Every finding on record at Garden Spring Rehab and Care Center

Based on facility policy review, clinical record review, family interview, and staff interview, it was determined that the facility failed to demonstrate that a resident's discharge from the facility was appropriate and that a discharge plan was implemented prior to the discharge for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Discharge Summary and Plan, last reviewed January 23, 2026, revealed that when the facility anticipates a resident's discharge to a private residence, a post-discharge plan will be developed to assist the resident to adjust to his or her new living environment. The post-discharge plan will be developed by the interdisciplinary team with the assistance of the resident and their representative(s). The plan will include: where the resident plans to live, arrangements that have been made for aftercare and services, a description of the resident's discharge goals, how the interdisciplinary team will support the resident and their representative in the transition to post-discharge care, what factors make the resident vulnerable to prevent readmission, and how those factors will be addressed. In addition, the resident and their representative will be involved in the post-discharge planning process and informed of the final post-discharge plan. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included rhabdomyolysis (breakdown of skeletal muscles), frostbite with tissue necrosis of the foot (severe cold injury), and an infection of the skin. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert, required assistance with activities of daily living, and was at risk for developing pressure ulcers. A review of the care plan revealed that the resident was at risk for pain related to a foot infection. On April 15, 2026, the physician discharge summary revealed that the resident was initially planned for surgical intervention on his foot as an outpatient, but no available appointments were available. The physician noted that the prolonged wait would not have been advised due to the level of necrosis/ischemia (death of cells and tissue) secondary to severe frostbite and had requested to send the resident to the hospital for re-evaluation. The physician further noted on April 15, 2026, that the resident reported feeling well and had voiced a desire to proceed with whatever intervention was able to be done to get his feet taken addressed. On April 15, 2026, a review of a nursing note revealed that the resident was discharged via ambulance. Resident received education on his medications and was encouraged to follow-up with a primary care physician. Medications, prescriptions, and belongings were sent with resident. Clinical record review revealed that Resident 1's discharge MDS assessment was completed on April 15, 2026. In an interview on May 6, 2026, at 11:10 a.m., the Social Services Director stated that she was unaware that Resident 1 had been discharged . She stated that Resident 1's mother had called her April 16, 2026, to assist her in obtaining homecare services. In an interview on May 6, 2026, at 1:50 p.m., the Nurse Practitioner stated that she had met with Resident 1 and had spoken to him about his foot. She stated that the resident's condition improved with physical therapy and the insurance canceled him soon after; however, the resident still had wounds on his foot when he was discharged to the hospital. In an interview on May 6, 2026, at 3:00 p.m., the Administrator stated that Resident 1 was not admitted to the hospital and that his foot was only bandaged prior to release. He further stated that Resident 1's representative was not informed by staff of the discharge and that Resident 1's belongings were still at the facility. During a phone interview with Resident 1's representative on May 6, 2026, at 4:10 p.m., she stated that she was not made aware that Resident 1 was discharged from the facility and she was unclear of what had happened. She stated that the resident asked to return to the facility; however he was sent home from the hospital in a cab. She further stated that he had not received home care, including wound care services, and that the resident's belongings remained at the facility. In an interview on May 6, 2026, at 4:45 p.m., the Administrator confirmed that the resident was not transferred to the hospital. The facility had discharged the resident to the hospital, and the resident was not provided the proper after-care planning and services. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2) Management. 28 Pa. Code 201.29(a)(c.3)(1) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) or legal representative of all required information, including the date of discharge, the reason for discharge, the location to which the resident was discharged , their appeal rights, and the State Long-Term Care Ombudsman's information in writing upon discharge from the facility for one of five sampled residents. (Resident 1)Findings include: Clinical record review revealed that Resident 1 was discharged to the hospital on April 15, 2026, after a change in condition. There was no documented evidence that the resident and resident's responsible party, or the legal representative were provided information regarding the location to which the resident was discharged , appeal rights, State Long-Term Care Ombudsman information, and agency information pertaining to protection of individuals with a mental disorder, and that the facility provided copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. During a phone interview on May 6, 2026, at 4:10 p.m., Resident 1's representative stated that she was not made aware that Resident 1 was discharged from the facility In an interview on May 6, 2026, at 4:45 p.m., the Administrator confirmed that the notification of discharge was not completed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(2) Management. 28 Pa. Code 201.29(a)(c.3)(2) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's responsible party was notified of a change in treatment for one of six sampled residents. (Resident 1) Findings include:Clinical record review revealed that Resident 1 had diagnoses that included Parkinson's disease and dementia. The Minimum Data Set assessment dated [DATE], indicated that the resident had cognitive impairment and was on hospice services. A review of the care plan revealed that the resident experienced behaviors of yelling out at times. On April 8, 2026, a physician changed an order for an anti-anxiety medication (Ativan). The Ativan had been given as needed until April 8, 2026, when the physician ordered for the medication to be administered six times a day for anxiety. There was no documented evidence that the responsible party was notified of the change in the frequency of the medication. In an interview on April 15, 2026, at 9:52 a.m., the Director of Nursing confirmed that the responsible party had not been notified of the change in the medication in a timely manner. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, review of manufacturer's instructions, clinical record review, observation, and staff interview, it was determined that the facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four of 21 residents that utilized one of two medication carts on the nursing unit. This resulted in an Immediate Jeopardy situation due to an increased likelihood of transmitting bloodborne pathogens between residents who required fingerstick blood glucose testing. (Residents 38, 42, 43, 48)Findings include: Review of the facility policy entitled, Obtaining a Fingerstick Glucose Level, last reviewed October 1, 2025, revealed that blood glucose meters intended for reuse were to be cleaned and disinfected between resident uses according to the manufacturer's instructions and current infection control standards of practice. Review of manufacturer's instructions for the blood glucose meters used by the facility revealed that staff should clean the product with a commercially available Environmental Protection Agency (EPA) registered disinfectant detergent or germicide wipe. Clinical record review revealed that Resident 38 had diagnoses that included diabetes mellitus (a chronic disorder characterized by high blood sugar levels due the body's inability to produce or effectively use insulin) and viral hepatitis C (a viral infection that can be transmitted via bodily fluids, causes liver swelling, and can lead to serious liver damage). A physician's order dated August 14, 2024, directed staff to administer insulin lispro subcutaneously (insert a needle under the skin) based on a sliding scale (a method of managing diabetes by adjusting insulin doses in response to the individual's current blood glucose levels) four times a day. Clinical record review revealed that Resident 42 had diagnoses that included diabetes mellitus and human immunodeficiency virus (a virus that can be transmitted via bodily fluids and weakens the immune system by attacking and destroying cells that are essential for the body's ability to fight off infection). A physician's order dated December 31, 2024, directed staff to administer insulin lispro subcutaneously before meals based on a sliding scale. Clinical record review revealed Resident 43 had diagnoses that included diabetes mellitus and chronic viral hepatitis C. A physician's order dated September 19, 2025, directed staff to check resident's blood glucose level four times a day on Tuesdays, Thursdays, Saturdays, and Sundays, and three times a day on Mondays, Wednesdays, and Fridays. Clinical record review revealed Resident 48 had a diagnosis of diabetes mellitus. A physician's order dated July 8, 2024, directed staff to administer insulin lispro subcutaneously based on a sliding scale four times a day. Observations on November 5, 2025, at 8:30 a.m., revealed that licensed practical nurse 1 (LPN 1) prepared the blood glucose meter to obtain a blood glucose reading for Resident 48. LPN 1 wiped the blood glucose meter with a 70% isopropyl alcohol wipe and proceeded to use the device to test the resident's blood glucose. LPN 1 then cleaned the blood glucose meter with 70% isopropyl alcohol and put the device back in the top drawer of the cart. Observation of the medication cart that LPN 1 was using was checked at that time and no EPA registered disinfectant detergent or germicide wipes were present. In an interview at that time, LPN 1 stated that she cleaned the blood glucose meter with 70% isopropyl alcohol wipes before and after testing each resident. Observation on November 5, 2025, at 10:07 a.m., revealed that LPN 1 again cleaned the blood glucose meter with a 70% isopropyl alcohol wipe and escorted Resident 38 to his room. In an interview with LPN 1 at that time, LPN 1 confirmed that she was going to use the blood glucose meter used earlier and cleaned with the 70% alcohol wipe to test the blood glucose level of Resident 38. LPN 1 confirmed that she was assigned to the medication cart servicing Residents 38, 42, 43, and 48 and that the blood glucose meter on the cart would be used to obtain blood glucose levels for all residents in the assigned rooms who required blood glucose checks. In an interview on November 5, 2025, at 10:20 a.m., the Director of Nursing (DON) stated that blood glucose meters were to be disinfected using available EPA germicidal disposable wipes and that blood sugar checks with a blood glucose meter were required when residents had physician's orders for sliding scale insulin. In an interview on November 5, 2025, at 3:00 p.m., the Infection Preventionist confirmed that facility staff were to use EPA germicidal disposable wipes to clean and disinfect the blood glucose meters. On November 5, 2025, at 2:40 p.m., the Administrator and the DON were notified that on November 5, 2025, at 10:07 a.m., the failure to implement proper infection control procedures regarding the proper use and disinfecting of blood glucose meters resulted in an Immediate Jeopardy situation at F880-K and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on November 5, 2025, at 6:38 p.m. The facility's action plan contained the following: 1. Facility was notified on 11/5/25 that LPN 1 was observed cleaning the glucometer device with 70% Isopropyl Alcohol wipes. LPN 1 was removed from schedule immediately and will not be returning to the facility. 2. Director of central supplies ensured that each of the eight medication carts had the disinfecting agents that meet the requirements of the Environmental Protection Agency (EPA) registered cleaning products as noted in the manufacturer's instructions. 3. The Medical Director was notified on 11/5/2025. 4. All nurses will be educated on the Obtaining a Fingerstick Glucose Level, policy and procedure. In addition, they will be educated on the necessity of using the approved EPA registered germicidal wipe as required in the manufacturer's instructions and where to obtain them, by 11:59 p.m., on 11/5/2025. Education provided by the DON/designee. No licensed nurse will be permitted to begin their shift until they have been educated on the proper use and disinfection of the glucometer. 5. Newly hired licensed nurses will be educated at orientation on the Obtaining a Fingerstick Glucose Level, policy and procedure using the approved EPA registered germicidal wipe requirements as noted in the manufacturer's instructions. All agency licensed nurses will be educated before they begin their first shift in the facility. 6. Central supply department received education on 11/5/2025, regarding ensuring that the EPA germicidal wipes are in the carts. 7. DON/designee will complete random glucometer cleaning and disinfecting observation audits daily for seven days plus weekly for four weeks and monthly for three months ensuring education has been effective. 8. DON/designee will be monitoring steps of the action plan for continued compliance. 9. Central supply/designee will monitor three times a week ensuring the EPA germicidal wipes are in the carts. 10. Audits will be brought to QA&A for review and recommendations. 11. QAPI committee will determine the need for further audits. The survey team validated that Immediate Jeopardy was removed on November 5, 2025, at 6:38 p.m., through observation, review of the facility training, and staff interviews following the facility's implementation of the plan for removal of the Immediate Jeopardy. The deficient practice remained at scope/severity E (pattern with potential for more than minimal harm) following the removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, and resident interview, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff on two of two nursing units toured. (Section Two, Section Four)Findings include:Review of the facility policy entitled, Oxygen Storage Policy, last reviewed on October 10, 2024, revealed that oxygen cylinders must be secured in a cylinder rack or holder to prevent tipping. Observations on July 11, 2025, at 10:30 a.m., in room [ROOM NUMBER] revealed the top and front of the air conditioning unit was covered in a black substance. Resident 4 was observed standing next to bed A. The fitted sheet had a large brown stain on it and two pillows without case covers on them. Resident 8 was observed in bed B. There was an uncapped 50 milliliter syringe, typically used for flushing feeding tubes, lying on the resident's bed. The resident was observed sleeping in bed and a tube feeding was infusing.In an interview on July 11, 2025, at 10:30 a.m., Resident 4 stated that his linens were dirty, and he needed new pillowcases and sheets, staff were aware. The resident stated that the air conditioner has had the black substance on it. On July 11, 2025, at 10:35 a.m., staff entered room [ROOM NUMBER] and provided Resident 4 with new pillowcases but did not change the dirty fitted sheet, remove the syringe from the B bed, or address the black substance on the air conditioner unit.Observations on July 11, 2025, from 10:38 a.m. to 12:00 p.m., in room [ROOM NUMBER], revealed that Resident 2 was lying in the B bed, the fitted sheet was worn. There was an unsecured oxygen tank standing at the bottom of the bed, between the air conditioner and the dresser. Staff entered the room multiple times during the observation period but did not change the sheet. Observations on July 11, 2025, at 10:45 a.m., in room [ROOM NUMBER] revealed an unsecured oxygen tank standing in between the two dressers. Observations on July 11, 2025, at 11:05 a.m., of the shower room on Section 4 revealed the following:There was a commode chair with a black dirt ring on the seat. There were two wash cloths on the grab bars.There was a thermometer to check water temperatures hanging from the faucet. The front of the blue thermometer was covered in a dried black substance. The shower curtain had gray stains on the bottom end of it. In an interview on July 11, 2025, at 3:47 p.m., the Administrator confirmed the environmental problems should have been addressed.28 Pa. Code 201.18 (b) (1) Management.

Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for two of eight sampled residents who required assistance with activities of daily living (ADLs). (Resident 2, 6)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included aphasia, hypertension, and had severe physical limitations. The Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 2 was dependent on staff for personal hygiene, grooming, and bathing. Review of the care plan revealed that the resident required assistance from staff for activities of daily living (ADLs). On July 11, 2025, at 10:40 a.m., the resident was observed in bed. Her fingernails were long and dirty. There was no documented evidence that staff assisted Resident 2 with trimming and cleaning her nails. Clinical record review revealed that Resident 6 had diagnoses that included a tracheostomy, heart failure, and weakness to an upper extremity. The MDS assessment dated [DATE], revealed that Resident 6 was alert and oriented required assistance from staff for personal hygiene, grooming, and bathing. Review of the care plan revealed that the resident required assistance from staff for ADLs. On July 11, 2025, at 11:10 a.m., the resident was observed in bed. His fingernails were long and dirty. In an interview at that time the resident stated he wanted his nail trimmed but needed help from staff. There was no documented evidence that staff assisted Resident 6 with trimming and cleaning his nails. In an interview on July 11, 2025, at 3:49 p.m., the Director of Nursing confirmed that nail care was to be done when nursing staff provided routine care and as needed.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of eight sampled residents. (Resident 2)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included a history of stroke, dysphagia, and had a feeding tube. A physician's order dated January 21, 2025, directed staff to flush the feeding tube with 200 milliliters (ml) of water every six hours for a total volume of 800 ml daily. On July 11, 2025, at 10:48 a.m., the water flush bag was observed on the pole and infusing into Resident 2's feeding tube. The flush rate was observed to be 30 ml per hour. In an interview, Licensed Practical Nurse 1 stated that the pump ran for 22 hours per day and confirmed the rate was set for 30 ml per hour. The pump rate as observed infused 660 ml per day, which was 140 ml less than the total flush amount ordered by the resident's physician.In an interview on July 11, 2025, at 3:46 p.m., the Director of Nursing confirmed the pump should have been programmed to deliver the total water amount per the physician's order. CFR 483.25 Quality of CarePreviously cited 10/18/2428 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide interventions to prevent pressure ulcers for one of eight sampled residents with a history of wounds. (Resident 2)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included aphasia (a communication disorder that creates impaired ability to comprehend or formulate language due to a brain dysfunction), hypertension, and had severe physical limitations. Review of the Minimum Data Set assessment, dated June 9, 2025, revealed the resident was at risk for pressure ulcers, was immobile, and could not communicate her needs. Review of the care plan revealed that the resident had potential for impairment to skin integrity due to deconditioning and staff were to apply cushioned heel boots to bilateral feet when the resident was in bed. Multiple observations on July 11, 2025, between 10:40 a.m. and 12:00 p.m., revealed that Resident 2 was in bed. The heel boots were not in place and her heels were not elevated. In an interview on July 11, 2025, at 3:45 p.m., the Director of Nursing confirmed that Resident 2 should have had bilateral heel boots on while in bed.28 Pa. Code 211.12 (d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection for one of eight sampled residents. (Resident 5)Findings include:Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on October 10, 2024, revealed that staff were to wear a gown and gloves during high contact resident care activities such as tracheostomy care to reduce the spread of multi-drug resistant organisms (MDRO) to residents with indwelling medical devices regardless of their MDRO colonization status. Review of Resident 5's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of respiratory failure requiring a tracheostomy, history of a stroke, and had a feeding tube. Review of the care plan revealed that Resident 5 required Enhanced Barrier Precautions and called for staff to wear gloves and gowns during close contact interactions.Observations on July 11, 2025, at 11:30 a.m., revealed a sign outside of Resident 5's room which directed staff to follow Enhanced Barrier Precautions by wearing a gown and gloves when providing high contact care including tracheostomy care. During the same observation period, Licensed Practical Nurse (LPN) 1 entered Resident 5's room and performed suctioning of the tracheostomy only wearing gloves. LPN1 did not wear a gown.In an interview on July 11, 2025, at 3:40 p.m., the Director of Nursing confirmed that staff should have worn a gown when providing care.28 Pa Code 201.14(a) Responsibility of licensee

Based on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to verify professional license and complete a criminal background check prior to the start of employment for one of five newly hired employees. (E5) Findings include: A review of the facility policy entitled, Background Screening Investigations, dated October 23, 2023, revealed that the facility was to conduct screening for all potential hires. This included license/registration verification and a criminal background check. Employee 5 (E5) had been working in the facility as a Registered Nurse since August 16, 2024, and an inquiry to the state licensure board and a criminal background check were not completed until October 16, 2024. In an interview on October 18, 2024, at 9:45 a.m., the Administrator confirmed there was no documented evidence that the license verification and criminal background check were done prior to start of employment per facility policy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.19(3) Personnel policies and procedures.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 26 sampled residents. (Resident 65) Findings include: Clinical record review revealed that Resident 65 had diagnoses that included hypotension (low blood pressure). A physician's order dated February 9, 2022, directed staff to administer a medication (midodrine) three times a day for hypotension. Staff were not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm Hg). Review of Resident 65's medication administration records revealed that staff administered the medication 17 times in September and six times in October 2024, when the resident's SBP was greater than 120 mm Hg. In an interview on October 18, 2024, at 9:39 a.m., the Director of Nursing confirmed that the medications were administered outside established parameters for Resident 65. CFR 483.25 Quality of Care Previously cited 11/16/23 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident and the resident's representative(s) of transfer(s), including the reasons for the moves and Ombudsman information, in writing upon transfer from the facility for five of five sampled residents who were transferred to the hospital. (Residents 41, 48, 50, 81, 117) Findings include: Clinical record review revealed that Resident 41 was transferred to the hospital on August 2 and 16, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the hospital. Clinical record review revealed that Resident 48 was transferred to the hospital on June 25, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 50 was transferred to the hospital on October 5, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 81 was transferred to the hospital on September 15, 2024, after a change in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfer to the hospital. Clinical record review revealed that Resident 117 was transferred to the hospital on February 21, February 26, April 1, and May 24, 2024, after changes in condition. There was no documentation to support that the resident or the resident's responsible party or legal representative was provided written information regarding the transfers to the hospital. In an interview on October 18, 2024, at 9:51 a.m., the Administrator confirmed that the residents or resident representatives were not given written notices regarding their transfers.

Based on review of facility policy, clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to implement interventions that prevented new or worsened pressure ulcers for three of three sampled residents with skin impairments. (Residents 1, 2, 3) Findings include: Review of a facility policy entitled, Pressure Ulcer Prevention, last reviewed September 2024, revealed that staff were to conduct a skin assessment with the weekly risk assessment. Residents at risk for pressure ulcers were to be repositioned on an individualized schedule. Clinical record review revealed that Resident 1 had diagnoses that included protein calorie malnutrition (PCM), muscle weakness, and hemiplegia to the left side. The resident had a stage four pressure ulcer to the sacrum and a stage three pressure ulcer to the left shoulder. Staff were to turn and reposition the resident every two hours and check the resident for incontinence episodes and soiled bedding every hour. Review of the documentation for August and September 2024, revealed no evidence that staff turned and repositioned the resident every two hours on 11 of 78 shifts in August and 22 of 78 shifts in September and no evidence that staff checked the resident for incontinence and soiled bedding throughout 10 of 78 shifts in August and 19 of 78 shifts in September. There were no documented refusals. There was no documented evidence that a weekly skin assessment was completed since May 2024. Clinical record review revealed that Resident 2 had diagnoses that included PCM, anemia and muscle weakness. The resident had an unstageable pressure ulcer to the left heel. There was no documented evidence that a weekly skin assessment was completed since March 2024. A physician's order dated May 7, 2024, directed staff to apply a heel boot to the left foot when the resident was in and out of bed. On October 2, 2024, at 11:17 a.m., 11:58 a.m., and 1:04 p.m., the resident was observed in bed; the heel boot was not in place. In an interview at 11:58 a.m., the licensed practical nurse (LPN 1) who was assigned to the resident, confirmed that the heel boot was not in place. In an interview at 1:25 p.m., the Director of Nursing (DON) stated that the heel boot should have been applied as ordered. Clinical record review revealed that Resident 3 had diagnoses that included multiple sclerosis, anxiety, and anemia. The resident had a stage four pressure ulcer to the sacrum. Review of the care plan revealed that the resident had a self-care performance deficit and was totally dependent on staff for bed mobility. Review of scheduled tasks revealed that staff were to reposition the resident every two hours. In an interview on October 2, 2024, at 11:50 a.m., the resident stated that staff did not regularly offer to turn and reposition her in bed, she preferred to be repositioned for comfort, and she was not able to reposition herself. Review of the task documentation for September 2024, revealed no evidence that staff repositioned the resident every two hours on 32 of 90 shifts in September. In interviews on October 2, 2024, at 1:25 p.m. and 2:13 p.m., the DON confirmed that skin assessments should have been performed weekly and documented in the residents' electronic medical record. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of five sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included gastroesophageal reflux disease (acid reflux), pain, and neuropathy (nerve damage). Physician's orders dated July 26, 2024, directed staff to administer Acetaminophen (a medication for pain) and gabapentin (a medication for nerve pain) at 6:00 a.m. daily. A physician's order dated July 27, 2024, directed staff to administer omeprazole (a medication to treat acid reflux) at 6:00 a.m. daily. There was no evidence that the medications were offered or administered on August 7, 2024, per the physician's orders. In an interview on August 8, 2024, at 2:07 p.m., the Director of Nursing confirmed there was no evidence that the medications were administered per the physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) on one of five nursing units. (Section 2) Findings include: A review of the facility policy entitled, Administering Medications, last reviewed September 2023, revealed that Medications were to be administered in accordance with the prescriber's orders, which included any required timeframe. Medications were to be administered within one hour of their prescribed time. Clinical record review revealed that Resident 2 had diagnoses that included major depressive disorder and multiple sclerosis. A review of physician's orders dated June 29, 2018, June 9, 2021, March 28, 2023, and August 5, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: vitamin D3 1000 international units (IU), Zeposia 0.92 milligrams (mg), escitalopram 20 mg, and Bactrim 160 mg. Observation of the medication pass on August 8, 2024, revealed that licensed practical nurse (LPN) 1 did not administer the medications until 9:30 a.m. Clinical record review revealed that Resident 3 had diagnoses that included depression, allergies, hypertension (high blood pressure), and pain. A review of physician's orders dated April 12, 2024, April 24, 2024, May 16, 2024, July 11, 2024, July 16, 2024, and July 30, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: cholecalciferol (vitamin D) 50 micrograms (mcg), bupropion (a medication for depression) 300 mg , lidocaine patch 4 % to the right knee, fluticasone propionate (a medication for allergies) 50 mcg, sertraline (a medication for depression) 75 mg, and lisinopril (a medication for high blood pressure) 5 mg. Observation of the medication pass on August 8, 2024, revealed that LPN 1 did not administer the medications until 9:40 a.m. Observation during the medication pass on August 8, 2024, from 9:30 a.m. to 9:40 a.m., revealed 28 opportunities with 10 errors which resulted in a medication error rate of 35.7%. In an interview on August 8, 2024, at 2:10 p.m., the Director of Nursing confirmed that the medications should have been adminstered by 9:00 a.m. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, and resident interview, it was determined that the facility failed to accommodate resident needs by providing access to the call bell system for two of six sampled residents. (Residents 4, 5) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, abnormalities of gait and mobility, and muscle weakness. According to the Minimum Data Set (MDS) assessment, dated May 16, 2024, the resident could communicate her care needs and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell within reach. Observations on July 12, 2024, at 10:00 a.m. and 12:15 p.m., revealed the resident was in bed and the call bell was wrapped around the armchair, out of reach. Clinical record review revealed that Resident 5 had diagnoses that included hemiplegia and hemiparesis (paralysis on left side) and heart failure. According to the MDS assessment, dated April 30, 2024, the resident was alert and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and that staff was to keep her call bell within reach. On July 12, 2024, at 10:20 a.m., the resident was in bed and the call bell was on the dresser tucked under stuffed animals, out of reach. At that time the resident stated, I can't find my call bell. At 12:35 p.m., the resident was observed sitting in her wheelchair eating her meal. The call bell was observed behind the resident on the dresser tucked under stuffed animals, out of reach. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and observation, it was determined that the facility failed to ensure that safety interventions for falls were in place for one of six sampled residents. (Resident 4) Findings include: Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, abnormalities of gait and mobility, and muscle weakness. According to the Minimum Data Set assessment, dated May 16, 2024, the resident could communicate her care needs and was dependent on staff for care. Review of the care plan revealed that the resident was at risk for falls and staff was instructed to place the bed in the low position with floor mats on both sides of the bed while the resident was in bed. Observations on July 12, 2024, at 10:00 a.m. and 12:15 p.m., revealed the resident was in bed without the floor mats in place, and the bed was not in a low position. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for four of 12 sampled residents. (Residents 9, 10, 11, 12) Findings include: Review of the facility policy entitled Room Change/Roommate Assignment, last reviewed Ocotber 30, 2023, revealed that prior to changing a room or roommate assignment residents and their representatives are given advanced written notice of the change. The advance notice would include why the change is being made and documention of the change would be recorded in the resident's medical record. Clinical record review revealed that Resident 9 had a room change completed on May 24, 2024. There was no documented evidence that Resident 9 and their representative were given notice, including written notice, of the room change. In an interview on June 17, 2024, at 10:45 a.m., Resident 9 stated he did not know why or when he changes rooms, they just moved him. Clinical record review revealed that Resident 10 had a room change completed on May 24, 2024. There was no documented evidence that Resident 10 and their representative were given notice, including written notice, of the room change. Clinical record review revealed that Resident 11 had a room change completed on June 14, 2024. There was no documented evidence that Resident 11 and their representative were given notice, including written notice, of the room change. Clinical record review revealed that Resident 12 had room changes completed on June 3 and 14, 2024. There was no documented evidence that Resident 12 and their representative were given notice, including written notice, of the room changes. In an interview on June 17, 2024, at 12:22 p.m., the Director of Nursing confirmed there was no documented evidence that the residents and their representatives were notified of the room changes. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and staff interview, it was determined that the facility failed to post accurate and current nurse staffing information. Findings include: During a tour of the facility on February 27, 2024, at 9:15 a.m., the staffing information that was posted in the lobby was dated for January 23, 2024. During an interview on February 27, 2024, at 2:00 p.m., the Director of Nursing confirmed that incorrect staffing data was posted.

Based on observation, it was determined that the facility failed to ensure that a safe, clean, and comfortable environment was maintained on three of four nursing units. (Units 1, 2, 3) Findings include: On November 13, 2023, at 11:24 a.m., standing water was observed on the floor in the hallway outside of room [ROOM NUMBER] and the shower room opposite room [ROOM NUMBER]. In an interview at this time with Housekeeper 1, it was revealed that this had been an ongoing problem for longer than two weeks. On November 15, 2023, at 11:40 a.m., the shower room opposite room [ROOM NUMBER] was cluttered with numerous shower beds and equipment, the toilet seat on the toilet was crooked, protruding into a walking path. There were black spots on the floor and the sink. The sharps container on the wall was filled beyond capacity. Multiple bottles of soap/shampoo were sitting on top of the sharps container and blocking the grab rails of the shower stall sides. There was a rust stain on the shower stall floor. On November 13, 2023, at 11:02 a.m., there was a hole in the wall behind the door in room [ROOM NUMBER], molding was missing from around the air conditioning unit, and a black piece of foam was dangling in the space between the wall and the air conditioner. The threshold in the doorway between the bedroom floor and the bathroom floor was missing, creating an uneven floor surface. On November 13, 2023, at 9:53 a.m. and on November 16, 2023, at 11:46 a.m., the cover to the air conditioning unit in room [ROOM NUMBER] was missing. On November 13, 2023, at 12:00 p.m., the cover to the air conditioning unit in room [ROOM NUMBER] was missing. On November 14, 2023, at 1:10 p.m., the toilet bowl in room [ROOM NUMBER] had a dark ring around it. The bathroom door was marred and scratched. On November 13, and November 14, 2023, at various times, there was a broken closet door and a broken lower dresser drawer in room [ROOM NUMBER]. In room [ROOM NUMBER], the closet door was off the track, the privacy curtain was soiled with brown stains, and there was a hole on the bathroom door. CFR 483.10(i) Safe Environment Previously cited 12/2/22 28 Pa. Code 201.18(b)(3) Management.

Based on facility policy and documentation review, clinical record review, observation, and staff interview, it was determined that the facility failed to provide an environment and adequate supervision to prevent accidents related to elopement (unauthorized departure from the facility), resulting in actual harm that required transfer to the hospital for treatment of a head wound and failed to conduct a thorough incident investigation for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitiled, Accidents and Incidents - Investigating and Reporting, revealed that all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. Data, as applicable, to be part of the Report of Incident/Accident form, included the circumstances surrounding the incident, the name(s) of witnesses and their account(s) of the incident, and follow-up information. Clinical record review revealed that Resident 1 had diagnoses that included paranoid [CONDITION(S)] (a brain disorder which can make it difficult to determine fantasy from reality), adjustment disorder with anxiety, chronic systolic (congestive) heart failure and [CONDITION(S)] (conditions where the heart cannot properly/effectively pump blood), chronic obstructive pulmonary disease (characterized by respiratory symptoms such as breathlessness and cough), hypertensive (high blood pressure) heart disease with heart failure, and COVID-19 (Coronavirus Disease 2019 - positive test September 30, 2022). The resident had a physician's order dated March 4, 2022, for staff to administer [MEDICATION(S)] 20 milligrams daily for anticoagulant (blood thinner used to prevent blood clots from forming which increases the risk of bleeding). The Minimum Data Set assessment (a periodic evaluation of resident care needs) dated August 8, 2022, indicated that the resident was oriented, exhibited symptoms of depression, and ambulated (walked) independently with the use of a cane. A late entry note by the nurse on October 3, 2022, indicated that the resident was informed of a positive COVID-19 status (positive test September 30, 2022), isolation procedures were explained, the resident was redirected to their room, and the resident voiced refusal to stay in the room. Review of a facility Incident/Accident Report form dated October 4, 2022, revealed that Resident 1 could not be located at 12:11 p.m. A nurse's note of the same date indicated that the resident had last been seen that morning on the lower level of the facility (resident resided on the upper level). Facility documentation labeled Elopement Action Plan signed by the Administrator on October 5, 2022, indicated that the resident was last seen in the facility on October 4, 2022, at approximately 8:00 a.m. and had been missing, with whereabouts unknown, until approximately 9:00 a.m. on October 5, 2022, (a period of 25 hours since last seen and over 20 hours since identified as missing.) It was noted that the resident was interviewed upon return and stated that exit was through the lobby side door to the parking lot due to anger, having COVID, and wanting to get out of the facility. Documentation also indicated that the lobby door was checked immediately and it did not alarm correctly; even though daily door audits indicated that the door's locking mechanism had been functioning the day before the incident. Observation of door A 5 on October 19, 2022, at 12:23 p.m., revealed that it was located in the lobby area (which was under construction) and led to the parking lot. The door's locking device was deactivated by pushing on the door for 15 seconds and an alarm sounded when this occurred. During an interview at that time, the Administrator confirmed that the door identified as A 5 did not alarm when tested on [DATE]. Nurses' notes dated October 5, 2022, indicated that Resident 1 returned to the facility at 10:06 a.m., that the resident reported falling while outside the facility, and that an open area (laceration) was observed to the back/left side of the head. The resident was transferred to the hospital and received four staples to close the head wound/injury. In addition, during an interview on October 19, 2022, at 12:23 p.m., the Administrator reported that documentation on the Elopement Action Plan regarding how the resident exited the building was obtained initially, had not been confirmed, and could be inaccurate. He stated that the facility had not determined how the resident was able to elope from the building. Review of the facility Incident/Accident Report form revealed a lack of documentation to support that a thorough investigation, including circumstances surrounding the incident, possible witnesses with their accounts of the incident, and follow-up information had been completed. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(a)(b)(1)(d) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing services.

Based on observation, review of clinical records and facility documentation and interviews with residents, family and staff, it was determined that the facility failed to ensure that hot liquids were served to residents at safe temperatures. This failure resulted in one resident (Resident R14) sustaining a burn and placed the health and safety of all other residents who are served hot liquids in the facility in an Immediate Jeopardy situation. Findings include: Review of the clinical record for Resident R14 revealed that the resident was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Further review of Resident R14's clinical record revealed a quarterly Minimum Data Set (MDS) (an assessment tool used to determine resident care needs) completed on (MONTH) 26, (YEAR), which indicated that the resident had a severe cognitive impairment. Continued review for Resident R14's clinical record revealed a nursing progress note for (MONTH) 4, (YEAR), at 1:53 p.m. by Employee E7, Registered Nurse (RN), Nurse Manager, which stated, Late Entry: Note Text: Resident was eating lunch in the dining hall when he alerted staff that he had spilled his beverage on his right thigh. Resident was assessed immediately and was cleaned up with a moist cold towel. Residents thigh was pink (baseline) and there was no signs of injury. The resident rated his pain level as a 3-4 out of 10 from the cup falling into his lap, but the pain quickly subsided. The charge nurse followed up 15 minutes later with an assessment and the thigh remained clear and free. The resident was monitored throughout the day and evening. Resident had 0 out of 10 pain by evening shift. Family and physician made aware. Continued clinical record review for Resident R14 on (MONTH) 11, (YEAR), revealed a nursing progress note written by Employee E7 that was entered on (MONTH) 5, (YEAR), at 3:29 p.m. and then crossed out. The crossed-out note, revealed: Duplicate Order - Note Text: Resident was in dining hall for lunch when incident occurred. Resident claims he had placed a spoon in his coffee for stirring and left it in the cup. The resident was placing a cup of juice on the table when he hit the spoon in the coffee cup causing it to spill towards him. The resident immediately notified the unit manager who was on dining room watch. The unit manager removed the resident from where the incident occurred and assessed the resident. The resident's right thigh was reddened but no blistering occurred. A cool, damp towel was placed on the reddened area. The charge nurse for the resident contacted the physician and the resident's daughter. [MEDICATION NAME] (cream used on the skin [MEDICAL CONDITION] helps to prevent or treat serious infection) was applied the reddened area. The reddened area was continuously monitored and no blistering had developed. Interview on (MONTH) 11, (YEAR), from 3:29 p.m. to 3:34 p.m. with Employee E7 regarding resident R14's burn revealed Employee E7 stated, when it happened, I saw it and he had a four-inch diameter pink burn on his right upper thigh. I did this in the dining room, at the table in front of other residents. His meal hadn't come out yet. We took him down to his room to disrobe him to look at his skin. When the burn happened his pain score was two to three. and . I took him, put a cool compress on it and we kept an eye on it. The nurses did put [MEDICATION NAME] on it because he had a burn. Additionally, Resident R14's clinical record review revealed a physician progress notes [REDACTED]. Continued review of physician progress notes [REDACTED]. no blisters/ulcers/ttp. skin is intact Further review of the clinical record for Resident R14 revealed an eINTERACT Change in Condition Evaluation form dated (MONTH) 4, (YEAR), at 1:26 p.m The evaluation listed the change in condition as, spilled hot coffee on right upper thigh , for 12/4/2018 in the morning. The documentation revealed a skin change of, scald on right thigh (front), the resident had pain, and a summary of the observations and evaluation read, Resident was in dining room for lunch he took one sip of coffee ,while he attempt to put the cup back on table unfortunately he put the cup on the spoon and it flip over. Lastly, the REVIEW AND NOTIFY section revealed the resident's physician was notified on (MONTH) 4, (YEAR), at 1:00 p.m The recommendation of primary clinician read, applied [MEDICATION NAME] cream to thigh. Monitor site q shift (meaning every shift). Clinical record review for Resident R14, revealed a PAIN TOOL completed on (MONTH) 4, (YEAR), at 1:31 p.m., five minutes after the Change in Condition Evaluation was documented. It revealed that the resident had a pain score of six out of ten on the numerical pain scale where zero is no pain and 10 is the worst pain the resident can imagine. Further review of the note indicated under the section what makes the pain better? revealed cold rug, Tylenol and [MEDICATION NAME] cream. Additionally, the Medications and Treatment sections revealed interventions of Tylenol and [MEDICATION NAME] cream (Tylenol also know as [MEDICATION NAME] is a pain medication). Interview on (MONTH) 11, (YEAR), at 3:20 p.m. with Resident R14 and his daughter Resident R14 indicated, I'm still getting the white stuff on it (the resident was pointing to the area of what he believed to be his first-degree burn on his right upper thigh when he referred to it). Asked by his daughter whether he was still getting [MEDICATION NAME], the resident responded, yes, it's the [MEDICATION NAME]. Resident R14 continued, I was putting down my coffee and I hit my spoon and it knocked my cup over. It spilled onto my lap. It was very painful and it's still painful now. Resident R14 was asked to rate his pain on a scale from zero to 10 where zero is no pain and 10 is the worst pain he can image. Resident R14 stated, it's a two to three pain score now. Resident R14's daughter stated that as recently as today, she had seen nursing staff applying the [MEDICATION NAME] cream to her father's burn. Resident R14 offered to show the burn and voluntarily pulled down his sweat pants. Observation revealed an area of skin with a pink and red discoloration to the right upper thigh, on his lap, that looked to measure approximately four by six inches. Review of facility documentation COFFEE HOUR TEMPERATURES for food and drink POS (POS-Point of Service) temperature testing logs on (MONTH) 11, (YEAR), at 3:00 p.m. revealed the hot coffee and hot water temperature audits for the month of (MONTH) (YEAR), as follows: December 1, (YEAR), Lounge 1, 8:15 a.m., coffee temperature 168 F, water temperature 173 F; December 2, (YEAR), Lounge 2, 11:35 a.m., coffee temperature 160 F, water temperature 164 F; December 3, (YEAR), Lounge 3, 12:00 p.m., coffee temperature 162 F, water temperature 160 F; December 4, (YEAR), Lounge 4, 7:30 a.m., coffee temperature 171 F, water temperature 168 F - December 5, (YEAR), Main Dining Room, 7:45 a.m., coffee temperature 168 F, water temperature 164 F; December 6, (YEAR), Lounge 1, 8:30 a.m., coffee temperature 166 F, water temperature 170 F; December 7, (YEAR), Lounge 2, 1:15 p.m., coffee temperature 164 F, water temperature 168 F; December 8, (YEAR), Lounge 3, 5:00 p.m., coffee temperature 170 F, water temperature 172 F; December 9, (YEAR), Lounge 4, 5:15 p.m., coffee temperature 168 F, water temperature 168 F; December 10, (YEAR), Main Dining Room, 7:45 a.m., coffee temperature 180 F, water temperature 185 F, and December 11, (YEAR), Lounge 1, 12:00 p.m., coffee temperature 183 F, water temperature 186 F - this was the day of the unannounced survey. Interview on (MONTH) 11, (YEAR), at 3:06 p.m. with the Food Service Director (FSD), confirmed that the temperature logs for the hot coffee and hot water were accurate. The FSD stated, we take the coffee to the lounge and then we do POS testing. and . the temperature listed are the temperatures we serve it at. Continued interview with the FSD revealed, the residents get coffee at 150 to 155 Fahrenheit. 165 F is the maximum temperature for resident comfort. Further Review of the POS [REDACTED]. Interview with the FSD on (MONTH) 11, (YEAR), at approximately 3:06 p.m. revealed that per facility practice the temperatures of hot beverages at point of service are not tested daily on each unit for each meal. Further interview with the FSD confirmed that he was unaware of what the temperature of the coffee served to Resident R14 was at the time of his burn. An Immediate Jeopardy situation was identified to Employees E1, Nursing Home Administrator (NHA) and the DON (director of Nursing) on (MONTH) 11, (YEAR), at 5:17 p.m., related to Resident R14 having been burned by hot coffee on (MONTH) 4, (YEAR), and all other residents in the facility who had the potential to consume hot liquids being at immediate risk of being burned by hot beverages. The corrective action plan included the following interventions: 1. The facility immediately conducted a QAPI (quality assurance performance improvement) meeting and root cause analysis. Facility immediately reviewed and revised the guidelines for Hot Beverages and created two new temperature logs for hot beverages leaving the kitchen and temperature at Point of Service for each Dining room or unit. Research for Point of Service temperatures was taken from the US National Library of Medicine National Institute of Health abstract on Calculating the optimum temperature for serving hot beverages. 2. Kitchen staff were immediately in-serviced on changes and Guidelines for Hot Beverages and liquids not to leave the kitchen if over 185 degrees Fahrenheit. Corrective action - or holding the beverage to be documented in the appropriate area of the log. Kitchen staff will be in-serviced prior to the start of their shift until 100% completion. 3. Unit nursing staff were immediately in-serviced on taking the temperature of the first hot beverages served and placing them on the log. Corrective action - or holding the beverage to be documented in the appropriate area of the log. Hot beverages may be served in the range of 135 +/- 10 degrees Fahrenheit to residents. If temperatures are above the expectable range beverages are not to be served until, they cool to an appropriate temperature. Corrective actions to be documented in the log. Nursing staff will be in-serviced prior to the start of their shift until 100% completion. 4. Dietician or designee will audit temperature logs daily. Findings of the audits will be reported to the QAPI committee. 5. All hot liquids must be tested prior to being served. Temperatures must be 125-145 degrees Fahrenheit. 6. A digital thermometer will be on the beverage cart to test the first cup from each pitcher. If temperature less than 125 or more than 145 degrees Fahrenheit it cannot be served and returned to the kitchen. 7. There will be a test soup on each cart and MUST be tested for temperature prior to serving the trays from the cart. If the soup is too hot it cannot be served until temperatures are 125-145 degrees Fahrenheit notify the kitchen and administration IMMEDIATELY. The Immediate Jeopardy was removed on (MONTH) 13, (YEAR), at 11:35 a.m. after it was verified that the corrective action plan was implemented. The facility failed to ensure that hot liquid were served to residents at safe temperatures. This failure resulted in actual harm to one resident (Resident R14) who sustained a first degree burn to his right thigh from coffee on (MONTH) 4, (YEAR), and resulted in an Immediate Jeopardy situation on (MONTH) 11, (YEAR). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 7/27/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, review of clinical records and facility documentation and interviews with residents, family and staff, it was determined that the facility failed to ensure that hot liquids were served to residents at safe temperatures. This failure resulted in one resident (Resident R14) sustaining a burn and placed the health and safety of all other residents who are served hot liquids in the facility in an Immediate Jeopardy situation. Findings include: Review of the clinical record for Resident R14 revealed that the resident was admitted to the facility on (MONTH) 30, (YEAR), with [DIAGNOSES REDACTED]. Further review of Resident R14's clinical record revealed a quarterly Minimum Data Set (MDS) (an assessment tool used to determine resident care needs) completed on (MONTH) 26, (YEAR), which indicated that the resident had a severe cognitive impairment. Continued review for Resident R14's clinical record revealed a nursing progress note for (MONTH) 4, (YEAR), at 1:53 p.m. by Employee E7, Registered Nurse (RN), Nurse Manager, which stated, Late Entry: Note Text: Resident was eating lunch in the dining hall when he alerted staff that he had spilled his beverage on his right thigh. Resident was assessed immediately and was cleaned up with a moist cold towel. Residents thigh was pink (baseline) and there was no signs of injury. The resident rated his pain level as a 3-4 out of 10 from the cup falling into his lap, but the pain quickly subsided. The charge nurse followed up 15 minutes later with an assessment and the thigh remained clear and free. The resident was monitored throughout the day and evening. Resident had 0 out of 10 pain by evening shift. Family and physician made aware. Continued clinical record review for Resident R14 on (MONTH) 11, (YEAR), revealed a nursing progress note written by Employee E7 that was entered on (MONTH) 5, (YEAR), at 3:29 p.m. and then crossed out. The crossed-out note, revealed: Duplicate Order - Note Text: Resident was in dining hall for lunch when incident occurred. Resident claims he had placed a spoon in his coffee for stirring and left it in the cup. The resident was placing a cup of juice on the table when he hit the spoon in the coffee cup causing it to spill towards him. The resident immediately notified the unit manager who was on dining room watch. The unit manager removed the resident from where the incident occurred and assessed the resident. The resident's right thigh was reddened but no blistering occurred. A cool, damp towel was placed on the reddened area. The charge nurse for the resident contacted the physician and the resident's daughter. [MEDICATION NAME] (cream used on the skin [MEDICAL CONDITION] helps to prevent or treat serious infection) was applied the reddened area. The reddened area was continuously monitored and no blistering had developed. Interview on (MONTH) 11, (YEAR), from 3:29 p.m. to 3:34 p.m. with Employee E7 regarding resident R14's burn revealed Employee E7 stated, when it happened, I saw it and he had a four-inch diameter pink burn on his right upper thigh. I did this in the dining room, at the table in front of other residents. His meal hadn't come out yet. We took him down to his room to disrobe him to look at his skin. When the burn happened his pain score was two to three. and . I took him, put a cool compress on it and we kept an eye on it. The nurses did put [MEDICATION NAME] on it because he had a burn. Additionally, Resident R14's clinical record review revealed a physician progress notes [REDACTED]. Continued review of physician progress notes [REDACTED]. no blisters/ulcers/ttp. skin is intact Further review of the clinical record for Resident R14 revealed an eINTERACT Change in Condition Evaluation form dated (MONTH) 4, (YEAR), at 1:26 p.m The evaluation listed the change in condition as, spilled hot coffee on right upper thigh , for 12/4/2018 in the morning. The documentation revealed a skin change of, scald on right thigh (front), the resident had pain, and a summary of the observations and evaluation read, Resident was in dining room for lunch he took one sip of coffee ,while he attempt to put the cup back on table unfortunately he put the cup on the spoon and it flip over. Lastly, the REVIEW AND NOTIFY section revealed the resident's physician was notified on (MONTH) 4, (YEAR), at 1:00 p.m The recommendation of primary clinician read, applied [MEDICATION NAME] cream to thigh. Monitor site q shift (meaning every shift). Clinical record review for Resident R14, revealed a PAIN TOOL completed on (MONTH) 4, (YEAR), at 1:31 p.m., five minutes after the Change in Condition Evaluation was documented. It revealed that the resident had a pain score of six out of ten on the numerical pain scale where zero is no pain and 10 is the worst pain the resident can imagine. Further review of the note indicated under the section what makes the pain better? revealed cold rug, Tylenol and [MEDICATION NAME] cream. Additionally, the Medications and Treatment sections revealed interventions of Tylenol and [MEDICATION NAME] cream (Tylenol also know as [MEDICATION NAME] is a pain medication). Interview on (MONTH) 11, (YEAR), at 3:20 p.m. with Resident R14 and his daughter Resident R14 indicated, I'm still getting the white stuff on it (the resident was pointing to the area of what he believed to be his first-degree burn on his right upper thigh when he referred to it). Asked by his daughter whether he was still getting [MEDICATION NAME], the resident responded, yes, it's the [MEDICATION NAME]. Resident R14 continued, I was putting down my coffee and I hit my spoon and it knocked my cup over. It spilled onto my lap. It was very painful and it's still painful now. Resident R14 was asked to rate his pain on a scale from zero to 10 where zero is no pain and 10 is the worst pain he can image. Resident R14 stated, it's a two to three pain score now. Resident R14's daughter stated that as recently as today, she had seen nursing staff applying the [MEDICATION NAME] cream to her father's burn. Resident R14 offered to show the burn and voluntarily pulled down his sweat pants. Observation revealed an area of skin with a pink and red discoloration to the right upper thigh, on his lap, that looked to measure approximately four by six inches. Review of facility documentation COFFEE HOUR TEMPERATURES for food and drink POS (POS-Point of Service) temperature testing logs on (MONTH) 11, (YEAR), at 3:00 p.m. revealed the hot coffee and hot water temperature audits for the month of (MONTH) (YEAR), as follows: December 1, (YEAR), Lounge 1, 8:15 a.m., coffee temperature 168 F, water temperature 173 F; December 2, (YEAR), Lounge 2, 11:35 a.m., coffee temperature 160 F, water temperature 164 F; December 3, (YEAR), Lounge 3, 12:00 p.m., coffee temperature 162 F, water temperature 160 F; December 4, (YEAR), Lounge 4, 7:30 a.m., coffee temperature 171 F, water temperature 168 F - December 5, (YEAR), Main Dining Room, 7:45 a.m., coffee temperature 168 F, water temperature 164 F; December 6, (YEAR), Lounge 1, 8:30 a.m., coffee temperature 166 F, water temperature 170 F; December 7, (YEAR), Lounge 2, 1:15 p.m., coffee temperature 164 F, water temperature 168 F; December 8, (YEAR), Lounge 3, 5:00 p.m., coffee temperature 170 F, water temperature 172 F; December 9, (YEAR), Lounge 4, 5:15 p.m., coffee temperature 168 F, water temperature 168 F; December 10, (YEAR), Main Dining Room, 7:45 a.m., coffee temperature 180 F, water temperature 185 F, and December 11, (YEAR), Lounge 1, 12:00 p.m., coffee temperature 183 F, water temperature 186 F - this was the day of the unannounced survey. Interview on (MONTH) 11, (YEAR), at 3:06 p.m. with the Food Service Director (FSD), confirmed that the temperature logs for the hot coffee and hot water were accurate. The FSD stated, we take the coffee to the lounge and then we do POS testing. and . the temperature listed are the temperatures we serve it at. Continued interview with the FSD revealed, the residents get coffee at 150 to 155 Fahrenheit. 165 F is the maximum temperature for resident comfort. Further Review of the POS [REDACTED]. Interview with the FSD on (MONTH) 11, (YEAR), at approximately 3:06 p.m. revealed that per facility practice the temperatures of hot beverages at point of service are not tested daily on each unit for each meal. Further interview with the FSD confirmed that he was unaware of what the temperature of the coffee served to Resident R14 was at the time of his burn. An Immediate Jeopardy situation was identified to Employees E1, Nursing Home Administrator (NHA) and the DON (director of Nursing) on (MONTH) 11, (YEAR), at 5:17 p.m., related to Resident R14 having been burned by hot coffee on (MONTH) 4, (YEAR), and all other residents in the facility who had the potential to consume hot liquids being at immediate risk of being burned by hot beverages. The corrective action plan included the following interventions: 1. The facility immediately conducted a QAPI (quality assurance performance improvement) meeting and root cause analysis. Facility immediately reviewed and revised the guidelines for Hot Beverages and created two new temperature logs for hot beverages leaving the kitchen and temperature at Point of Service for each Dining room or unit. Research for Point of Service temperatures was taken from the US National Library of Medicine National Institute of Health abstract on Calculating the optimum temperature for serving hot beverages. 2. Kitchen staff were immediately in-serviced on changes and Guidelines for Hot Beverages and liquids not to leave the kitchen if over 185 degrees Fahrenheit. Corrective action - or holding the beverage to be documented in the appropriate area of the log. Kitchen staff will be in-serviced prior to the start of their shift until 100% completion. 3. Unit nursing staff were immediately in-serviced on taking the temperature of the first hot beverages served and placing them on the log. Corrective action - or holding the beverage to be documented in the appropriate area of the log. Hot beverages may be served in the range of 135 +/- 10 degrees Fahrenheit to residents. If temperatures are above the expectable range beverages are not to be served until, they cool to an appropriate temperature. Corrective actions to be documented in the log. Nursing staff will be in-serviced prior to the start of their shift until 100% completion. 4. Dietician or designee will audit temperature logs daily. Findings of the audits will be reported to the QAPI committee. 5. All hot liquids must be tested prior to being served. Temperatures must be 125-145 degrees Fahrenheit. 6. A digital thermometer will be on the beverage cart to test the first cup from each pitcher. If temperature less than 125 or more than 145 degrees Fahrenheit it cannot be served and returned to the kitchen. 7. There will be a test soup on each cart and MUST be tested for temperature prior to serving the trays from the cart. If the soup is too hot it cannot be served until temperatures are 125-145 degrees Fahrenheit notify the kitchen and administration IMMEDIATELY. The Immediate Jeopardy was removed on (MONTH) 13, (YEAR), at 11:35 a.m. after it was verified that the corrective action plan was implemented. The facility failed to ensure that hot liquid were served to residents at safe temperatures. This failure resulted in actual harm to one resident (Resident R14) who sustained a first degree burn to his right thigh from coffee on (MONTH) 4, (YEAR), and resulted in an Immediate Jeopardy situation on (MONTH) 11, (YEAR). 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited 7/27/17 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of a clinical record, facility documentation, and a reportable event, and interviews with staff, it was determined that the facility failed to provide adequate supervision to prevent an accident which resulted in actual harm for one of 26 residents reviewed (Resident Cl1). Finding include: Review of Resident Cl1's clinical record revealed July 2013 [DIAGNOSES REDACTED]. Review of nursing progress notes dated July 20, 2013 revealed that when the resident was being assisted with morning care and incontinent care, the nurse aide (Employee E2) assisted the resident to turn on her side when the resident's leg went over the side of the bed and pulled the resident off the bed to the floor. Further review of the nurse's notes revealed that Employee E2 called out for help. Further review revealed that the resident was complaining of intense and constant left hip pain, had an abrasion to the left shin, and bruises on both lower legs, was transferred to the hospital via an ambulance, and admitted with a left hip fracture. Review of the significant change MDS (minimum data set-a periodic assessment of needs) dated March 30, 2013, revealed the resident's weight at 480 pounds. Further review of the MDS dated [DATE], and a Medicare assessment MDS dated [DATE], revealed Resident Cl1 needed extensive assistance with two people for bed mobility. Further review of the two MDS's revealed that Resident Cl1 had total dependence, and needed two people for bathing. Further review revealed that Resident Cl1 had a range of motion impairment of both lower extremities (legs-hips knees, ankles, feet). Review of a physical therapy evaluation dated June 11, 2013 revealed that the resident was referred to therapy with the primary [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident was dependent for all mobility including rolling, can initiate upper body roll, but can not effectively move her legs and trunk to complete roll. Further review revealed that the resident must be transferred via a mechanical lift. Interview with Employee E5 on July 26, 2013 at 10:00 a.m. revealed that Employee E2 should not have been alone. Interview with Employee E3 on July 26, 2013 at 9:40 a.m. revealed that this employee would ask for help in rolling the resident because of the resident's weight. The facility failed to provide adequate and needed supervision to prevent an accident which resulted in a fracture of the left hip. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/21/2012.

Based on clinical record review, review of facility documentation, review of the facility's abuse policy, and interviews with staff, it was determined that the facility failed to effectively implement the abuse policy and failed to provide for the immediate protection and safety of one of one resident reviewed (Resident R1). Findings include: A review of the revised facility policy entitled, "Abuse Prohibition," dated August 3, 2009, stated that anyone who witnessed an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of resident property was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. Review of Resident R1's clinical record revealed admission [DIAGNOSES REDACTED]. A social service note dated March 15, 2011, at 11:00 a.m., stated that the resident was alert at times, responded to hand holding and touch, will occasionally answer simple questions appropriately, had a [DIAGNOSES REDACTED]. Review of facility incident documentation revealed a written statement dated March 13, 2011, by Employee E7, a member of the nursing staff, which stated that at 11:45 a.m., she observed two men turning Resident R1 from side to side, lifting the resident's legs up and down, and noticed a red light that resembled a pen light touching Resident R1. Employee E7 thought that the two men were taking pictures of the resident because the red light was beaming. There was no evidence that the staff member stopped the two men or notified the supervisor of the observed activity. On March 15, 2011, interview with Employee E6, a member of the nursing staff, stated that before the lunch meal on March 13, 2011, at approximately 10:55 a.m., she observed that Resident R1's door was closed and when she entered the room, she saw two men in the room. The two men looked like they were doing something together, at which time, Employee E6 observed a black box on the bed next to the resident's hip area with something pointy in contact with the hip. Employee E6 saw a red light on the resident's hip and assumed the man was a doctor and the black box was some type of instrument for the resident's wound. Employee E6 stated further that she left the room, (without stopping the activity of the two men in the room), and went to the nurses' station and explained to Employee E5 (Licensed Nurse), who was on the phone with a doctor, that two men were in the room examining the resident. Interview with Employee E5 (Licensed Nurse) on March 15, 2011, at approximately 10:30 a.m., indicated that she was taking Tylenol to Resident R1 for an elevated temperature on March 13, 2011, at 11:17 a.m., and upon entering the room she saw two males; one was the responsible party. Employee E5 noted that the resident was in the bed lying on her back covered with a sheet with a black box on top of the sheet placed between her knees. The black box had a "cord hanging from it with a screen on it." The screen had silver inscription on it. Employee E5 reported that the two gentlemen were "secretive" about the black box, but Employee E5 did not know anything about the contents of the black box or did not recognize the box. Resident R1's responsible party, at that time, raised Resident R1's right arm and said, "Look what I have noticed in the last hour; the area was hard to touch, blisters were forming, the area was bright pink and it had not been there two hours previously when you (Employee E5) changed the PEG (Percutaneous Endoscopic Gastrostomy) tube (feeding tube that is entered through the abdominal wall into the stomach) dressing." Employee E5 administered the Tylenol to the resident through the PEG tube, left the resident without stopping the activity of the two men, and returned to the nurses' station to have the charge nurse notify the unit manager. Review of facility incident documentation revealed a written statement dated March 13, 2011, at 1:00 p.m., by Employee E4 (a Registered Nurse Manager) which stated that a nurse asked her to assess the resident because she had some strange marks on her arm and leg, noted three areas that appeared to be second degree burns, and that two men left after she entered the room. The written statement further reported that after Employee E4 finished the assessment and "left the room, was told by the other nurses that the men had a laser in the room with them and were using the light on the resident." A review of the facility incident/accident investigation report dated March 13, 2011, at 1:00 p.m., stated that, "throughout the morning shift care was given with direct contact and visualization of the resident's body parts during care, with no signs of any reddened or blistered areas noted prior to visitors coming into room." The skin integrity report dated March 13, 2011, indicated a right arm second degree burn, serous (mucous watery discharge) blister, approximately 8 centimeters long by 2.5 centimeters wide with the surrounding tissue noted to be reddened; a right wrist second degree burn, serous blister, approximately 1.5 centimeters long by 2.0 centimeters wide with the surrounding tissue noted to be reddened; and a right hip second degree burn, serous blister, approximately 4.0 centimeters long by 2.5 centimeters wide with the surrounding tissue noted to be reddened. The facility failed to implement the abuse policy and failed to protect the resident by stopping the use of unauthorized equipment, failed to immediately notify the supervisor of a visitor's possible use of unauthorized equipment on a cognitively impaired resident, who was unable to consent to this treatment, and resulted in actual harm to Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 07/21/2009, 12/30/2009, 08/03/2010. 28 Pa. Code: 201.18(a)(b)(2) Management. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 07/21/2009, 12/30/2009, 08/03/2010. 28 Pa. Code: 201.18(e)(1) Management. Previously cited 07/21/2009. 28 Pa. Code: 201.29(d) Resident rights. 28 Pa. Code: 211.10(d) Resident care policies. Previously cited 07/21/2009. 28 Pa. Code: 211. 12(d)(1)(5) Nursing services. Previously cited 07/21/2009, 11/21/2009, 12/30/2009, 08/03/2010.

Based on observations, clinical record review, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure the safety of a resident by providing adequate monitoring and supervision of treatments provided to the resident resulting in actual harm to Resident R1. Findings include: Review of Resident R1's clinical record revealed an admission [DIAGNOSES REDACTED]. A social service note dated March 15, 2011, at 11:00 a.m., indicated that the resident was alert at times, responded to hand holding and touch, would occasionally answer simple questions appropriately, had a [DIAGNOSES REDACTED]. Review of a facility event report electronically submitted on March 14, 2011, indicated that Resident R1's responsible party brought a chiropractor into the building the previous day, and that they were witnessed by staff using some kind of "black box with a laser" on the resident. The staff summoned the unit manager to the resident's room to find three reddened blistered areas on the resident's arm and thigh. A review of the visitors' log for March 13, 2011, indicated that Resident R1's two visitors entered the facility at approximately 11:00 a.m. Review of nursing notes dated March 13, 2011, at 2:04 p.m., revealed that the resident had a change in skin integrity on the right wrist, right arm and right hip that appeared to be second [MEDICAL CONDITION](a burn with damage down to the second layer of skin (dermis) that can produce blisters, reddened skin, severe pain and swelling). The skin integrity report dated March 13, 2011, indicated a right arm second degree burn, serous (mucous and watery discharge) blister approximately 8 centimeters long by 2.5 centimeters wide with the surrounding tissue noted to be reddened; a right wrist second degree burn, serous blister approximately 1.5 centimeters long by 2.0 centimeters wide with the surrounding tissue noted to be reddened; and a right hip second degree burn, serous blister approximately 4.0 centimeters long by 2.5 centimeters wide with the surrounding tissue noted to be reddened. A review of the facility incident/accident investigation report dated March 13, 2011, at 1:00 p.m., stated that "throughout the morning shift care was given with direct contact and visualization of the resident's body parts during care, with no signs of any reddened or blistered areas noted prior to visitors coming into room." The Director of Nursing (DON) stated during an interview on March 15, 2011, at approximately 9:00 a.m., that in January 2011, the resident's responsible party in the accompaniment of a friend, who was a chiropractor, met with him while Resident R1 was hospitalized , to discuss "building a stand box that looks like a coffin" and that the responsible party stated, he would "buy Velcro straps to tie her in the box." The DON stated further that the responsible party spoke about "laser therapy" and the chiropractor had the device with him. The device was presented and a red light would shine from the device across the room. The responsible party indicated that the laser was to be used for contractures. In addition, the DON advised both of them that nothing could be done without approval by the medical director and the attending physician. A review of physician progress notes [REDACTED]. party numerous times, most recently at the care conference in January, 2011." Review of facility incident documentation revealed a written statement dated March 13, 2011, by Employee E7, a member of the nursing staff, which stated that at 11:45 a.m., Employee E7 observed two men turning Resident R1 from side to side, lifting the resident's legs up and down, noticed a red light that resembled a pen touching Resident R1, and thought that the two men were taking pictures of the resident because the red light was beaming. There was no indication that the staff member stopped the two men or notified the supervisor of the observed activity. Review of a statement by Employee E4 (Nurse Manager) dated March 13, 2011, at 1:00 p.m., indicated that a nurse asked her to assess the resident because she had some strange marks on her arm and leg, noted three areas that appeared to be second degree burns, and that two men left after she entered the room. After Employee E4 finished the assessment, she "left the room and was told by the other nurses that the men had a laser in the room with them and were using the light on the resident." On March 15, 2011, at approximately 10:55 a.m., interview with Employee E6 (a member of the nursing staff) stated that before lunch on March 13, 2011, she observed Resident R1's door was closed. She entered the room and found two men in the room, and they looked like they were doing something together. She noticed a black box on the bed next to the resident's hip area with something pointy in contact with the hip, while it emitted a red light on the hip, and assumed one of the men was a doctor and this was some type of instrument for the resident's wound. Employee E6 stated further that she left the room, (without stopping the activity of the two men in the room), went to the nurses' station, and explained to Employee E5 (Licensed Nurse), who was on the phone with a doctor, that two men were in the room examining the resident. Employee E5 stated during an interview on March 15, 2011, at approximately 10:30 a.m., that she was taking Tylenol to Resident R1 for an elevated temperature on March 13, 2011, at 11:17 a.m. Upon entering the room, Employee E5 stated that she saw two males, one who was the responsible party, and noted that the resident was in the bed lying on her back covered with a sheet with a black box on top of the sheet placed between her knees. Further observation by Employee E5 revealed there was a cord on the box with a screen and silver writing on it. Employee E5 did not know what the box was and the responsible party raised Resident R1's right arm and said, "Look what I have noticed in the last hour; the area was hard to touch, blisters were forming, the area was bright pink and it had not been there two hours previously when you (Employee E5) changed the PEG (Percutaneous Endoscopic Gastrostomy) tube (feeding tube that is entered through the abdominal wall into the stomach) dressing." Employee E5 administered the Tylenol to the resident through the PEG tube, and then left the resident without stopping the activity of the two men. Employee E5 returned to the nurses' station, after lunch, to have the charge nurse notify the unit manager. Employee E4 (Registered Nurse Manager) stated in an interview on March 15, 2011, at approximately 9:25 a.m., that it was after lunch when the charge nurse (Employee 8) stopped her, as she was getting off the elevator, and asked her to look at Resident R1's arm. As Employee E4 entered Resident R1's room, the two men quickly left, and she noticed that the resident's right arm was swollen, red, inflamed, and there were three to six blisters. Employee E4 stated that she went back to the nurses' station, there were several staff at the desk, and she reported that the resident's arm looked like a burn. Employee E4 stated that several staff members at the nurses' station reported that the two men were observed with a laser, it had a red light, and several staff saw one man using the black box with the red light. Employee E4 stated that she caught up with the two men outside at the back steps and asked them about the laser. Resident R1's responsible party reported that he had received permission from the Director of Nursing and the Administrator to utilize the services of the chiropractor and the laser. Employee E4 reported that Resident R1's responsible party stated that he had planned on taking the resident to his home to do the treatments and that is why he brought the conversion van to the facility, but then he saw the blisters and changed his mind. Employee E4 indicated that the two men left the facility at that time, at 12:00 p.m. Employee E4 returned to the resident and found two more burns, one on the right wrist and one on the outer thigh; both were inflamed, red, and painful to the touch as evidenced by noises from the resident, with wincing and grimacing. The resident was medicated with [MEDICATION NAME] (medication used for moderate to severe pain) for pain. A physician's orders [REDACTED]. Observation of wound care for Resident R1 on March 15, 2011, at approximately 12:20 p.m., revealed that the resident's upper right forearm had a fluid filled blister approximately 8 cm long by 2.5 cm wide with the surrounding tissue noted to be reddened; the area under the right wrist revealed a fluid filled blister approximately 1.5 cm long by 2.0 cm wide with the surrounding tissue noted to be reddened; and on the outer right thigh, there was a dark red, circular area with no drainage noted which was approximately 4.0 cm long by 2.5 cm wide with the surrounding tissue appearing reddened. The resident was transferred to the hospital on March 16, 2011, for treatment of [REDACTED]." Instructions by the emergency room physician stated, "Based on our physical exam, it appears that this patient has suffered partial-thickness [MEDICAL CONDITION](described by the E.R. physician as second [MEDICAL CONDITION] blistering of the skin) on R (right) arm and R (right) thigh. Because of the appearance on the [MEDICAL CONDITION] and the well-circumscribed nature, it appears the patient was burned by an object. These do not appear the result of a systemic disease given the acuity and localization of the [MEDICAL CONDITION]. Please restrict contact with visitors whom this wound is associated until investigation is complete." There was no evidence that a plan of care had been developed following the facility's knowledge of the responsible party's desire to use unauthorized therapies to protect the resident from use of these therapies or to direct facility staff to identify the use of unauthorized therapies. The facility failed to implement interventions to protect the resident from the use of unauthorized treatments, failed to alert the staff to a visitor's possible use of unauthorized treatments, and failed to intervene in a timely manner, when unauthorized treatments were being performed on a cognitively impaired resident, which resulted in actual harm to Resident R1. 28 Pa. Code: 201.14(a) Responsibility of licensee. Previously cited 07/21/2009, 12/30/2009, 08/03/2010. 28 Pa. Code: 201.18(a)(b)(2) Management. 28 Pa. Code: 201.18(b)(1) Management. Previously cited 07/21/2009, 12/30/2009, 08/03/2010. 28 Pa. Code: 201.18(e)(1) Management. Previously cited 07/21/2009. 28 Pa. Code: 211.11(a)(b) Resident care plan. 28 Pa. Code: 211.11(d) Resident care plan. Previously cited 07/21/2009. 28 Pa. Code: 211.12 (d)(1)(5) Nursing services. Previously cited 07/21/2009, 11/21/2009, 12/30/2009, 08/03/2010.