycodone, 5 mg, every four hours as needed for severe pain. Review of Resident 1's controlled drug record for the oxycodone (a form used to maintain accurate records of all controlled substances that are being administered) revealed a signature for the nurse dispensing the medication, the date, time and amount dispensed, and the amount of medication remaining. Further review of the form revealed 17 times the oxycodone was documented as being dispensed, between March 4, 2025, and April 14, 2025. Review of Resident 1's MARs (medication administration record), dated March 2025 and April 2025, revealed only eight times that the oxycodone was signed off as being given. Further review of the MAR revealed that two of the eight administrations were documented on the MAR well after the time that the oxycodone was documented as being dispensed; and three of the eight administrations were documented as being administered prior to the time documented as being dispensed. Review of the oxycodone drug record revealed the oxycodone was signed out as being dispensed on the following dates and times, with review of the corresponding [DATE] for those dates and times: March 4 at 11:00 PM- not signed off on the MAR as being administered; March 4 at 2:30 AM- not signed off on the MAR as being administered; March 4 at 9:00 AM- signed off as being administered at 9:14 AM; March 4 at 4:00 PM- signed off as being administered at 3:42 PM, prior to the medication being dispensed; March 4 at 8:30 PM- not signed off on the MAR as being administered; March 5 at 1:00 AM- not signed off on the MAR as being administered; March 11 at 11:28 PM- signed off as being administered at 11:28 PM; March 13 at 12:48 PM- signed off as being administered at 12:47 PM, prior to the medication being dispensed; March 14 at 11:00 AM- not signed off on the MAR as being administered March 18 at 9:00 PM- not signed off on the MAR as being administered; March 19 at 6:00 PM- not signed off on the MAR as being administered; March 22 at 11:00 AM- signed off as being administered at 12:31 PM, one hour and 31 minutes after the medication was dispensed; March 29 at 1:30 PM- signed off as being administered at 7:39 PM, six hours and 9 minutes after the medication was dispensed; March 31 at 1:00 AM- not signed off on the MAR as being administered; April 5 at 10:47 PM- signed off as being administered at 10:47 PM; April 12 at 9:45 PM- signed off as being administered at 9:10 PM, prior to the medication being dispensed; April 14 at 12:00 PM- not signed off on the MAR as being administered. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing on April 28, 2025, at 1:02 PM, they stated that when staff dispense a controlled substance, they should be signing it off on the controlled drug record with the date and time it is dispensed, and then documenting it on the MAR when the medication is administered. They stated they have no additional information as to why the oxycodone was not always being signed off on the MAR. In a follow up interview with the Nursing Home Administrator and DON on April 28, 2025, at 2:02 PM, it was stated that nursing staff should be documenting on the MAR when a medication is administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident record was complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: Review of facility policy, titled Verbal Orders, Physician Orders and Diagnostic/Lab Results, updated November 30, 2018, revealed Upon receipt of a verbal diagnostic or laboratory test result, the nurse will document the results in PCC [Point Click Care-the facility's electronic medical record system] or appropriate form. Review of Resident 1's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition where the heart cannot pump blood effectively, leading to fluid buildup in the lungs, legs, and other parts of the body) and hypertension (high blood pressure). Review of Resident 1's physician orders revealed an order for labs dated March 8, 2025, for a CBC (complete blood count- a blood test used to look at overall health and find a wide range of conditions, including anemia, infection), a BMP (basic metabolic panel- a blood test that measures several important aspects of the blood, like electrolytes and blood sugar), and a urinalysis (urine test used to detect and manage a wide range of disorders, such as urinary tract infections [UTI], kidney disease, and diabetes). Review of Resident 1's clinical record revealed documentation of the CBC results and the urinalysis results. Further review failed to reveal documentation of the BMP results. Review of Resident 1's nursing progress note, written by Employee 1 (Licensed Practical Nurse) dated March 9, 2025, revealed that the CBC and the urinalysis results were received and reviewed and the provider was aware. Urinalysis results were positive for a UTI and the CBC showed a white blood cell count (WBC-help protect the body from infection) of 23.1 (normal is 3.9-9.5). Further review of the note failed to reveal any documentation regarding the BMP results. During an interview with Employee 1 on March 24, 2025, at 12:46 PM, Employee 1 stated that on March 9, 2025, she called the lab to get the results. She stated that the lab notified her of the positive urinalysis, elevated WBC, and that the BMP was not viable, as there was not enough blood to run the test. Employee 1 stated that Resident 1's provider was beside her when she was on the phone with the lab and the provider was aware at that time that the BMP was not viable. Employee 1 stated that since Resident 1 was showing symptoms of an infection and the CBC and urinalysis showed an infection, the provider decided it wasn't necessary to redraw the BMP. During an interview with Employee 2 (Physician) on March 24, 2025, at 1:09 PM, he stated that on March 8 and 9, 2025, the main concern for Resident 1 was infection, which was confirmed by the urinalysis and CBC. Employee 2 stated that because of the infection, there was no need to have to redraw the BMP at that time. Review of Resident 1's clinical record revealed no documentation that Employee 1 notified the provider that the BMP was not viable and no documentation that the provider stated not to redraw the BMP. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 24, 2025, at 2:40 PM, the NHA stated he would expect Employee 1's conversation with the provider regarding Resident 1's BMP would be documented in Resident 1's clinical record. 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary medications for one of one resident reviewed for antibiotic use (Resident 9). Findings include: Review of facility policy, titled Medication Regimen Review and Reporting, with a last review date of December 31, 2024, indicated that a Medication Regimen Review (MRR) is a thorough evaluation of the drug regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication and the consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), tracheostomy (an opening or incision in the windpipe to relieve an obstruction to breathing), and dependence on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, unable to breathe on their own, or under anesthesia). Review of Resident 9's physician orders on January 7, 2025, revealed an order to apply triple antibiotic ointment to moisture associated skin damage (MASD) at tracheostomy stoma site every shift, dated September 24, 2024. Review of Resident 9's clinical record failed to reveal documentation or assessment of any identified skin damage on September 24, 2024, through January 8, 2025. Review of Resident 9's clinical record revealed that the facility's consultant pharmacist had reviewed Resident 9's medication regimen on October 15, 2024; November 12, 2024; and again between December 1-15, 2024, with no recommendations made regarding the ongoing use of the triple antibiotic ointment. During a staff interview with the Director of Nursing (DON), Employee 1, and Employee 2 on January 9, 2025, at 10:38 AM, the DON confirmed that she could not find any clinical documentation identifying that Resident 9 had any MASD at their tracheostomy site, that they should have caught the ongoing antibiotic cream order prior to yesterday, and that it should not have been utilized for this long. She further indicated that Resident 9's physician had assessed their tracheostomy site on January 8, 2025, and noted there was no skin damage noted and discontinued the antibiotic ointment. The DON also confirmed that the monthly consultant pharmacist reviews failed to identify the lack of clinical documentation to support the use of the ongoing antibiotic cream or the overall ongoing use of the antibiotic cream as a concern. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident was free of unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 26). Findings include: Review of Resident 26's clinical record on January 7, 2025, revealed diagnoses that included hypertension (elevated/high blood pressure) and bipolar disorder (mental health disorder that causes extreme shifts in mood from depression to manic hyperactivity). Review of Resident 26's physician orders revealed orders for clonazepam (schedule IV controlled medication in the drug class of benzodiazepine) 3 milligrams (mg - metric unit of measure) every 24 hours as needed for restlessness for 14 days, with a start date of December 30, 2024, and end date of January 13, 2024. Review of Resident 26's clinical record revealed the as needed clonazepam had been continuously reordered every 14 days over the course of the prior year and beyond. Resident 26 also had a separate, standing order for clonazepam 1 mg two times a day for anxiety disorder (mental health disorder characterized by excessive worry or fear), which was dated September 13, 2024. Review of Resident 26's physician orders revealed that Resident 26 had an order for lorazepam (schedule IV controlled medication in the drug class of benzodiazepine) 1 mg every six hours as needed for anxiety for 14 days, with a start date of December 30, 2024, and end date of January 13, 2024. Review of Resident 26's clinical record revealed the as needed lorazepam had been continuously reordered since October, 2022. Review of available documentation revealed no clinical rationale was documented as to why Resident 26 was receiving duplicative medications of the same drug class with duplicative therapeutic effect. Further, review of a pharmacy recommendation dated November 12, 2024, revealed the consultant pharmacist identified that Resident 26 was receiving Duplicate PRN [as-needed] anxiolytics [anti-anxiety medications] and recommended, Please evaluate and consider consolidating to one. To which the provider checked, Disagree - Perceived risks are outweighed by benefits. Order to remain as is. The response was dated November 19, 2024. Review of Resident 26's clinical record revealed no documented review of the risks and/or benefits of Resident 26 receiving duplicative medications of the same medication class and therapeutic effect. During a staff interview on January 9, 2025, Director of Nursing (DON) revealed the facility was unable to locate a documented rationale for the duplicative medication use at that time. Review of Resident 26's order for lorazepam 1 mg revealed it was to be provided every six hours as needed. Review of the Controlled Drug Record (documentation tool utilized to record the amount of medication, amount administered, and date and time the medication is administered) for Resident 26's lorazepam revealed staff documented administering one tablet of lorazepam on September 25, 2024, at 1:00 PM, then a second administration at 4:00 PM, less than six hours between administration. Review of the electronic medication administration record (MAR - document tool utilized to record when medications or treatments are administered) revealed neither administration recorded on the Controlled Drug Record was recorded in Resident 26's electronic MAR. Further review of the Controlled Drug Record revealed staff documented administering one tablet of lorazepam on October 19, 2024, at 4:30 PM, and then a second administration was documented at 8:00 PM, less than six hours in between doses. Review of the electronic MAR revealed staff did not record the 8:00 PM lorazepam administration. Finally, on October 20, 2024, staff recorded on the Controlled Drug Record administration of the lorazepam at 3:45 PM, then another administration was recorded at 8:00 PM, less than 6 hours between doses. Review of the electronic MAR revealed the 8:00 PM administration was not documented. During a staff interview on January 9, 2024, at approximately 11:30 AM, DON revealed it was the facility's expectation that staff follow the as needed time frame as prescribed by the physician when administering as needed medications. During review of the aforementioned Controlled Drug Record for Resident 26's lorazepam 1 mg tablet, the following was identified: Between the dates of September 14 and 26, 2024, 19 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of October 11 and 28, 2024, 11 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of November 13, 2024, and December 6, 2024, 16 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of December 7 and 25, 2024, 17 tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. Between the dates of December 29, 2024, and January 8, 2025, nine tablets were recorded on the Controlled Drug Record as being administered but not recorded in Resident 26's Medication Administration Record. During the staff interview on January 9, 2025, at approximately 11:30 AM, DON revealed it was the facility's expectation that staff document on the electronic MAR when medications are administered. Review of Resident 26's clinical record revealed that between November 27, 2024, and December 1, 2024, Resident 26 did not have an active order for lorazepam; however, staff administered lorazepam 1 mg tablet on the following dates and time: November 29, 2024, at 12:00 AM November 29, 2024, at 8:00 PM December 1, 2024, at 1:27 AM During the staff interview on January 9, 2025, at approximately 11:30 AM, DON revealed that staff should only administer medication when there is an order by a physician. 28 Pa code 211.9(d)(j.1) Pharmacy services 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, observations, clinical record review, and staff interviews, it was determined the facility failed to review and revise the resident's care plan for four of 14 residents reviewed (Residents 2, 26, 29, and 37). Findings include: Review of facility policy, titled Care Plan and Conference, last revised November 30, 2018, read, in part, Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes. Ongoing communication will occur between nursing and RNAC (Registered Nurse Assessment Coordinator) will occur with any change in resident condition. Review of Resident 2's clinical record revealed diagnoses that included dependence on respirator (ventilator) status (when a patient is unable to wean off a ventilator and breathe independently, they become ventilator dependent), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and muscle weakness. Observation of Resident 2 on January 7, 2025, at 10:31 AM, revealed she was lying in bed and had fall mats on both sides of her bed. Observation of Resident 2 on January 8, 2025, at 12:46 PM, revealed she was lying in bed and had fall mats on both sides of her bed. Review of Resident 2's care plan revealed a focus area of The resident is at risk for falls related to medication side effects and history of fall, last revised May 15, 2024, with an intervention for Fall mat to floor on right (door) side of bed, last revised January 21, 2024. Review of Resident 2's clinical record revealed she had an unwitnessed fall on July 13, 2024, with an intervention for bilateral fall mats. Interview with Employee 1 (RNAC) on January 9, 2025, at 10:09 AM, revealed Resident 2's physician order did not get revised to reflect the new order for bilateral floor mats, therefore, the new order did not make it to the care plan to be updated. Interview with the Director of Nursing (DON) on January 9, 2025, at 12:03 PM, revealed she would expect Resident 2's care plan to be updated with her fall intervention from July 13, 2024. Review of Resident 26's clinical record on January 7, 2025, revealed diagnoses included hypertension (elevated/high blood pressure) and bipolar disorder (mental health disorder that causes extreme shifts in mood from depression to manic hyperactivity). Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: CNS [central nervous system] Stimulants- Amphetamine-Dextroamphet[[NAME]] . which had an initiation date of March 4, 2024. Review of the Goal section of the care plan revealed the goal of, Resident will be free of adverse reaction to CNS stimulates administered, which had a revision date of November 26, 2024. Review of Resident 26's clinical record revealed that Resident 26's order for Amphetamine-Dextroamphetamine was discontinued on September 20, 2024. During an electronic communication on January 9, 2025, at 12:37 PM, Nursing Home Administrator revealed Resident 26 had a care plan meeting (interdisciplinary meeting utilized to review the plan of care to adjust according to the residents' needs) on November 19, 2024. During a staff interview on January 9, 2025, at approximately 12:50 PM, DON revealed that Resident 26's care plan for CNS stimulants should have been discontinued, at least, during the care plan meeting. Review of Resident 26's physician's orders revealed an order for clonazepam (schedule IV controlled medication used to treat anxiety disorders) 3 mg as-needed every 24 hours for restlessness; clonazepam 1 mg twice a day for anxiety disorder; lorazepam (schedule IV controlled medication used to treat anxiety disorders) 1 mg every six hours as needed for anxiety. Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: Anti-Anxiety Medications, with an initiation date of February 7, 2024. Review of the Interventions section of the care plan revealed only one intervention, which stated, Notify physician for adverse effects of medication, which had an initiation date of February 7, 2024. Resident 26's care plan for anti-anxiety medications did not include additional information such as, but not limited to, target symptoms to monitor, possible non-pharmacological interventions to attempt prior to administration of an as-needed anti-anxiety medication, nor on-going consultation with psychiatric health services. Resident 26 also had a physician order for Seroquel 25 mg (antipsychotic medication used to treat mental health disorders) one time a day for bipolar disorder. Review of Resident 26's comprehensive plan of care revealed a care plan with a focus of, Potential for adverse reaction to prescribed psychotropic medications: Anti-Psychotic medication, with an initiated date of March 11, 2021. Review of the Interventions section of the care plan revealed only one intervention, which stated, Notify physician for adverse effects of medications, which was initiated March 11, 2021. During a staff interview on January 9, 2025, at approximately 12:50 PM, Nursing Home Administrator revealed that Resident 26's care plan did not appear to be individualized. Review of Resident 29's clinical record revealed diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly) and quadriplegia (paralysis that affects all a person's limbs). Observation of Resident 29 on January 7, 2025, at 10:48 AM, revealed bilateral thick fall mats on both sides of the bed. Review of Resident 29's care plan on January 7, 2025, revealed a care plan for falls related to seizure disorder, with an initiation date of May 9, 2024. Resident 29's care plan failed to include bilateral thick fall mats. Review of Resident 29's physician's orders revealed an order for bilateral thick fall mats, with an active date of January 8, 2025. Review of Resident 29's care plan on January 8, 2025, revealed bilateral thick fall mats were added to the fall care plan, with an initiation date of January 8, 2025. During an interview with the DON on January 9, 2025, at 12:04 PM, revealed they would have expected Resident 29 to have had an order for the fall mats and would have expected them to have been added to their care plan afterward. DON revealed Resident 29 has had bilateral thick fall mats since the Resident was admitted to the facility in May 2024. Review of Resident 37's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure, and muscle weakness. Review of Resident 37's care plan revealed a focus area of Resident has impaired skin integrity related to blister right lateral heel, last revised March 8, 2024. During an interview with the DON on January 9, 2025, at 12:06 PM, she revealed Resident 37's blister wound has been resolved since March 2024, and she would expect her wound care plan to be revised. 28 Pa. Code 211.11 (d) Resident care plan 28 Pa. Code 211.12(d)(3) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections, consistent with physician orders and the resident's person-centered care plan, for one of five residents reviewed for catheter care (Resident 37). Findings include: Review of facility policy, titled Catheter- Indwelling, last revised November 30, 2021, read, in part, Purpose: To maintain constant urinary drainage, facilitate bladder irrigation, and monitor renal function and contain urinary drainage in seriously ill residents while maintaining a closed system. Criteria: must be documented for strict (foley- catheter) output if ordered by the physician. Review of Resident 37's clinical record revealed diagnoses that included obstructive uropathy (when urine can't flow normally through your urinary tract due to a blockage), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and muscle weakness. Review of Resident 37's physician orders revealed orders for the following: Document foley output every shift, with a start date of July 5, 2023. Foley catheter care every shift per policy, with a start date of July 5, 2023. Change foley flush kit every night shift, with a start date of July 18, 2023. Review of Resident 37's care plan revealed a focus area: The resident has the potential for infection related to indwelling catheter. Diagnosis: Obstructive Uropathy with an intervention for, Empty foley catheter and document output every shift, initiated July 4, 2023; Foley catheter care every shift per facility policy, initiated July 4, 2023; and Change foley flush kit every night shift, initiated February 26, 2024. Review of Resident 37's TAR (Medication Administration Record- documentation for treatments/medication administered or monitored) from April 2024 through December 2024, revealed the order to document foley output every shift was not documented as completed 18 times during day shift and 14 times during night shift. Further review of Resident 37's TAR from April 2024 through December 2024 revealed the order for foley catheter care was not documented as completed on April 15 during night shift; May 10 during night shift; June 5 during day shift; August 23 during day shift; August 6, 14, 27, and 28 during night shift; and December 17 and 18 during night shift. Further review of Resident 37's TAR from April 2024 through December 2024 revealed the order to change the foley flush kit was not documented as completed on April 15; August 6, 14, 27, and 28; and December 17 and 18. Review of Resident 37's clinical record revealed she received antibiotic treatment for urinary tract infections from July 15-22, 2024; and November 3-15, 2024. Interview with the Director of Nursing on January 9, 2025, at 12:03 PM, revealed she would expect foley output, catheter care, and changing of the foley flush kit to be completed per facility process and physician order. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for three of 14 residents reviewed (Residents 9, 14, and 17). Findings include: Review of facility policy, titled Medication Administration, with a last review date of December 31, 2024, revealed Medications are given at the time ordered or within 60 minutes before or after the time for bid [twice a day], tid [three times a day], or qid [four times a day] passes. Review of Resident 9's clinical record revealed diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), chronic respiratory failure (long term condition in which the respiratory system is unable to adequately exchange oxygen and carbon dioxide in the body), tracheostomy (an opening or incision in the windpipe to relieve an obstruction to breathing), and dependence on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured, unable to breathe on their own, or under anesthesia). Review of Resident 9's physician orders on January 7, 2024, revealed an order to apply triple antibiotic ointment to moisture associated skin damage (MASD) at tracheostomy stoma site every shift, dated September 24, 2024. Review of Resident 9's clinical record failed to reveal any progress notes, weekly skin assessments, nursing assessments, or respiratory assessments between September 24, 2024, and January 8, 2025, that included any identified skin damage to their tracheostomy site or otherwise. During a staff interview with the Director of Nursing (DON), Employee 1, and Employee 2 on January 9, 2025, at 10:38 AM, the DON confirmed that she could not find any clinical documentation indicating that Resident 9 had any MASD at their tracheostomy site. She further indicated that Resident 9's physician had assessed their tracheostomy site on January 8, 2025, and noted there was no skin damage noted and discontinued the antibiotic ointment. The DON also indicated that, if a resident had skin issues, that she would expect staff to document them accordingly. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe) and hypertension (high blood pressure). Review of Resident 14's December 2024 treatment administration record (TAR) revealed the following treatment orders: cleanse pressure area to left buttock cleanse with normal saline solution (NSS) cover with calcium alginate and foam border gauze daily, every night shift for pressure area, with a start date of July 5, 2024; treatment for left buttock - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of December 2, 2024; and treatment to left superior thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night for wound care, with a start date of November 13, 2024. Further review of Resident 14's December 2024 TAR revealed the treatment orders above were blank on December 14 and 18, 2024, indicating they were not completed. Review of Resident 14's November 2024 TAR revealed the following treatment orders: treatment to left superior thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of November 13, 2024; and treatment to left thigh - cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of September 9, 2024. Further review of Resident 14's November 2024 TAR revealed the treatment orders above were blank on November 16, 2024, indicating they were not completed. Review of Resident 14's October 2024 TAR revealed a treatment order to cleanse pressure area to left buttock, cleanse with NSS, cover with calcium alginate and foam border gauze daily every night shift for pressure area, with a start date of July 5, 2024. Further review of Resident 14's October 2024 TAR revealed the treatment order above was blank on October 25, 2024, indicating the treatment was not completed. Review of Resident 14's October 2024 TAR revealed a treatment order for the left thigh, to cleanse with NSS, apply Medi honey to area and cover with foam dressing daily and as needed every night shift for wound care, with a start date of September 9, 2024. Further review of Resident 14's October 2024 TAR revealed the treatment order above was blank on October 16 and 25, 2024, indicating the treatment was not completed. During a staff interview with the DON on January 9, 2025, at 12:51 PM, revealed that she believed Resident 14's treatment was completed on the dates above, but had careless documentation. DON revealed if the treatment was completed, it should have been documented on the TAR. Review of Resident 17's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), hypotension (low blood pressure), and end stage renal disease (ESRD - condition in which a person's kidneys cease functioning on a permanent basis) with dependence on dialysis(external filtering of the blood performed by a machine by removing the blood and replacing it). Review of Resident 17's physician orders revealed orders for Midodrine HCl Oral Tablet 5 MG [milligram] give three tablets by mouth three times a day related to hypotension. Hold for SBP [systolic blood pressure] greater than 120, dated October 29, 2024; and Insulin Aspartame Injection Solution 100 units/ml [milliliter] Inject as per sliding scale: if 151 - 200 = 1; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400= 5; 401+ = Call Physician, subcutaneously before meals related to Type 2 Diabetes Mellitus, dated October 29, 2024. Review of Resident 17's October 2024 Medication Administration Record revealed that on October 30 and 31, 2024, that there were no documented blood sugars for 6:00 AM, 11:00 AM, or 4:00 PM. All boxes were marked with an X. Review of Resident 17's progress notes revealed a medication administration note on October 30, 2024, at 5:16 PM, related to their ordered 4:00 PM blood sugar check, that indicated Resident 17 was sleeping, not woken at this time. verbally abusive to staff prior to falling asleep will check blood sugar when she wakes up. Further review of Resident 17's progress notes and Medication Administration record failed to reveal that this occurred. In addition, the review failed to reveal any other nursing progress notes as to why Resident 17's blood sugars were marked with an X on the aforementioned dates and times. Review of Resident 17's November 2024 Medication Administration Record revealed their 6:00 AM ordered blood sugar was blank on November 1, 2024. Review of Resident 17's November 2024 nursing progress notes failed to reveal any documentation as to why their ordered blood sugar was not completed. Review of Resident 17's December 2024 Medication Administration Record revealed their 6:00 AM ordered blood sugar was blank on December 6, 16, 17, 18, and 20, 2024; their 11:00 AM ordered blood sugar was blank on December 15, 16, and 17, 2024; and their 4:00 PM ordered blood sugar was blank on December 15 and 17, 2024. In addition, their blood sugar was documented on December 23, 2024, at 4:00 PM, as being 471. Review of Resident 17's December nursing progress notes failed to reveal any documentation as to why their ordered blood sugars were not completed on the aforementioned dates and times, or that Resident 17's physician was notified of the blood sugar being greater than 401 on December 23, 2024, as ordered. Review of Resident 17's January 2025 Medication Administration Record revealed that on January 3, 2025, at 6:00 AM, their ordered blood sugar test was blank; and that on January 7, 2025, at 9:00 PM, Resident 17's blood pressure was recorded as 134/84 and their dose of Midodrine was administered. Review of Resident 17's January nursing progress notes failed to reveal any documentation as to why their ordered blood sugar was not completed or why the Midodrine was not held as ordered. During a staff interview with the DON, Employee 1, and Employee 2 on January 9, 2025, at approximately 10:16 AM, the DON indicated that she called the nurse who documented Resident 17's blood sugar as being 471 on December 23, 2024, and the nurse said they did not recall Resident 17's blood sugar ever being that high, that they know they would have called the physician, but that they could not clearly recall for sure. The DON indicated that she had no additional information regarding Resident 17's blood sugars not being obtained as per physician orders on the dates and times identified. The DON confirmed that Resident 17 was documented as receiving their Midodrine on January 7, 2025, when it should have been held. The DON said she would expect nursing staff to administer resident medications as ordered or to document why medications were not given as ordered and include all necessary follow-up communication with the physician. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(2)(3)(5) Nursing Services

Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure residents were afforded the right to secure and confidential personal and medical records for one of 14 residents reviewed (Resident 18). Findings include: Review of Resident 18's clinical record revealed diagnoses that included quadriplegia (paralysis of both arms and both legs) and tracheostomy status (artificial opening to the trachea [aka windpipe] through which a machine provides breathing assistance). During observations on January 7, 2025, it was observed, from the hallway, that a paper was taped to the wall outside Resident 18's room to the left of the room number sign. It was observed that written on the paper was Resident 18's first name and clinical assessment findings, along with other statements. Written on the paper was the date of January 4, 202[5]. During a staff interview on January 8, 2025, at approximately 1:20 PM, Nursing Home Administrator (NHA) revealed that the paper contained notes written to communicate information for Resident 18's treatment in regard to suctioning Resident 18's tracheostomy. During the interview, NHA revealed it should have been placed on the back of the Resident's door where it would not have been in plain sight from the hallway. 28 Pa code 201.18(b)(2)(3) Management

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the listed emergency contact person (Resident's Representative) of a critical lab value for one of three residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Notification of Change in Status, updated November 30, 2018, revealed Purpose: To notify patient and/or family of any change in treatments or status, and to allow patient and/or family the opportunity to be involved in treatment or care if they so desire. Procedure: .B. Non-life threatening situation or a change in care due to a minor process i.e. pneumonia, change in treatment or medication, test results. Documentation: B. Non-life threatening situation: 1. The nurse taking off or receiving new information will discuss the change(s) with the patient and/or family member and document the discussion. Review of Resident 1's clinical record revealed diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body) and atrial fibrillation (Afib - an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 1's lab work dated August 9, 2024, revealed that Resident 1's hemoglobin was critically low, at 6.0, with the reference range being listed as 12.8-16.6. Review of Resident 1's clinical record revealed no evidence that Resident 1's Representative was notified of the critically low hemoglobin. During an interview with the Assistant Director of Nursing (ADON) on October 21, 2024, at 11:25 AM, she stated that Resident 1's Representative should have been notified of Resident 1's hemoglobin lab result. In a follow-up interview with the Nursing Home Administrator and the ADON on October 21, 2024, at 2:37 PM, no additional information was provided. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of three residents reviewed (Resident 1). Findings Include: Review of Resident 1's clinical record revealed diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body) and atrial fibrillation (Afib - an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 1's physician note dated August 8, 2024, revealed that the physician assessed Resident 1 for an episode of hematuria (blood in the urine). Further review of the physician note revealed I told nurses we will hold blood thinners for 2 days and will check CBC [complete blood count lab work], BMP [basic metabolic panel blood test] and magnesium [a blood test to measure the amount of magnesium in the blood]. Review of Resident 1's clinical record revealed an order written and signed by the physician on August 8, 2024, to discontinue blood thinners and get a CBC, BMP, and Magnesium level. Review of Resident 1's Medication Administration Record (MAR) dated August 2024, revealed that Resident 1's aspirin (a type of nonsteroidal anti-inflammatory drug [NSAID] that can treat mild to moderate pain, inflammation, or arthritis. It also lowers the risk of heart attack, stroke, or blood clot) was to be on hold from August 8, 2024, at 1:59 PM, to August 10, 2024, at 1:58 PM. Further review of the MAR revealed Resident 1's aspirin was documented as being held on August 9, 2024, at 9:00 AM, and August 10, 2024, at 9:00 AM. Review of Resident 1's MAR for August 2024, revealed that Resident 1 received Coumadin (blood thinner medication) on August 9 and 10, 2024. Review of Resident 1's clinical record revealed no evidence that Resident 1's Coumadin was discontinued, per the written physician order to discontinue blood thinners. There was also no evidence that the order was clarified with the physician to determine which blood thinner medications should be discontinued, and no evidence of any order to hold the aspirin. During an interview with the Nursing Home Administrator and Assistant Director of Nursing (ADON) on October 22, 2024, at 2:37 PM, they were made aware that the written physician order to discontinue the blood thinners was not followed, and there was no evidence that the order was clarified to confirm which medications the physician was referring to as blood thinners. In an email correspondence from the ADON on October 22, 2024, at 2:43 PM, she stated that the facility was unable to find any clarification for the order to discontinue blood thinners. Review of Resident 1's clinical record revealed an order for a PT (prothrombin time-measures how long it takes for a blood sample to clot), INR (international normalized ratio- measures how long it takes for blood to clot), and BMP blood test weekly. Review of Resident 1's INR results from August 2, 2024, revealed an INR of 3.9 (therapeutic range is 2.0 to 3.0 for standard oral anticoagulation therapy and 2.5 to 3.5 for high dose therapy). Review of Resident 1's physician orders, based off of the INR result from August 2, 2024, revealed an order to hold one dose of Coumadin and then decrease the dosage from 6 mg (milligrams) at bedtime to 5 mg at bedtime. Review of Resident 1's MAR dated August 2024, revealed the Coumadin was held on August 2, 2024, and then decreased to 5 mg starting August 3, 2024. Review of Resident 1's clinical record revealed the next INR blood draw was due on August 9, 2024. Review of Resident 1's clinical record revealed that the INR lab results from August 9, 2024, were not part of the clinical record. On October 21, 2024, at 12:57 PM, the ADON provided the INR result from August 9, 2024, which was 4.2. In an email correspondence from the ADON on October 22, 2024, at 2:43 PM, she stated that the facility was unable to find any evidence indicating that the INR lab result was ever faxed to the facility from the lab. She also stated that in a conversation with the physician assistant (PA), the PA stated she was not aware of the INR of 4.2. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance in that they had failed to ensure each resident the right to be free from neglect, resulting in harm for one of three resident records reviewed (Resident 1). Findings include: Review of facility policy, titled Abuse Reporting, last reviewed January 23, 2023, revealed the policy statement was, The facility shall protect its residents to the fullest extent possible from physical[,] verbal, sexual or mental abuse, acts of neglect, corporal punishment, involuntary seclusion and misappropriation of residents' property. As all residents have the right to be free from abuse, mistreatment, neglect or misappropriation of property. All individuals not adhering to said policy shall jeopardize their position with the facility. Review of the policy's definitions section revealed the policy defined neglect as, .failure to provide oneself or the failure of a caretaker, to provide goods or services essential to avoid a clear and serious threat to a resident's physical or mental health. This may include the failure of the caretaker to provide adequate nutrition, assistance with activities of daily living, health related services .medical services for the person unable to care for him/herself . Activities of Daily Living (ADLs) are defined as activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. Review of facility document, titled Certified Nurse Aide Job Description, last updated November 1, 2020, revealed the Position Summary stated, The Certified Nursing Assistant (NA) is responsible for providing direct resident care including personal, nutritional and restorative care in the skilled nursing operations and other areas throughout the facility as appropriate. Review of Job Responsibilities revealed it included that Nurse Aides .Performs individualized personal care and activities of daily living (ADL); documents in Point of Care (POC) .Reports all incidents immediately to appropriate supervisor/team member .Practices safe procedures during all resident repositioning, transfers and transport. Review of Employee 1's (Nurse Aide) employee file revealed Employee 1 signed an acknowledgement of receiving, reading, and understanding the Nurse Aide job responsibilities on September 27, 2023. Review of Employee 1's (Agency Nurse Aid) employee file revealed a facility document, titled Orientation - Agency Staff, which included the statement, Our patients all have transfer orders in POC [Plan of Care] and you are expected to follow them. Mechanical Lifts require two (2) [person] assist AND must use the proper sling size determined by weight .All orders must be followed. If you have any questions, it is your responsibility to ask the Registered Nurse or an experienced member of the [NAME] team. Employee 1 signed the document on June 29, 2023, acknowledging he had received, read, and understood the facility policies. Review of Employee 1's employee file revealed that on September 27, 2023, Employee 1 was hired by the facility as a full time Nurse Aide employee. Employee 1 signed an acknowledgement document, acknowledging receiving the facility's employee handbook, understanding the contents of the facility employee handbook, and was provided an opportunity to ask any questions regarding the facility's policies outlined in the facility handbook. Review of the orientation skills check list revealed it also included, Safely transfers resident from bed or chair using Hoyer lift, which was demonstrated on October 4, 2023. Review of Resident 1's clinical record revealed diagnoses that included cerebral palsy (congenital disorder affecting movement, muscle tone, and/or posture) and end stage renal disease (severe decrease/inability of the kidneys to filter toxins from the blood requiring need for dialysis). Review of Resident 1's comprehensive plan of care revealed that Resident 1's care plan for assistance with ADLs included the intervention of, Transfers 2 [person] assist with full Mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) to powerchair or gerichair with pressure reducing cushion when out of bed, which was initiated on March 6, 2022. Review of Resident 1's physician orders revealed an order for, Transfers 2 [person] assist with full Mechanical lift to gerichair with pressure reducing cushion when out of bed, which was ordered on February 14, 2023. Review of Resident 1's Kardex (clinical documentation developed for care givers [nurse aides, licensed practical nurses, registered nurses] from a resident comprehensive plan of care that condenses a resident's specific care needs) revealed it included, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed. Review of Resident 1's nurse aide task documentation from October 30, 2023, to November 28, 2023, revealed Resident 1 was documented as being totally depended on staff for transfers. Further, the Resident required the assistance of two staff during all transfers documented in the 30-day period between October 30, 2023, to November 28, 2023. Review of the Nurse Aide task documentation for the dates of October 30, 2023, to November 17, 2023, revealed that Employee 1 documented that Resident 1 was totally dependent for transfers with the assistance of two staff on November 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 15, and 17, 2023. Review of Resident 1's interdisciplinary progress notes revealed that Employee 2 (Registered Nurse) entered a progress note stating that on November 17, 2023 at 7:00 PM, [Employee 1 {Nurse Aide}] approached this nurse and reported that during transfer from chair to bed, resident's left leg was bumped and bent back against the bed. [Resident 1] had [complaints of] mild pain at time of incident but had just had Tylenol approx[imately] 1 hour prior for headache. Resident was ok with having recently had Tylenol and did not want any other pain medication. Resting in bed at present with no visible injury to left leg. Review of an interdisciplinary progress note documented by Employee 3 (Registered Nurse) stated, Resident reported left upper leg 6/10 [pain] at [8:00 PM of November 17, 2023]. No apparent injury noted. Tylenol given no further complaint for the duration of the shift. Staff attempted to get resident ready for transport to dialysis at [4:30 AM]. Resident refusing citing left hip pain 7/10. Tylenol given. Left leg assess[ed] no apparent injury noted. [Physician] notified. [New order] received for X-ray left hip, left femur, left fibula[,] left tibia, left ankle and left foot . Review of an x-ray performed on Resident 1's left leg on November 18, 2023, revealed a fractured tibia (front most bone of the lower leg; also known as the shin bone). Review of Resident 1's clinical record revealed that on November 18, 2023, Resident 1 was sent to a hospital emergency department for treatment of the fractured left tibia. Review of facility investigation report revealed a witness statement, dated November 18, 2023, provided by Resident 1 which stated, .male aide picked her up without using lift from bed to wheelchair[.] [Resident 1] states she heard a 'popping' noise when she was lifted up. [Resident 1] states she felt paint from [her left leg]. Further review of the investigation report revealed a witness statement given by Resident 1's mother, dated November 18, 2023, which included, [Resident 1] was in her wheelchair, and asked to be put back in bed. [Employee 1] pushed [Resident 1's] chair up to the bed. [Employee 1] said ok ready here we go, scooped [Resident 1] up and was lying her down on the bed. There was a pop and [Resident 1] hollered ['my leg']. I was standing at the door when this occurred. [Resident 1's] foot was bent and leg when it popped. [Resident 1] got situated in bed and asked for pain medicine. She didn't want to be moved or the covers tight . Review of an undated, written witness statement provided by Employee 1 (Nurse Aid) revealed it stated, The incident happen[ed] on Nov[[NAME]] 17, 2023 around 6:30 pm. I was transferring [Resident 1] from her wheelchair to her bed and in the midst of everything her left leg was bent onto the bed. Review of the available information revealed that on the evening of November 17, 2023, Employee 1 transferred Resident 1 from the wheelchair to the Resident's bed without the use a mechanical lift and assistance from a second staff; thus, neglecting Resident 1's physician order for transfer and care planned transfer status. As a result of the transfer, Resident 1 sustained a fracture to the lower left leg which required hospitalization . During a staff interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA), NHA revealed that during a verbal interview on November 18, 2023, Employee 1 acknowledged that he transferred Resident 1 by himself without the use of a mechanical lift. During the interview, the NHA and DON confirmed that as a result of the facility investigation, the actions of Employee 1 met the definition of neglect by not providing Resident 1 a transfer with a mechanical lift and two staff assistance per Resident 1's physician orders and care plan. During the abbreviated survey, the NHA and DON provided information and documentation of an immediate action plan put into place after the transfer that subsequently caused injury to Resident 1. The immediate action plan was put into place on November 18, 2023. On November 18, 2023, Employee 1 was suspended pending an investigation and, subsequently, employment of Employee 1 was terminated on November 20, 2023, as a result of the facility investigation finding Employee 1 had committed Abuse. On November 18, 2023, the facility began educating all nursing staff (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) on providing transfers in accordance with a residents' physician orders, as determined by the therapy department. All facility employees were educated as of November 20, 2023. On November 22, 2023, the facility began an audit of five resident transfers to be done weekly. The audits are to ensure resident transfers are conducted in accordance with the physician orders, therapy determination, and resident care planned transfer status. The facility will continue to audit three resident transfers five times per week for three months. The results of the audit will be reviewed by the facility's Quality Assurance process. During an onsite investigation on November 28, 2023, the facility's audits and education were reviewed. Direct care staff were interviewed and confirmed that they received education and voiced understanding of the abuse policy and resident's transfer status. Observations of residents being transferred to and from bed were made and no concerns were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility investigation, facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility displayed past noncompliance in the failure to follow the plan of care and provide the required assistance during a transfer, resulting in harm as evidenced by a leg fracture, for one of three resident records reviewed (Resident 1). Findings include: The facility's expectations for direct care staff states, Our patients all have transfer orders in POC [Plan of Care] and you are expected to follow them. Mechanical Lifts require two (2) [person] assist AND must use the proper sling size determined by weight .All orders must be followed. If you have any questions, it is your responsibility to ask the Registered Nurse or an experienced member of the [NAME] team. Review of Resident 1's clinical record revealed diagnoses that included cerebral palsy (congenital disorder affecting movement, muscle tone, and/or posture) and end stage renal disease (severe decrease/inability of the kidneys to filter toxins from the blood requiring need for dialysis). Review of Resident 1's comprehensive plan of care revealed that Resident 1's care plan for assistance with activities of daily living included the intervention of, Transfers 2 [person] assist with full Mechanical lift (device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) to powerchair or gerichair with pressure reducing cushion when out of bed, which was initiated on March 6, 2022. Review of Resident 1's physician orders revealed an order for, Transfers 2 [person] assist with full Mechanical lift to gerichair with pressure reducing cushion when out of bed, which was ordered on February 14, 2023. Review of Resident 1's Kardex (clinical documentation developed for care givers [nurse aides, licensed practical nurses, registered nurses] from a resident comprehensive plan of care that condenses a resident's specific care needs) revealed it included, Transfers 2 [person] assist with full Mechanical lift to powerchair or gerichair with pressure reducing cushion when out of bed. Review of Resident 1's nurse aide task documentation from October 30, 2023, to November 28, 2023, revealed Resident 1 was documented as being totally dependent on staff for transfers. Further, the Resident required the assistance of two staff during all transfers documented in the 30-day period between October 30, 2023, to November 28, 2023. Review of the Nurse Aide task documentation for the dates of October 30, 2023, to November 17, 2023, revealed that Employee 1 documented that Resident 1 was totally dependent for transfers with the assistance of two staff on November 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 15, and 17, 2023. Review of Resident 1's interdisciplinary progress notes revealed that Employee 2 (Registered Nurse) entered a progress note stating that on November 17, 2023 at 7:00 PM, [Nurse Aide] approached this nurse and reported that during transfer from chair to bed, resident's left leg was bumped and bent back against the bed. [Resident 1] had [complaints of] mild pain at time of incident but had just had Tylenol approx[imately] 1 hour prior for headache. Resident was ok with having recently had Tylenol and did not want any other pain medication. Resting in bed at present with no visible injury to left leg. Review of an interdisciplinary progress note documented by Employee 3 (Registered Nurse) stated, Resident reported left upper leg 6/10 [pain] at [8:00 PM of November 17, 2023]. No apparent injury noted. Tylenol given no further complaint for the duration of the shift. Staff attempted to get resident ready for transport to dialysis at [4:30 AM]. Resident refusing citing left hip pain 7/10. Tylenol given. Left leg assess[ed] no apparent injury noted. [Physician] notified. [New order] received for X-ray left hip, left femur, left fibula[,] left tibia, left ankle and left foot . Review of the clinical record revealed that X-ray results were positive for left leg fibula and tibula (lower leg bones) fracture. On November 18, 2023, that facility initiated an investigation into Resident 1's fractured left leg. Review of investigation revealed a statement from Resident 1. Resident 1 stated that a male aide picked her up without using lift. States she heard a popping noise when she was lifted up and that she felt pain. Review of the statement obtained from Resident 1's mother, who was in the room during the incident, stated that Resident 1 was in her chair and asked to be put back to bed. Employee 1 (Nurse Aide) pushed the chair up to the bed and said ok ready here we go, scooped [Resident 1] up and was laying her down on the bed. There was a pop and [Resident 1] [NAME][e]d my leg. Further review of the facility investigation revealed a statement from Employee 2 (Registered Nurse) dated November 18, 2023, that stated that Employee 1 (Nurse Aide) approached the nurse stating that Resident 1 was requesting something for pain. He continued to say that, during a transfer from chair to bed, [Resident 1's] left leg bent back slightly and she said it hurt. Employee 2 told Resident 1 that she just had Tylenol and asked the resident if she was ok and she said yes. Employee 2 stated that no visible injuries were observed to left leg at that time. Review of the statement obtained from the facility from Employee 1 (Nurse Aide) stated, I was transferring [Resident 1] from her wheelchair to her bed and in the midst of everything her left leg was bent onto the bed. The investigation concluded that on the evening of November 17, 2023, at approximately 6:30 PM, Employee 1 transferred Resident 1 without the use of a mechanical lift (Hoyer) and second person assist as ordered by the physician and included in Resident 1's comprehensive plan of care. Instead, Employee 1 lifted Resident 1 out of her wheelchair with his arms and placed Resident 1 in bed, at which time Resident 1's left leg and left foot were bent behind the Resident. As a result, Resident 1 suffered a fracture to the lower left leg, specifically a fracture of the fibula and tibula of the left leg. During the abbreviated survey, the Nursing Home Administrator (NHA) and Director of Nursing (DON) provided information and documentation of an immediate action plan put into place after the transfer that subsequently caused injury to Resident 1. The immediate action plan was put into place on November 18, 2023. On November 18, 2023, Employee 1 was suspended pending an investigation and, subsequently, employment of Employee 1 was terminated on November 20, 2023, as a result of the facility investigation finding Employee 1 had committed Abuse. On November 18, 2023, the facility began educating all nursing staff (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) on providing transfers in accordance with a residents' physician orders, as determined by the therapy department. All facility employees were educated as of November 20, 2023. On November 22, 2023, the facility began an audit of five resident transfers to be done weekly. The audits are to ensure resident transfers are conducted in accordance with the physician orders, therapy determination, and resident care planned transfer status. The facility will continue to audit three resident transfers five times per week for three months. The results of the audit will be reviewed by the facility's Quality Assurance process. During an onsite investigation on November 28, 2023, the facility's audits and education were reviewed. Direct care staff were interviewed and confirmed that they received education and voiced understanding of the abuse policy and resident's transfer status. Observations of residents being transferred to and from bed were made and no concerns were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review, interviews, facility policy, and a facility event investigation report it was determined that the facility failed to follow the established care plan, this failure of not implementing required care for the resident that was a two person assist and received only one assist resulted in harm from a fall out of a Hoyer lift sling and a laceration to the occiput (back of the head)which required two staples at a hospital emergency department for one of three residents reviewed (Resident 1). Findings include: Review of the current facility policy titled, Abuse Reporting, dated (MONTH) (YEAR), provided by the Nursing Home Administrator states under the subsection titled Neglect, neglect is defined as the failure of a caretaker to provide goods or services essential to avoid a threat to a resident's physical or mental health. A review of Resident 1's closed clinical record on (MONTH) 15, 2019, revealed [DIAGNOSES REDACTED]. A review of Resident 1's physician orders [REDACTED]. A review of Resident 1's care plan regarding transfer status was initiated (MONTH) 6, 2019 and stated, Transfer 2 assist with Hoyer Lift to Geri-chair. A facility injury event dated (MONTH) 31, 2019, at approximately 7:30 PM was reviewed on (MONTH) 15, 2019, at 9:00 AM. The facility investigation indicated Nurse Aide 1 failed to have a second person assist with the mechanical lift transfer of Resident 1. The investigation indicated Resident 1 slipped out of the mechanical lift sling when the mechanical lift was being pulled away from the bed. Resident 1 fell on top of the mechanical lift legs, hitting her head. The resident was sent to the hospital and required two staples to a laceration on the occiput (back of the head). During an interview with Nurse Aide 1 on (MONTH) 15, 2019 at 11:10 AM Nurse Aide 1 revealed Hoyer lift transfers require two staff. During an interview with Resident 3 on (MONTH) 15, 2019, at 12:30 PM revealed that when staff gets him out of bed with the Hoyer lift two staff always do the transfer. During an interview with the Nursing Home Administrator on (MONTH) 15, 2019, she stated that all staff are trained to use two-persons when transferring with a mechanical lift and that is the expectation. The facility neglected to follow the established care plan resulting in harm from a fall out of a Hoyer lift sling with injury for one of three residents reviewed (Resident 1). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 8/2/19, 6/21/19, 3/18/19, 5/23/18. 28 Pa Code 201.18(b)(1)(3) Management. Previously cited 8/2/19, 6/21/19, 3/18/19, 5/23/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 8/2/19, 3/18/19, 5/23/18. 28 Pa. Code 201.29(d) Resident rights. Previously cited 8/2/19, 3/18/19. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 8/2/19, 3/18/19. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 8/2/19, 6/4/19, 5/7/19, 3/18/19, 5/23/18. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 6/21/19, 10/26/18, 5/23/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/2/19, 6/21/19, 3/18/19, 10/26/18, 8/14/18, 5/23/18. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited 8/2/19, 6/21/19, 3/18/19, 5/23/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/2/19, 6/21/19, 3/18/19, 8/14/18, 5/23/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/2/19, 6/21/19, 6/4/19, 5/7/19, 3/18/19, 10/26/18, 8/14/18, 5/23/18.

APPEAL FILED Based on observations, facility document review and staff interviews, it was determined that the facility failed to consistently maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers to prevent infection as per the Glucometers policy which is reviewed annually. This deficient practice affected 23 of 52 sampled residents who require glucometer checks (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23) placing them at risk for the potential infection and the facility in an Immediate Jeopardy situation. See F726 for further findings. Findings Include: Review of facility policy titled, Glucometers (a device used to test the amount of sugar in a person's blood) with an adopted date of (MONTH) 1, (YEAR) and updated (MONTH) 30, (YEAR), revealed that Each glucometer must be wiped down with a towelette in between patients' usage per manufacturer's recommendation. Review of facility policy titled Glucometers-Assure Platinum with an adopted date of (MONTH) 1, (YEAR) and an updated date of (MONTH) 30, (YEAR), revealed Cleaning and Maintenance: 1. The meter should be cleaned between each patient. 2. Put on sterile gloves or clean gloves. 3. Inspect for blood, debris, dust or lint anywhere on the meter. 4. Clean or disinfect meter per manufacturer's recommendation. Review of the glucometer manufacturer's recommendation provided by the facility under Cleaning and Disinfecting Guidelines revealed, Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA- (Environmental Protection Agency) registered disinfectant detergent or germicide wipe. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70-80%). To disinfect the meter, dilute 1 ml (milliliter) of household bleach (5%-6% sodium hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. On (MONTH) 9, 2019, at 10:49 AM an observation was made on the first floor in the presence of the Nursing Home Administrator (NHA) of the south glucometer which was in the possession of Licensed Practical Nurse (LPN) 2 revealed two spots of a red substance, appearing to be blood. LPN 2 stated that she used the glucometer that morning and cleaned it. She went on to say she must not have seen the red spots. When asked what she cleaned the glucometer with she hesitated and then said Purell (hand sanitizer) and a tissue. On (MONTH) 9, 2019, at 10:55 AM surveyor observed a glucometer on the second floor with LPN 1. Surveyor observation revealed two spots of a red substance, appearing to be blood, on the glucometer near where the test strip is inserted into the machine. LPN 1 stated the red substance looked like blood. She stated that she used the machine earlier but that she cleaned it. When the surveyor asked LPN 1 how the glucometer is cleaned, she stated that the facility uses Cavi bleach wipes (1:10 bleach dilution disinfecting towelettes). LPN 1 then took a Sterile Alcohol Prep Pad (saturated with 70% [MEDICATION NAME] alcohol) and wiped the glucometer around the area where there was blood. LPN 1 did not perform hand hygiene prior to or after cleaning the glucometer and LPN 1 did not wear gloves while cleaning the glucometer. LPN 1 only used one wipe and failed to disinfect the glucometer, per the manufacturer's recommendation when there is blood visible. An interview on (MONTH) 9, 2019, 10:59 AM the NHA disclosed that she was made aware of the glucometer issue the day before by another state agency and started staff education on the proper cleaning of glucometers. Review of the facility provided education sign-in sheet revealed LPN 2 received training on (MONTH) 9, 2019. On (MONTH) 9, 2019, at 5:08 PM the NHA was informed of Immediate Jeopardy at the facility and request for a written Correction Action Plan. The Correction Action Plan was accepted on (MONTH) 9, 2019, at 8:00 PM and included the following: 1. RN (Registered Nurse) completed an assessment of all residents that have orders for Accu-check (blood sugar checks with a glucometer). Glucometers were removed immediately, cleaned, and verified they are functioning properly. Bags and glucometer supplies containing glucometers were removed and disposed of immediately. Carts storing the glucometers were cleaned immediately. 2. Both nurses who were observed with glucometers with a red substance did not have open wounds or areas on their hands and attested that they utilized gloves during use. 3. Immediate education was provided to all licensed nursing staff educating the proper cleaning before, during, and after use, hand hygiene, and storage of the glucometer. Education included return demonstration for all licensed nursing staff prior to any additional use of glucometers. 4. Audits verifying licensed nursing staff are following the properly cleaning before, during, and after use, hand hygiene, and storage of the glucometer were immediately implemented per policy and Accu-check manufacturer guidelines daily x 7 days, then 3 x's per week for 2 weeks, then weekly for 2 weeks, then monthly for 2 months. All results will be presented at monthly QAPI (Quality Assurance Performance Improvement) for review and recommendations. 5. Administrator, Director of Nursing, and /or designee will follow recommendations provided by the State Agency regarding proper glucometer use. 6. Night shift licensed nursing staff were immediately educated on proper verification of the Accu-Check Daily Log to ensure glucometers are within the acceptable parameter range and if outside of the acceptable range the appropriate way to address/replace the glucometer. Day shift licensed nursing staff will verify night shift licensed nurse verified the Accu-Check Daily Log was completed. The Glucometers-Assure Platinum policy and the manufacturer guidelines were laminated and placed in each Accu-Check Daily Log Glucometer Binder. 7. Audits verifying glucometers are within the acceptable range conducted immediately and being audited daily will be completed daily X 7 days, then 3 X's per week for 2 weeks, then monthly for 2 months. All results will be presented at monthly QAPI for review and recommendations. On (MONTH) 10, 2019, at 10:45 AM the Immediate Correction Action Plan was reviewed, observations and interviews were conducted to assure implementation. On (MONTH) 10, 2019, at 10:51 AM LPN 3 demonstrated proper cleaning of a glucometer; (MONTH) 10, 2019, at 10:59 AM LPN 2 demonstrated proper cleaning of a glucometer; and (MONTH) 10, 2019, at 11:04 AM LPN 4 demonstrated proper cleaning of a glucometer. LPN 3 explained the process for a glucometer for proper verification of the Accu-Check Daily Log to ensure glucometers are within the acceptable parameter range and if outside of the acceptable range the appropriate way to address/replace the glucometer. On (MONTH) 10, 2019, at 11:45 AM the NHA was notified that the Immediate Jeopardy was lifted. The facility failed to consistently maintain an infection prevention and control program which ensured proper cleaning and disinfecting of glucometers to prevent infection as per the Glucometers policy which is reviewed annually. This deficient practice affected 23 of 52 sampled residents who require glucometer checks (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23,) placing them at risk for the potential infection and the facility in an Immediate Jeopardy situation. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control. Previously cited 6/21/19, 6/4/19, 5/7/19, 8/14/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/21/19, 3/18/19, 5/23/18. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 6/21/19, 3/18/19, 5/23/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 3/18/19, 5/23/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 6/21/19, 3/18/19, 10/26/18, 8/14/18, 5/23/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 6/21/19, 3/18/19, 8/14/18, 5/23/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/21/19, 6/4/19, 5/7/19, 3/18/19, 10/26/18, 8/14/18, 5/23/18.

Based on review of clinical records, facility documentation, hospital records and interviews with facility staff it was determined that the facility failed to accurately assess and obtain services timely for a resident who had an elevated temperature and deteriorating pressure ulcer which resulted in a transfer to the hospital and admission to the intensive care unit with a [DIAGNOSES REDACTED]. Findings Include: Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed that Resident 1 also had an unstageable pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) due to necrosis (occurs when there is not enough blood flowing to the tissue, ultimately resulting in death of body tissue) on the sacrum (area below the spine). Review of the clinical record revealed that Resident 1 had an elevated temperature on (MONTH) 1, (YEAR), of 102 degrees Fahrenheit (F). Tylenol was administered, and new orders were obtained for a sputum culture and IV (intravenous fluids) at 60 milliliters (ML) an hour. On (MONTH) 2, (YEAR), Resident 1 received Tylenol again for an elevated temperature of 101.1 F. The resident continued with elevated temperatures until (MONTH) 6, (YEAR). (MONTH) 3 it was 99.9 F, (MONTH) 4 it was 99.7 F, (MONTH) 5 it was 99.2 F, and (MONTH) 6 it was 100 F (normal body temperature is 98.6). Review of the physician's progress notes revealed that on (MONTH) 3, (YEAR), the physician noted a temperature of 102 F, and stated to continue to monitor. On (MONTH) 4, (YEAR), the physician noted the temperature of 99.2 F, and stated to continue to monitor. The sputum culture was reviewed by the physician on (MONTH) 4, (YEAR), with no new orders. On (MONTH) 6, (YEAR), the physician noted a temperature of 101 F and stated again to continue to monitor for pneumonia, however, no new orders were placed at that time. Review of the (wound doctor), wound evaluation summary on (MONTH) 27, (YEAR), revealed that the pressure ulcer deteriorated. Review of the wound nurse flow sheet dated (MONTH) 27, (YEAR), indicated that the pressure ulcer was 6 cm x 1.5 cm x 5 cm depth. There was 5% slough (dead tissue) and 95% granulation (new tissue that forms on the surfaces of a wound during the healing process) and moderate drainage. The wound evaluation on (MONTH) 4, (YEAR), revealed that the pressure ulcer further deteriorated. The wound nurse flow sheet dated (MONTH) 4, (YEAR), revealed that the ulcer was now 6.3 cm x 2.7 cm x 1.5 cm. The wound was now 100% slough. The drainage from the wound was heavy and the wound base was yellow. There was no change to the treatment. On (MONTH) 7, (YEAR), at 1:16 p.m. a respiratory note was entered into the progress notes stating that Resident 1's respiratory rate had increased to the mid 40's (normal is ,[DATE]). The resident had secretions gurgling in the back of her throat and her heart rate decreased to 38 (normal is ,[DATE]). On (MONTH) 7, (YEAR), at 2:06 p.m. a nursing note was entered that the resident was unresponsive with eyes unfocused but slightly opened. Resident also had audible coarse rattling rales (abnormal lung sounds) with each breath. On (MONTH) 7, (YEAR), at 3:44 p.m. there was a nursing note that stated that the daughter was made aware of the change in condition. The daughter asked if they could call the physician again. The physician was made aware and a new order was obtained for a chest X-ray. The X-ray was not obtained at the facility due to the resident being sent to the hospital per the daughter's request. On (MONTH) 7, (YEAR), at 4:20 p.m. a Registered Nurse (RN) assessment was completed and revealed the resident was cold from the mid-thigh to toes and from the elbows to the hands. The resident continued to have elevated respiratory rate with audible gurgles (increase in sputum) despite oral suctioning. The physician was aware and there were no new orders. On (MONTH) 7, (YEAR), at 5:49 p.m. a call was placed to the resident's daughter again. Update was made, and the daughter demanded that the resident be sent to the hospital. The resident was taken via ambulance to the hospital at 6:20 p.m. Review of the hospital records for Resident 1 revealed that the resident came to the hospital unresponsive with fever and [MEDICAL CONDITION] (low blood pressure), and large infected decubitus ulcer (pressure ulcer). Review of the labs performed at the hospital on (MONTH) 7, (YEAR), revealed that Resident 1's White Blood Cells (WBC) were elevated at 34.43 (normal is ,[DATE].8, an elevated WBC is indicative of infection). The resident was started on IV (intravenous) fluids and two IV antibiotics. Review of the emergency room (ER) physician note revealed that the resident arrived at the ER in [MEDICAL CONDITION] (a life-threatening illness caused by the body's response to an infection) with the most likely source being an extensive foul-smelling sacral pressure ulcer, which appeared infected upon inspection. Other [DIAGNOSES REDACTED]. Resident 1 was started on two IV antibiotics and [MEDICATION NAME] infusion (to treat metabolic acidosis). She was admitted to the intensive care unit and infectious disease, general surgery for [REDACTED]. Resident 1 continued with low heart rate and secretions. A family meeting was held to discuss the resident's condition, multi-organ failure, and significantly infected sacral ulcer, no further interventions were recommenced by the family and the resident died on (MONTH) 8, (YEAR). Review of the death certificate lists the cause of death as cardiorespiratory arrest, multi-organ failure, [MEDICAL CONDITION], and severe infection of the sacral ulcer. The facility failed to accurately assess and obtain services timely for a resident who had an elevated temperature and deteriorating pressure ulcer, which resulted in a transfer to the hospital and admission to the intensive care unit with a [DIAGNOSES REDACTED]. 42 CFR 483.25 Quality of Care. Previously cited [DATE], [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(3) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.29(a)(d) Resident rights. 28 Pa. Code 211.2(a) Physician services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.10(a)(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(2) Nursing services. Previously cited [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE].

Based on clinical record review and staff interview it was determined that the facility failed to ensure that residents who enter the facility without pressure sores do not develop pressure sores and that residents having pressure sores receive necessary treatment and services to promote healing for 1 of 2 resident records reviewed (Resident 1). Findings include: Review of the facility policy document titled, "Skin Care - Protective and Preventative Protocol" updated February 2015, revealed that the facility staff were to maintain optimal skin integrity for all residents/patients by establishing assessment protocols, protective and preventative skin care protocols. Licensed Nurses, nursing assistants, restorative aides, respiratory therapists, dieticians, occupational therapists and physical therapists were responsible for maintaining the residents' skin integrity and on-going assessments for skin turgor, redness and open areas. Identified areas were to be documented daily on the Treatment Administration Record (TAR - record of treatment provided). When a pressure ulcer was identified, the staff were to refer to the policy and procedure for wound assessment and documentation. Review of the facility policy document, updated February 2015, entitled, "Wound Documentation," section I revealed, "Documentation to be performed on all wounds that are acquired in the facility or wounds of newly admitted /readmitted patients. Wounds to be assessed weekly by the wound nurse." Review of Resident 1's May 2015, physician's orders revealed [DIAGNOSES REDACTED]. Review of Resident 1's admission records revealed an admitted [DATE]. An admission assessment revealed no skin integrity concerns at the time of admission. Review of the progress notes dated April 9, 2015, at 2:19 p.m., revealed that Licensed Practical Nurse (LPN) 1 documented, "Patient lying on his supine (back) position all the time. 2 open area on buttocks [MEDICATION NAME] cream (a skin protectant paste) with incontinent care applied." Review of the clinical record revealed that no changes in the treatment or the plan of care were implemented at this time. Review of the progress notes dated April 14, 2015, at 5:15 p.m., revealed that LPN 2 documented, "...sacral (buttock)wounds cleansed." Review of the clinical record revealed no changes in the treatment or the plan of care were implemented at this time. Review of the facility document titled, "Care Conference" dated April 16, 2015, revealed that a care area concern was identified regarding Resident 1's pressure ulcers. Review of Resident 1's Treatment Administration Record (TAR - record of treatments given) revealed that the facility Wound Nurse was notified via text message on April 21, 2015, of the open areas on Resident 1's buttocks. Review of the facility documentation titled, "Wound Record/Assessment" revealed that on April 22, 2015, Resident 1 had one Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer) measuring 7.0 centimeter(cm) by 4.0 cm on his right buttock and one Stage II pressure ulcer measuring 8 cm by 2.5 cm on his left buttock. Review of the physician's orders revealed that on April 22, 2015, at 4:17 p.m., an order was received from the physician for, "wound care to buttocks, cleansed with wound cleanser, apply [MEDICATION NAME] (medical grade honey for the management of wounds) to opened areas, cover with non-stick dressing every day shift." During an interview on May 11, 2015, at approximately 2:20 p.m., facility Wound Nurse, LPN 2, explained that when a wound is identified by the staff, they are to alert the Wound Nurse via a text message. During the wound rounds the following Wednesday, the wounds would be assessed by the Wound Nurse. According to Resident 1's clinical record, two pressure ulcers on Resident 1's buttock were identified and documented on April 9, and 14, 2015, which were not assessed until April 22, 2015; further treatment was not provided to Resident 1's wounds until April 22, 2015. During a staff interview on May 5, 2015, at approximately 3:30 p.m., the Director of Nursing revealed it is the facility's expectation that staff follow the facility's policies and procedures when a wound is identified. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12(d)(1)(5) Nursing services.