Every finding on record at Gardens at Camp Hill, The

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for seven of 18 residents reviewed (Residents 1, 5, 20, 27, 60, 76, and 92). Findings include: Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 1's Quarterly Minimum Data Sets (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of assessment) of May 19, 2026, indicated in Section N. Medications that Resident 1 had received a diuretic (a medication that increases the passing of urine) during the assessment reference period. Review of Resident 1's clinical record revealed that his diuretic was discontinued on May 12, 2026, which was outside of the assessment look back period. During a staff interview with Employee 1 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on August 13, 2026, at 10:36 AM, Employee 1 confirmed that Resident 1's MDS was coded inaccurately. The NHA indicated that he would expect a resident's MDS's to be coded accurately. Review of Resident 5's clinical record revealed diagnoses that included depression and dementia. Review of Resident 5's Medicare/ 5 Day MDS with the assessment reference date of July 28, 2026, revealed in Section N. Medications that he was not coded as receiving an antidepressant or an antibiotic during the look-back period. Review of Resident 5's Medication Administration Record for July 2026, revealed that Resident 5 had received his ordered antidepressant and antibiotic during the look-back period. During a staff interview with Employee 1 and Employee 2 (Registered Nurse Assessment Coordinator-RNAC) on August 13, 2026, at 11:37 AM, Employee 2 confirmed that Resident 5's MDS was not coded accurately for his medications. Review of Resident 20's clinical record revealed diagnoses that included atrial fibrillation (a common irregular and fast heart rate) and hyperlipidemia (high fats in the blood).Review of Resident 20's physician orders revealed an order for oxygen at 2 liters per minute per nasal cannula every shift for shortness of breath, with a start date of May 23, 2026, and a discontinue date of June 26, 2026. Review of Resident 20's June 2026 Treatment Administration Record (TAR), Resident 20 was documented as receiving oxygen daily during that month.Review of Resident 20's Quarterly MDS dated [DATE], Section O0110. Special Treatments, Procedures, and Programs, C1. Oxygen Therapy is marked No, indicating the Resident was not receiving oxygen during the look back period.During an interview with the NHA and Director of Nursing (DON) on August 12, 2026, at 11:03 AM, revealed Resident 20's MDS completed on June 2, 2026, should have been coded for the Resident being on oxygen. Review of Resident 27's clinical record revealed diagnoses that included benign prostatic hyperplasia (noncancerous enlargement of the prostate gland causing trouble urinating) and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems). Review of Resident 27's physician orders revealed an order for 18 French foley catheter. Review of Resident 27's quarterly MDS dated [DATE], indicated Resident 27 had an ostomy. Further review of Resident 27's clinical record failed to reveal any mention of Resident 27 having an ostomy. An interview on August 12, 2026, at 10:29 AM, with the NHA and DON, revealed that the aforementioned MDS was coded incorrectly and that it was the facility's expectation that MDS reports be accurate. Review of Resident 60's clinical record revealed diagnoses that included muscle weakness, chronic pain syndrome, and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Review of Resident 60's clinical record revealed she sustained a fall at the facility on June 13, 2026. Review of Resident 60's clinical record revealed she was transferred out to the hospital on June 17, 2026. Review of Resident 60's Discharge Return Anticipated MDS with ARD of June 17, 2026, revealed she was marked as discharging to a skilled nursing facility, and she was coded no for having a fall since her prior assessment. Review of Resident 60's modification of Discharge Return Anticipated MDS with ARD of June 17, 2026, revealed she remained as coded no for having a fall since her prior assessment. During an interview with the DON on August 12, 2026, at 10:34 AM, she confirmed Resident 60 was coded inaccurately for her fall and transfer to the hospital on the aforementioned MDS assessments, and she would expect MDS assessments to be coded accurately. Review of Resident 76's clinical record revealed diagnoses that included hyperlipidemia and epilepsy (a brain disorder that causes repeated, unprovoked seizures).Review of Resident 76's clinical record revealed that she was admitted to hospice services on April 27, 2026.Review of Resident 76's annual MDS dated [DATE], Section O0110. Special Treatments, Procedures, and Programs, K1. Hospice Care B. While a resident was marked No, indicating the Resident was not receiving hospice services.During an interview with the NHA and DON on August 12, 2026, at 11:03 AM, revealed that the MDS was coded incorrectly and should have indicated the Resident was receiving hospice services at that time. Review of Resident 92's clinical record revealed diagnoses that included bipolar disorder (unusual shifts in mood, ranging from extreme highs to lows) and major depressive disorder. Review of Resident 92's discharge return not anticipated MDS dated [DATE], indicated Resident 92 was discharged to a short term hospital. Further review of Resident 92's clinical record revealed that Resident 92 was admitted to the facility from the hospital on June 23, 2026, and signed out AMA (against medical advice) June 23, 2026. An interview on August 13, 2026 at 10:54 AM, with the NHA, revealed that the aforementioned MDS was coded incorrectly and that it was the facility's expectation that MDS reports be accurate. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure the residents right to participate in the care planning process for one of one resident reviewed for participation in care planning (Resident 55); and failed to review and revise the care plan for five of 18 residents reviewed (Residents 1, 5, 8, 10, and 29). Findings include: Review of facility policy, titled Care Plans, Comprehensive Person-Centered last reviewed July 23, 2026, read, in part, Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: participate in the planning process and request meetings. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 1's care plan revealed a care plan focus for the Resident is on diuretic therapy related to hypertension dated January 15, 2025; and a care plan focus for resident has a foley catheter dated May 22, 2026. Further review of Resident 1's clinical record revealed that his diuretic and catheter had been discontinued in May, 2026. During a staff interview with Employee 1 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on August 13, 2026, at 10:36 AM, the NHA indicated that he would expect a resident's care plan to be revised accordingly when changes occur. Review of Resident 5's clinical record revealed diagnoses that included depression and dementia. Review of Resident 5's care plan revealed a care plan focus for anticoagulant therapy related to post-surgery dated May 11, 2026; antibiotic therapy related to a prosthetic knee infection dated May 11, 2026; antiplatelet therapy dated May 11, 2026, and hospice services dated July 3, 2026. Further review of Resident 5's clinical record revealed that his anticoagulant and antiplatelet medications were discontinued on June 25, 2026; his antibiotic had been completed on July 24, 2026; and that he had been discharged from hospice services on July 11, 2026. During a staff interview with Employee 1 and the NHA on August 13, 2026, at 10:50 AM, the NHA indicated that he would expect a resident's care plan to be revised accordingly when changes occur. Review of Resident 8's clinical record revealed diagnoses that included traumatic brain injury and encounter for palliative care. Observations of Resident 8 on August 10, 2026, at 10:28 AM, and August 11, 2026, at 9:39 AM and 12:21 PM, all revealed that Resident 8's oxygen concentrator was on and running, but his nasal cannula was noted to be out of his nose and laying on his chest. During an observation and staff interview with the Director of Nursing (DON) on August 11, 2026, at 1:42 PM, Resident 8 was observed to have his oxygen concentrator on and running, but his nasal cannula was noted to be out of his nose and laying on his chest. The DON indicated that Resident 8 was capable of removing the oxygen. Resident 8 was noted to have his hands up near his face. The DON indicated that staff put the cannula in place and that he takes it off. Review of Resident 8's care plan revealed a care plan focus for oxygen therapy dated August 4, 2026. Further review of the care plan failed to reveal any documentation that Resident 8 frequently removes his oxygen. During a staff interview with Employee 1 and the NHA on August 13, 2026, at 10:53 AM, the NHA indicated that Resident 8's care plan should have included that he often removes his oxygen. Review of Resident 10's clinical record revealed diagnoses that included hypertension and major depressive disorder (a mental health condition that causes a lasting sad mood, loss of joy in daily life, and low energy). Review of Resident 10's physician orders revealed the Resident was not currently prescribed any psychotropic medications.Review of Resident 10's quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) dated May 5, 2026, and August 5, 2026, Section N - Medications, A. Antipsychotic - revealed the Resident was not coded as being on any antipsychotic medications. Review of Resident 10's care plan revealed a focus area that the Resident uses psychotropic medication related to mood disturbance, initiated on September 24, 2024, and revised on February 18, 2026. During an interview with the NHA on August 13, 2026, at 10:25 AM, he revealed that he would have expected Resident 10's psychotropic care plan to have been updated once the Resident was no longer taking any psychotropic medications. Review of Resident 29's clinical record revealed diagnoses that included arthritis and repeated falls. Review of Resident 29's care plan revealed a care plan focus for the Resident wishes to discharge back to the community after rehab dated April 4, 2026; Resident is expected to be discharged home after completion of care for ambulatory dysfunction dated April 4, 2026; and Resident wishes to remain long-term care at the facility dated April 7, 2026. During a staff interview with Employee 1 and the NHA on August 13, 2026, at 12:10 PM, Employee 1 indicated that she had confirmed that Resident 29's plan was to remain at the facility long-term and that the care plan had been revised. Review of Resident 55's clinical record revealed diagnoses that included a major depressive disorder, muscle weakness, and unspecified protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets). During an interview with Resident 55 on August 10, 2026, at 12:36 PM, she revealed she does not get asked to attend quarterly care plan meetings. Review of Resident 55's clinical record failed to reveal notation that quarterly care plan meetings were held looking back in her record through August of 2025. During an interview with the DON on August 12, 2026, at 10:34 AM, she revealed she was unable to locate any quarterly care plan meetings that were held during the aforementioned time frame. She further revealed there was a lot of employee turnover in the social services department during that time that contributed to the lack of meetings held, and she would expect that care plan meetings are held on a quarterly basis. 28 Pa. Code 211.10(d) Resident care policies.28 Pa. Code 211.11(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and monitor equipment in accordance with professional standards for food service safety in two of two nourishment areas.Findings include: Review of facility policy, titled Policy: Food from Outside Sources last reviewed July 23, 2026, read, in part, Visitors/family members will label food and beverages with the resident's name, room number and date. Perishable foods with a 'use by' date which is 3 days from the date that it was brought into the facility. Food or beverage items without manufacturers expiration date that have written dates should be thrown away 3 days after the date marked. Any suspicious or obviously contaminated food or beverages should be thrown away. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Observation of the Refrigerator and Freezer Temperature Log for the First-Floor Pantry on August 10, 2026, at 9:57 AM, failed to reveal temperatures logged for August 8 and 9, 2026. During an interview with Employee 3 (Dietary Manager) on August 10, 2026, at 9:58 AM, he revealed he will do an education with the staff about recording temperatures, as they were not recorded by the weekend staff. Observation in the First-Floor Pantry Refrigerator on August 10, 2026, at 10:00 AM, revealed a to go box in a plastic bag with a resident's name and it was dated July 26; a to-go bowl container with a resident's name and not dated; and two chocolate candies on a stick without any labeling. Interview with Employee 3 on August 10, 2026, at 10:00 AM, revealed the chocolate probably belongs to staff members and he has had ongoing education with them to keep their food items out of the pantry refrigerators. Observation of the Refrigerator and Freezer Temperature Log for the Second-Floor Pantry August 10, 2026, at 10:04 AM, failed to reveal temperatures logged for August 8 and 9, 2026. Observation in the Second-Floor Pantry Refrigerator on August 10, 2026, at 10:05 AM, revealed an individual pepperoni pizza with a use by date of August 8, 2026; a small to-go box container of food without a name or date; a box of kiwi fruit dated June 5, 2026, that looked expired; and a wrapped sandwich from a fast-food restaurant dated June 9, 2026. During an interview with the Director of Nursing and the Nursing Home Administrator on August 12, 2026, at 10:19 AM, they revealed their expectation that foods items are labeled, dated, and discarded per facility policy, and equipment temperatures are logged in accordance with professional standards. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management

Based on policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call system is within reach of the resident for one of 18 residents reviewed (Resident 3).Findings include: Review of the facility policy, titled Call Lights with a last review date of July 23, 2026, revealed 3. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Review of Resident 3's clinical record revealed diagnoses that included bradycardia (slow heart rate) and hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side (total paralysis caused by a stroke). Review of Resident 3's care plan revealed a focus area that the Resident was at risk for falls related to impaired mobility secondary to CVA (cerebrovascular accident or stroke) with left side hemiplegia (paralysis), with an intervention to be sure the Resident's call light is within reach right side and encourage the Resident to use it for assistance as needed. Provide a prompt response to all requests for assistance, initiated on May 15, 2019, and revised on January 24, 2020. Observation of Resident 3 on August 10, 2026, at 11:01 AM, revealed the Resident was lying in bed with the call bell on their left side. Interview conducted with Resident 3 on August 10, 2026, at 11:01 AM, revealed the Resident was unable to use the call bell or reach it to ask for assistance due to having a stroke and being unable to use the left side of their body. Observation of Resident 3 on August 12, 2026, at 9:23 AM, revealed the Resident lying in bed with the call bell on the left side of their body, out of reach of the Resident. Resident 3 was observed yelling out for assistance from staff. Interview conducted with Resident 3 on August 12, 2026, at 9:24 AM, revealed the Resident was unable to push the call bell button to request staffing assistance. During an interview conducted with the Nursing Home Administrator and Director of Nursing on August 12, 2026, at 10:46 AM, they acknowledged Resident 3's call bell should be within reach on the right side of their bed. Pa. Code 211.12(d)(1) Nursing Services

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to promote an environment that enhances each resident's dignity by labeling residents in a public manner on one of two nursing floors observed (second floor).Findings include: Review of facility policy, titled Quality of Life-Dignity, dated August 2009, with a last policy review date of July 23, 2026, revealed, in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. 9. Staff shall maintain an environment in which confidential clinical information is protected, for example: a. Verbal staff-to-staff communication (e.g., change of shift reports) shall be conducted outside the hearing range of residents and the public. b. Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door). Observations of the second-floor nursing unit on August 10, 2026, at 11:32 AM; August 11, 2026, at 9:10 AM and 11:32 AM; revealed a dry erase board in hallway across from the nurses' station, which stated Feeds: 205A, 205B, 206A, 206B. The date written on the board was April 5, 2026. During an observation of the second-floor bulletin board and staff interview with the Director of Nursing on August 11, 2026, at 1:24 PM, she acknowledged the documentation on the board was labeling residents in a public manner and erased what was written on the board. 28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.12(d)(1)(2) Nursing services.

Based on clinical record reviews and staff interviews, it was determined the facility failed to complete a comprehensive assessment after a significant change in condition for two of 18 residents reviewed (Residents 5 and 76). Findings include: Review of Resident 5's clinical record revealed diagnoses that included moderate protein-calorie malnutrition (a nutritional deficiency caused by inadequate food intake or inadequate absorption of protein and calories) and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 5's clinical record revealed that he was admitted to hospice services on July 3, 2026. Review of Resident 5's Minimum Data Set's (MDS- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) revealed that there was not a significant change MDS completed when Resident 5 was admitted to hospice. During a staff interview with Employee 1 (Regional Director of Clinical Services) and Employee 2 (Registered Nurse Assessment Coordinator-RNAC) on August 13, 2026, at 11:37 AM, Employee 2 indicated that she should have completed a Significant Change assessment when Resident 5 signed onto hospice care. Review of Resident 76's clinical record revealed diagnoses that included hyperlipidemia (high fats in the blood) and epilepsy (a brain disorder that causes repeated, unprovoked seizures). Review of Resident 76's clinical record revealed that she was admitted to hospice services on April 27, 2026. Review of Resident 76's MDS's revealed that there was not a significant change MDS completed when Resident 76 was admitted to hospice. During a staff interview with the Nursing Home Administrator and Director of Nursing on August 12, 2026, at 10:48 AM, they revealed Resident 76 should have had a Significant Change assessment completed when the resident signed onto hospice care. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Based on facility policy review, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that a resident receives necessary treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 60).Findings include: Review of facility policy, titled Skin and Wound Management System last reviewed July 23, 2026, read, in part, It is the policy of this center's Skin Management System to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided with appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Residents identified with skin impairments will have appropriate interventions, treatment and services implemented to promote healing and impede infection. Review of Resident 60's clinical record revealed diagnoses that included muscle weakness, chronic pain syndrome, and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). Review of Resident 60's clinical record revealed she had a facility acquired deep tissue injury (injury to the skin and underlying tissue caused by prolonged pressure on the skin) to her right heel. Review of Resident 60's physician orders revealed an order for Prevalon boots (heel protector boots to help heal or reduce the risk of wounds caused by pressure) to bilateral feet, every shift, with a start date of July 23, 2026. Review of Resident 60's comprehensive care plan revealed an order for elevate heels off bed/pillows under calves of legs when in bed, last revised August 16, 2021. Observation of Resident 60 on August 11, 2026, at 10:59 AM, revealed she was in bed and her Prevalon boots were beside her bed not in place, and her heels were lying directly on her bed not elevated, no pillow was under her calf. Review of Resident 60's August 2026 TAR (Treatment Administration Record- documentation for medication/treatment administered or monitored), revealed the Prevalon boots were marked as being in place at the time of surveyor observation. During an interview with the Director of Nursing on August 12, 2026, at 10:32 AM, she revealed her expectation that devices to encourage healing of pressure ulcers should be in place as ordered and care planned. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.10(c)(d) Resident care policies

Based on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed (Resident 8).Findings include: Review of facility policy, titled Oxygen Therapy last reviewed July 23, 2026, read, in part, licensed/credentialed persons with equivalent training and documented ability to perform the tasks and may assess patients, initiate and monitor oxygen delivery systems and recommend changes in therapy. All patients starting on oxygen must have LPM (Liters per Minute) or oxygen percentage and type of device prescribed by a physician. The policy failed to reveal any oxygen administration documentation guidelines. Review of Resident 8's clinical record revealed diagnoses that included traumatic brain injury and encounter for palliative care. Observations of Resident 8 on August 10, 2026, at 10:28 AM, and August 11, 2026, at 9:39 AM and 12:21 PM, all revealed that Resident 8's oxygen concentrator was set at 4 LPM, but his nasal cannula was noted to be out of his nose and laying on his chest. During an observation and staff interview with the Director of Nursing (DON) on August 11, 2026, at 1:42 PM, Resident 8 was observed to have his oxygen concentrator on and running, but his nasal cannula was noted to be out of his nose and laying on his chest. The DON indicated that Resident 8 was capable of removing the oxygen. Resident 8 was noted to have his hands up near his face. The DON indicated that staff put the cannula in place and that he takes it off. Review of Resident 8's physician orders revealed an order for Oxygen at 2-4 LPM per Nasal Cannula for shortness of breath or comfort, dated December 10, 2025. Review of Resident 8's August 2026 Medication Administration Record revealed that his oxygen saturation was being monitored every shift, but failed to indicate what level of oxygen, if any, was being administered at the time his oxygen saturation level was obtained. During a staff interview with the DON on August 12, 2026, at 10:08 AM, the DON indicated that hospice ordered the oxygen primarily for comfort. She said that nurses would titrate oxygen between 2 and 4 LPM based on oxygen saturation levels. She indicated she would look to see where staff may be charting the actual oxygen liter flow being administered to Resident 8. During a staff interview with Employee 4 (Licensed Practical Nurse) on August 13, 2026, at 8:59 AM, she indicated that she added the oxygen liter to be documented with the oxygen saturation level. A follow-up review of Resident 8's clinical record revealed that his oxygen order had been changed to oxygen 2 LPM per nasal cannula as needed for shortness of breath or comfort on August 12, 2026. Observation of Resident 8 on August 13, 2026, at 9:49 AM, revealed that Resident 8's oxygen concentrator was on and running at 4 LPM. His nasal cannula was lying on his chest. Employee 4 was made aware of observation. Follow-up review of Resident 8's August 2026 Medication Administration Record revealed that were no signatures indicating that Resident 8 had received oxygen since the order was changed on August 12, 2026. During a staff interview with Employee 1 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on August 13, 2026, at 10:53 AM, Employee 1 indicated that typically the facility does not accept titration orders, but Resident 8's order was generated by hospice. Employee 1 indicated that since there was a titration order, staff should have been documenting Resident 8's oxygen administration level with his oxygen saturation levels. Employee 1 further indicated that the order had been revised. Observation of Resident 8's oxygen concentrator running at 4 LPM and that the lack of signatures for oxygen administration since August 12, 2026, were shared. The NHA confirmed that he would have expected staff to be clearly documenting a resident's respiratory status and interventions. 28 Pa. Code 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon timely for two of five residents reviewed for unnecessary medications (Residents 1 and 60).Findings include: Review of facility policy, titled Medication Regimen Review (Monthly Report) last reviewed July 23, 2026, read, in part, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing, the attending physician, the medical director and if appropriate the administrator. Recommendations are acted upon and documented by the facility staff and or the prescriber. The policy failed to indicate time frames for the different steps in the process of the monthly drug regimen review. Review of Resident 1's clinical record revealed diagnoses that included hypertension (high blood pressure), major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning). Review of Resident 1's clinical record revealed the consultant pharmacist completed a Medication Regimen Review (MRR) on December 5, 2025, which indicated his ordered escitalopram was due for an assessment for a gradual dose reduction (GDR- tapering reduction of a medication). The MRR revealed that the provider disagreed with the GDR, provided a rationale, and signed the form on January 12, 2026. Review of Resident 1's clinical record revealed his next monthly MRR was completed on January 8, 2026. Further review of Resident 1's clinical record revealed the consultant pharmacist completed a MRR on June 4, 2026, and made a nursing recommendation as follows: This Resident is receiving Questran (cholestyramine) bid (twice a day). Due to the potential to bind to most medications, please dose Questran at least 1 hour after taking other medications. The MRR was signed in agreement by the provider on June 9, 2026. Review of Resident 1's physician orders revealed an order for cholestyramine light packet 4 GM (grams) Give 1 packet by mouth two times a day related to hyperlipidemia (abnormally high levels of fats). Mix in 8 ounces of liquid dated May 12, 2026. The order failed to include the special dosing instructions to administer at least one hour after taking other medications. Review of Resident 1's Medication Administration Records (MAR's) from June 9, 2026, through August 12, 2026, revealed that his evening dose of the medication was changed to 6:00 PM, but his morning dose remained at 9:00 AM the same time as his other morning medications. The MAR also failed to reveal any special dosing instructions to administer at least one hour after taking other medications. During an interview with Employee 1 (Regional Director of Clinical Services) and the Nursing Home Administrator (NHA) on August 13, 2026, at 10:38 AM, Employee 1 confirmed that the evening administration time was changed when the provider signed the MRR, but the morning dose administration time was never changed. Employee 1 and the NHA both confirmed that special medication administration instructions should be included in the order which would then populate to the MAR for nurses to follow. Employee 1 also indicated that the pharmacist failed to send the monthly pharmacy reviews in December 2025 to the facility until the following month, which was why they were responded to after the January 2026 MRR's were completed. Employee 1 provided a copy of an email exchange between the Director of Nursing (DON) and the pharmacist, which revealed that the DON contacted the pharmacist on January 8, 2026, at 3:54 PM, regarding the December 2025 reviews and that the pharmacist sent the December 2025 reviews on January 8, 2026, at 4:04 PM. The NHA confirmed that he would expect pharmacy recommendations to be completed and responded to in a timely manner (prior to next review). Review of Resident 60's clinical record revealed diagnoses that included muscle weakness, chronic pain syndrome, and major depressive disorder .Review of Resident 60's clinical record revealed physician orders for: Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG, give 3 capsules by mouth one time a day related to major depressive disorder, with a start date of October 24, 2024, and a discontinued date of January 12, 2026. Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG, give 2 capsules by mouth one time a day related to major depressive disorder, with a start date of January 13, 2026, and a discontinued date of May 19, 2026. Review of Resident 60's clinical record revealed a monthly MRR dated December 5, 2025, that revealed the following: The Resident's order for [duloxetine] 90 MG is due for an assessment. GDR indicated at this time as follows: If no dose reduction is indicated, please include clinical rationale below. The MRR was signed in agreement by the provider on January 12, 2026, and noted to reduce the dose to 60 MG daily in the morning. Review of Resident 60's clinical record revealed her next monthly MRR was completed on January 7, 2026. During an interview with Employee 1 and the NHA on August 13, 2026, at 10:37 AM, Employee 1 revealed the pharmacist failed to send the monthly pharmacy reviews in December 2025 to the facility until the following month, and the policy does not outline the appropriate time frames for the different steps in the MRR process, but that timely MRRs are completed prior to the next MRR. 28 Pa Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to obtain consent prior to searching a resident's personal possessions for one of three residents reviewed (Resident 1). Findings include: Review of facility policy, titled Resident Rights last revised June 2023, read, in part, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence, and retain and use personal possessions to the maximum extent the space and safety permit. Review of Resident 1's clinical record revealed diagnoses that included pain and difficulty in walking. During an interview with the Nursing Home Administrator (NHA) on July 1, 2026, at 10:03 AM, he revealed about two weeks ago he was informed that Resident 1 had a camera in his room, so he and Employee 1 (Maintenance) went to Resident 1's room to search his room. Resident 1 was at an outing for residents outside of the facility at the time, and he was not made aware of his room search. He further revealed he found a video camera in his room, and he confiscated it and has current possession of the camera. Interview with Resident 1 on July 1, 2026, at 10:24 AM, he revealed he was at an outing away from the facility, and his roommate told him that the NHA and Employee 1 came to search his room and took his camera without his permission. He further revealed he keeps all his belongings bagged in his drawers and closet to ensure no one goes through his things, and he feels that he shouldn't have to live that way. Resident 2 (Roommate) confirmed the search to have occurred at that time and revealed he would not want that to happen to him. During a follow up interview with the NHA on July 1, 2026, at 10:58 AM, the surveyor revealed the concern with resident rights in regard to the room search without notifying the resident first, as well as the confiscation of Resident 1's personal properly. He revealed he understood the perspective of resident rights in this situation. 28 Pa. Code 201.18(b)(2) Management28 Pa. Code 201.29 (a) Resident Rights

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Policy: Storage Areas last reviewed June 5, 2025, read, in part, The kitchen manager will retain temperature logs for 12 months. Plastic containers with tight-fitting covers must be used for storing cereals, flour, and broken lots of bulk food. All containers must be legible and accurately labeled and dated. Scoops are not to be stored in food or ice containers but are kept covered in a protected area near the containers. Observation in the main kitchen on July 7, 2025, at 6:38 AM, revealed a container of bran flake cereal labeled use by May 21, 2025. Observation in the four-door reach in refrigerator on July 7, 2025, at 6:40 AM, revealed seven beverage containers with various color beverages not labeled or dated. Further observation in the four-door reach in refrigerator on July 7, 2025, at 6:41 AM, revealed a pan of individual chocolate pudding not properly covered, and the pudding appeared to be dry on the top. Observation in the two-door reach in refrigerator on July 7, 2025, at 6:43 AM, revealed two containers of a brown beverage appearing not be iced tea, not labeled and date with a use by date of June 27, 2025. Further observation in the four-door reach in refrigerator on July 7, 2025, at 6:44 AM, revealed four containers of orange juice not labeled or dated. Observation in the walk-in freezer on July 7, 2025, at 6:45 AM, revealed a frozen water bottle and frozen energy drink belonging to kitchen staff, and a bag of frozen green beans not dated and appeared to be freezer burned. Observation in the main kitchen on July 7, 2025, at 6:48 AM, revealed a container of thickener with a scoop stored inside, one container of flour, open, not sealed properly and not dated, and one bag of open milk powder not dated. Review of temperature logs for the kitchen equipment dating back to October 2024, revealed the facility was unable to locate temperature logs for the dish machine from November 2024; the three pot sink from November 2024-March 2025; the two-door reach in refrigerator from November 2024-February 2025; the four-door reach in refrigerator from November 2024-February 2025; the walk-in refrigerator from November 2024-February 2025; the walk-in freezer from November 2024-February 2025; and the stockroom from October 2024-February 2025. Review of the dish machine temperature logs provided, dating back to October 2024, revealed wash and rinse temperatures failed to be recorded on January 31, 2025, at dinner; March 7, 2025, at lunch and dinner; and April 30, 2025, at dinner. Review of the two-door reach-in refrigerator temperature logs provided, dating back to October 2024, revealed temperatures failed to be recorded on October 25-31 in AM and PM; March 1-20, 22-24, and 26-31 in PM; and April 9-20 and 22-30 in PM. Review of the four-door reach-in refrigerator temperature logs provided, dating back to October 2024, revealed temperatures failed to be recorded on October 25-31 in AM and PM; and March 1-20, 22-24, and 26-31 in PM. Review of the walk-in refrigerator temperature logs provided, dating back to October 2024, revealed temperatures failed to be recorded on October 25-31 in AM and PM; March 1-20, 22, 23, and 26-31 in PM; and April 9-20 and 22-30 in PM. Review of the walk-in freezer temperature logs provided, dating back to October 2024, revealed temperatures failed to be recorded on October 25-31 in AM and PM; March 1-20, 22, 23, and 26-31 in PM; and April 9-20 and 22-30 in PM. Review of the stockroom temperature logs provided, revealed temperatures failed to be recorded on March 1-4, 2025; and May 29-31, 2025. Interview with the Nursing Home Administrator on July 8, 2025, at 11:25 AM, revealed it was the facility's expectation that food and beverages are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards. 28 Pa. Code 211.6(f) Dietary services.

Based on observations and staff interviews, it was determined that the facility failed to ensure one of two medication storage areas observed were secure and access was limited to authorized personnel via a key (Second floor medication storage room). Findings include: During multiple observations on July 7, 2025, between 7:00 AM and 11:30 AM, it was observed that the door to the second story medication room was ajar. Further observation of the door revealed the door was prevented from fully closing due to the door catching on the door frame at the top. During the observations, staff were observed entering the second story medication room without the use of a key. On July 8, 2025,at approximately 10:05 AM, observation of the second story medication storage room revealed that the door was left ajar. At that time it was observed that no staff were present within line of sight of the medication room. At that time, the surveyor was able to access the medication storage room without a key. Observation of the medication room at that time revealed it stored multiple-dose containers of medications, injection supplies such as needles and syringes, and treatment supplies such as bandages and scissors. During an observation on July 8, 2025, at approximately 10:20 AM, while accompanied by the Director of Nursing (DON), Employee 5 was observed opening the second floor medication room door with out a key. During the observation, the DON confirmed that the facility was aware that the door did not fully close and lock as intended. During a staff interview on July 8, 2025, at approximately 11:45 AM, the DON revealed there was no outstanding work order to address the second story medication room door not closing and locking as intended. 28 Pa code 205.28(c)(3) Nurses' station

Based on review of facility meal assessment form, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide food and a beverage that were at a palatable and appealing temperatures at one of one meal observed. Findings include: Review of facility document, titled Nutrition Service Test Meal, revealed hot entrée, starch and vegetable should have a temperature of 135 degrees Fahrenheit (F- unit of measure) or above at the time of service, and cold beverages should be 40 degrees F or below at the time of service. Interview with Resident 67 on July 7, 2025, at 7:03 AM, he revealed his dislike for the food served at the facility, including the temperature, and that at times the steam table is not always functional. Interview with Resident 24 on July 7, 2025, at 7:59 AM, the Resident revealed that the hot food is not served hot. Interview with Resident 13 on July 7, 2025, at 9:50 AM, revealed her food is served cold sometimes at her meals. A test tray was completed on July 8, 2025, at 12:48 PM, upon the completion of lunch meal service on the 2nd floor with Employee 3 (Kitchen Supervisor). The tray came directly from the steam table on the unit and was tested within 2 minutes from service. The test tray consisted of Sliced Ham, Mashed Sweet Potatoes, [NAME] Beans, Coffee, and Milk. Employee 3 took the temperature of the food and beverages on the cart. The temperature of the ham was 107 degrees F, the temperature of the green beans was 109 degrees F, the temperature of the mashed sweet potatoes was 130 degrees F, and the temperature of the milk was 50 degrees F. Therefore, the food on the tray as well as the milk were not at appetizing temperatures. Interview with Employee 3 on July 8, 2025, at 12:51 PM, revealed the way the pans were arranged on the steam table created empty space in between the pans, which allowed for more heat to escape, and she planned to educate staff to ensure pans were arranged on the steam table properly. Interview with the Nursing Home Administrator on July 8, 2025, at 1:22 PM, the surveyor revealed the concern with the test tray evaluation. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review, review of Centers for Medicare and Medicaid RAI manual, and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 20 resident records reviewed (Residents 19 and 86). Findings include: Review of Resident 19's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (high cholesterol), and dysphagia (difficulty swallowing). Review of Resident 19's clinical record revealed he had facility acquired pressure ulcers (wound that occurs when the skin and tissue are damaged by prolonged pressure), had a fall without injury on February 17, 2025, had a fall with an injury on February 27, 2025, and was receiving hospice services (end of life care). Further review of Resident 19's clinical record revealed he did not have any significant weight changes around the time of May 9, 2025. Review of Resident 19's Quarterly MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical mental or psychosocial needs) with ARD (assessment reference date- last day of the reference period) of May 9, 2025, revealed Resident 19 was coded for a significant weight gain, no for receiving hospice care, no for having any falls since the previous assessment, and was coded for having community acquired pressure ulcers. During an interview with Employee 4 (MDS Coordinator) on July 9, 2025, at 10:31 AM, she revealed Resident 19's MDS assessment with ARD of May 9, 2025, was coded inaccurately for his falls, pressure ulcers, hospice care, and weight gain, and she has since modified the assessment to revise the errors. Interview with the Director of Nursing (DON) on July 9, 2025, at 11:14 AM, revealed she would expect MDS assessments to be coded accurately. Centers for Medicare and Medicaid RAI manual (Resident Assessment Instrument- a standardized process is the basis for the accurate assessment of each nursing home resident) version 3.0, October 2024, chapter 3, page 42 read, in part, discharged status documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Review of Resident 86's clinical record revealed diagnoses that included dehiscence (split open) of closure of surgical wound, COPD, diabetes mellitus (chronic metabolic disease where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels) with polyneuropathy (damage to peripheral nerves on both sides of the body causing numbness, weakness and pain), artificial hip joint, history of falling, chronic kidney disease, and muscle weakness. Resident 86 was admitted to the facility on [DATE], and billing was topped on June 7, 2025. Review of Resident 86's discharge MDS dated [DATE], documented a planned discharge return not anticipated to short-term general hospital (acute hospital). Further review of Resident 86's clinical record it was documented that she discharged home, in the community. Interview with the DON on July 9, 2025, at 11:10 AM, revealed the discharge MDS was coded incorrectly and it should've been coded for discharged to the community. 28 Pa. Code 211.5 Medical records

Based on clinical record review and staff interview, it was determined that the facility failed to complete a significant change assessment after a significant change in health status was identified in one of 20 residents reviewed (Resident 80). Findings include: Review of Resident 80's clinical record revealed diagnoses that included congestive heart failure (decreased ability of the heart to pump blood effectively throughout the body) and hypertension (elevated/high blood pressure). Review of Resident 80's completed Minimum Data Sets (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial health needs) revealed the most recently completed MDS was a Quarterly MDS with an assessment reference date of May 6, 2025. Review of the Quarterly MDS revealed Resident 80 was not coded as having either significant weight loss (Section K), nor a pressure injury (Section M). After May 6, 2025, Clinical record review revealed Resident 80 was diagnosed with a stage III pressure ulcer (injury of the skin that extends below the layers of the skin) on May 13, 2025. On June 3, 2025, Resident 80 was identified as having a significant weight loss over the previous 30-day period (weight loss of 5% or more). At the time that the significant change in Resident 80's weight was identified, Resident 80 was still receiving treatment for an active stage III pressure ulcer. Review of Resident 80's MDS history revealed that the facility failed to initiate a Significant Change MDS within 14 days of identifying two significant changes in Resident 80's health status, which would be captured under section K and section M of the MDS. During a staff interview on July 9, 2025, at approximately 12:30 PM, Director of Nursing confirmed that no Significant Change MDS was completed for Resident 80. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observations as well as resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on one of two nursing units (second floor). Findings include: Interview with Resident 67 on July 7, 2025, at 7:11 AM, it was revealed that he utilizes the shower and the bathroom in his room and feel it should be cleaner. Observation in Resident 67's bathroom on July 7, 2025, at 7:11 AM, revealed there was a black substance on the floor at the base of the three walls in the shower, the shower chair had a black substance on the mesh material that attached to the arms and seat base, and the towel hanging on the toilet seat had a faded light brown stain. The wall vent to the left of the toilet contained a dried brown substance and a dark grey fuzzy substance, and the pipes at the ceiling and ceiling vent contained a dark grey fuzzy substance. Observation and interview with Director of Nursing (DON) on July 8, 2025, at 1:40 PM, in Resident 67's bathroom revealed it was in the same condition as documented above. The DON revealed that the aforementioned areas should be clean, and the towel should be changed out daily. Interview with the DON on July 8, 2025, at 2:10 PM, it was revealed that resident bathrooms should be cleaned daily. Observation on July 7, 2025, at 6:42 AM, and July 9, 2025, at 11:00 AM, with the DON in the 2nd floor dining room, revealed the blinds on two of the six windows were broken (slats missing or broken). Also, the wall unit air conditioner under the window on the left wall, as you enter the room, had half of an orange foam pool noodle filling the gap above the unit and a piece of crumpled paper filing the space to the right of the foam. The window above the air unit contained multiple cobwebs, dried grass, and bug nests. Interview with the DON on July 9, 2025, at 11:00 AM, revealed the blinds should be replaced and the window on the left wall as you enter the dining room should be cleaned. 28 Pa. Code 201.18 (e)(1)(2.1) Management

Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure the resident has a right to personal privacy and confidentiality, including the right to privacy in his or her oral communications, for one of 20 Residents reviewed (Resident 13). Findings include: Review of facility policy, titled Quality of Life- Dignity last reviewed June 5, 2025, read, in part, Residents private space and property shall be respected at all times. Staff will knock and request permission before entering residents' rooms. Staff shall promote, maintain, and protect resident privacy. During an interview with Resident 13 on July 7, 2025, at 9:51 AM, in her room, Employee 1 (Nurse Aide) came to her doorway, entered the room without permission, and proceeded to attempt to make her bed. Resident 13 looked over at Employee 1 and stated Honey, I am trying to talk to [the surveyor]. Employee 1 then exited the room and closed the door behind him. Further into interview with Resident 13 on July 7, 2025, at 9:54 AM, in her room, her door was swung completely open by Employee 2 (Nurse Aide), without knocking, peeking in or asking permission, Employee 2 replied I am so sorry and proceeded to drop an activity calendar off on the bedside table by the door and left. Resident 13 then stated, she does that because she wants to hear everything. During an interview with the Director of Nursing (DON) on July 8, 2025, at 11:31 AM, the surveyor revealed the concern with lack of privacy for Resident 13. The DON revealed her expectation that staff would treat all residents with respect, dignity, and privacy. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations and staff interview, it was determined that the facility failed to administer medications in a safe and sanitary manner for two of three residents observed during medication administration observation (Residents 7 and 24). Findings include: is there a policy? During medication administration observations conducted on July 8, 2025, at approximately 8:30 AM, Employee 5 was observed donning gloves. Employee 5 was then observed touching multiple services of the medication cart with gloved hands. Employee 5 was also observed retrieving a blood pressure cuff from the medication cart, entering the resident room and performing a blood pressure check on for Resident 7, which required touching Resident 7's skin. Employee 5 did not remove his soiled gloves after performing the blood pressure check on Resident 7. After exiting Resident 7's room, Employee 5 was observed preparing medications for Resident 7. During preparation of Resident 7's medication, Employee 5 was observed dispensing Vitamin D3 tablets from a multi-dose container into the lid of the multi-dose container. Then, using his soiled gloved hand, Employee 5 placed a finger on one of the Vitamin D3 tablets to prevent it from falling out while he poured one tablet into a medication cup. At approximately 8:39 AM, Employee 5 was observed administering the medications to Resident 7. After medication administration to Resident 7, Employee 5 was observed retrieving the blood pressure cuff from the medication cart and performing a blood pressure check on Resident 24, which required touching Resident 24's skin. At no time did Employee 5 change gloves or perform hand hygiene between residents. After Employee 5 obtained Resident 24's blood pressure, Employee 5 began preparing Resident 24's medication. During medication preparation, Employee 5 was observed dispensing Resident 24's medications into a medication cup. Employee 5 then informed the surveyor that Resident 24's medications would be crushed. Employee 5 was then observed retrieving a medication crushing packet. As Employee 5 was pouring Resident 24's medication tablets from the medication cup into the medication crushing packet, one round white tablet was observed to fall to the surface of the medication cart. Employee 5 was observed to use his soiled gloved hand to pick up the tablet and place it in the medication crushing packet. Employee 5 then proceeded to crush the medications. At approximately 8:52 AM, Employee 5 was observed administering the crushed medications to Resident 25. After which, Employee 5 then removed his gloves and performed hand hygiene. During a staff interview on July 8, 2025, at approximately 11:45 AM, Director of Nursing revealed that Employee 5 should not have handled Resident 7 and Resident 24's medications with gloves that had made contact with surfaces of the medication cart, the blood pressure cuff, or unclean surfaces. 28 Pa code 211.12(d)(1)(5) Nursing services

Based on observation and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, homelike interior, and failed to ensure that bath linens were in good condition on two of two nursing units observed (first and second floor). Findings include: Observations made on March 26, 2025, at the noted times revealed the following: - 10:38 AM - The metal ring around the pipe coming out of the top of Resident 1's toilet was rusted and disintegrating. The towel/safety bars near the toilet were noted to have corrosion. The top of the heater unit under the sink had multiple rusty areas. - 10:40 AM - The wall outside of Resident 1's room had multiple dried liquid stains. - 10:40 AM - a washcloth in the first floor linen closet was observed to have visible brownish stains, and the corner of another was tattered. The towels in the linen closet were grayish-white in color. - 10:49 AM - The frame of the raised toilet seat in Resident 2's room was soiled and rusty. The paint on the post next to the shower and on the ceiling near the post was bubbled up and peeling in multiple areas. The towel and safety bars near the toilet were noted to have corrosion. The plate to the call bell cord next to the toilet was rusty. The heater next to the toilet had dried liquid streaks and chipped paint. - 11:10 AM - The frame of the raised toilet seat in Resident 4's bathroom was soiled, and an accumulation of dust and debris was present on the heater unit next to the toilet. - 11:12 AM - The threshold of Resident 5's bathroom was missing several tiles. Two large tiles were missing on the wall behind the toilet, the safety/towel bars were noted to have corrosion, and the heater unit next to the toilet had an accumulation of dried debris and dust. - 11:20 AM - towels and washcloths in the second floor linen closet were noted to be grayish-white in color. - 11:21 AM - the toilet paper holder in Resident 6's bathroom was noted to be crooked on the wall. It did not appear to be in use as the toilet paper was mounted on another holder. The metal bars mounted on the wall were noted to have corrosion. - 11:25 AM - The wall next to Resident 7's bed had numerous dried brown spots. The floor at the base of the wall had areas of dried liquid. The heater next to the toilet in Resident 7's bathroom was badly rusted and the metal was disintegrating in some areas. Multiple tiles were missing from the floor next to the toilet. The safety/towel bars were noted to have corrosion, as did the leg of the sink counter. Dried brown spots were present on the floor coming out of the bathroom. A clear plastic bucket with a dried brown substance was sitting on the bathroom windowsill. During an interview with Resident 2 on March 26, 2025, at 10:49 AM, she expressed concern with the cleanliness of her room and bathroom. During a tour on March 26, 2025, at 12:00 PM, with the Director of Nursing, the aforementioned areas were observed, and she acknowledged the concerns. During an interview with the Nursing Home Administrator on March 26, 2025, at 12:39 PM, he confirmed that the was aware of the aforementioned concerns. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (e)(2.1) Management

Based on policy review, clinical record review, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide care and services in accordance with professional standards of practice to ensure the resident's highest level of well-being for one of four residents reviewed (Resident 11). Findings include: Review of facility policy, Medication Administration, undated, revealed, Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label .Residents are identified before medication is administered. Methods of identification include: a. Checking identification band, b. Checking photograph attached to medical record, c. If necessary, verifying resident identification with other facility personnel .Medications supplied for one resident are never administered to another resident. Review of Resident 11's clinical record revealed diagnoses that included Cauda Equina Syndrome (occurs when the bundle of the nerves at the lower end of the spinal cord are compressed causing pain, numbness, and incontinence) and infection of intervertebral disc (located between the vertebrae in the spine). Further review of Resident 11's clinical record revealed the following nursing progress note dated February 24, 2025, this writer was with orientation prepared resident medication. gave wrong resident the medication. notified supervisor, np [Nurse Practitioner], notified resident representative. [Nurse Practitioner] ordered vss q [Vital sign each] shift, monitoring bleeding x 3 days. Per email correspondence received from the Director of Nursing (DON) on March 26, 2025, at 11:35 AM, the following medications were provided in error to Resident 11 on February 24, 2025: Cholecalciferol Oral Tablet 50 MCG (vitamin supplement), cyanocobalamin Sublingual Tablet Sublingual 5000 mcg (vitamin B12), Iron 325 mg (supplement), Magnesium lactate 84 mg (mineral supplement), Mag ox 800 mg (supplement), Apixaban 2.5 mg (anticoagulant), Lasix 40 mg (diuretic), Keppra 500mg (anticonvulsant), Senna plus (laxative), and Metoprolol 25 mg (treats high blood pressure and other heart problems). Review of facility incident report and supporting documentation dated February 24, 2025, revealed that Employee 1 (Registered Nurse), who was being oriented by Employee 2 (Licensed Practical Nurse), prepared and administered the incorrect medications to Resident 11. Further review revealed that following the incident, Employee 1 and Employee 2 were re-educated by the DON and disciplinary action was taken. During an interview with the DON and Nursing Home Administrator on March 26, 2025, at approximately 12:45 PM, they were made aware of the concern with Resident 11's medication administration error. The DON revealed that an internal plan of correction was completed following this incident. Review of Resident 11's February 2025 Treatment Administration Record (TAR) revealed that following the incident, an order was written effective February 24, 2025, to monitor her vital signs each shift for three days. Further review of the TAR revealed that this was documented as being completed. No abnormal vital signs were recorded. It was also noted that Resident 11 was monitored for side effects, including bleeding. Following Resident 11's medication error, the facility reviewed incident reports for the two weeks preceding the error, and none were found. No medication error reports were present since the time of Resident 11's medication error on February 24, 2025. Review of an education sign-in sheet revealed that education was provided to licensed nursing staff on the Ten Rights of medication administration on March 10, 2025. A Medication Administration Test was administered to attendees on that date. Review of facility audits revealed that a medication administration competency checklist was completed during medication pass observation for two nurses during the weeks of February 24, 2025, and March 10, 2025, and four were completed during the week of March 19, 2025. Observations made and resident and staff interviews conducted during the onsite survey on March 26, 2025, failed to reveal any concerns with medication administration errors. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of the pharmacy contract, medication guide review, clinical record review, and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident, which resulted in one resident not receiving their seizure medication and suffering from a seizure, for one of 24 residents reviewed (Resident 240). Findings include: Review of the Pharmacy Products and Services agreement, dated February 1, 2018, read, in part, the pharmacy shall provide pharmacy products to the facility and its residents in a prompt and timely manner. The facility will order exclusively from Pharmacy all pharmacy products and services required for individual residents. Pharmacy may assign its rights and delegate its duties and obligations under the Agreement to any other licensed entity which is owned, directly or indirectly, provided that Facility is within the geographic service area of such assignee. Review of Resident 240's clinical record revealed diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination typically caused by damage to the brain), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or stated of awareness), schizophrenia (mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, affects a person's ability to think, feel, and behave clearly), and bipolar disorder (a mental health condition alternating periods of elation and depression). Review of pre-admission hospital documentation, dated August 30, 2023, revealed that Resident 240 was hospitalized on [DATE]. The Resident has history of seizures and home medications, including Xcopri (medication used to treat seizures) 200 milligrams (mg-unit of measure) once daily and Lamictal (medication used to treat seizures) 200mg once daily. Further review of hospital documentation revealed that Resident 240 received Xcopri 200 mg once daily and Lamictal 200 mg twice daily while in the hospital, with no seizure activity noted as of August 29, 2023. Review of Hospital After Visit Summary documented Resident 24 was hospitalized [DATE], through September 22, 2023, for self-care deficit and diagnoses including seizures. Further review of the Hospital After Visit Summary medication list included Lamictal 200 mg in the morning and evening, with last dose given September 21, 2023, at 11:06 PM; and Xcopri 200 mg every morning, with last dose given September 21, 2023, at 9:23 AM. It was noted that the aforementioned medications were not administered by the hospital the morning the Resident was discharged from the hospital to the facility on [DATE]. Review of Resident 240's September 2023 Physician orders included a verbal order for Xcopri 200 mg one time a day for seizures, with a start date of September 23, 2023, and a verbal order for Lamotrigine (Lamictal) 200 mg two times a day for bipolar disorder, with a start date of September 22, 2023. Review of Resident 240's September 2023 Medication Administration Record (MAR-documentation of medication administration) included Xcopri 200 mg at 9:00 AM, start date September 23, 2023, at 9:00 AM, documented 16 (hold, see nurse's note) on September 23rd and 24th, 2023. Further review of the MAR documented Lamotrigine (Lamictal) 200 mg at 9:00 AM and 5:00 PM, start September 22, 2023, at 5:00 PM, medication was documented as administered per physician orders. Review of progress notes dated September 22, 2023, read in part, admitted at 10:00 AM from the hospital, call placed to facility Physician (Employee 1) who was in the facility at time of Resident's arrival; and orders were reviewed and verified. Review of a progress note dated September 23, 2023, at 9:10 AM, read, in part, Xcopri 200 mg one time a day for seizures not available, supervisor aware. Progress note dated September 24, 2023, at 1:34 PM, read, in part, Xcopri 200 mg one time a day for seizures, awaiting from pharmacy. Progress note dated September 24, 2023, at 10:50 PM, read, in part, Resident had a seizure at 10:15 PM today, which lasted for three minutes. Resident has history of seizures/has routine seizure medication, Xcopri 200 mg, which he gets in the morning; however, it wasn't administered related to waiting from pharmacy. Progress note dated September 24, 2023, at 11:22 PM, read, in part, pharmacy was called regarding Resident's medication and a copy of the physician orders faxed to pharmacy; endorsed to night shift to follow-up. Progress note dated September 25, 2023, at 5:00 AM, read, in part, Resident found on floor beside left side of bed with Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) tube in his hand; PEG site cleansed and a dressing was applied. Unable to understand the Resident as to what happened. Nursing Assistant provided incontinence care at 4:00 AM. At time of fall, floor was dry, brief was wet, bed was in low position and locked, the Resident was alert and responding per baseline. Resident's mother was notified, and requested he be sent out for evaluation and PEG replacement. Ambulance transported the Resident at 5:25 AM. Review of prescriptions sent to pharmacy revealed two prescriptions were sent to the contract pharmacy for Xcopri; one on September 22, 2023, for 30 tablets, and a second on September 24, 2023, for 30 tablets. Review of the physician's (Employee 1) History and Physical dated September 24, 2023, at 10:19 PM, documented a diagnosis of seizure disorder. Xcopri and Lamictal were ordered for seizures, and both orders were active. Care plan and medication list were documented as reviewed; continue current medications, management, and interventions. There was no documentation regarding Xcopri not available from the pharmacy and the Resident having missed two doses of the medication. During an interview on September 27, 2023, at 1:45 PM, with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Employee 3 (Registered Nurse), it was revealed that Xcopri is a controlled medication and requires a prescription. It was also revealed that the pharmacy didn't have the medication in stock and failed to communicate that to the facility. The NHA noted that Resident 240 was ordered and administered Lamictal, which is a medication used to treat seizures and bipolar disorder, and Resident 240 was receiving the medication for seizures. The incorrect diagnoses was documented on the physician orders, per hospital discharge summary and the Physician's history and physical. The Lamictal was being administered for seizures. During the interview, Employee 3 stated that there are two local pharmacies that the contract pharmacy should utilize if they don't have a required medication in stock. There is a process in place where the local pharmacies utilize a transportation company to deliver medications to the facility. Review of Employee 2's (Registered Nurse Supervisor) phone statement obtained by the DON, dated September 27, 2023, revealed that he was notified the Xcopri wasn't available for administration on September 23rd, 2023; at which time, he called the pharmacy and then the physician. He obtained the prescription, sent it to the pharmacy, and confirmed the pharmacy received the prescription. He reviewed the process with the night shift supervisor to ensure the appropriate people were notified. It was revealed that on September 24, 2023, the physcian (Employee 1) was in the building and assessed Resident 240. Employee 2 stated he spoke with Employee 1 regarding Resident 240's status and his medication. On September 24, 2023, Employee 2 contacted the pharmacy again, at which point he was told Xcopri wasn't in stock and it would be delivered on September 25th, 2023. During a phone interview with Resident 240's physician, Employee 1, on September 28, 2023, at 10:30 AM, it was revealed he was not notified that the Xcopri was unavailable or that Resident 240 missed two doses. Employee 1 stated that he wouldn't of ordered another medication, his recommendation would've been to send the Xcopri perscription to another pharmacy to obtain the Xcopri as soon as possible. Xcopri prescribing medication guide, revised June 2022, read, in part, withdrawal of Xcopri - advise patients not to discontinue use of Xcopri without consulting with their healthcare provider. Xcopri should normally be gradually withdrawn to reduce the potential for increased seizure frequency and status epilepticus (seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures). Review of Resident 240's hospital discharge summary dated September 29, 2023, noted that the dislodged PEG tube was not replaced. It also noted that the dislodged PEG tube was likely accident due to fall, there was no documentation about breakthrough seizure prior to arrival {to hospital}. Further review of the discharge summary notes a history of traumatic brain injury/cognitive decline and history of seizure disorder. The hospital physician gave instructions to the facility for Resident 240 to continue taking antiseizure medication because even with medication he is low threshold [more likely] to have a breakthrough seizure because of his previous history of traumatic brain injury. During an interview on September 28, 2023, at 12:00 PM, with the NHA, it was revealed that he would expect pharmacy to contact the facility if a prescribed medication wasn't readily available. Further, the NHA stated if a substitute medication wasn't applicable, the contract pharmacy should utilize a local pharmacy to fulfill the prescription. The pharmacy failed to provide and facility failed to obtain and administer a prescribed seizure medication, which lead to one Resident missing two doses of a seizure medication and having a seizure. 28 Pa. Code 201.14(a) Responsibility of Licensee 211.9(a)(1)(4) Pharmacy services 211.10(c) Resident Care Policies 211.12(d)(5) Nursing Services

Based on observation, clinical record review, review of facility policies and staff interviews, it was determined that the facility failed to create an infection prevention and control program and follow infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections and prevent cross-contamination during the COVID-19 pandemic for one out of two nursing units (first floor nursing unit). This failure placed the facility in an Immediate Jeopardy situation. Findings Include: Review of the facility policy titled, Coronavirus (Covid-19) Policy dated May 14, 2021, revealed under title, Managing a confirmed, suspected or patient under investigation (PUI) confirmed Covid-19 individual states upon identification, place the [Covid-19 Positive] individual in a private room (if available) with a closed door and a dedicated bathroom, They may also be cohorted with other residents with the same infectious status. The policy further revealed under the title, Prevention to ensure staff clean their hands according to CDC guidelines, including before and after contact with patients, after contact with contaminated surfaces or equipment, and after removing personal protective equipment. Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated March 29, 2021, revealed Ideally a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection do not need to be placed into an airborne infection isolation room but should be cared for by healthcare personnel using an N95 or higher-level respirator, eye protection (i.e., goggles or face shield that covers the front and sides of the face), gloves and gown. Review of the Pennsylvania Health Alert Network (PA-HAN) 570, with the subject: Response to an Outbreak and Residents with Exposure to COVID-19 for Long-term Care Facilities dated May 10, 2021 revealed that isolation for residents refers to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, HCP (health care personnel), or visitors. Isolation in long term care residents includes: Use of standard and transmission-based precautions, private rooms with private bathrooms or with another resident with confirmed COVID-19 and restrict resident to room with the door closed .Transmission-based precautions for COVID-19: HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Review of clinical records and facility documentation revealed seven residents that tested positive for Covid-19 on September 8, 2021 (Resident 5, 11, 14, 44, 56, 57, and 69). Six Covid-19 negative residents were residing in the same room with those positive residents (Residents 7, 24, 28, 41, 64, and 83). During an interview with the Nursing Home Administrator (NHA) on September 9, 2021 at 10:15 AM, it was revealed that they would not be changing rooms for Covid-19 positive residents who were sharing a room with Covid-19 negative residents. Observation on September 7, 2021, at 8:45 AM revealed Nurse Aide (NA) 1 standing at the first floor nursing station with her mask pulled down, not covering her mouth or nose. On September 7, 2021, at 1:36 PM revealed NA 1 walking down the hallway on the first floor nursing unit with her mask pulled down under her chin, not covering her mouth or nose. Observation on September 7, 2021, at approximately 11:30 AM revealed Dietary Aide (DA) 1 on the second floor, standing in the hallway near the dining room. Dietary Aide 1 was observed with his mask pulled down, not covering his mouth or nose. On September 8, 2021, at 1:15 PM the Nursing Home Administrator and Director of Nursing were made aware of the above observations. Further observation on September 8, 2021, at 2:48 PM revealed an X-ray technician standing at the first floor nurse's station with the strap of the mask hanging from his right ear, not covering his mouth or nose. On September 9, 2021, at 9:35 AM the Nursing Home Administrator and Director of Nursing were made aware of the above observation. Observation on September 9, 2021, from 7:58 AM to 8:30AM, revealed DA 1 was stationed in the hallway on the first floor nursing unit south hall, which is a designated isolation zone containing Covid-19 positive patients. DA 1 was wearing a surgical mask while preparing resident's breakfast plates from the steam table. Observation on September 9, 2021 at 8:00 AM, revealed Resident 11's room had a red paper on the door stating red zone with the door open. Further observation revealed Resident 44's room had Red Zone signage next to door on shelving units and the door to room was open. Interview with Registered Nurse (RN) 1 on September 9, 2021 at 8:04 AM revealed resident rooms with positive Covid-19 residents have shower curtains hanging on the door frame to separate the room from the hall. Surveyor asked RN 1 about Resident 11's room and Resident 44's room with Red Zone signage and if they had positive Covid-19 residents inside, RN 1 stated she was unsure if those residents were positive. Observation of Maintenance Employee (ME) 1 on September 9, 2021, at 8:07 AM, revealed ME 1 wearing a surgical mask, face shield, and gown. ME 1 entered the room of Covid-19 negative Residents 63 and 34, when ME 1 exited room he did not remove the gown or perform hand hygiene. ME 1 then entered the room of Covid-19 positive Resident 11 and Covid-19 negative Resident 41, when he exited the room, he did not remove the gown or perform hand hygiene. ME 1 then entered the room of Covid-19 negative Residents 65 and 78, when ME 1 exited the room he did not remove the gown or perform hand hygiene. ME 1 then entered the room of Covid-19 negative Residents 10 and 15, ME 1 then exited the room, removed the gown and discarded it in the trash can. ME 1 did not perform hand hygiene after gown removal. Observation on September 9, 2021 at 8:26 AM, Revealed RN 2 entered Resident 89's room in the isolation zone. RN 2 was wearing a gown, a N95 mask, face shield, and gloves to check Resident 89's blood sugar level. RN 2 exited the resident's room, removed gloves and performed hand hygiene. RN 2 did not remove the gown and entered the hallway to gather medications from the medication cart. RN 2 then returned to resident's room to administer medications. RN 2 exited Resident 89's room and returned to the medication cart without removing gown. RN 2 then started to prepare medication for a resident in a different room with same gown on. ADON witnessed RN 2 not removing gown when leaving resident's rooms and spoke with RN 2 regarding proper gown changing procedures. RN 2 removed the gown and placed it in the trash. During an interview with the Assistant Director of Nursing (ADON) on September 9, 2021 at 8:30 AM, she stated that it is required for all staff to wear N95 masks and face shields at all times on the first floor (red/yellow zone). When staff enter patient rooms, they are to be wearing an N95 mask, face shield, gloves, and a gown. The gown needs to be changed between each resident and hand washing or sanitizing needs to be completed. ADON stated Resident 11 and Resident 44's room with Red Zone signage both have Covid-19 positive residents inside, and they should have shower curtains over door frame. Observation on September 9, 2021 at 8:40AM revealed ADON talked with DA 1 and DA 1 applied an N95 mask. Observation on September 9, 2021 at 8:45AM revealed ADON talked with ME 1 and ME 1 applied an N95 mask. Observation of Dietary Aide (DA) 2 on September 9, 2021 at 8:48 AM, revealed DA 2 entered the First floor nursing unit North Hall, which is a designated Covid isolation area, with only a surgical mask on. The ADON stopped DA 2 and told him he needed to be wearing an N95 mask and face shield. DA 2 stated, they told me already, I just got here ADON went to supply area and provided DA 2 with N95 mask and he stated, no I'm not wearing that, they don't fit because of my beard. The ADON gave him a shield and said wear this for now. The ADON told the surveyor she was going to report his behavior and he would have to leave if he did not put on an N95 mask. ADON alerted surveyor at 8:55 AM that she found DA 2 a larger N95. The ADON stated DA 2 stated he would not wear it then I told him he would have to leave so he put in on. Interview with NHA on September 9, 2021 at 11:30 AM, revealed DA 2 was not fit tested for an N95 Mask in April due to his beard. NHA states he was asked to shave his beard and he refused. NHA stated he was educated about proper fit of the N95 mask and removal of beard. Surveyor asked about further steps to fit test for N95 or enforce wearing mask and NHA states she did not believe it went further than that. During an interview with ME 1 on September 9, 2021 at 11:00 AM revealed he was educated upon hire and two days prior to observation, regarding need for N95 mask, face shield, and gown. Surveyor asked ME 1 about observation of ME 1 wearing a surgical mask in place of N95 and not changing gown between resident rooms, ME 1 stated he did not realize he still had a surgical mask on and thought he had changed it. ME 1 stated he thought the changing of the gown had something to do with direct contact, but he must have misunderstood, and he should have changed his gown. On September 9, 2021, at 12:03 PM the NHA and the Director of Nursing (DON) were made aware that an immediate Jeopardy existed due to failing to follow infection control guidelines from the CDC and the PA DOH to reduce the spread of infections and prevent cross-contamination during the Covid-19 pandemic and that a corrective action plan was required. The IJ template was provided to the NHA at this time. On September 9, 2021, at 7:27 PM an acceptable corrective action plan was approved which included the following interventions: Immediate Actions: 1. All rooms identified with COVID positive residents have had a barrier installed on the doorway or the door has been closed. 2. A whole house audit of rooms where COVID positive residents reside has been completed on 9/9/2021 to ensure a barrier is installed on the doorway or the door has been closed. Any additional rooms with COVID positive residents will have a barrier installed on the doorway or the door has been closed. All residents have been tested and all COVID positive residents are currently being cohorted according to COVID status. Outbreak testing will be completed per CDC guidance. 3. The central supply clerk, the maintenance assistant, the dietary aide, and the LPN identified will be re-educated on proper PPE usage for each of the red, yellow, and green zones. PPE donning and doffing, and the hand hygiene policy prior to the start of their next shift by the Director of Nursing/Designee. All staff in Nursing, Dietary, Housekeeping, Maintenance, Therapy, Activities, and Administration will be re-educated on proper PPE usage for the red, yellow, and green zones, PPE donning and doffing, and the hand hygiene policy prior to the start of their next shift by the DNS/Designee. All staff in Nursing, Dietary, Housekeeping, Maintenance, Therapy, Activities, and Administration will be re-educated on ensuring rooms that have covid positive residents in them will have a barrier installed on the doorway or the door closed prior to the start of their next shift by DNS/designee. Education for staff currently working is ongoing. This education will be completed by 9/1/2021. System Revision: 1. Any staff who are unable/unwilling to comply with PPE requirements will not be allowed to work on yellow/red zones. Facility will develop a policy and procedure for staff who refuse to comply with PPE requirements. On-going monitoring: 1. Administration/Designee will randomly audit rooms with covid positive residents to ensure they have a barrier on the doorway, or their door is closed. These audits will be conducted and documented each shift x1 week, then daily x1 week, then 3x per week x 2 weeks, the 1x per week x 2 weeks to ensure substantial compliance has been maintained. 2. Director of Nursing Services/Designee will do random observations of staff on red/yellow units to ensure proper PPE is being utilized, proper donning/doffing of PPE is occurring, and appropriate hand hygiene is being utilized. These audits will be conducted and documented each shift x1 week, then daily x1 week, then 3x per week x 2 weeks, the 1x per week x 2 weeks to ensure substantial compliance has been maintained. 3. Audits will be presented to the QAPI committee for further review and recommendation Observation on September 10, 2021, at 9:15 AM revealed COVID-19 positive Residents 5, 11, 14, 44, 56, 57, and 69 were cohorted together based on infectious status and had either the door closed or a barrier to the hallway in place. Observations on September 10, 2021 between 9:15 AM to 10:00 AM, revealed all staff wearing appropriate PPE, donning and doffing correctly, and performing hand hygiene appropriately. Staff interviews completed on September 10, 2021, between 9:15AM and 10:00AM, with multiple departments, revealed that staff had been educated prior to shift and were knowledgeable regarding proper PPE to be worn throughout red, yellow, and green zones, donning and doffing procedure, hand hygiene, and doors to covid positive resident rooms needing to remain closed or have a barrier in place at all times. Staff In-service education reviewed on September 10, 2021, at 10:15 AM for evening shift September 9, 2021 and first shift September 10, 2021. Training completed included the topics of infection control regarding appropriate PPE in green, yellow, and red zones, PPE donning and doffing procedure, hand hygiene procedure, facemask dos and don'ts, Respirator on/Respirator off, caring for patients with confirmed or suspected Covid-19, green zone, yellow zone, and red zone, barriers for Covid positive resident doors, and refusal of N95 masks. Audits completed September 9, 2021 for 3PM to 11 PM shift and 11 PM to 7AM September 10, 2021 shift regarding staff donning/ doffing PPE appropriately, staff performing hand hygiene appropriately, staff using proper PPE for the different zones, and Covid positive rooms having barrier on doorway or door is closed. On September 10, 2021, at 10:48 AM the NHA was made aware that the Immediate Jeopardy was removed. 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on observation, review of clinical records, facility documentation, and interviews with staff and residents, it was determined that the facility failed to adequately supervise and implement interventions for each resident and their environment to ensure that the residents remained free of accident hazard risks created by a fall for one of three residents reviewed (Resident 1) who broke a window in her room and fell to the ground from the second floor of the building resulting in internal bleeding in the skull. Findings include: Review of Resident 1's clinical record revealed the resident was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. Review of a behavioral progress note by Certified Registered Nurse Practioner (CRNP) 1 dated (MONTH) 3, 2019, revealed chief complaints of [MEDICAL CONDITION], delusional thoughts, and visual hallucinations. Resident 1 revealed she was given a [DIAGNOSES REDACTED]. The note stated to continue to monitor for worsening [MEDICAL CONDITION]. Review of a progress note dated (MONTH) 11, 2019, reported, Psychiatrist was here yesterday and Resident's psychiatric medications were discussed. Psychiatrist suggest we continue one on one (1:1), distraction, and redirection as needed. Review of Resident 1's plan of care dated (MONTH) 14, 2019, revealed, a problematic manner in which resident acts characterized by ineffective coping, behaviors related to depression, attempted to open a window on admission, and talks to the curtains. Intervention listed was 1:1 monitoring as needed and Crisis Intervention if needed. With a resolved date of (MONTH) 22, 2019, two days after Resident 1 was found outside on the ground, after falling from the second-floor window in her room. Progress note dated (MONTH) 13, 2019, at 10:02 AM reports Resident 1 pacing in her room and hallway, speaking loudly in Spanish, and talking to her wall, pillow, and door. The resident was looking around as though someone was standing behind her. Resident was laughing loudly, having an extensive conversation with herself, and telling everyone that her cousin and husband were in a fatal accident. She was also noted looking out the window and trying to lift the window up. A wander guard (a device designed to alarm staff when a resident attempt to leave the facility without supervision) was placed on resident's right ankle and maintenance secured the windows in the resident's room. CRNP was notified and resident was placed on 1:1 as needed, with q 30-minute checks. Review of a progress note dated (MONTH) 20, 2019, at 4:34 AM revealed Resident 1 wandering about her room, constantly looking out her bedroom window, and claiming to be talking to family members. Resident was not sleeping tonight and just continued to wander throughout her room. Wander guard remained in place. Review of a progress note dated (MONTH) 20, 2019, at 5:30 AM revealed privacy curtain was pulled in front of resident's window and window curtain were used to detour Resident 1 from looking out the window, due to hallucinations. Resident did sit on her bed and was redirected with some effect. Resident 1:1 with nurse aide when she wandered out of her room at the end of the south hallway. The resident was pleasant and cooperative with redirection from nurse aide, no exit seeking behavior observed. Review of a progress note dated (MONTH) 20, 2019, at 2:14 PM reported, Resident 1 left for [MEDICAL TREATMENT] in stable condition, vital signs stable. When the nurse entered Resident 1's room this morning, resident was very tearful and stated her brother died . Resident then began to talk to the air and curtains. Attempted to redirect resident by taking her to activities, which resident calmed down a little. Review of [MEDICAL TREATMENT] Communication form dated (MONTH) 20, 2019, revealed [MEDICAL TREATMENT] shortened by 1.5 hours, patient agitated, paranoid (excessive or irrational suspiciousness and distrustfulness of others), believes someone is out to kill her? Hallucinations. Attempts to get out of the chair pulling on her line. Review of progress note dated (MONTH) 20, 2019, at 10:18 PM revealed call was received from [MEDICAL TREATMENT]. Nurse stated that she stopped resident's treatment 1.5 hours early, as resident was agitated, and the [MEDICAL TREATMENT] nurse was worried she would pull the catheter (tubing) out. Resident 1 returned to the facility at approximately 4:15 PM. Resident stood against the wall near the dining room and was asked if she was going to go in for dinner, and she stated, later. A staff member brought her a chair, but she did not want to sit. Resident did not appear agitated or anxious. Approximately ,[DATE] minutes after returning from [MEDICAL TREATMENT], one of her roommates came out of the room stating, Resident 1 is going to break the window and jump out! Another staff member and I ran to her room. The window was broken out almost completely. Resident was not in the room and there was blood on the ledge. We observed the resident lying on her back on the ground below. We rushed outside. Resident was alert, was able to state her name and date of birth. Pupils equal, round and reactive. She had a laceration to the right hand and wrist. Emergency Medical Services (EMS) arrived and resident left by ambulance. Review of facility provided documentation dated (MONTH) 20, 2019, at 4:38 PM revealed that Resident 1 broke the glass of her window with her television, sat on the window ledge, and jumped out the window. Resident 1 was stabilized until Emergency Medical Services arrived. Medical Doctor notified. No injuries observed. Review of a facility provided witness statement dated (MONTH) 20, 2019, by Transport Driver 1 revealed when asked how Resident 1 was upon picking her up from [MEDICAL TREATMENT], the reply was she was agitated but redirectable, and she followed directions. When you say she was agitated what was she doing? She was hallucinating, waving to people that weren't there. Review of hospital records dated (MONTH) 20, 2019, revealed Multiple [MEDICAL CONDITION] (bleeding within the skull), Subdural hematoma (collection of blood outside the brain), Subarachnoid hematoma (the inner most area that surrounds the central nervous system) and laceration to right wrist with sutures (stitches). An interview with Resident 2 on (MONTH) 22, 2019, at 11:00 AM revealed that she had been in bed on Saturday ([DATE]) afternoon when she heard glass break. Got up to see roommate sitting on the window ledge facing outside, immediately went to get help, and when she returned to the room her roommate was on the ground. Resident 2 stated roommate had been pounding on the door and window trying to get out. Staff told her to go back to bed. Roommate also tried to open the window a few days prior, to let her daughter in. During an interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 22, 2019, at 11:00 AM revealed they had no policy for the use of 1:1 as needed, when to implement it, who is to implement it, and how long does it last. During an interview with the Nursing Home Administrator on (MONTH) 22, 2019, at 2:00 PM she revealed the resident was only back from [MEDICAL TREATMENT] 15 minutes and she was fine. The facility failed to adequately supervise and implement interventions for each resident and their environment to ensure that the residents remained free of accident hazard risks created by a fall from a window for (Resident 1) who broke a window in her room and fell to the ground from the second floor, resulting internal bleeding in the skull. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.18(e)(1) Management. Previously cited [DATE]. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. Previously cited [DATE]. 28 Pa. Code 211.12(c) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited [DATE], [DATE].

Based on review of job descriptions, facility policies and clinical records, observations and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure that staff are provided guidance on the implementation of one on one to maintain resident safety for one of three resident reviewed (Resident 1) who broke a window in her room and fell to the ground from the second floor resulting in harm, internal bleeding in the skull and hospitalization . Findings include: The job description for the NHA specified the primary purpose of the job position is to manage the facility in accordance with current applicable federal, state and local standards, guidelines and regulations that govern long-term care facilities. To ensure the highest degree of quality care is always provided to all residents. The job description for the DON specified the purpose of the job position was to plan, organize, develop, and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility to ensure that the highest degree of quality of care is always maintained. During an interview with the NHA and DON on (MONTH) 22, 2019, at 11:00 AM revealed they had no policy for the use of one on one (1:1) as needed, when to implement it, who is to implement it, and how long does it last. Review of Resident 1's clinical record revealed, the resident was admitted to the facility on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. Review of a progress note dated (MONTH) 11, 2019, stated Psychiatrist was here yesterday and Resident's psychiatric medication were discussed. Psychiatrist suggest we continue 1:1 distraction and redirection as needed. Review of Resident 1's plan of care dated (MONTH) 14, 2019, revealed, a problematic manner in which resident acts characterized by ineffective coping, behaviors related to depression, attempted to open a window on admission, and talks to the curtains. Intervention listed was 1:1 monitoring as needed and Crisis Intervention if needed. With a resolved date of (MONTH) 22, 2019, two days after Resident 1 was found outside on the ground, after falling from the second-floor window in her room. Progress note dated (MONTH) 13, 2019, at 10:02 AM reports Resident 1 pacing in her room and hallway, speaking loudly in Spanish, and talking to her wall, pillow, and door. The resident was looking around as though someone was standing behind her. Resident was laughing loudly, having an extensive conversation with herself, and telling everyone that her cousin and husband were in a fatal accident. She was also noted looking out the window and trying to lift the window up. A wander guard (a device designed to alarm staff when a resident attempt to leave the facility without supervision) was placed on resident's right ankle and maintenance secured the windows in the resident's room. Certified Registered Nurse Practioner (CRNP) was notified and resident was placed on 1:1 as needed, with q 30-minute checks. Review of a progress note dated (MONTH) 20, 2019, at 4:34 AM revealed Resident 1 wandering about her room, constantly looking out her bedroom window, and claiming to be talking to family members. Resident was not sleeping tonight and just continued to wander throughout her room. Wander guard remained in place. Review of [MEDICAL TREATMENT] Communication form dated (MONTH) 20, 2019, revealed [MEDICAL TREATMENT] shortened by 1.5 hours. Patient agitated, paranoid (excessive or irrational suspiciousness and distrustfulness of others), believes someone is out to kill her? Hallucinations. Attempts to get out of the chair pulling on her line. Review of progress note dated (MONTH) 20, 2019, at 10:18 PM revealed call was received from [MEDICAL TREATMENT]. Nurse stated that she stopped resident's treatment 1.5 hours early, as resident was agitated, and the [MEDICAL TREATMENT] nurse was worried she would pull the catheter (tubing) out. Resident 1 returned to the facility at approximately 4:15 PM. Resident stood against the wall near the dining room and was asked if she was going to go in for dinner, and she stated, later. A staff member brought her a chair, but she did not want to sit. Resident did not appear agitated or anxious. Approximately 10-15 minutes after returning from [MEDICAL TREATMENT], one of her roommates came out of the room stating, Resident 1 is going to break the window and jump out! Another staff member and I ran to her room. The window was broken out almost completely. Resident was not in the room and there was blood on the ledge. We observed the resident lying on her back on the ground below. We rushed outside. Resident was alert, was able to state her name and date of birth. Pupils equal, round and reactive. She had a laceration to the right hand and wrist. Emergency Medical Services (EMS) arrived and resident left by ambulance. Review of a facility provided witness statement dated (MONTH) 20, 2019, by Transport Driver 1 revealed when asked how Resident 1 was upon picking her up from [MEDICAL TREATMENT], the reply was she was agitated but redirectable, and she followed directions. When you say she was agitated what was she doing? She was hallucinating, waving to people that weren't there. Review of hospital records dated (MONTH) 20, 2019, revealed Multiple [MEDICAL CONDITION] (bleeding within the skull), Subdural hematoma (collection of blood outside the brain), Subarachnoid hematoma (the inner most area that surrounds the central nervous system) and laceration to right wrist with sutures (stitches). An interview with Resident 2 on (MONTH) 22, 2019, at 11:00 AM revealed that she had been in bed on Saturday (April 20, 2019) afternoon when she heard glass break. Got up to see roommate sitting on the window ledge facing outside, immediately went to get help, and when she returned to the room her roommate was on the ground. Resident 2 stated roommate had been pounding on the door and window trying to get out. Staff told her to go back to bed. Roommate also tried to open the window a few days prior, to let her daughter in. During an interview with the NHA on (MONTH) 22, 2019, at 2:00 PM she revealed the resident was only back from [MEDICAL TREATMENT] 15 minutes and she was fine. The facility failed to ensure that staff are provided guidance on the implementation of 1:1 to maintain safety for (Resident 1) who broke a window in her room and fell to the ground from the second floor resulting in harm, internal bleeding in the skull and hospitalization . 42 CFR 483.70 Administration. Previously cited 3/9/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 3/14/19, 3/9/18. 28 Pa. Code 201.18(a)(e)(2) Management. 28 Pa. Code 201.18(b)(1)(3) Management. Previously cited 3/14/19, 3/9/18. 28 Pa. Code 201.18(e)(1) Management. Previously cited 3/14/19. 28 Pa. Code 211.12(a) Nursing services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/14/19, 12/6/18, 3/9/18 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/14/19, 3/9/18.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that neurological checks were performed following a fall for one out of six residents reviewed (Resident 1) and that physician's orders [REDACTED]. Findings include: Review of the facility's current neurological check (assessment of the nervous system) policy revealed that neurological checks shall be documented on the designated record (neurological assessment form) and changes in neurological status, should be reported immediately to the resident's physician by licensed nursing staff. The neurological assessment should include: date and time, level of consciousness, eye opening, verbal response, motor response, pupillary response, limb response and vital signs. Review of the clinical record for Resident 1 revealed [DIAGNOSES REDACTED]. Review of an incident report revealed that Resident 1 had an unwitnessed fall on April 17, 2017. The fall report indicated the immediate resident protection that was initiated was neurological checks and a pressure alarm placed on the bed. Further review of the clinical record revealed that there was no evidence of a neurological assessment form completed following the fall on April 17, 2017. During an interview with the Director of Nursing on June 30, 2017, at 8:45 a.m. she confirmed that neurological checks should be documented on the neurological assessment form following a fall. Review of Resident 3's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 3's current physician's orders [REDACTED]. [REDACTED]. Review of Resident 3's clinical record revealed that from June 17, 2017, through June 21, 2017, Resident 3 did not have a bowel movement. Review of Resident 3's Medication Administration Record [REDACTED]. Resident 3 was not given Milk of Magnesia until June 22, 2017, which was day six of no bowel movement. Further review of Resident 3's MAR indicated [REDACTED]. During an interview with the Director of Nursing on June 30, 2017, at 8:50 a.m. she stated that she would expect that the staff would follow the bowel protocol. Review of Resident 6's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 6's plan of care revealed an intervention dated October 19, 2016, to report to Nursing/Physician any changes in poorly healing wounds. Review of the clinical record revealed that on May 31, 2017, Resident 6 was seen by a podiatrist (foot physician) and was diagnosed with [REDACTED]. Review of Resident 6's facility form titled, Wound Evaluation Flow Sheet Weeks revealed that LPN 1 completed a wound evaluation on May 31, 2017, which measured the(NAME)Type 1 Ulcer to be 1 cm (centimeter) long by 1.6 cm wide by 0.1 cm deep. The wound bed was assessed as 75% slough (dead tissue separated from living tissue) and 25% necrosis (the death of most or all of the cells in an organ or tissue). The wound evaluation completed by LPN 1 on June 7, 2017, revealed the(NAME)ulcer was increasing in size and was now 1.6 cm long by 1.6 cm wide by 0.1 cm deep with 75% slough and 25% necrosis. The wound evaluation on June 14, 2017, revealed the(NAME)ulcer was 1.6 cm long by 1.4 cm wide by 0.1 cm deep with 100% slough. Review of Resident 6's clinical record revealed no evidence that the physician was notified of the increase in size of the(NAME)ulcer as written in the care plan. On April 5, 12, 19, 26, and 31, 2017, a Weekly Skin Review was completed by Licensed Practical Nurse (LPN) 1 that revealed scabbed areas remain to bilateral (both) feet. Review of Resident 6's Weekly Skin Review completed by LPN 1 on May 31, 2017, revealed that the scabbed areas remained to Resident 6's bilateral feet but the scab located on the left outer foot came off. On June 7 and 14, 2017, a Weekly Skin Review was again completed by Licensed Practical Nurse (LPN) 1 that revealed scabbed areas remain to bilateral (both) feet. The weekly skin review did not reveal the number of scabbed areas, nor the exact location of the scabbed areas to the feet. Review of Resident 6's clinical record revealed no evidence that the physician was notified that there was no improvement to the scabbed areas to the bilateral feet as written in the care plan. During an interview on June 30, 2017, at 8:50 a.m. the Director of Nursing (DON) confirmed that there was no RN (Registered Nurse) assessment of the right foot and that there was not an RN assessment of the wound bed of the left foot(NAME)ulcer. Review of Resident 6's nursing progress notes revealed a nursing note dated June 21, 2017, at 7:57 a.m. which stated, RN assessment. Resident slow to verbally respond to commands. Extremities app (appear) flaccid (soft and hanging loosely or limply). T (temperature) 102.2, P (pulse) 82, R (respirations) 18, BP (blood pressure) 85/48, BS (blood sugar) 223. Physician notified. Further review of the nursing progress notes revealed a nursing note dated June 21, 2017, at 9:26 a.m. which stated Resident 6 was transferred to the hospital around 9:30 a.m. From 7:57 a.m. until 9:26 a.m., there was no evidence that Resident 6's vital signs were being monitored. Review of Resident 6's current physician's orders [REDACTED]. Review of Resident 6's hospital records revealed that Resident 6 was admitted to the hospital on June 21, 2017, with [DIAGNOSES REDACTED]. Further review of Resident 6's hospital records revealed a history and physical examination [REDACTED]. The history and physical note also stated that the right foot wound was, consistent with possibly a [DIAGNOSES REDACTED] (flesh-eating disease). During an interview on June 30, 2017, at 8:50 a.m. the DON also confirmed that [MEDICATION NAME] was not given to Resident 6 for his elevated temperature. The facility was unable to provide any evidence that Resident 6 was being monitored or had additional vital signs taken for approximately one and a half hours, prior to being transferred to the hospital. There was no evidence that the facility notified the physician regarding changes in condition to the(NAME)ulcer and the scabbed areas on the bilateral feet until the resident developed signs and symptoms of an infection(temperature) and did not implement treatment for [REDACTED]. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 2/2/17, 3/10/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/7/17, 2/2/17, 3/10/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/17, 3/10/16.

Based on review of clinical records, facility policies and staff interviews, it was determined that the facility failed to provide timely care and necessary services designed to promote healing and prevent further deterioration of a pressure sore, resulting in the worsening condition of the pressure sore and infection requiring above the knee amputation for one out of six residents reviewed (Resident 1). Findings include: Review of the current policy titled, Skin and Wound Management System, last revised April 2017, stated that residents with pressure ulcers are provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. The multidisciplinary team will meet regularly to evaluate resident skin changes, treatment and interventions and make recommendations. Review of the clinical record for Resident 1 revealed an admitted [DATE], with [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated April 11, 2017, revealed that Resident 1 had two pressure ulcers. The one pressure ulcer was on the right knee and the other pressure ulcer was on the right stump (the part of the leg that is left after an amputation) below the knee. Review of wound assessments for Resident 1 revealed that the first assessment was not completed until April 17, 2017, six days after the admission of the resident. Review of the wound evaluation flow sheet, completed by Registered Nurse 1 on April 17, 2017, revealed that Resident 1 had a pressure ulcer on the right stump, below the knee, measuring 4.8 centimeters (cm) long by 6.3 cm wide and 0.1 cm deep. There was 90% necrotic tissue (non-viable tissue due to reduced blood supply) and 10% slough (dead tissue, usually cream or yellow in color). The wound evaluation dated April 20, 2017, indicated that the measurements of the pressure ulcer increased to 5 cm by 6.7 cm. On May 12, 2017, the wound evaluation revealed that the pressure ulcer increased again to 5.5 cm by 6.7 cm and 0.1 cm deep. The necrotic tissue changed to 80% and slough was 20%. There was serosanguinous drainage (thin with red blood cells present) and redness around the pressure ulcer. On May 20, 2017, the wound evaluation revealed the pressure ulcer changed to 70% necrotic and 30% slough. The pressure ulcer had purulent drainage (a thick liquid that can be yellow, green or brown in color and is a sign of infection). The surrounding tissue was red and warm. The final wound evaluation dated May 25, 2017, revealed that the wound increased to 6 cm by 6 cm and 0.2 cm deep. The drainage continued and there was a foul odor present. Further review of the wound evaluation flow sheets completed by RN 1 revealed another pressure ulcer on the right knee. The initial assessment on April 17, 2017, indicated the pressure ulcer was 5.4 cm by 7.6 cm with 100% necrotic tissue. Review of the wound evaluation dated April 26, 2017, revealed the tissue around the pressure ulcer was red. The wound evaluation dated May 20, 2017, indicated that the pressure ulcer increased in size to 8.3 cm by 10 cm and the surrounding tissue was red and warm. The final wound evaluation dated May 25, 2017, revealed the pressure ulcer increased to 8.6 cm by 10.8 cm. Review of the Treatment Administration Record (TAR) for April 2017, revealed a physician's orders [REDACTED]. Review of the TAR for April 2017, revealed two days that the treatment was not performed on April 13 and 25, 2017. Review of the May 2017, TAR revealed five days that the treatment was not performed on May 2, 6, 9,16 and 27, 2017. During an interview on June 23, 2017, at 5:15 p.m. in the presence of the Director of Nursing, Licensed Practical Nurse 2 stated that Resident 1 went to [MEDICAL TREATMENT] on those days. His chair time ([MEDICAL TREATMENT] start time) was 10:00 a.m. and he returned at approximately 2:30 p.m., therefore, the nurse was passing medications in the morning and that is why the treatments were not performed prior to [MEDICAL TREATMENT]. Review of the clinical record revealed that the first time that a change in the pressure ulcer was noted was on May 20, 2017. The note stated wound care was completed for Resident 1 and measurements continued to increase, redness and warmth noted, purulent drainage noted and the physician was made aware via fax. The note also stated that Resident 1 had an appointment with Infectious Disease on June 7, 2017. Review of the clinical record revealed that prior to admission to the facility on [DATE], the resident was being followed by infectious disease for complications from a spine incision. There was no evidence of a fax or physician response on May 20, 2017. Review of the progress notes revealed a note dated May 22, 2017, that stated Registered Nurse 2 was made aware of redness to stump area. Infectious Disease was called and stated that they follow Resident 1 for his resolved back infection not his stump infection. The physician was made aware of changes to the pressure ulcers. No new orders were given. The physician was going to see the resident on May 23, 2017, however, a nursing note dated May 23, 2017, revealed Resident 1 left for [MEDICAL TREATMENT] prior to the physician arrival and the physician would look at the resident's stump on the next visit to the facility. During an interview with the Director of Nursing (DON) on June 23, 2017, she stated that the physician makes visits to the facility on Tuesday and Thursday. On Thursday, May 25, 2017, there was no evidence that the physician assessed Resident 1 while in the facility. On May 25, 2017, the physician was notified via fax on the status of the wound. He replied to the fax with new orders to consult Infectious Disease and Vascular Surgery. A nursing progress note dated May 25, 2017, stated that the pressure ulcer had a foul smell. The note stated Infectious Disease was called and the facility was awaiting a return call. Review of the clinical record revealed a consult from Infectious Disease dated May 3, 2017. The consult was a follow-up for the resident's spine incision. The consult did not address the stump wounds. The consult read to follow up in 4 weeks and the appointment was made for June 7, 2017. The facility was unable to provide a referral or consultation for the pressure ulcer from Infectious Disease or Vascular Surgery. A physician's progress note dated May 4, 2017, stated there were no new issues. The note did not address the pressure ulcers and there were no subsequent physician progress notes [REDACTED]. Further review of the nursing notes revealed on May 27, 2017, Resident 1 was having hallucinations and was not himself. The resident was sent to [MEDICAL TREATMENT]. A call was received from the [MEDICAL TREATMENT] clinic that Resident 1 was sent to the hospital for a change in mental status, dropping blood pressures and concerns regarding his stump site. Review of the hospital records revealed Resident 1 was admitted to the hospital on May 27, 2017, [MEDICAL CONDITION] (a potentially life-threatening complication of an infection) secondary to infection of right BKA (below knee amputation). While in the hospital the resident received IV (intravenous) antibiotics. Due to the deterioration of the wounds, on June 2, 2017, Resident 1 underwent surgery for [REDACTED]. During an interview with the DON on June 30, 2017, at 8:49 a.m. she confirmed that Resident 1 was not seen by the physician related to the changes in the pressure ulcers. There was no evidence that the facility implemented and provided timely care and necessary services designed to promote healing and prevent further deterioration of a pressure sore, resulting in the worsening condition of the pressure sore, hospitalization ,[MEDICAL CONDITION] and the above the knee amputation for one out of six residents reviewed (Resident 1). 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 6/7/17, 2/2/17. 28 Pa. Code 211.2(a) Physician services. Previously cited 3/10/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/7/17, 2/2/17, 3/10/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/17, 3/10/16.

Based on review of clinical records and staff interview, it was determined that the facility failed to ensure the highest practicable well-being regarding a physician's review of laboratory results and the monitoring of a resident's blood pressure prior to the administration of a medication for one of 19 residents reviewed (Resident 11). Findings include: Review of the clinical record for Resident 11 revealed [DIAGNOSES REDACTED]. Review of a progress note completed by Licensed Practical Nurse (LPN) 2 revealed a note dated February 16, 2016, which stated that Resident 11 had sustained an unwitnessed fall on February 16, 2016 at 11:10 a.m. A nursing note dated February 16, 2016 at 12:00 p.m., revealed that Resident 11 was complaining of pain in the left chest area. A call was placed to the physician and a new order was obtained for an X-ray (image of structure inside the body) of the left clavicle (the bone between the center of the chest and the shoulder). Review of the radiology report (X-ray result) dated February 16, 2016 at 4:19 p.m., revealed that the results were negative for a fracture. The conclusion of the radiology report stated that Resident 11 had, bilateral pleural effusions (excess fluid accumulation around the lungs), recommend chest X-ray. Review of the clavicle X-ray revealed no physician signature that the physician had reviewed the results of the X-ray. Review of the nursing notes revealed a change in condition note entered by Registered Nurse (RN) 1 on February 17, 2016 at 5:30 a.m. The note stated that Resident 11 was found with blood on her pillowcase and upon assessment an open area was found on her left occipital area (lower back part of the skull). The open area was not discovered during the assessment after her fall. Resident 11's blood pressure at the time of the note was 102/32 (a normal blood pressure is 120/80, 102/32 constituted a low blood pressure resulting in an inadequate flow of blood to the body's organs which can cause a stroke, a [MEDICAL CONDITION] or kidney failure). The physician was made aware and a new order for treatment to the wound on the left occipital area (the rear section of the head) area was obtained. Review of the nursing notes dated February 17, 2016 at 11:19 a.m., nearly 20 hours after the first clavicle X-ray results were received, revealed that the Licensed Practical Nurse (LPN) 2 spoke to the physician and he ordered a repeat chest X-ray in one week, an electrolyte panel (a blood test that measures the levels of electrolytes and carbon [MEDICATION NAME] in your blood. Electrolytes are minerals that keep your body's fluids in balance and help keep your body working normally, including your heart rhythm, muscle contraction, and brain function) and [MEDICATION NAME] (a medication to reduce fluid in the body) 40 milligrams (mg), one time a day, for one week. Review of laboratory documentation revealed that on February 18, 2016 at 8:20 a.m., blood was drawn for laboratory testing. Further review of the laboratory documentation revealed abnormal results. The results revealed that Resident 11's carbon [MEDICATION NAME] levels were 20 mM/L (which may indicate kidney or other organ dysfunction - the normal range is 22-30 mM/L). Review of the electrolyte lab (laboratory results) results were not filed in the clinical record and there was no indication that the physician reviewed the abnormal results. Review of a nursing note dated February 22, 2016 at 4:35 a.m., revealed a note from RN 1 which stated that Resident 11's blood pressure was 102/46 and the pulse oximetry was 88% (the amount of oxygen in the blood; normal is 95-100%) and that Resident 11 had +1 [MEDICAL CONDITION] (swelling 2 millimeters (mm) or less) in the left ankle (which may indicate kidney disease or heart failure). Review of the [MEDICATION NAME]-XL (brand name for [MEDICATION NAME] (a medication used to treat high blood pressure)) page from the Premium Version of the Epocrats Online Drug Guide (the medication reference source used by the medication nurses in the facility), which was printed by the facility and provided to the survey team on March 3, 2016, revealed that [MEDICATION NAME] is contraindicated if the systolic (first audible beat of the heart) blood pressure is less than 100. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Resident 11's clinical record revealed that an additional nursing note was entered on February 22, 2016 at 9:52 a.m., for a hold parameter on [MEDICATION NAME] Extended Release obtained along with an order for [REDACTED]. Review of the MAR for February 2016, revealed that the 9:00 a.m., dose of [MEDICATION NAME] Extended Release was given on February 23 and February 24, 2016. Review of the blood pressure summary report revealed that there were no blood pressures obtained on February 23 or February 24, 2016, prior to giving the medication to ensure that Resident 11's blood pressure was within the parameters as established by the physician. Review of Resident 11's lab results, revealed a CMP dated February 23, 2016, that indicated abnormal results with kidney function (BUN was 40 MG/DL, normal range 8-23 MG/DL and Creatinine 1.7 MG/DL, normal range 0.5-1.0 MG/DL), a low calcium level of 6.4 MG/DL (normal 8.2-9.6 MG/DL) and a low carbon [MEDICATION NAME] level of 18 mM/L (normal range 22-30 mM/L). The chest X-ray revealed moderate pleural effusions bilaterally (both sides). Review of the lab reports on March 3, 2016 at 9: 30 a.m., revealed that the results were not filed in Resident 11's chart. However, a nursing note dated February 23, 2016 at 10:33 p.m., stated that the physician was made aware of the blood work and new orders were obtained to draw a serum [MEDICATION NAME] (amount of [MEDICATION NAME] in blood) and a serum [MEDICAL CONDITION] (amount [MEDICAL CONDITION] hormone in the blood). Review of the lab results for the blood sample obtained on February 24, 2016 at 7:57 a.m., for the serum [MEDICATION NAME] and serum [MEDICAL CONDITION] levels, revealed that the serum [MEDICAL CONDITION] levels were elevated at 173 pg/ml (normal is 15-65 pg/ml). There was no indication that the physician was aware of the abnormal result. Review of the progress notes revealed a nursing note by RN 2 dated February 25, 2016 at 10:35 a.m., titled, change in condition. The resident's oxygen saturation was 88%, the resident was confused and her blood pressure was 88/50. A call was placed to the resident's daughter who told the nurse to send the resident to the hospital and nursing notified the physician. Review of the physician's progress notes revealed that the last time he saw Resident 11 to write a progress note was on February 18, 2016. Review of the hospital documentation dated February 25, 2016, revealed that the resident was admitted to the hospital in acute renal (kidney) failure, possible pneumonia (lung infection) and dehydration (the body does not have as much fluids as it needs). While admitted to the hospital, the [MEDICATION NAME] was held (not given), the resident was given intravenous (IV-through the vein) fluids, was given IV antibiotics, and had a consult with cardiology (a heart specialist) and nephrology (a kidney specialist). Review of the discharge instructions dated March 2, 2016, revealed that the resident would be discharged back to the facility with new orders for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill). The discharge medication list included to discontinue the [MEDICATION NAME]. During an interview with the ADON (Assistant Director of Nursing) on March 2, 2016 at 10:15 a.m., she revealed that she does not know if the lab results or the X-ray reports were reviewed by the physician. She confirmed that the labs and the reports were not signed by the physician and were not in the chart and there was no physician note that the physician reviewed the resident's care. She also confirmed that there were no blood pressures obtained on February 23 or 24, 2016, prior to giving the [MEDICATION NAME] Extended Release. During an interview with the Director of Nursing (DON) on March 2, 2016 at 10:20 a.m., he stated that he would not have given the blood pressure medication with a blood pressure of 82/33. During an interview with the DON on March 2, 2016 at 12:55 p.m., he stated that he would expect blood pressures to be obtained prior to giving the [MEDICATION NAME] Extended Release. 42 CFR 483.25 Provide care/services for highest well-being. Previously cited 02/20/16, 02/05/15, 03/06/14 28 Pa Code 201.18(b)(1) Management Previously Cited 02/20/16, 12/21/15, 02/05/15, 03/06/14 28 Pa Code 211.2(a) Physician Services Previously cited 02/05/15 28 Pa Code 211.10(c) Resident care policies. Previously Cited 02/05/15 and 03/06/14 28 Pa Code 211.10(a) Resident care policies. Previously Cited 03/06/14 28 Pa Code 211.12(d)(1) Nursing services. Previously Cited 02/05/15, 04/22/14, 03/06/14 28 Pa Code 211.12(d)(3) Nursing services. Previously Cited 02/05/15 28 Pa Code 211.12(d)(5) Nursing services. Previously Cited 12/21/15, 04/21/15, 02/05/15, 04/22/14 and 03/06/14