Every finding on record at Gardens at Stevens, The

Based on observations, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to provide necessary respiratory care and services for three of four residents reviewed (Residents 1, 2, and 3).Findings include:Observation of Resident 1's oxygen tubing on April 28, 2026, at 10:30 a.m. revealed a piece of border gauze wrapped around the tubing with a date of April 17, 2026, written on it.Review of Resident 1's diagnosis list included diagnoses of but not limited to congestive heart failure (CHF - chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and chronic obstructive pulmonary disease (COPD - progressive lung disease).Review of Resident 1's physician's order dated November 17, 2025, instructed staff to monitor oxygen saturation every shift. An additional order dated March 20, 2026, instructed staff to change nasal cannula (medical device used to deliver supplemental oxygen directly into the nostrils) tubing weekly.Review of Resident 1's April Treatment Administration Record (TAR) indicated that the nasal cannula tubing was changed on April 17, 2026, and again on April 24, 2026.Interview with Resident 1 on April 28, 2026, at 10:30 a.m. revealed that resident uses oxygen at night or when napping. Resident 1 also revealed that tubing was last changed on April 17, 2026.Observation in presence of licensed Employee E2 on April 28, 2026, at 12:00 p.m. confirmed that the date on the oxygen tubing was April 17, 2026.Review of Resident 2's diagnosis list included diagnoses of but not limited to COPD and centrilobular emphysema (form of chronic lung disease affecting the upper lobes of the lungs).Review of Resident 2's physician's order dated January 2, 2025, instructed staff to apply oxygen at 2 liters via nasal cannula to maintain saturation above 92% every shift.Observation in presence of licensed Employee E2 on April 28, 2026, at 12:05 p.m. revealed that the date on the oxygen tubing was illegible. Further review of Resident 2's physician orders revealed no order for changing the oxygen tubing.Review of Resident 3's diagnosis list included diagnoses of but not limited to COPD and obstructive sleep apnea (sleep disorder characterized by repeated interruptions in breathing during sleep). Review of physician's order dated January 16, 2026, instructed staff to monitor oxygen saturation every shift. An additional order dated January 17, 2026, instructed staff to change oxygen tubing and humidification bottle, clean oxygen bottle, and inspect easy foam wraps every night shift every Friday.Review of Resident 3's TAR indicated that the oxygen tubing was changed on April 24, 2026. However, observation in presence of licensed Employee E2 on April 28, 2026, at 12:10 p.m. revealed that the date on the oxygen tubing was April 17, 2026.The above information was presented to the Nursing Home Administrator on April 28, 2026, at 1:00 p.m. and it was confirmed that Resident 2 had no orders for changing the oxygen tubing.28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 2/27/2628 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of employee personnel records, it was determined that the facility failed to complete performance reviews at least once every 12 months for five of five nurse aides reviewed (Employees 5-9).Findings include: Review of personnel records for Employee E5-E9 revealed no evidence that performance reviews were completed at least once every 12 months. Interview with the Nursing Home Administrator on February 27, 2026, at 1:00 p.m. confirmed that there was no documentation of the performance reviews for the five employees. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.19(2) personnel policies and procedures

Based upon review of employee records, it was determined the facility failed to ensure that nurse aides completed 12 hours of annual in-service training for five of five employee files reviewed (Employees E5-E), Findings include:Personnel files for Employees E5-E9 were reviewed for completion of the 12-hour annual in-service training.Review of the employee files failed to reveal evidence that the Employees E5-E9 completed the required 12-hour annual in-service training.Interview with the Nursing Home Administrator on February 27, 2026, at 1:00 p.m. confirmed that there was no evidence that Employees E5-E9 completed the required 12 hours of in-service training.483.95 Training RequirementsPreviously cited 3/14/2528 Pa. Code 201.19(7) Personnel polices and procedures

Based upon observation, it was determined that the facility failed to ensure insulin pens were properly identified with open and expiration dates and failed to ensure unopened insulin pens were kept refrigerated according to package directions for two of three medication carts observed (Second Floor Back Hall Medication Cart and First Floor Medication Cart).Findings include:Observation of the Second Floor Back Hall Medication Cart on February 27, 2026, at 11:15 a.m. revealed one open Toujeo (long-acting insulin) Insulin Pen with an open date of January 18, 2026, and no expiration date. Further observation of the Second Floor Back Hall Medication Cart revealed one Toujeo Insulin Pen unopened and not stored in the refrigerator as recommended by the manufacturer.Observation of the First Floor Medication Cart on February 27, 2026, at 11:25 a.m. revealed one opened Lantus Insulin Pen with no open or expiration date and one Lantus Insulin Pen unopened and unrefrigerated as recommended by the manufacturer.Interview with the Director of Nursing on February 27, 2026, at 11:30 a.m. confirmed the above medication was not properly identified with open and expiration dates. 28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services

Based on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for three of six hospitalizations reviewed (Resident 1, 6, 11) and one of three closed records reviewed (Resident CR75), and failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of three closed records reviewed (Resident CR8). Findings include: Review of Resident 1's clinical record revealed a nursing progress note dated December 12, 2025, indicated the resident was transferred to the local hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 1's facility-initiated emergency transfers to the hospital. Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed that the office of the state long-term ombudsman was not made aware of Resident 1's hospital transfer. Review of Resident 6's clinical record revealed a nursing progress note dated January 17, 2026, indicating that the resident was transferred to the hospital for evaluation. Review of documentation provided by the Nursing Home Administrator on February 26, 2026, revealed the Office of the State Long Term Care Ombudsman was not made aware of Resident 6's facility-initiated emergency transfers to the hospital. Interview conducted February 26, 2026, at 11:54 a.m. with Employee E4, confirmed the ombudsman was not made aware of Resident 6's hospital transfer. Review of Resident 11's clinical record revealed Resident 11 was discharged to the hospital on January 1, 2026, and re-admitted to the facility on [DATE]. Further review of Resident 11's clinical record failed to reveal evidence that the office of the State Ombudsman was notified of Resident 11's admission to the hospital. Interview with the Director of Nursing on February 26, 2026, at 11:00 a.m. confirmed that the office of the State Ombudsman was not notified of Resident 11's transfer to the hospital. Review of Resident CR8's clinical record revealed a nursing progress note dated February 10, 2026, at 10:46 a.m. indicated the resident was discharged from the facility to their home. Review of Resident CR8's Minimum Data Set, dated [DATE], indicated the discharge was planned. Interview conducted with the Nursing Home Administrator (NHA) on February 27, 2026, at 1:15 p.m. reported that the facility did not complete a discharge summary, including a recapitulation of the resident's stay for Resident CR8. The NHA also confirmed that the facility did not notify the Office of the State Long-Term Care Ombudsman of Resident 1's or Resident CR75's transfer to a hospital. Review of Resident CR75's clinical record revealed a nursing progress note dated February 2, 2025, indicated the resident was admitted to a local hospital for evaluation. Review of Resident CR75's Minimum Data Set (a standardized assessment tool used in Skilled Nursing Facilities to evaluate resident health, guide care planning, and support Medicare and Medicaid reimbursement) dated February 2, 2026, revealed the resident was transferred to a nearby hospital and subsequently discharged from the facility on the same day. Interview conducted February 26, 2026, at 11:54 a.m. with the Social Services Department, confirmed the ombudsman was not made aware of Resident CR75's hospital transfer. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for one of 24 residents reviewed (Resident 3).Findings include: Review of Resident 3's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of February 2, 2025, section N0415 - High Risk Drug Classes, indicated that the resident was receiving an anticoagulant. Further review of the physician's orders and Medication Administration Record revealed no evidence that the resident received an anticoagulant during the assessment lookback period. Interview with licensed staff, E3, on February 27, 2025, at 12:10 p.m. confirmed that the assessment was coded inaccurately. 483.20 Accuracy of AssessmentsPreviously cited 3/14/25 28 Pa. Code 211.5(f) Clinical recordsPreviously cited 6/4/25, 3/14/25

Based on review of the clinical record and an interview with the resident and staff, it was determined that the facility failed to invite the resident and/or the resident's representative to participate in the care plan process for one of 22 residents reviewed (Resident 37). Findings include: Review of Resident 37's clinical record revealed that the resident was admitted to the facility on [DATE]. Interview with Resident 37 on February 24, 2026, at 11:10 a.m. indicated that the resident had not been invited to participate in an interdisciplinary care plan meeting. Review of the clinical record revealed no evidence that the resident or the resident's representative had been invited to participate in care plan meetings.Interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m. confirmed that there was no evidence that the resident or resident's representative had been invited to an interdisciplinary care plan meeting.28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.12(d)(3)(5) Nursing services

Based upon clinical record review and interviews with staff it was determined that the facility failed to provide treatment and care in accordance with standards of care for two of twenty-two residents reviewed (Residents 41 and 72). Findings include: Review of Resident 41's diagnosis list included a diagnosis of but not limited to secondary malignant neoplasm of unspecified lung (cancer that has spread to the lungs from a primary tumor elsewhere in the body). Review of Resident 41's progress note dated February 17, 2025, revealed that resident was to receive 4 mg (milligrams) of decadron (corticosteroid) to be given the day before the infusion, the day of the infusion, and the day after the infusion. Review of the February 2026 Medication Administration Record revealed that the decadron was administered on February 24, 2026. Review of Resident 41's progress note of February 25, 2026, revealed that resident had an appointment on this date at Cancer Center, but transportation was not available. Additional progress note of February 25, 2026, revealed that the CRNP gave order to discontinue three days of decadron since infusion was not given. Review of Resident 41's progress note of February 26, 2026, revealed that the cancer center rescheduled appointments for labs and office visit. Interview with the Nursing Home Administrator on February 27, 2026, at 12:00 p.m, confirmed that transportation had not been set up for Resident 41 and the appointment had to be rescheduled. Review of Resident 72's clinical record revealed an order for Resident 72 to remain NPO (nothing by mouth) after midnight prior to cataract surgery scheduled for Monday, February 16, 2026. Further review of Resident 72's clinical record revealed that the appointment for cataract surgery was cancelled after the resident received a breakfast tray from the kitchen and ate breakfast. Review of a Diet Order and Communication slip sent from nursing to the kitchen on January 28, 2026, revealed Resident 72 was not to receive a breakfast tray on February 16, 2026. Interview with the Director of Nursing on Thursday, February 26, 2026, at 1:00 p.m. confirmed that Resident 72 received a breakfast tray while the NPO order was in place. 483.25 Quality of Care Previously cited 12/16/25, 3/14/25 28 Pa. Code 211.5(f) Clinical recordsPreviously cited 12/16/25, 6/4/25, 3/14/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing ServicesPreviously cited 12/16/25,6/4/25, 3/14/25

Based on a review of clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for one of seven residents reviewed (Resident 6).Finding include:Review of Resident 6's Diagnosis Sheet revealed medical diagnosis that includes Osteoarthritis (condition that occurs when the protective cartilage that cushions the ends of the bones wears down over time) left knee, pain in left hip, arthritis (inflammation, pain, and stiffness in the joints) in left hip, lower back pain and other chronic (constantly recurring) pain.Review of Resident 6's physician orders revealed an order dated November 1, 2025, for Fentanyl Transdermal Patch (an opioid pain medication that is used to treat moderate to severe chronic pain around the clock administered through the skin) 72 Hour 25 MCG/HR (micrograms per hour), apply 1 patch trans dermally every 72 hours for pain and remove per schedule.Review of Resident 6's December 2025 Medication Administration Reports (MAR) revealed no documentation of the resident's patch being removed and reapplied between December 1, 2025, and December 6, 2025.Interview with Resident 6 on December 16, 2025, at 10:50 a.m., Resident 6 confirmed his/her pain patch was not changed between December 1, 2025, and December 6, 2025. Resident 6 stated he/she experienced pain during that time and informed nursing staff, but the patch was not changed. Interview conducted with the Nursing Home Administrator (NHA) on December 16, 2025, at 2:30 p.m., when the above information was presented the NHA confirmed knowledge of the medications not being administered properly. 28 Pa. Code 211.5(f) Clinical Records28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on staff and resident interviews, it was determined that the facility failed to ensure residents were assisted out of bed in a timely manner to attend scheduled Sunday religious services.Findings include:An interview conducted with the Activities Director on October 29, 2025, at approximately 12:30 p.m. revealed that some residents are unable to attend Sunday services because nursing staff do not get them out of bed in time. The Activities Director stated that this occurs every weekend.An interview conducted with the Activities Assistant on October 29, 2025, at approximately 12:40 p.m. revealed similar concerns. The Activities Assistant reported that 1-2 residents are unable to attend Sunday services weekly due to nursing staff not assisting them out of bed in time. She further stated that this issue occurs every weekend and that she reports it to nursing staff when it happens.Both the Activities Director and Activities Assistant reported that they did not inform the Nursing Home Administrator (NHA) of the issue because they did not think about it during the week. An interview conducted with Resident R1 on October 29, 2025, at approximately 1:30 p.m. revealed that she missed Sunday service on October 26, 2025, because nursing staff did not get her out of bed in time. Resident R1 stated that staff are aware in advance that she needs to be up before 9:30 a.m. to attend Sunday service.An interview conducted with the NHA on October 29, 2025, at approximately 3:00 p.m. confirmed the above.S 211.12(e) Nursing Services S 201.14(b) Responsibility of licensee

Based on observations, staff interviews, and review of facility records and policies, it was determined that the facility failed to implement contact precautions for a resident diagnosed with scabies (Resident R3).Findings include:Review of Resident R3's clinical record on October 29, 2025, revealed a diagnosis of scabies (a skin infestation caused by microscopic parasites that results in intense itching) with a start date of October 28, 2025.Review of the facility policy titled Scabies Identification, Treatment and Environmental Cleaning, revised August 2016, indicated: Affected residents should remain on Contact Precautions until twenty-four (24) hours after treatment.Further review of the clinical record failed to reveal any physician orders for contact precautions.Review of Resident R3's physician orders revealed an order for Permethrin 5% cream (a topical medication used to treat scabies) with a start date of October 28, 2025, and with a note to hold treatment until after a dermatology appointment scheduled for October 30, 2025.Observations conducted of Resident R3's room revealed no signage indicating that the resident was on contact precautions.An interview conducted with the Assistant Director of Nursing (ADON) on October 29, 2025, at approximately 1:45 p.m. revealed that she had not been informed of Resident R3's recent scabies diagnosis. The ADON stated that if she had been made aware of the diagnosis, she would have immediately implemented contact precautions and educated staff on appropriate procedures.The ADON further reported that Resident R3's dermatology appointments in July and August 2025 indicated that the resident did not have scabies at that time.Resident R3 was unavailable for interview due to cognitive impairment.A follow-up interview with the ADON at approximately 2:00 p.m. confirmed that Resident R3 should have been placed on contact precautions upon diagnosis.S 211.2(d)(5) Medical DirectorS 211.12(d)(5) Nursing Services

Based on review of clinical records, as well as family and staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for six of 8 residents reviewed (Resident 1,4,5,6,7,8). Findings include: An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. Resident 1's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday evening shift. Review of Resident 1's bathing records for May and June 2025 revealed that the resident received a bed bath on May 6, 16, 27, and June 3, 2025. There was no documented evidence Resident 1 was offered a shower on May 2,13,20,23, and 30, 2025. An admission diagnosis for Resident 4 revealed the resident was admitted to the facility on [DATE], with diabetes mellitus. Resident 4's shower schedule revealed that the resident preferred showering two times per week on Wednesday and Saturday morning shift. Review of Resident 4's bathing records for May and June 2025 revealed that the resident received a bed bath on May 31, 2025. There was no documented evidence that Resident 4 was offered a shower on May 21, 28, and June 4. Interview of Resident 4 on June 4, 2024, at 11:41 a. m. revealed that she was unaware of when her shower days are and would prefer having a shower instead of a bed bath. Observations of Resident 4 on June 4, 2024, at 11:41 revealed the resident was in bed in a hospital gown her hair was greasy and had large white flakes throughout. Her fingers were dirty and unkempt. An annual MDS for Resident 5 dated, May 2, 2025, revealed that the resident was cognitively impaired, was usually understood, and usually understood others. Resident 5's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday morning shift. Review of Resident 5's bathing records for May and June 2025 revealed that the resident received a bed bath on May 6,13, and 20. There was no documented evidence Resident 5 was offered a shower on May 27, 30 and June 3. Interview of Resident 5 on June 4, 2024, at 9:11 a.m. revealed the resident didn't receive her showers like she prefers. Observations of Resident 5 on June 4, 2024, at 9:11 a.m. revealed that the resident was unkempt and dirty. Her hair was dirty and matted, and she was covered on her chest, arms, and back with an unknown rash. Resident stated that it felt like bugs crawling on her, and showers feel better. A quarterly MDS for Resident 6 dated, May 11, 2025, revealed the resident was cognitively intact and required moderate assistance from staff for daily care needs. Resident 6's shower schedule revealed that the resident preferred to shower on Wednesday and Saturday morning shift. Review of Resident 6's bathing records for May and June 2025 revealed that the resident received a bed bath on May 3,14,21, and 31. There was no documented evidence that the resident was offered a shower on May 10, 17, 24 and June 4, 2025. Interview with Resident 6 on June 4, 2024, 11:21 a.m. revealed that he did not receive showers like he should, and he would prefer a shower. He will get bed baths when they don't have enough staff to get him showers. A significant change MDS for Resident 7 dated February 10, 2025, revealed that the resident was cognitively intact and was dependent on staff for daily care. Resident 7's shower schedule revealed that the resident preferred to shower on Wednesday and Saturday evening shift. Review of Resident 7's bathing records for May 2025 revealed that the resident received a bed bath on May 3,10,17, and 24. There was no documented evidence that the resident was offered a shower on May 7,21,28, and 31, 2025. A quarterly MDS for Resident 8 dated April 2, 2025, revealed that the resident was cognitively impaired and required moderate assistance with shower needs. Resident 8's shower schedule revealed that the resident preferred to shower on Mondays and Thursday day shift. Review of Resident 8's bathing records for May and June 2025 revealed that there was no documented evidence the resident was offered a shower on May 5, 29 and June 2, 5, 2025. Interview with the Director of Nursing and Nursing Home Administrator on June 4, 2025, at 2:39 p.m. confirmed that there was no documented evidence in the resident's medical records of the resident receiving showers on the above dates. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide showers as scheduled for six of 8 residents reviewed (Residents 1,4,5,6,7). Findings include: The facility's policy regarding bathing/showering, dated February 18, 2025, indicated that all residents will be provided a shower at least one time weekly. An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. Resident 1's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday evening shift. Review of Resident 1's bathing records for May and June 2025 revealed that the resident received one shower in the last 34 days. She had not refused any showers. An admission diagnosis for Resident 4 revealed the resident was admitted to the facility on [DATE], with diabetes mellitus. Resident 4's shower schedule revealed that the resident preferred showering two times per week on Wednesday and Saturday morning shift. Review of Resident 4's bathing records for May and June 2025 revealed that as of June 4, 2025, the resident has not received a shower since her admission on [DATE]. The resident has not refused any showers. Interview of Resident 4 on June 4, 2024, at 11:41a.m. revealed that she was unaware of when her shower days are and would prefer having a shower instead of a bed bath. Observations of Resident 4 on Jun 4, 2024, at 11:41 revealed the resident was in bed in a hospital gown her hair was greasy and had large white flakes throughout. Her fingers were dirty and unkempt. Resident revealed that she would prefer a shower, but was told they don't have enough staff to provide her a shower. An annual MDS for Resident 5 dated, May 2, 2025, revealed that the resident was cognitively impaired, was usually understood, and usually understood others. Resident 5's shower schedule revealed that the resident preferred showering two times per week on Tuesday and Friday morning shift. Review of Resident 5's bathing records for May and June 2025 revealed that as of June 4, 2025, the resident has not had a shower since May 15, 2025. The resident refused one shower in the last 39 days on May 9, 2025. Interview of Resident 5 on June 4, 2024, at 9:11 a.m. revealed the resident hasn't received a shower in a while, and it feels like bugs crawling on her. She was informed it was due to not having enough staff to get her a shower. Observations of Resident 5 on June 4, 2024, at 9:11 a.m. revealed that the resident was unkempt and dirty. Her hair was dirty and matted, and she was covered on her chest, arms, and back with an unknown rash. A quarterly MDS for Resident 6 dated, May 11, 2025, revealed the resident was cognitively intact and required moderate assistance from staff for daily care needs. Resident 6's shower schedule revealed that the resident preferred to shower on Wednesday and Saturday morning shift. Review of Resident 6's bathing records for May and June 2025 revealed the resident received 2 showers in the last 34 days, and did not refuse any showers. Interview with Resident 6 on June 4, 2024, 11:21 a.m. revealed that he did not receive showers like he should, and he would prefer a shower. He will get bed baths when they don't have enough staff to get him showers. A significant change MDS for Resident 7 dated February 10, 2025, revealed that the resident was cognitively intact and was dependent on staff for daily care. Resident 7's shower schedule revealed that the resident preferred to shower on Wednesday and Saturday evening shift. Review of Resident 7's bathing records for May and June 2025 revealed that the resident received 1 shower in the last 34 days, and did not refuse any showers. Interview with Nurse Aide 1 on June 4, 2025, at 12:39 p.m. revealed that there was not enough staff and they did not always have time to get showers done for residents they will cycle which resident's receive showers. Interview with Licensed Practical Nurse (LPN) 2, at 12:39 p.m. revealed that she will have to help the girls with toileting, and she is not able to get the resident's showers done, turning and repositioning is not always done, and the care is not quality care because staff are rushed. Interview with Nurse Aide 3 on June 4, 2025, at 11:37 a.m. revealed that they do not have enough staff to complete their daily tasks, showers are not done on all residents. Interview with Nurse Aide 4 on June 4, 2025, at 11:45 a.m. revealed that they do not have enough staff to shower all residents they will only have time to shower 1 out of the 5 scheduled on June 4, 2025. Interview with the Nursing Home Administrator and Director of Nursing on June 4 at 1:34 p.m. revealed that they do the best to schedule enough staff. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record reviews and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for six of 8 residents reviewed (Resident 1,4,5,6,7,8), and that documentation of incident was in the clinical records for one of 8 residents reviewed (Resident 1). Findings include: An annual Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 1, dated May 5, 2025, revealed that the resident was cognitively impaired and required moderate assistance from staff for personal care needs. The shower record for Resident 1 for May and June 2025 revealed that on May 2,13,20,23, and 30, 2025 had no documentation. An admission diagnosis for Resident 4 revealed the resident was admitted to the facility on [DATE], with diabetes mellitus. The shower record for Resident 4 for May and June 2025 revealed that on May 21, 2025 NA was documented, and on May 24 and July 4, 2025, the shower record had no documentation. An annual MDS for Resident 5 dated, May 2, 2025, revealed that the resident was cognitively impaired, was usually understood, and usually understood others. The shower record for Resident 5 for May and June 2025 revealed that May 23, 27, 30, and June 3, 2025, had no documentation. A quarterly MDS for Resident 6 dated, May 11, 2025, revealed the resident was cognitively intact and required moderate assistance from staff for daily care needs. The shower record for Resident 6 for May and June 2025 revealed that May 10, 17, 24, and June 4, 2025, had no documentation. A significant change MDS for Resident 7 dated February 10, 2025, revealed that the resident was cognitively intact and was dependent on staff for daily care. The shower record for Resident 7 for May 2025 revealed May 7 and 28, 2025 had no documentation, May 21, 2025, was documented NA May 31, 2025. A quarterly MDS for Resident 8 dated April 2, 2025, revealed that the resident was cognitively impaired and required moderate assistance with shower needs. The shower record for Resident 8 for May and June 2025 revealed that May 5, 2025 was had no documentation and May 29 and June 2, 2025 was documented NA. Interview with the Director of Nursing on June 4, 2025, at 1:45 p.m. confirmed that the documentation for the shower record should never be left blank and documenting NA is unacceptable. 28 Pa Code 211.5(f) Clinical records. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure a system of surveillance was in place to identify, prevent, monitor, and report potential infectious skin conditions. Findings include: Observations of Resident 5 on June 4, 2025, at 9:21 a.m. revealed the resident had a rash on her upper arms, chest and back. An interview with the resident on June 4, 2025, at 9:21 a.m. revealed the resident has had this rash for a while, and it feels like bugs crawling on her. Observations of Resident 3 on June 4, 2025, at 9:15 a.m. revealed resident had a rash all over his arms, chest, and back. A review of the resident's clinical records revealed that the resident receives permethrin cream (a medication for the treatment of scabies) on June 3, 2025, at 6:00 p.m. Interview with Resident 3 on June 4, 2025, at 9:45 a.m. revealed that he wasn't itchy for the first time in months after the treatment. Interview with the Nurse Practitioner on June 4, 2025, at 12:04 p.m. revealed that it is the infection prevention nurse's job to track and trend skin conditions, and that Resident 3 was treated with permethrin cream because they tried different treatments, and nothing else had worked. The resident was not tested for scabies because the rash didn't present like typical scabies, and that he has an appointment with dermatology for follow-up testing. Interview with the Infection Prevention Nurse on June 4, 2025, at 9:45 a.m. revealed that she does not have a system in place to track and trend skin conditions. She believes that the Nurse Practitioner has that information. Interview with the Director of Nursing on June 4, 2025, at 1:52 p.m. revealed that they do not have a system in place to track and trend skin conditions. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out that neglect and/or abuse were involved for two of eight residents reviewed (Resident 1 and Resident 8). Findings include: Review of the facility Abuse Policy, dated February 18, 2025, section labeled investigation and Reporting allegation of Abuse guidelines. States All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local state and federal agencies and thoroughly investigated by the administrator and or designee. A Quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 5, 2025, indicated that the resident was cognitively impaired, was sometimes able to understand and sometimes understood by others, required moderate assistance from staff for her care, and had diagnoses that included Alzheimer's Disease and dementia. A grievance for Resident 1, dated April 24, 2025, revealed that the daughter for Resident 1 was concerned that a male resident was found in the resident's bed thinking it was his room. He was only removed after the roommate for Resident 1 yelled for staff for several minutes. There was no documented evidence in the resident's medical records of the incident, and there was no documented evidence of an investigation completed by the facility. A significant change MDS assessment for Resident 8, dated February 10, 2025, indicated that the resident was cognitively intact, was usually understood and usually understood others, was dependent on staff for daily care needs and had anemia (a medical condition blood has a lower-than-normal number of red blood cells). An incident report log revealed Resident 8 was involved in an incident on May 20, 2025. A nursing note for Resident 8 dated May 20, 2025 revealed that he receieved a skin tear. Witness statement from DON dated May 20, 2025 revealed the she heard a bang and questioned the resident if he needed help, and the resident stated he was ok. There was no documented evidence of an investigation completed by the facility to rule out neglect or abuse. Interview with the Director of Nursing and Nursing Home Administrator on June 4, 2025. at 1:45 p.m. revealed that they do not do a paper investigation and confirmed that she did not specifically ask staff or residents involved for written statements to complete a facility investigation to rule out neglect or abuse. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a registered nurse (RN) after an incident occurred where a male resident was found in her bed for one of 8 residents reviewed (Resident 1). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's risk management guide for incident and accidents, dated February 18, 2025, indicated that there should be an RN assessment after the incident in the clinical record. A Quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 5, 2025, indicated that the resident was cognitively impaired, was sometimes able to understand and sometimes understood by others, required moderate assistance from staff for her care, and had diagnoses that included Alzheimer's Disease and dementia. A grievance for Resident 1, dated April 24, 2025, revealed that the daughter for Resident 1 was concerned that a male resident was found in the resident's bed thinking it was his room. He was only removed after the roommate for Resident 1 yelled for staff for several minutes. There was no documented evidence in the clinical record for Resident 1 that there was a RN assessment completed after a male resident was found in the bed of Resident 1. Interview with the Director of Nursing and Nursing Home Administrator at 1:45 p.m. revealed that there was no RN assessment completed of Resident 1 at the time when a male resident was found in her bed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based upon review of employee records, it was determined the facility failed to ensure that nuse aides completed 12 hours of annual inservice training for five of five employee files reviewed. Findings include: Five nurse aide employee files were reviewed for completion of the 12 hour annual inservice training. Review of the five nurse aide employee files failed to reveal evidence that the five nurse aides completed the required 12 hour annual inservice training. Interview with the Nursing Home Administrator on March 14, 2025 at 12:00 p.m. confirmed the five nuse aides did not complete the 12 hour annual inservice training required.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflect the residents' status for five of 24 residents reviewed (Residents 1, 39, 45, 58 and 74). Findings include: Review of Resident 1 quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated February 2, 2025, revealed under section N0415 - High Risk Drug Classes, that the resident was marked as receiving anticoagulant medication. Review of Resident 1's physician orders revealed that the resident was not ordered an anticoagulant. Review of the Medication Administration Record (MAR) revealed that the resident did not receive an anticoagulant. Review of Resident 39's quarterly MDS dated [DATE], revealed under section N0350 - Insulin, that the resident was marked as receiving insulin medication. Review of Resident 39's physician's orders revealed that the resident was not ordered insulin. Review of the MAR revealed that the resident did not receive insulin. Review of Resident 45's admission MDS of December 26, 2024, section N0415 - High Risk Drug Classes, indicated that the resident was receiving an anticoagulant. Further review of the December 2024 physician's orders and MAR revealed no evidence that the resident received an anticoagulant. Review of Resident 58's quarterly admission MDS of January 30, 2025, section N0415 - High Risk Drug Classes, indicated that the resident was receiving an anticoagulant. Further review of the January 2025 physician's orders and MAR revealed no evidence that the resident received an anticoagulant. Review of Resident 78's discharge MDS dated [DATE], revealed under section A2105-Discharge Status, that the resident was marked as being discharged to a short-term general hospital. Review of Resident 78 closed records revealed resident was discharged home. Interview with licensed staff, E3, on March 14, 2025, at 12:33 p.m. confirmed that the assessments were coded inaccurately for Residents 45 and 58. Interview with the licensed staff, Employee E3, on March 14, 2025, at 2:10 p.m. confirmed that the MDS assessments for Resident 39, Resident 1 and Resident 78 were coded incorrectly. 483.20 Accuracy of Assessments Previously cited 2/1/24 28 Pa. Code 211.5(f) Clinical records Previously cited 2/1/24 28 Pa. Code 211.12(c) Nursing services

Based on review of facility policy, resident interviews, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide the necessary services to maintain personal hygiene for residents unable to carry out activities of daily living for four of 24 residents reviewed (Residents 2, 6, 14, and 25). Findings include: Review of facility policy, Shower/Bathing Policy, revised August 2018 revealed that resident's preferences will be considered and shower/bath/bed bath shall be provided at least weekly. Interview during a group meeting on March 12, 2024, at 1:30 p.m. with alert and oriented Residents 2, 6, 14, revealed that they do not receive showers as scheduled because of staffing shortages. Additional interview with Resident 25 on March 13, 2025, at 9:45 a.m. indicated that the resident does not receive showers. Review of Resident 2's admission MDS (Minimum Data Set - periodic assessment of resident needs) dated February 10, 2025, indicated that the resident had moderate cognitive impairment and was dependent on staff to shower/bathe. Review of resident's bathing records from February 26 - March 13, 2025 (16 days), revealed that the resident did not receive a shower, but did receive bed baths. There was no documentation that the resident refused showers. Review of Resident 6's quarterly MDS assessment dated [DATE], indicated that the resident had moderate cognitive impairment and required substantial/maximal assistance to shower/bathe. Review of resident's bathing records from February 26 - March 13, 2025 (16 days), revealed that the resident did not receive a shower, but did receive bed baths. There was no documentation that the resident refused showers. Review of Resident 14's significant change MDS dated [DATE], indicated that the resident had moderate cognitive impairment and required partial/moderate assistance to shower/bathe. Review of resident's bathing records from February 26 - March 13, 2025 (16 days), revealed that the resident did not receive a shower, but did receive bed baths. There was no documentation that the resident refused showers. Review of Resident 25's quarterly MDS assessment dated [DATE], indicated that the resident was cognitively intact and required partial/moderate assistance to shower/bathe. Review of resident's bathing records from February 26 - March 13, 2025 (16 days), revealed that the resident did not received a shower on February 26, 2024, and also received bed baths. There was no documentation that the resident refused showers. Interview with the Director of Nursing on March 14, 2025, at 1:45 p.m. indicated that residents are to receive showers twice a week and are to be offered a bed bath if a shower is refused. 483.24 Quality of Life Previously cited 1/21/25 28 Pa. Code: 211.5(f) Clinical records Previously cited 2/1/24 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 2/1/24

Based upon clinical record and facility documentation review, it was determined the facility failed to ensure adequate supervision of a resident to prevent resident from falling from a facility window resulting in physical harm and hospitalization for Resident 1. Findings include: Review of Resident 1's diagnosis list revealed diagnoses including left side Hemiplegia (paralysis or weakness to one side of the body), difficulty in walking, Vascular Dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability), muscle weakness, Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real.[3] Symptoms may include delusions and hallucinations), Alcohol abuse with Alcohol induced sleep disorder, and Alcohol Dependence with Alcohol-induced persisting Dementia. Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated February 2, 2024, revealed Resident 1 had a Brief Interview for Mental Status Score of 5 indicating severe cognitive impairment. Review of Resident 1's Elopement Risk assessment dated [DATE], revealed Resident 1 was a moderate wander risk. Review of Resident 1's Fall Risk Assessment/Evaluation dated March 26, 2024, revealed Resident 1 was a high risk for falls. Review of Resident R 1's care plan initiated on Sepember 26, 2022 revealed a focus goal of [Resident] has adjustment issues to admission distractibility r/t (related/to) cognitive deficits, feelings of loss of independence/phsysical decline. Further review of same care plan revealed interventions of a Consult with [community provider] to monitor medications, Encourage [Resident 1] to participate in conversation with staff and other residents daily, Encourage ongoing family involvement, and Help [Resident 1] to identify stressors which may be early warning signs of problem behavior. Intervene and remove stressors as possible. Further review of Resident 1's care plan revealed a care plan related to risk of falls and notation of recent falls occurring on March 1, 2023; March 25, 2023; May 25, 2023; November 14, 2023 and March 26, 2024 during which resident was identified as self ambulating. Interventions included but not limited to Anticipate and meet [Resident 1]'s needs, Assist of 1 for transfers and ambulation with RW (rolling walker). Review of Resident 1's care plan revealed a focus goal initiated November 22, 2022 for Elopement and associated injury related to exit seeking behavior. Further review of same care plan revealed interventions including; Assist in orientation to room and facility using verbal cues and reminders, Encourage group activity and attempt to keep occupied, Notify social services for persistent attempts to leave building and not responding to redirection, provide diversional activities when exit seeking, and wanderguard function checked each night shift and placement checked each shift. Review of Resident 1's clinical record including progress notes dated April 2, 2024, revealed CNA [certified nurse aide] for night shift entered unit at 2211 [10:11 p.m.] stating to other RN [registered nurse] supervisor that she saw a man outside the kitchen a minute before. This RN followed other RN down hall to check on situation. Exiting back kitchen door we observed [Resident 1] standing and leaning against stair wall. Resident noted he fell but could not determine how he got outside. Another staff member found resident glasses on ground around the other side of the building next to air conditioner units. No alarms had gone off in building. Staff had last seen [Resident 1] at 2155 [9:55 p.m.] in hallway in wheelchair. Wheelchair was not with resident when he was observed outside. Resident taken inside and placed in wheelchair. This RN assessed resident for injuries and notified [director of nursing, nursing home administrator and on call provider]. Resident with multiple abrasions to head, ankles, and knees. Decision to send to ED [emergency department] for evaluation since resident stated he fell and it was unwitnessed. Call placed to EMS. Resident's son notified of situation and ongoing investigation of events. Staff continued to search for resident's wheelchair which was found in 2nd floor restorative dining room where a window was noted to be open. EMS arrived with [police officer]. Resident transported to [acute care facility]. Resident left facility vital signs stable though not within residents normal limits, resident awake though more hypoactive, verbalized no complaints of pain however resident appeared pale and facial expressions and body language indicative of pain, injuries as noted above. Review of Resident 1's emergency room record dated April 2, 2024, revealed patient admitted following a fall out of window at [facility], Patient found to have two left facial fractures, left 3-6 rib fractures, left pneumothorax [air leakage between lungs and chest wall] and subarachnoid hemorrhage [type of brain bleed]. Further review of Resident 1's acute care facility records indicate the following injuries as of April 2, 2024: traumatic fracture of ribs of left side with pneumothorax required chest tube insertion; left zygomatic arch [portion of jaw/mandible] fracture; left orbital wall [bone around eye] fracture; left maxillary [portion of jaw] fracture and left third through six rib fractures. Review of facility documentation and witness statements dated April 1, 2024, revealed Resident 1 was observed at 9:30 p.m. near the nurses' station and last observed at 9:55 p.m. near or in resident's room in a wheelchair. Resident 1 was next observed at approximately 10:11 p.m. outside the building near a set of stairs leading to the kitchen entrance. Observation of the activity room windows on April 3, 2024, at approximately 9:30 a.m. revealed all windows in the activity room to have two window stop brackets on each window. Further observation of the window on the left side of the activity room revealed two window stop brackets secured in the upper portion of the window. Interview with the Nursing Home Administrator on April 3, 2024, at 11:00 a.m. revealed Resident 1's wheelchair was found approximately four feet from the window on the left side of the activity room on the night of the fall and the window was observed to be open at that time. Further interview with the Nursing Home Administrator revealed no staff members were present in the activity room at the time Resident 1 opened the window or in the hours preceding the fall. The facility failed to provide adequate supervision by facility staff to prevent accidents to a resident noted to be a High fall risk and moderate elopement risk resulting in harm and hospitalization to Resident 1. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 3/10/2022, 3/15/2023, 10/5/2023, 2/1/2024 28 Pa. Code 211.12(a)(d)(4)(5) Nursing Services Previously cited 3/10/22, 3/15/2023, 5/13/2023, 8/8/2023, 2/1/2024

Based on clinical record review, observations, and interviews with staff, it was determined that the facility failed to ensure that one of two residents (Resident 50) reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new ulcers from developing, resulting in actual harm of pressure ulcer development for Resident 50. Findings include: Review of Resident 50's diagnosis list revealed diagnoses including; Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), Muscle Weakness (reduction in the power exerted by muscles resulting in an inability to perform a given task), Cognitive communication deficit (difficulty with communication that is caused by a problem with thinking). Review of Resident 50's comprehensive assessment Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) Dated November 15, 2023, revealed that Resident 50 had no skin impairment. Additionally the MDS revealed Resident 50 has a BIMS (Brief Interview for Mental Status- used to assess cognitive status in elderly) of 00 (indicating severe impairment). Review of Resident 50's care plan dated November 11, 2023, revealed the following focus areas: Resident 50 has potential for pressure ulcer development regarding to impaired mobility, Resident 50 has potential/actual impairment to skin integrity issues regarding to a history of cellulitis (bacterial skin infection), Resident 50 exhibits behaviors such as picking at the skin creating/enlarging wounds and MASD (Moisture-Associated Skin Damage) to sacrum. Additional review of Resident 50's care plan revealed the following interventions: Keep skin clean and dry. Use lotion on dry skin. Do not apply to open areas initiated date of April 18, 2023. Encourage good nutrition and hydration in order to promote healthier skin, initiated date of April 18, 2023. Observe for/document breaks in skin and notify MD (Medical Doctor), initiated date of April 18, 2023. Pressure reduction mattress to prevent skin breakdown as ordered initiated date of April 18, 2023. Observe for/document breaks in skin and notify MD, initiated date of April 18, 2023. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) etc. to MD initiated date of November 22, 2023. Review of Resident 50's clinical record revealed a weekly skin assessment dated [DATE], at 2:47 p.m. indicating Resident 50 had MASD Damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, or sweat) located on Resident 50's sacrum (triangular bone at the base of the spine) which resolved (healed) on January 2, 2024. Review of the facilities wound tracking logs revealed Resident 50's Stage 4 pressure injury was first observed on January 9, 2024. Review of information provided by Director of Nursing revealed Resident 50's weekly skin assessment dated [DATE], stating, Skin Condition: Skin intact. Review of Resident 50's initial wound evaluation and management summary dated January 16, 2024, by wound specialist physicians revealed the following wound measurements 0.5 x 0.5 x 0.3 cm (centimeters). Further review of Resident 50's clinical medical record revealed a Dietitian progress note dated January 18, 2024, at 5:12 p.m. indicating, Aware of resident with a stage 4 pressure injury (break in the skin that extending through the muscle and bone) on sacrum. On February 1, 2024, at 10:50 a.m. the surveyor asked the Director of Nursing regarding any investigation into Resident 50's stage 4 pressure injury. The Director of Nursing was unable to provide investigation documentation. Additional review of Resident 50's clinical record failed to reveal additional documentation of the Stage 4 pressure injury. Interview conducted with the Director of Nursing (DON) on February 1, 2024, at 10:10 a.m. reported Resident 50 tested positive of COVID-19 which resulted in Resident 50 becoming lethargic (sluggish) staying in bed all day and refusing to eat. The Director of Nursing reported that Resident 50's COVID-19 symptoms resulted in Resident 50 developing a stage 4 pressure injury due to staying in bed and refusing to eat for multiple days. Review of Resident 50's clinical medical record revealed a progress note dated January 8, 2024, at 10:09 a.m. stating resident presents with increased congestion (stuffy nose) and productive cough (wet cough). covid test positive. verified by RN supervisor. Review of Resident 50's electronic treatment administration record (eTAR) revealed an order for House barrier cream (reduces friction and irritation of the skin), every shift for prevention Apply bilateral buttock, peri area and sacrum with care, nurse aide may apply, may keep at bedside with a start date April 18, 2023. Additional review of Resident 50's eTAR revealed the barrier cream was documented as applied to Resident 50's sacrum January 1, 2024, through January 29, 2024, for each morning, evening, and night shift but failed to reveal documentation related to Resident 50's stage 4 pressure injury. Review of Resident 50's care plan failed to reveal new interventions initiated after the discovery of the stage 4 pressure injury on January 9, 2024. The above information was conveyed to the Nursing Home Administrator and Director of Nursing during an interview on February 1, 2024, at approximately 11:31 a.m. The facility failed to identify, assess and monitor skin integrity and develop and implement a plan of care to prevent pressure ulcers from developing on the sacrum of Resident 50, resulting in actual harm for this resident. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(3) Nursing Services 28 Pa. Code 211.12(d)(5) Nursing Services

Based upon clinical record review and observation, it was determined that the facility failed to timely identify and treat a pressure ulcer causing actual harm to two of four residents reviewed (Resident 36 and Resident 53). Findings include: Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 36's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated November 18, 2021, revealed Resident 36 required the extensive assistance of two staff members for turning and repositioning in bed, transferring between surfaces and required total dependence on staff members for bathing. Review of Resident 36's Weekly Skin Review dated November 1, 2021, revealed open area to coccyx. Treatment in place. Review of Resident 36's Weekly Skin Review dated November 8, 2021, revealed dry pre-existing skin condition with no further information noted. Review of Resident 36's Weekly Skin Review dated November 15, 2021, revealed skin intact. Review of Resident 36's Weekly Skin Review dated November 24, 2021, revealed dry pre-existing skin condition and left eyebrow healing skin tear. Review of Resident 36's clinical progress notes dated November 27, 2021, revealed coccyx wound identified, 1/2 cm [centimeter] with drainage. Review of Resident 36's clinical record including the November 2021 Treatment Administration Record (TAR) failed to reveal any evidence that treatments were performed on the coccyx/sacral wound during the month of November 2021. Review of Resident 36's [NAME] Wound Physicians Wound Evaluation and Management Summary dated December 2, 2021, revealed a Stage 4 Pressure Wound Sacrum, Full Thickness with 100 percent necrotic [dry, black] tissue. The Wound Summary further revealed that an excisional debridement procedure was conducted on December 2, 2021, to remove some of the devitalized tissue and necrotic muscle in the wound. Review of Resident 36's clinical record including the December 2021 TAR revealed that treatments were initiated on December 3, 2021, one day after being treated by the [NAME] Wound Physician. Observation conducted for Resident 36's wound treatment on March 9, 2022, at 1:30 p.m for infection control procedures. The facility documentation presented including care plans, progress notes, and wound assessments did not reveal any wound treatments in place for Resident 36 from November 1 until December 3, when seen by the wound specialist. According to the documentation presented; the wound treatment began when the specialist debrided the wound and ordered treatment. The facility failed to timely identify and treat Resident 36's coccyx/sacral pressure ulcer prior to the wound developing to a Stage 4 causing harm to Resident 36. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on March 10, 2022, at approximately 1:00 p.m. Review of Resident 53's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 53's clinical record dated February 15, 2022, new admission skin assessment revealed that the resident was admitted to the facility with a left and right buttocks stage 2 pressure ulcer (an ulcer involving loss of the top layers of the skin). Left buttock measured 1.5 x 1.0 cm and the right buttock wound measure 1.0 x 0.5 cm. Further review of the clinical record revealed there was no documentation that the physician was notified about this wound and no treatment initiated. Physician's note from the wound clinic dated February 18, 2022, revealed a Stage 3 (ulcer involving the full thickness of skin loss, exposing tissue) pressure wound on the sacrum measured 0.7 x 0.6 cm with moderate serous exudate and 50% granulation tissue. The wound was debrided to promote healing. A treatment order was given for border foam dressing three times a week. Review of Resident 53 clinical record including care plans revealed, staff are to conduct treatment as ordered but did not identify wound stage or specific treatment. The care plan also indicated a consult for wound care specialist, reduction cushion on wheelchair, and staff are to turn and reposition resident every 2 hours. Progress notes reviewed only indicated observation of a Stage 2 wound on resident's bilateral buttocks. An interview conducted with the Director of Nursing on March 10, 2022, at 1:00 p.m. revealed that the facility was unclear if the sacral pressure wound was new or if the two bilateral Stage 2 buttock wounds merged. The Director of Nursing confirmed the lack of wound progression knowledge. The Director of Nursing confirmed the only wound treatment administered for the two buttock wounds was barrier cream, present upon admission. The facility failed to timely assess and treat Resident 53's sacral wound which resulted in actual harm of an advanced stage pressure ulcer. 28 Pa. Code 211.12(c)(d)(1)(3) Nursing services Previously cited 1/19/22

Based on observations, review of facility policy, review of the clinical records and interviews with the staff, it was determined that the facility failed to accurately assess, timely identify, and provide all the necessary care and services to prevent the development and promote healing of pressure ulcer, causing actual harm to one of 17 residents reviewed (Residents: E4). Findings include: Review of facility's policy titled Pressure Ulcer- Prevention and Treatment revised December 11, 2013 revealed its policy states that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individuals clinical condition demonstrates that they are unavoidable. The policy indicated a resident with existing pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The policy indicated that nursing will routinely assess and document the condition of the resident ' s skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown and immediately report any signs of developing pressure ulcer to the supervisor. Review of Resident E4's quarterly Minimum Data Set (MDS- assessment of resident care needs and status) dated January 14, 2015 revealed a [DIAGNOSES REDACTED]. Review of physician ' s February, 2015 orders included an order for [REDACTED]. Review of Resident E4 ' s nursing notes dated January 19, 2015 at 9:16 p.m. revealed that the resident had a non-bleachable hard area (skin that does not turn white or purple when pressed) that was weeping clear fluid on her heel and fluid filled area on right side of her left heel. physician's order [REDACTED]. Weekly nursing assessment documentation dated January 20, 2015 at 10:42 a.m. revealed that the resident ' s abdominal excoriation was resolved and no new skin condition was noted. There was no mention of the area on the resident ' s left heel. Wound sheet dated January 20, 2015 at 10:56 a.m. revealed that the resident had a left heel unstageable pressure ulcer (slough (soft moist dead tissue. It may be white, yellow, tan, gray or green) and eschar (tan, brown or black) in the wound bed. The wound measured 5 cm (centimeters) x 6cm and undocumented depth (due to eschar in the wound bed.) The documentation indicated that the center of the heel was hard and measured 1.0 cm x 0.3cm with white surrounding perimeter, and surrounding tissue was described as macerated (excessive moisture in tissue) The treatment include to apply foam dressing and interventions was to consult wound specialist. Wound Care Specialist initial evaluation of the wound dated January 20, 2015 revealed unstageable necrosis (dead tissue), pressure wound measuring 5 cm x 6 cm. and depth was not measurable. It indicated that the wound had 50% thick necrotic (dead) tissue and 50% granulation tissue (new tissue). The wound specialist indicated for staff to continue with foam dressing (helps to offload the wound) once a day, and to off load wound. Review of the Medication Administration Record [REDACTED]. It was not ordered or implemented when the wound specialist recommended it January 20, 2015. Wound Care Specialist evaluation dated January 27, 2015 revealed that the resident continued with an unstageable necrosis pressure wound measuring 5cm x 6 cm and depth not measurable with 25% thick adherent black necrotic (dead)tissue, 25% thick adherent devitalized necrotic tissue and 50% granulation tissue (new tissue) . The wound specialist evaluation indicated the left heel wound debridement was done by surgical excision and subcutaneous tissue removed along with necrotic tissue that was completed and for staff to continue with foam dressing once a daily. Calcium alginate with silver was recommended to be done once daily and to off load the wound. Review of the Medication Administration Record [REDACTED]. The treatment administration record revealed a check on January 29, 2015 indicating that the treatment was completed on the right heel and no documentation on January 30, 2015 that the treatment was completed. The treatment administration record also indicated that staff completed both treatment of [REDACTED]. Staff failed to clarify the order. Observation on February 6, 2015 11: 15 a.m. of nursing, Employee E6 during wound care to Resident E4 ' s left heel revealed an old dressing of gauze was in place and the gauze was dried and stuck to the wound. There was also no foam dressing on the wound. Employee E6 proceeded and soaked the gauze on the wound with normal saline to loosen the dried gauze, after the removal of the gauze the wound was noted to be bleeding around the edges and the main wound was noted to be blackish. During the wound care Employee E6 was observed to wash her hands, set up a clean field, placed a pair of scissors on the clean field without cleaning the scissors, the employee proceeded and continued to set up supplies on the clean field. Employee E6 then moved trash can from one side of the bed to the opposite side of the bed, failed to wash her hands preceded and continued to open and set up dressing supplies on the clean field area. The employee then performed hand hygiene proceeded and wiped the scissors with alcohol swab and placed the scissors in the same area that she had previously placed it. The employee later used the scissors to cut the calcium alginate with silver which she applied to the resident's wound. Interview in the morning on January 9, 2015 with Employee E3 and the Director of Nursing (DON) revealed that staff missed foam dressing indicated on January 20, 2015, and did not clarify the order for Calcium alginate with silver in the morning and the application of skin prep at night to the same wound area. During the interview the DON indicated and that the skin prep should have been discontinued when the order for Calcium alginate with silver was started on January 29, 2015. Interview regarding the observed wound care with the Nursing Home Administrator and the DON on February 10, 2015 at approximately 1:15 p.m. revealed no response. The facility failed to accurately assess, timely identify, ensure adequate care and services were in place leading to actual harm to Resident E 4 identified with pressure ulcer. 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18((b)(1)(e)(1) Management 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.10(c)(d) Resident care policies 28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services Previously cited 3/14/14