Every finding on record at Fulton County Medical Center

Based on review of policies, observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include:The facility policy regarding food storage, dated February 12, 2026, revealed that any food that has been opened, should then be secured in such a way that the food item is airtight. Observations in the kitchen's walk-in refrigerator on May 11, 2026, at 9:55 a.m. revealed that the following food items were unsecured and open to the air; one-and-a-half-pound bag of spinach and a two-pound bag of lettuce. Observations in the kitchen's walk-in freezer on May 11, 2026, at 10:10 a.m. revealed that 11 slices of pizza, eight biscuits, 10 pounds of pastry, approximately four pounds of chicken, and seven pounds of fried chicken breaded patties, were unsecured and open to the air.Interview with the Dietician and Assistant Dietary Manager on May 11, 2026, at 10:15 a.m. confirmed that all food items in the walk-in refrigerator and freezer should be secured, and they were not. 42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary.28 Pa. Code 211.6(f) Dietary services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to show documented evidence that a peripherally-inserted central catheter (PICC- catheter inserted in a vein used to deliver fluids and/or medications) was flushed prior to and/or after medication administration for two of 23 residents reviewed (Residents 4, 26). Findings include:The facility's policy regarding PICC flushing, dated February 12, 2026, included to flush the intravenous catheter with normal saline (NSS- a saltwater solution) before and after medication/antibiotic administration. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated April 4, 2026, revealed that the resident was moderately cognitively intact, required substantial assistance with care needs, had diagnoses that included diabetic foot ulcers, and was receiving daily intravenous antibiotics via a PICC line related to diabetic foot wounds.Physician's orders for Resident 4, dated May 1, 2026, included an order for the resident to receive 0.75 grams of Vancomycin (an antibiotic) via his PICC daily at 4:00 p.m.Review of Resident 4's Medication Administration Record (MAR), dated May 2026, revealed that staff administered 0.75 grams of Vancomycin intravenously on May 1-12, 2026, at 4:00 p.m.; however, there was no documented evidence that Resident 4's PICC was flushed with NSS prior to and/or after administration of the Vancomycin. A comprehensive MDS assessment for Resident 26, dated March 4, 2026, revealed that the resident was cognitively impaired, required maximum assistance with daily care needs, had diagnoses that included Diabetes Mellitus, had stage 2 pressure ulcers (partial thickness skin loss) on his toes, and was receiving intravenous antibiotics via a PICC line related to stage 2 pressure ulcers.Physician's orders for Resident 26, dated April 13, 2026, included an order for the resident to receive 0.75 grams of Vancomycin via PICC line every 36 hours.Review of Resident 26's MAR for April and May 2026 revealed that the resident received 0.75 grams of Vancomycin intravenously on April 14 thru May 13, 2026; however, there was no documented evidence that staff flushed the PICC line before and after the administrationsInterview with the Director of Nursing on May 12, 2026, at 1:20 p.m. confirmed that there was no documented evidence that the PICC lines for Residents 4 and 26 were flushed with NSS prior to and/or after their antibiotic administration on the above-mentioned dates as per the facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined the facility failed to ensure that a medication reconciliation was completed after discharge for one out of 23 residents reviewed (Resident 56).Findings include:A review of Resident 56's clinical record revealed that the resident was admitted to the facility on [DATE].A nursing note, dated March 31, 2026, at 12:40 p.m. revealed Resident 56 was cleared for discharge from the facility on April 3, 2026, with home health.There was no documented evidence in the resident's clinical record at the time of the survey ending May 13, 2026, that a medication reconciliation was completed for the medications returned to the pharmacy after the resident was discharged .An interview with the Director of Nursing on May 13, 2026, at 11:57 a.m. confirmed that the the facility did not complete a medication reconciliation for Resident 56 upon discharge. 28 Pa. Code 201.29(j) Resident Rights.

Based on observations and staff interviews, it was determined that the facility failed to discard expired medical supplies in two of two medication rooms reviewed (Overly Meadows and [NAME] Trails). Findings include: Observations in the Overly Meadows medication room on [DATE], at 11:22 a.m. revealed that there were six 24 gauge angiocatheters (small teflon tubing inserted into the vein to administer fluids or medication) that expired [DATE]; one 18 gauge needle expired on [DATE]; and one 25 vial box of 20 cc's each normal saline solution that expired on [DATE]. Interview with Licensed Practical Nurse 1 on [DATE], at 11:26 a.m. confirmed that the above angiocatheters, needles and syringe should not have been in circulation in the medication room if they were expired. Observations in the [NAME] Trails medication room on [DATE], at 12:20 p.m. revealed that there were nine 24 gauge IV catheters that expired [DATE]; two 20 gauge IV catheters that expired [DATE]; twenty- seven 22 gauge IV catheters, 26 that expired [DATE], and one that expired [DATE]; four 18 gauge needles that expired [DATE]; and one 10 cc syringe that expired [DATE]. Interview with Licensed Practical Nurse 2 on [DATE], at 12:25 p.m. confirmed that the above angiocatheters, needles and syringe should not have been in circulation in the medication room if they were expired. Interview with the Nursing Home Administrator on [DATE], at at 12:46 p.m. confirmed that the intravenous catheters, needles and syringe should not have been in circulation in the medication rooms if they were expired, and they were. 28 Pa. Code 211.9(a)(1) Pharmacy Services.

Based on a review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 25 residents reviewed (Resident 8). Findings include: A facility policy regarding administering medication, dated August March 6, 2025, revealed that staff were to administer medications that were ordered by the physician; to ensure the right resident received the right medication at the right time. Medication given to a resident shall be prescribed by the physician. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 25, 2025, indicated that the resident was cognitively intact, required assistance from staff for care needs, had diagnoses that included Type I diabetes (unable to produce insulin needed to regulate blood sugar), and was administered insulin (medication to lower blood sugar). Physician's orders for Resident 8, dated January 10, 2025, included an order for the resident to receive Insulin Admelog (Lispro- a rapid-acting insulin) based on a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and bedtime. The sliding scale for before meals included giving 3 units of insulin for a blood sugar of 151-200 milligrams per deciliter (mg/dL); 6 units for a blood sugar of 201-250 mg/dL; 9 units for a blood sugar of 251-300 mg/dL; 12 units for a blood sugar of 301-350 mg/dL; and 15 units for a blood sugar of 351-400 mg/dL. The sliding scale for bedtime included giving 0 units of insulin for a blood sugar of 151-200 mg/dL; 2 units for a blood sugar of 201-250 mg/dL; 3 units for a blood sugar of 251-300 mg/dL; 4 units for a blood sugar of 301-350 mg/dL; and 5 units for a blood sugar of 351-400 mg/dL. Special instruction that were included indicated that the dosages of insulin for before meals and bedtime were different and to read the entire scale before administering. Review of the Medication Administration Record (MAR) for Resident 8, dated March and April 2025, revealed that on March 18, 2025, at 7:59 p.m. the resident had a blood sugar of 258 mg/dl and was administered 9 units when 3 units of Admelog was ordered; on March 19, 2025, at 8:24 p.m. the resident had a blood sugar of 268 mg/dl and was administered 9 units when 3 units of Admelog was ordered; on March 20, 2025, at 7:41 p.m. the resident had a blood sugar of 173 mg/dl and was administered 3 units of Admelog when the insulin should have been held as ordered; on March 31, 2025, at 7:56 p.m. the resident had a blood sugar of 202 mg/dl and was administered 6 units when 2 units of Admelog was ordered; on April 3, 2025, at 7:56 p.m. the resident had a blood sugar of 160 mg/dl and was administered 3 units when the insulin should have been held as ordered; on April 7, 2025, at 7:42 p.m. the resident had a blood sugar of 161 mg/dl and was administered 3 units when the insulin should have been held as ordered; and on April 15, 2025, at 8:14 p.m. the resident had a blood sugar of 204 mg/dl and was administered 6 units when 2 units of Admelog was ordered. Interview with the Director of Nursing on April 16, 2025, at 9:25 a.m. confirmed that Resident 8's bedtime insulin was not administered as physician ordered for the dates listed above. 28 Pa Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of hospice contracts, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 25 residents reviewed (Residents 27, 36) who received hospice services. Findings include: An agreement between the facility and a hospice provider (provider of end-of-life services), dated March 9, 2018, revealed that it was the responsibility of the hospice to provide information to the skilled nursing facility to include plan of care, Benefit of Election form (a form used to formally enroll a patient in hospice care), advance directives, certification and recertification of terminal illness (a form signed by the resident's hospice physician and specific to each patient), names and contact info of hospice personnel, instructions for access of hospice 24 hour on-call system, hospice medication information, hospice and attending orders. The facility's policy regarding hospice care (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life), dated March 6, 2025, revealed that residents electing to receive hospice services will be referred to the hospice agency of choice, and care will be coordinated with the nursing home through the interdisciplinary care planning process. Nursing will communicate with hospice in coordinating the resident's overall care and incorporate hospice care into the resident's care plan. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated February 6, 2025, revealed that the resident was usually understood, could usually understand others, had diagnoses that included heart failure (occurs when the heart can not pump enough blood to meet the body's needs), and adult failure to thrive (a syndrome characterized by a decline in a person's overall health, function, and well-being, often accompanied by symptoms like weight loss, decreased appetite, and cognitive impairment), and received hospice care. A care plan, dated January 31, 2025, revealed that the resident had an anticipated decline due to the progression of the disease process, with a less than six months life expectancy. A nursing note for Resident 27, dated January 31, 2025, revealed that the resident was admitted to the facility this afternoon and that the resident was receiving hospice care. A hospice provider care plan for Resident 27, for the hospice certification period of February 23, 2025, through April 23, 2025, revealed that the hospice nurse would visit the resident two times per week for six weeks, then one time a week for one week and would make four as needed visits for any changes in condition. As of April 17, 2025, there was no documented evidence that Resident 27's clinical record and/or the hospice provider's clinical record contained the Hospice Benefit of Election form and communication from the contracted hospice provider after March 14, 2025. An admission MDS assessment for Resident 36, dated March 18, 2025, revealed that the resident was sometimes understood, could sometimes understand others, had a diagnoses that included cerebral vascular accident (CVA - commonly known as a stroke) with hemiplegia (paralysis on one side of the body), aphasia (a language disorder that results from damage to the brain's language centers, affecting the ability to speak, understand language, and read or write), and adult failure to thrive, and received hospice care. A care plan, dated March 12, 2025, revealed that the resident has an anticipated decline due to the progression of the disease process, with a less than six months life expectancy. A nursing note for Resident 36, dated March 12, 2025, revealed that the resident was admitted to the facility, and that the resident has been receiving hospice care for the past two months. As of April 17, 2025, there was no documented evidence that Resident 36's clinical record and the hospice provider's clinical record contained the Hospice Benefit of Election form. Interview with the Nursing Home Administrator on April 17, 2025, at 11:00 a.m. confirmed that the Hospice Benefit of Election form and Hospice nurse visit notes for Resident 27 and the Hospice Benefit of Election form for Resident 36 had to be faxed over from the contracted hospice provider and that there was no documented evidence that as of April 17, 2025, that the above information was in Resident 27's and Resident 36's clinical records and/or the hospice provider's clinical records. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital for two of 25 residents reviewed (Residents 8, 23). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 25, 2025, indicated that the resident was cognitively intact, was understood, could understand others, and required assistance from staff for care needs. A review of the medical record revealed that Resident 8 had his sister listed as the person to be notified in an emergency. A nursing note, dated September 23, 2024, at 3:45 p.m., revealed that Resident 8 reported he was not himself, was shaking, and was confused. He had developed a skin rash to creases in skin folds, behind his knees, under his arms, and groin. The rash spread to his arms, legs, trunk, and back. He was then sent to the emergency room for evaluation and treatment. Nursing notes, dated January 7, 2025, at 5:52 a.m. and 8:13 a.m., revealed that nursing staff reported that there was blood in the toilet and that Resident 8 appeared to have blood at both his rectum and urethra. After another episode of hematuria (blood in urine) and rectal bleeding the resident reported he did not feel well. He was then sent to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 8's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital on September 23, 2024, or January 7, 2025. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 30, 2025, indicated that the resident was cognitively intact, was understood, could understand others, required assistance from staff for care needs, and had diagnoses that included sepsis (a medical emergency in response to an infection). A nursing note, dated March 9, 2025, at 6:45 a.m., revealed that Resident 23 was found to be shaking and experiencing tremors. The resident's blood pressure was abnormal at 142/46, and labwork indicated an elevated white blood cell (cells that fight infection) count. She was then sent to the emergency room for evaluation and treatment. There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital on March 9, 2025, Interview with the Director of Nursing on April 15, 2025, at 12:25 p.m. confirmed that there was no documented evidence that a written notice of Resident 8's and 23's transfer to the hospital was provided to the State Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update the care plan for one of 25 residents reviewed (Resident 37). Findings include: The facility's policy regarding care plans, dated March 6, 2025, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated September 7, 2024, indicated that the resident was cognitively intact, usually understood and understands, required assistance from staff for his daily care needs, and had diagnoses that included end-stage renal disease. A care plan, dated August 7, 2023, revealed that Resident 37 had a hemodialysis catheter (a type of catheter used for vascular access during hemodialysis treatment that is typically inserted into a large vein, such as the jugular or femoral vein, to facilitate the removal and return of blood during hemodialysis sessions) in place. Nursing notes for Resident 37, dated November 6, 2023, indicated that on that day, he had a left upper arm fistula (connection between an artery and a vein to facilitate dialysis) placed at the hospital. Nursing notes, dated May 8, 2024, indicated that on May 7, 2024, the resident had his hemodialysis catheter removed. Interview with the resident on April 15, 2024, at 2:02 p.m. indicated that his hemodialysis catheter was removed and now he has a fistula in his left arm. Interview with the Director of Nursing on April 15, 2025, at 3:25 p.m. confirmed that Resident 37's care plan should have been updated to reflect the fact that the resident's hemodialysis catheter was removed in May 2024 and was now using a fistula for dialysis treatment. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during wound care for one of 25 residents reviewed (Resident 23). Findings include: The facility's policy regarding hand hygiene, dated March 6, 2025, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 30, 2024, indicated that the resident was cognitively intact, was understood, could understand others, required assistance from staff for care needs, and had diagnoses that included left arm hematoma (blood clot) and sepsis (a medical emergency in response to an infection). Physician's orders for Resident 23, dated April 11, 2025, included an order to cleanse the left arm with normal saline (salt water) solution, lightly pack 1/4-inch iodoform (sterile gauze infused with antiseptic) into left forearm surgical site, cover with gauze, abdominal pad and kerlix then secure with tape. Observations on April 16, 2025, at 1:30 p.m. revealed that Licensed Practical Nurse 1 donned a gown and gloves and with scissors she removed Resident 23's left forearm dressing, cleansed the area with normal saline infused gauze, removed her gloves and without performing hand hygiene she donned new ones. Using a Q-tip she packed the wound with a 1/4-inch iodoform packing strip; covered the area with gauze, an abdominal pad, and kerlix and secured it with tape; gathered the garbage; and without removing her gloves and performing hand hygiene, Licensed Practical Nurse 1 repositioned three of the resident's pillows, then removed her gloves and washed her hands. Interview with Licensed Practical Nurse 1 on April 16, 2025, at 1:45 p.m. confirmed that while performing wound care on Resident 23, she did not perform hand hygiene after removing her gloves and donning new gloves, and did not remove her gloves and hand sanitize prior to repositioning the resident's pillows. Interview with the Director of Nursing on April 16, 2025, at 3:18 p.m. confirmed that Licensed Practical Nurse 1 should have washed her hands or sanitized them after removing her gloves and before donning new gloves, and should have removed her gloves and performed hand hygiene prior to repositioning Resident 23's pillows. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's laundry area. Findings include: A facility policy regarding chemical dispensing, dated August March 6, 2025, indicated that the automatic dispensing system was to ensure safe dispensing of chemicals for the laundry department. The automatic liquid dispensing system would dispense chemicals for the recommended amounts of detergent per the chemical manufacturer. Observations in the laundry department on April 18, 2025, at 12:50 p.m. revealed that the laundry area had two washing machines. There was a five-gallon bucket on the floor and a smaller bucket on the counter with blue liquid in it. Interview with Environmental Service Staff (ESS) 3 at the time of the observation revealed that the second washing machine's automatic feeder was not working and was not adding the detergent to the washing machine. She had to open the five-gallon bucket on the floor that had plastic tubing to the automatic feeding system, transfer some of the detergent to another bucket using a clear handled cup to put approximately 1/4 cup in the washer. This issue has been a concern for about three months, and she reported it to her supervisor. ESS 3 was the primary staff responsible for operating the facilities personal laundry. Interview with the Nursing Home Administrator on April 17, 2025, at 1:05 p.m. revealed that the Environmental Service Director was aware that the automatic detergent feeder was not working. The Environmental Service Director had contacted the company for replacement parts but was unsure when, and had no other contact with the manufacturer. Interview with the Nursing Home Administrator on April 17, 2025, at 1:35 p.m. revealed that she was unaware that the automatic feeding system was not working, there were no work orders for the repairs, and confirmed that the washing machine should be in functional order. 28 Pa. Code 201.18(b)(3) Administrator's Responsibility.

Based on a review of facility policies, investigative reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of two residents reviewed (Resident 1), resulting in a dislocated shoulder. Findings include: The facility's policy regarding abuse and neglect, dated March 14, 2024, indicated that every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; and involuntary seclusion. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. A nursing note for Resident 1, dated November 17, 2024, at 12:11 p.m., revealed that Resident 1 was exhibiting increased behaviors and requested something for pain. A nursing note for Resident 1, dated November 18, 2024, at 3:30 p.m., revealed that she had multiple scattered bruises on her upper arm measuring 15.0 centimeters (cm) x 8.5 cm and the arm was painful with touch. A nursing note for Resident 1, dated November 19, 2024, at 11:28 a.m., revealed that the bruise on the resident's upper arm was larger and the arm was more swollen. The resident was complaining of increased pain. New orders were received for an x-ray of the left upper arm. The x-ray report for Resident 1, dated November 19, 2024, at 12:22 p.m., revealed a dislocated left shoulder. Review of the facility's investigation for Resident 1, dated November 19, 2024, revealed that on November 14, 2024, Resident 1 was yelling and resisting care. A witness statement by Nurse Aide 1, dated November 20, 2024, revealed that she observed Nurse Aide 2 force Resident 1's left arm above her head, back against the bed, and then force the arm back to a normal position while putting on her deodorant. Nurse Aide 1 stated that she immediately observed a deformity in Resident 1's left shoulder and that the resident was complaining of pain, as well as tingling in her fingers. The investigation by the facility determined that Nurse Aide 2's forceful movement of Resident 1's arm caused the dislocated shoulder. An interview with Registered Nurse 3 on December 3, 2024, at 11:20 a.m. revealed that she assessed Resident 1 on November 15, 2024, when the resident was complaining of pain; however, she did not assess the resident's upper arm or shoulder. She stated that she only assessed from the elbow down because the resident was being resistive with the assessment. She medicated the resident for pain. An interview with the Director of Nursing on December 3, 2024, at 11:55 a.m. confirmed that Nurse Aide 2 forcibly raised and lowered Resident 1's left arm resulting in a dislocated shoulder. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that allegations of possible abuse were reported timely to the Nursing Home Administrator for one of two residents reviewed (Resident 1) resulting in pain and a delay in treatment for a dislocated shoulder. Findings include: The facility's abuse policy, dated March 14, 2024, indicated that staff were to report any allegation or suspicion of abuse immediately to their supervisor, and if the perpetrator was an employee, he/she would be suspended pending investigation to ensure protection of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. A nursing note for Resident 1, dated November 17, 2024, at 12:11 p.m., revealed that Resident 1 was exhibiting increased behaviors and requested something for pain. A nursing note for Resident 1, dated November 18, 2024, at 3:30 p.m., revealed that she had multiple scattered bruises on her upper arm measuring 15.0 centimeters (cm) x 8.5 cm and the arm was painful with touch. A nursing note for Resident 1, dated November 19, 2024, at 11:28 a.m., revealed that the bruise on the resident's upper arm was larger and the arm was more swollen. The resident was complaining of increased pain. New orders were received for an x-ray of the left upper arm. The x-ray report for Resident 1, dated November 19, 2024, at 12:22 p.m., revealed a dislocated left shoulder. Review of the facility's investigation for Resident 1, dated November 19, 2024, revealed that on November 14, 2024, Resident 1 was yelling and resisting care. A witness statement by Nurse Aide 1, dated November 20, 2024, revealed that she observed Nurse Aide 2 force Resident 1's left arm above her head, back against the bed, and then force the arm back to a normal position while putting on her deodorant. Nurse Aide 1 stated that she immediately observed a deformity in Resident 1's left shoulder and that the resident was complaining of pain, as well as tingling in her fingers. The investigation by the facility determined that Nurse Aide 2's forceful movement of Resident 1's arm caused the dislocated shoulder. An interview with Registered Nurse 3 on December 3, 2024, at 11:20 a.m. revealed that she assessed Resident 1 on November 15, 2024, when the resident was complaining of pain; however, she did not assess the resident's upper arm or shoulder. She stated that she only assessed from the elbow down because the resident was being resistive with the assessment. She medicated the resident for pain. There was no documented evidence that the alleged abuse witnessed by Nurse Aide 1 on November 14, 2024, was reported to anyone until she was questioned on November 20, 2024. Interview with the Director of Nursing on December 3, 2024, at 11:55 a.m. revealed that Nurse Aide 1 failed to report the allegations of abuse timely causing a delay in care and treatment for Resident 1 who suffered a dislocated shoulder. 28 Pa. Code 201.18(e)(1) Management.

Based on review of clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. Review of the facility's investigation for Resident 1, dated November 19, 2024, revealed that on November 14, 2024, Resident 1 was yelling and resisting care. A witness statement by Nurse Aide 1, dated November 20, 2024, revealed that she observed Nurse Aide 2 force Resident 1's left arm above her head, back against the bed, and then force the arm back to a normal position while putting on her deodorant. Nurse Aide 1 stated that she immediately observed a deformity in Resident 1's left shoulder and that the resident was complaining of pain, as well as tingling in her fingers. The resident was assessed for pain by Registered Nurse 4 and medicated for pain. An interview with Registered Nurse 3 on December 3, 2024, at 11:20 a.m. revealed that she assessed the resident on November 15, 2024, when the resident was complaining of pain; however, she did not assess the upper arm or shoulder. She stated she only assessed from the elbow down because the resident was being resistant towards the assessment. She medicated the resident for pain. There was no documented evidence in Resident 1's clinical record to indicate that she was assessed by the registered nurse on November 14 or November 15, 2024. Interview with the Director of Nursing on December 3, 2024, at 11:55 a.m. confirmed that there was no documented evidence in Resident 1's clinical record to indicate that she was assessed by a registered nurse on November 14 or 15, 2024, and there should have been. 28 Pa. Code 211.5(f) Clinical Records. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety. Findings include: The facility's policy regarding food safety, dated March 13, 2024, indicated that food needs to be stored in clear plastic containers covered with a lid, labeled with the name of the food, dated with a prepared date, and a use by date. The item can also be wrapped, dated, and labeled so that the food item was air tight. Observations in the walk-in freezer on April 29, 2024, at 9:45 a.m. revealed opened and unlabeled bags of corn with peppers and onions, green beans, hamburger patties, and hash browns that were not in a clear plastic container. Interview with the Dietary Manager at the time revealed that staff should be using a label maker to put a sticker on the food item when a new container is opened. Observations in the walk-in refrigerator on April 29, 2024, at 9:45 a.m. revealed that there was a five-pound plastic container of cottage cheese opened and unlabeled; a three-pound container of whipped cream cheese spread opened, undated, and with a best by dated of March 21, 2024; and a 64-ounce container of almond milk opened, unlabeled, with a best by date of April 15, 2024. Interview with the Dietary Manager at the time indicated that the dates are best by dates and not expiration dates, and that the containers should be labeled with the date when opened. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 27 residents reviewed (Residents 25, 30, 39, 40). Findings include: A facility policy regarding plans of care, dated March 13, 2024, revealed that the care plan will be reviewed and revised by the interdisciplinary team at least quarterly, or more often as changes occur, by nursing staff to include new orders, resident's individual preferences, effective interventions, etc. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 19, 2024, revealed that the resident was understood and could understand, could ambulate (walk) on the unit independently, and had diagnoses that included non-traumatic brain dysfunction (a brain injury not caused by external physical force or trauma exerted on the head), and dementia, requiring her placement on a locked unit. The resident's care plan regarding behaviors, revised January 24, 2024, revealed that the resident was at risk for injury related to behaviors. If Resident 25 presented with behaviors staff were to ensure the resident was safe and reapproach at a different time. Nursing notes for Resident 25, dated March 24, 2024, revealed that she was seeing a man named [NAME], who did not exist, and was concerned that staff needed to find him. Nursing notes for Resident 25, dated April 29, 2024, revealed that the resident was concerned about the naked people in the courtyard and was adamant that they were there. There was no documented evidence that Resident 25's care plan was revised to include her delusional thoughts or interventions to address them. Interview with the Director of Nursing on April 30, 2024, at 11:57 a.m. confirmed that Resident 25's care plan was not revised to include her delusional thoughts or interventions to address them. A quarterly MDS for Resident 30, dated March 12, 2024, indicated that the resident had clear speech, understood, could understand, was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included Alzheimer's disease. A nursing note, dated August 3, 2023, revealed that Resident 30 fell and hit his head, was bleeding from a laceration on the back of the head, and said that he was trying to pick something up off the floor. An interdisciplinary team note for Resident 30, dated August 4, 2023, revealed that the resident was reaching for something, lost his balance, and fell . Occupational therapy was to screen Resident 30 for the use of a reacher tool. An occupational therapy evaluation for Resident 30, on August 4, 2023, revealed the resident was assessed for safety and independence with reacher. Therapy staff notified staff in the communication book for reacher to be placed at the bedside to prevent falls. Interview and observation of Resident 30 on April 30, 2024, at 12:13 p.m. revealed that he was sitting in his wheelchair watching television, the reacher was on his recliner, and the resident said he uses it to pick up things. There was no documented evidence that the fall care plan was updated to reflect the use of a reacher as an intervention for fall prevention. Interview with the Director of Nursing on May 1, 2024, at 9:42 a.m. confirmed that Resident 30's care plan was not updated to reflect her current interventions for fall prevention and should have been. An admission MDS for Resident 39, dated February 26, 2024, revealed that the resident had clear speech and required either extensive assistance or was dependent on staff for his care needs, and had diagnoses that included dementia and Parkinson's. A nursing note for Resident 39, dated February 19, 2024, revealed that the resident was admitted from another nursing care facility and that the resident used Continuous Positive Airway Pressure (CPAP - a machine used to treat obstructive sleep apnea and other types of sleep-disorders) nightly. A care plan for Resident 39, dated February 19, 2024, revealed that the resident used CPAP. Physician's orders for Resident 39, dated March 22, 2024, included an order to discontinue the CPAP and start oxygen at two liters per minute (LPM) at night and as needed during the day and naps. There was no documented evidence that Resident 39's care plan was updated to indicate that the CPAP was discontinued or that the resident was to start the use of oxygen at night and as needed during the day and naps. Interview with the Director of Nursing on April 30, 2024, at 11:00 a.m. confirmed that Resident 39's care plan should have been updated to show that the CPAP was discontinued, and that the resident was to start the use of oxygen at night and as needed during the day and naps. A quarterly MDS for Resident 40, dated March 19, 2024, indicated that the resident had clear speech, understood, could understand, was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included Alzheimer's disease. A care plan for Resident 40, dated July 18, 2023, indicated that the resident had a potential for behaviors due to dementia and anxiety. A nursing note, dated December 17, 2023, revealed that Resident 40 verbalized she wanted to shoot herself and alert charting was started to monitor her for suicidal ideation. A nursing note, dated February 20, 2024, revealed that Resident 40 verbalized that she wanted to be dead and would be better off dead. A nursing note, dated February 21, 2024, revealed that Resident 40 verbalized negative thoughts, did not have a plan to hurt herself, and needed to watch what she said out loud. A behavioral health service consult, dated February 21, 2024, revealed that the Resident 40 was seen due to her negative thoughts and not wanting to live any more, and to follow up with her in two weeks. A nursing note, dated March 23, 2024, revealed that Resident 40 verbalized that she wanted to die. There was no documented evidence that the care plan was updated to reflect Resident 40's suicidal ideation comments or for the use of behavioral health services. Interview with the Director of Nursing on May 1, 2024, at 2:16 p.m. revealed that Resident 40's care plan was not updated to reflect her suicidal ideation and use of behavioral health services. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop a comprehensive care plan related to the use of anticoagulant medication for one of 27 residents reviewed (Resident 40). Findings include: The facility's policy regarding care plans, dated March 13, 2024, indicated that an individualized comprehensive care plan will be developed by the interdisciplinary team within 21 days of admission for each resident. The care plan will include focus issues, problems and needs (social, emotional, psychological, physical, behavioral, rehabilitation, cultural, spiritual, nutritional, leisure, prevention of decline in condition, ect.) that have been identified through resident involvement, direct observation, coordination of discipline observations and assessment. As each issue, problem or need is added to the care plan, a date will be recorded with the issue to document the specific time when the issue was identified. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated March 19, 2024, revealed that the resident had clear speech, was understood and could understand, was severely cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included pulmonary embolism (blood clot in lungs) requiring long-term use of anticoagulant (blood-thinning medications) medications. Current physician's orders for Resident 40 included an order for the resident to receive 5 mg of Apixaban (blood thinning medication) twice a day for a pulmonary embolism. There was no documented evidence that a care plan was created for the use and risks of anticoagulant medications. Interview with the Director of Nursing on May 1, 2024, at 2:16 p.m. confirmed that a care plan had not been created for Resident 40's use of anticoagulant medications. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to determine if residents were safe to self-administer medications for one of 27 residents reviewed (Resident 28). Findings include: The facility's self-administration of medications policy, dated March 13, 2024, indicated that if a resident desired to self-administer medications they would require a physician's order. The facility's medication administration policy, dated March 13, 2024, indicated that the nurse must stay with the resident until medication is taken. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated January 30, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff with care, had impaired movement of one side of upper and lower extremities, and had diagnoses that included hemiplegia (the inability to move one side of the body). Current physician's orders included an order for the resident to receive 1 gram of Carafate (a medication used to treat and prevent ulcers in the intestines) by mouth four times daily. The resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications and no evidence of a physician's order for self-administering medications. Observations during medication administration on May 1, 2024, at 10:48 a.m. revealed that Licensed Practical ([NAME]) prepared a 1 gram tablet of Carafate in a cup, placed the cup on Resident 28's bedside table, and left the room. Interview with Licensed Practical Nurse 1 on May 1, 2024, at 10:49 a.m. confirmed that she left the Carafate with Resident 28 and should not have. Interview with the Assistant Director of Nursing on May 1, 2024, at 3:00 p.m. confirmed that there was no assessment completed to determine if Resident 28 was safe to self-administer medications and no physician's order for self administration. She also confirmed that Licensed Practical Nurse 1 should not have left the Carafate tablet with Resident 28. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for two of 27 residents reviewed (Residents 40, 42). Findings include: The facility's policy on wheelchairs, dated March 13, 2024, indicated that all wheelchairs being utilized for transport purposes should be equipped with leg rests and utilized when residents are being transported. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated March 19, 2024, revealed that the resident had clear speech, understood, could understand, was severely cognitively impaired, required assistance from staff for daily care needs, used a wheelchair, and had diagnoses that included Alzheimer's disease. Observation of Resident 40 on April 29, 2024, at 11:17 a.m. revealed that the resident was sitting in a wheelchair while being transported to her room from the dining/community room by Licensed Practical Nurse 4. There were no footrests on her wheelchair to prevent her feet from dragging during transport. Interview with Licensed Practical Nurse 4 at that time revealed that she was unsure if footrests were needed since Resident 40 was able to self propel. Interview with Licensed Practical Nurse 4 on April 29, 2024, at 11:38 a.m. confirmed that the resident should have had footrests on her wheelchair to prevent injury during transport. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 6, 2024, revealed that the resident was cognitively intact and required assistance for daily care needs, including transfers and locomotion. Observation of Resident 42 on May 1, 2024, at 9:12 a.m. revealed that the resident was sitting in a wheelchair while being transported to her room from the shower room by Nurse Aide 5. There were no footrests on her wheelchair to prevent her feet from dragging during transport. An interview with Nurse Aide 5 on May 1, 2024, at 9:17 a.m. confirmed that the resident should have had footrests on her wheelchair to prevent injury during transport. An interview with the Director on Nursing on May 1, 2024, at 2:26 p.m. confirmed that footrests should have been used when transporting Residents 40 and 42 in their wheelchairs. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that appropriate treatment and services were provided to prevent the development of pressure ulcers for one of 27 residents reviewed (Resident 39). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated February 26, 2024, revealed that the resident was usually understood, could usually understands others, was frequently incontinent of bowel and bladder, had diagnoses that included Parkinson's disease and dementia, and had one Stage 2 pressure injury (a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) that was not present upon admission. A nursing note for Resident 39, dated February 19, 2024, revealed that the resident was admitted from another nursing care facility and that the resident had a small red mark to his right posterior thigh from his brief. A care plan for Resident 39, dated February 19, 2024, revealed that the resident was at risk for impaired skin integrity. A nursing note for Resident 39, dated February 24, 2024, revealed that at 3:05 a.m. the writer received a call from the licensed practical nurse that this resident had a blister to his leg. There was a 30 centimeter (cm) by 7 cm water blister to his left upper/inner thigh in the area of where the incontinent brief would normally be present. A nursing note for Resident 39, dated February 25, 2024, at 10:56 a.m. and completed as an addendum to the nursing note dated February 24, 2024, revealed that the serum-filled blister measured 1.5 cm x 3.0 cm x 0.0 cm. The resident's brief was checked at this time and noted with proper placement. A nursing note at 1:39 p.m. revealed that the serum-filled blister drained when the resident got up to go to the bathroom. A nursing note for Resident 39, dated February 26, 2024, revealed that the interdisciplinary team review of the blister to the resident's left leg revealed that the root cause was related to the brief placement, and that the intervention was to evaluate the placement of the brief and to reposition appropriately for comfort, as well as apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to the blister. However, there was no documented evidence that Resident 39's brief was evaluated and/or that preventive interventions were started when a red mark caused by the brief was identified on February 19, 2024, and progressed to a blister on February 24, 2024. Interview with the Director of Nursing on May 1, 2024, at 2:15 p.m. confirmed that there was no documented evidence that Resident 39's brief was evaluated and/or that preventive interventions were started when an area of concern was identified on February 19, 2024, and progressed to a blister on February 24, 2024. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 27 residents reviewed (Resident 25). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 29, 2024, indicated that the resident was understood and could understand, was cognitively intact, and independent for care. A care plan for Resident 25, dated January 24, 2024, indicated that the physician must be notified of all refusals of medication. Physician's orders for Resident 25, dated January 25, 2024, included an order for the resident to receive Cefdinir (a medication that destroys bacteria) twice a day for 11 doses. Physician's orders for Resident 25, dated November 15, 2023, included an order for Miacalcin nasal spray (a medication to treat the thinning of bones) 1 unit daily at 8:00 a.m. A review of the electronic medication administration record (MAR), dated January, February, and March 2024, for Resident 25 revealed that the resident refused her morning medication on January 3, 21, 23, 26, 2024; February 2, 25, 27, 2024; and March 3, 7, 15, 26, 2024. There was no documented evidence that the physician was notified of the refusals on the above dates. Interview with the Director of Nursing on April 30, 2024, at 11:54 a.m. confirmed that there was no documented evidence that Resident 25's physician was notified about the refusals of morning medications on the dates listed. 28 Pa. Code 211.12(d)(3) Nursing Services.