Every finding on record at Germantown Home

Based on a review of facility policies, review of clinical records, and staff interviews, it was determined the facility failed to maintain complete and accurate resident records for two of 35 residents reviewed (Resident R9 and R14).Findings include: Review of Resident R9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including, but not limited to, wandering, history of falling, and Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). Review of Resident R9's care plan revealed an intervention, dated December 17, 2025, which stated Wander Guard device .applied to right ankle. Review of Resident R9's clinical record revealed a progress note from May 21, 2026, at 4:07 a.m. that stated a Wander Guard device (a small device applied to the resident which triggers an alarm if the resident attempts to leave a designated area) was applied to the resident's left lower leg, per family request. Review of Resident R9's physician orders revealed that the most recent order for a Wander Guard device was dated December 17, 2025, and stated, Wander Guard .every shift for elopement risk applied to RT (right) ankle. This order was discontinued on January 12, 2026. Observations on June 22, 2026, at 10:30 a.m. of Resident R9, the surveyor was unable to locate any Wander Guard device on the resident. In an interview with Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, it was confirmed that Resident R9 had no current order for a Wander Guard device, was not wearing one at the time of the survey, and had not had one since January 2026. It was further confirmed that it is the expectation of the facility that care plans be updated when residents care needs change, and that progress notes accurately reflect the resident's current status. Review of Resident R14's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of bladder (bladder cancer), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side (weakness or paralysis of left half of the body following a brain bleed that was not caused by trauma), and hypertensive heart disease without heart failure (structural and functional changes of the heart muscle resulting from long-term high blood pressure, but not to the extent where the heart has lost its ability to pump blood effectively). Continued review of Resident R14's clinical records revealed an order dated June 27, 2025, for Mirtazapine (Remeron) 7.5 milligram (mg) tablet to be given by mouth at bedtime for depression (mood disorder characterized by persistent feelings of sadness). Additional review of Resident R14's clinical records revealed no diagnosis of depression listed among his diagnoses. Continued review of Resident R14's clinical records revealed a psychological evaluation, dated July 2, 2025, at the request of the facility, noting resident has a history of depression and substance abuse. The evaluation continues by saying, Per chart review, he currently receives medication management for depression. The evaluation indicated: Resident reported symptoms of depression related to interpersonal difficulties with his children with goals for the treatment session including, Resident will learn adaptive methods to cope with symptoms of depression. Review of Resident R14's care plan dated October 11, 2025, revealed the resident is at risk related to use of antidepressant medication for depression. Interview on June 25, 2026, at 9:45 a.m. with Registered Nurse Assessment Coordinators (RNAC), Employees E13 and E14, confirmed the lack of a depression diagnosis amongst Resident R14's list of diagnoses. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 211.5 (f) (viii) Medical records.

Based on review of facility policy, interviews with staff, and review of clinical records, it was determined that the facility failed to develop person-centered, comprehensive care plans for two of 35 residents reviewed (Residents R125 and R183).Findings Include:Review of facility policy titled, Baseline Care Plan with a revision date of January 2026 states, Purpose: The Baseline Care Plan is intended to promote continuity of care, Person Centered Care and communication among nursing home staff. Policy: A Baseline Care Plan will be developed and implemented, beginning with the resident's initial interdisciplinary assessments. It will include the instructions needed to provide continuity of person-centered care that meet professional standards of quality care. Completion and implementation of the Baseline Care Plan will be done within the 48 hours of a resident's admission. Review of Resident R125's clinical record revealed resident R125 was admitted to the facility on [DATE] and has diagnoses of Dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), Anxiety (a natural human emotion characterized by feelings of worry, tension, and dread in response to stress or anticipated threats), and Depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and a lack of energy).Continued review of Resident R125's clinical record revealed a physician order for a wander guard dated April 6, 2026.Review of Resident R125's clinical record revealed the resident had a Risk Assessment for Wandering completed on April 10, 2026. The assessment described Resident R1 as Disoriented and Forgetful and the diagnosis listed on the assessment was Early Dementia. Further review of the assessment revealed Resident R1 was described as a known wanderer/history of wandering. Review of Resident 125's clinical record revealed no documented evidence a person-centered, comprehensive care plan with goals and interventions was developed to address the resident's status related to elopement/wandering. Interview on June 25, 2026, at 1:00 p.m. with licensed nurse, Employee E3, confirmed that Resident R125's care plan does not include focus area related to elopement/wandering.Review of Resident R183's clinical record revealed the resident was admitted on [DATE], with a diagnosis of Post Traumatic Stress Disorder (a psychiatric condition that can develop after experiencing or witnessing a life-threatening or deeply traumatic event). Review of Resident R183's current care plan dated June 12, 2026, revealed no documented evidence a person-centered, comprehensive care plan with goals and interventions was developed related to the resident's diagnosis of Post Traumatic Stress Disorder. The findings above were confirmed with the Director of Nursing, Employee E2, on June 24, 2026, at 12:35 p.m. Interview on June 25, 2026, at 11:02 a.m. with Social Worker, Employee E8, confirmed a care plan to address Post Traumatic Stress Disorder should have been implemented for Resident R183. 28 Pa Code 211.10 (a) Resident care policies. 28 Pa Code 211.10 (d) Resident care policies.

Based review of facility documentation, facility policy, clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident's care plan was revised timely to address ongoing and escalating aggressive behaviors for one of two sampled residents. (Resident R1) Findings include: Review of facility's policy, titled Resident Centered Care Plans revised January 2011, establishes that care plans are person-centered, interdisciplinary, and written in language that is understandable to all involved. The purpose of the care plan is to provide a resident-specific, timely, and comprehensive plan of care that addresses each resident's needs, conditions, impairments, and strengths. Care plans are developed promptly and include measurable goals, specific interventions, and time frames. Importantly, care plans must be updated whenever there are changes in the resident's condition, status, or treatment needs, not only during quarterly reviews. While the interdisciplinary team conducts quarterly reviews to evaluate resident progress, any significant change in a resident's status between meetings triggers a revision or initiation of a new plan by the affected discipline. This policy ensures that care plans remain current, individualized, and reflective of each resident's evolving needs, emphasizing that revisions are required whenever a change in a resident's status occurs to maintain appropriate and timely care. Review of Resident R1's quarterly Minimum Data Set (MDS- a federally mandated assessment tool for all residents), dated September 4, 2025, revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses including dementia (decline in cognitive abilities), seizure disorder (a neurological condition characterized by recurrent seizures), and malnutrition (condition when the body does not receive enough nutrients or calories to function properly).The functional status assessment indicated that Resident R1 was independent with most activities of daily living and usually used a cane from mobility. The brief interview for mental status (BIMS) reflected a score of 10, indicating moderate cognitive impairment Further review of Resident R1's nursing notes dated October 13, 2025, noted that housekeeping staff reported observing Resident R1 raised his cane toward his roommate Resident R2 as if to strike him. Resident R2 was offered a room change but declined.Review of Psychiatric note dated October 19, 2025, documented Resident R1 with increased irritability and physical aggression. Review of nursing note dated October 21, 2025, revealed that staff reported Resident R1 struck a licensed nurse and verbally abused another staff member. On October 26, 2025, Resident R1 was observed swinging his cane toward staff members. Review of nursing notes dated November 1, 2025, revealed that at 6:30 am Resident R1 struck licensed nurse while she was providing care to roommate Resident R2. Continued review of nursing notes dated November 1, 2025, at 7:07 am revealed Resident R1 struct Resident R2 on the hand with his cane. Review of facility incident report revealed that on November 1, 2025, at approximately 7:07 a.m. a nurse heard somebody yelling for help coming from Resident R1's room. When the nurse entered the room, she observed Resident R2 lying in his bed with his right hand raised in front of his face as if to block the strike. Resident R1 was standing at bedside and witnessed striking Resident R2 right hand with his cane. Review of Resident R1's care plan-initiated June 6, 2025, revealed that the resident's care was not reviewed and/or revised until October 27, 2025 was reviewed and the intervention a psychiatric consult was added to the care plan. Interview with Social Service Director, Employee E4 on November 12, 2025, at 1:30 p.m. revealed that Resident R1 was usually pleasant but experienced periods of confusion and occasionally aggression significantly reduced. Employee E4 stated that prior to November 1, 2025, the resident was not considered a behavioral risk and had no documented history of aggressive behaviors. Following the incident on November 1, 2025, the resident's daughter suggested that the resident might suffer from post-traumatic stress disorder PTSD (Post Traumatic Stress Disorder). Employee E4 stated that he was unaware of any PTS diagnosis and confirmed that a PTSD screening had been completed upon a mission with no known diagnosis or identified triggers. He further stated that for the welfare and safety of all the residents , after resident R1 express violent behavior although the resident reported he was defending his roommate the interdisciplinary team determined it was in the residence best interest to be referred to in-patient psychiatric evaluation. Interview with the Director of Nursing, Employee E2, conducted on November 12, 2025, at 2:15 p.m. revealed the facility staff were aware of resident R1's behavior changes and were informally monitoring his aggression. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza for 51 of 54 residents reviewed (Resident R41, R26, R28, R29, R30, R34, R42, R3, R43, R50, R12, R64, R65, R73, R75, R86, R97, R114, R117, R119, R120, R132, R136, R140, R141, R143, R11, R146, R151, R154, R171, R8, R178, R18, R24, R77, R107, R130, R139, R1, R152, R162, R173, R175, R21, R22, R25, R10, R27, R32, R35) Findings include: Review of facility policy ‘Influenza vaccine - protocol for residents,' reviewed January 14, 2025, indicates that the immunization records of all residents in the facility will be reviewed annually. All residents will be offered the influenza vaccination unless there is a documented contraindication. Residents/Responsible Representative will be offered a copy of the current year Vaccination Information Statement (VIS) annually. Interview with facility's infection preventionist, Employee E6, on Wednesday, July 30, 2025, at 10:00 am, revealed that education on risks vs benefits for influenza immunizations is not completed unless a resident declines the vaccine.Review of facility provided documentation revealed Resident R41, received influenza immunization on October 18, 2024; review of Resident R41's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R26, received influenza immunization on October 2, 2024; review of Resident R26's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R28, received influenza immunization on October 2, 2024; review of Resident R28's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R29, received influenza immunization on October 2, 2024; review of Resident R29's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R30, received influenza immunization on October 2, 2024; review of Resident R30's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R34, received influenza immunization on October 2, 2024; review of Resident R34's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R42, received influenza immunization on October 2, 2024; review of Resident R42's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R3, received influenza immunization on October 2, 2024; review of Resident R3's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R43, received influenza immunization on October 2, 2024; review of Resident R43's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R50, received influenza immunization on October 2, 2024; review of Resident R50's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R12, received influenza immunization on October 2, 2024; review of Resident R12's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R64, received influenza immunization on October 2, 2024; review of Resident R64's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R65, received influenza immunization on October 2, 2024; review of Resident R65's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R28, received influenza immunization on October 2, 2024; review of Resident R28's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R73, received influenza immunization on October 2, 2024; review of Resident R73's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R75, received influenza immunization on October 2, 2024; review of R75's clinical record revealed no evidence of education provided. Resident Review of facility provided documentation revealed Resident R86, received influenza immunization on October 2, 2024; review of Resident R86's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R97, received influenza immunization on October 2, 2024; review of Resident 97's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R114, received influenza immunization on October 2, 2024; review of Resident R114's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R117, received influenza immunization on October 2, 2024; review of Resident R117's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R119, received influenza immunization on October 2, 2024; review of Resident R119's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R120, received influenza immunization on October 2, 2024; review of Resident R120's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R132, received influenza immunization on October 2, 2024; review of Resident R132's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R136, received influenza immunization on October 2, 2024; review of Resident R136's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R140, received influenza immunization on October 2, 2024; review of Resident R140's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R141, received influenza immunization on October 2, 2024; review of Resident R141's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R143, received influenza immunization on October 2, 2024; review of Resident R143's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R11, received influenza immunization on October 2, 2024; review of Resident R11's clinical record revealed no evidence of education provided.Resident Review of facility provided documentation revealed Resident R146, received influenza immunization on October 2, 2024; review of Resident 146's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R151, received influenza immunization on October 2, 2024; review of Resident 151's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R154, received influenza immunization on October 2, 2024; review of Resident 154's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R171, received influenza immunization on October 2, 2024; review of Resident R171's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R8, received influenza immunization on October 2, 2024; review of Resident R8's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R178, received influenza immunization on October 2, 2024; review of Resident R178's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R18, received influenza immunization on October 24, 2024; review of Resident R18's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R24, received influenza immunization on October 24, 2024; review of Resident R24's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R77, received influenza immunization on October 24, 2024; review of Resident R77's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R107, received influenza immunization on October 24, 2024; review of Resident R107's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R130, received influenza immunization on October 24, 2024; review of Resident R130's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R139, received influenza immunization on October 24, 2024; review of Resident R139's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R1, received influenza immunization on October 24, 2024; review of Resident R1's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R152, received influenza immunization on October 24, 2024; review of Resident R152's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R162, received influenza immunization on October 24, 2024; review of Resident R162's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R173, received influenza immunization on October 24, 2024; review of Resident 173's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R175, received influenza immunization on October 25, 2024; review of Resident R75's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R21, received influenza immunization on October 3, 2024; review of Resident R21's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R22, received influenza immunization on October 3, 2024; review of Resident R22's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R25, received influenza immunization on October 3, 2024; review of Resident R25's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R10, received influenza immunization on October 3, 2024; review of Resident R10's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R27, received influenza immunization on October 3, 2024; review of Resident R27's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R32, received influenza immunization on October 3, 2024; review of Resident R32's clinical record revealed no evidence of education providedReview of facility provided documentation revealed Resident R35, received influenza immunization on October 3, 2024; review of Resident R35's clinical record revealed no evidence of education provided28 Pa Code 201.18(b)(1)(d) Management28 Pa Code 211.12( c)(d)(1) Nursing services

Based on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for seven of seven residents reviewed (Residents R120, R24, R141, R43, R145, R156, R83) Findings include:Review of facility policy ‘Covid Vaccine protocol for staff and residents,' reviewed January 14, 2025, indicates that education will be provided for decline referencing CDC guideline.Interview with facility's infection preventionist, employee E6, on Wednesday, July 30, 2025, at 10:00 am, revealed that education on risks vs benefits for covid-19 immunizations is not completed unless a resident declines the vaccine.Review of facility provided documentation revealed Resident R120, received covid-19 immunization on March 25, 2025; review of R120's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R24, received covid-19 immunization on March 28, 2025; review of R24's clinical record revealed no evidence of education provided. Review of facility provided documentation revealed Resident R141, received covid-19 immunization on March 28, 2025; review of R141's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R43, received covid-19 immunization on March 29, 2025; review of R43's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R143, received covid-19 immunization on April 5, 2025; review of R143's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R156, received covid-19 immunization on April 8, 2025; review of R156's clinical record revealed no evidence of education provided.Review of facility provided documentation revealed Resident R83, received covid-19 immunization on April 15, 2025; review of R83's clinical record revealed no evidence of education provided.28 Pa Code 201.18(b)(1)(d) Management28 Pa Code 211.12( c)(d)(1) Nursing services

Based on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to ensure that urinary catheter bag were properly position to prevent contact with the floor for one of one residents review with an indwelling urinary catheter. (Resident Review of facility policy titled Urinary Catheter Care, last reviewed on June 20, 2019, revealed the purpose of the policy is to reduce the risk of the indwelling urinary catheter becoming the source of infection and to reduce the transmission of infection to or between residents/ participants with indwelling urinary catheters. Furthermore, Drainage Bags should never touch the floor. Review of Resident R63's clinical record revealed that resident was admitted to the facility on [DATE] with the diagnoses of End stage renal disease (Kidney failure), Aphasia (disorder that affects a person's ability to communicate). Review of Resident R63's physician order date March 20, 2024, revealed Change suprapubic catheter every 4 weeks and irrigate as needed for clots, dislodgement or occlusion. 18F/30mL change drainage bag as needed when foley catheter is changed. Observation of Resident R63's room on July 29, 2025 at 11:21am, revealed resident's foley catheter drainage bag touching floor. Interview with Employee E7, Licensed Practical Nurse on July 29, 2025 at 11:25am, confirmed findings of Resident R63's foley catheter drainage bag touching floor. Observation of Resident R63's room on July 31, 2025 at 10:46am, revealed resident's foley catheter drainage bag touching floor. Interview with Employee E8, Licensed Practical Nurse on July 31, 2025 at 10:50am, confirmed findings of Resident R63's foley catheter drainage bag touching floor. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of clinical records, review of facility policy, and interview with staff, it was determined that the facility did not develop and implement a comprehensive, resident-centered care plan for seven of 35 residents reviewed related to wounds and Enhanced Barrier Precaution's. (Resident R36, R71, R114, R156, R24, R187, and R41)Findings include:Review of facility policy Resident Centered Care Planning, revised on 06/06, indicates that purpose of policy is to utilize the Resident Assessment Process (RAP) according to Federal Regulations; further indicating that RAP is to be completed by Nursing staff for pressure ulcers.Review of Resident R36's clinical record revealed the resident was assessed with Stage IV (ulcer involving loss of skin layers, exposing muscle) pressure ulcer on coccyx.Review of R36's care plan revealed no evidence of goals or interventions related to Enhanced Barrier Precautions (EBP).Review of Resident R71's clinical record revealed the resident was assessed with Stage IV pressure ulcer on sacrum.Review of R71's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R114, clinical record revealed the resident was assessed with Stage III ( ulcer involving full thickness of skin loss, exposing tissue) pressure ulcer on intergluteal cleft/sacrum.Review of R114's care plan revealed no evidence of goals or interventions related to EBP's.Further review of clinical record revealed [AGE] year-old male resident R156, with diabetic foot ulcer on left lateral foot.Review of R156's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R24's clinical record revealed that the resident was assessed with full thickness venous ulcer on left medial lower leg.Review of R24's care plan revealed no evidence of goals or interventions related to EBP's and no evidence of goals or interventions related to venous ulcer.Review of Resident R187's clinical record revealed that the resident was assessed with full thickness arterial ulcer on right lower extremity.Review of R187's care plan revealed no evidence of goals or interventions related to EBP's.Review of Resident R41's clinical record revealed that the resident was assessed with full thickness arterial ulcers on left lower extremity.Review of R41's care plan revealed no evidence of goals or interventions related to EBP's.28 Pa Code 211.10(a) Resident care policies28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review revealed that the facility failed to ensure that a rational was documented related to pharmacy recommendations for one of 35 residents reviewed. (Resident R2)Findings include:Review of facility policy titled Pharmacy Consultation Recommendations revised on October 1, 2018, revealed The Pharmacy Consultant will review all resident charts monthly and as needed to assess the resident's medication regimen, associated orders to assure proper medication selection, and potential risks associated with pharmacological interventions and to suggest therapeutic changes. Under Procedure, policy states The Unit Manager/ RN supervisor will document the Physician/CRNP's (Certified Registered Nurse Practitioner) response as a verbal order if the Physician/ CRNP has accepted the recommendation, or as a narrative in the progress notes if the Physician/ CRNP has declined the recommendation including the Physician/ CRNP's reason for not accepting the recommendation. Review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Type 2 diabetes (failure of the body to produce insulin), heart disease, and Hypertension (High Blood Pressure). Review of Resident R2's pharmacy review dated May 20, 2025, completed by Employee E9, Consultant Pharmacist revealed This resident receives a fasting blood sugar three times a day with Humalog sliding scale insulin (SSI) coverage. Current geriatric literature recommends avoiding SSI without concurrent Basal Insulin therapy regardless of care setting due to a higher risk of hypoglycemia without improvement in hyperglycemia management. Since SSI is being used minimally, please consider discontinuing SSI. If no changes in current diabetes management are indicated for this resident, please comment. Further review indicated that physician disagreed with the recommendation however provided no further rationale. 28 Pa Code 211.12(d)(1)(3) Nursing services

Based on review of facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to accurately complete a resident assessment for one of 35 residents reviewed (Resident R37).Findings Include: Review of Resident R37's clinical record revealed a progress note dated June 5, 2025, that the resident was assessed and evaluated by the hospice care team. Resident R37 was subsequently admitted on to hospice with a diagnosis of cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain occurs). Review of Resident 37's clinical record revealed a physician order dated June 5, 2025, for hospice care services. Review of Resident R37's significant change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 11, 2025, revealed Section O - Special Treatments, Procedures, and Programs hospice care was marked as no. Interview on August 1, 2025, with the Nursing Home Administrator, Employee E1, confirmed Resident R37's Significant Change MDS dated [DATE], was coded incorrectly for hospice. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1) Nursing services

Based on observation, clinical record review, and interview with staff and residents, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to use of a urinary catheter and discharge status for two of 38 records reviewed (Residents R50 and R178). Findings include: Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to the facility on [DATE], and had diagnoses of pressure ulcer of the sacral region, stage 4 (stage 4 pressure ulcers extend through the skin and fat layers into the muscle, and may extend to the bone), and muscle weakness. Also revealed was a physician order to discontinue the resident's urinary catheter, dated June 15, 2024. Continued review revealed that an MDS assessment (Minimum Data Set- a periodic assessment of resident care needs) was signed by the Registered Nurse Assessment Coordinator (RNAC), Employee E15, on August 9, 2024. In section H, Bladder and Bowel, Employee E15 recorded that the resident was utilizing an indwelling urinary catheter. Interview with RNAC, Employee E15 on September 20, 2024, at 12:15 p.m. confirmed that the catheter had been coded in error. A review of Resident R178's Discharge MDS assessment dated [DATE], revealed that he was admitted to the facility on [DATE], and discharged on [DATE], and that Section A2105 Discharge Status revealed that Resident R178 was coded 04, Short-Term General Hospital (Acute Care). Review of Resident 178's clinical record revealed an August 4, 2024, progress note documenting that the resident is being discharged to home after successful stay for management of status post hospitalization for positive Covid 19 virus, urinary tract infection and sepsis. Interview with the Assistant Administrator, Employee E3 on September 20, 2024, at 11:30 a.m. revealed that Resident R178 had been discharged home with his family and that the MDS was coded in error as the resident did not discharge to the hospital. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records

Based on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice on non-medical coverage (NOMNC) for one of three residents reviewed. (Resident 117) Findings Include: Review of Resident R117's clinical records shows the resident was readmitted to the facility on [DATE]. Resident R117 remained at the facility after his last day of coverage was September 2, 2024. Review of the social service note from September 18, 2024 revealed Note Text: Resident Representative, notified on September 18, 2024 of resident's last coverage date of September 3, 2024. Resident Representative informed of right to appeal last coverage date. Resident Representative stated they would like resident to continue working with therapy. Social Services informed Resident Representative that resident will be picked up by rehab on Physical Therapy caseload per rehab Director. Social Services will provide Resident Representative copies of Notice of Medicare Non-Coverage and Advance Beneficiary Notification via email. Interview with facility Social Worker, Employee E12 held September 19, 2024 at 1:38 p.m. confirmed social services relies on an e-mail from the rehab department for the last date of coverage. Employee E12 stated that for Resident R117 they never received the e-mail from the rehab department. The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare A services, as required. 28 Pa. Code 201.29(f) Resident rights

Based on review of facility policy, observation, clinical record review, and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related oxygen use for one of 35 records reviewed (Resident R167). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Review of clinical documentation for Resident R167 revealed that she was admitted to the facility on [DATE], and had diagnoses of asthma and obstructive sleep apnea. A physician's order was obtained on January 29, 2024, which stated O2 (oxygen) at 2LPM (liters per minute) via nasal cannula at bedtime for hypoxia (low blood oxygen levels). Review of the resident's care plan revealed that no care plan had been developed for the resident use of oxygen. Observations of rResident R167 conducted on September 17, 2024, at 10:45 a.m., revealed that the resident was wearing her oxygen cannula, with the concentrator running at 2 liters per minute. She stated that I wear it every night until I get up. Interview with Employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, on September 20, 2024, at 2:00 p.m., revealed that it is the expectation of the facility that the care plan for all residents utilizing oxygen should reflect that use. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not revise and update the resident's plan of care related to urinary catheter use for one of 35 records reviewed (Resident R50). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside, but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to the facility on [DATE], and had diagnoses of pressure ulcer of the sacral region, stage 4 (stage 4 pressure ulcers extend through the skin and fat layers into the muscle, and may extend to the bone), and muscle weakness. Also revealed was a physician order to discontinue the resident's urinary catheter, dated June 15, 2024. Continued review revealed that a care plan which stated, I have an indwelling catheter for .sacral wound management, which was created on December 24, 2023, and revised on February 2, 2024. The Last Care Plan Review Completed of the overall plan of care was dated on August 21, 2024. Interview with Employees E1, the Nursing Home Administrator, and E2, the Director of Nursing, on September 20, 2024, at 2:00 p.m., confirmed that the care plan had not been updated to reflect the resident's current urinary status at the time of the care plan review. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that services were provided to maintain hearing and vision for two of 35 records reviewed (Residents R53 and R142). Findings include: Review of Guidelines for Use of the Consult Tracking Log policy reviewed April 2022, revealed that a physician's order for a consult is entered in the electronic record as needed. A progress note should be written in PCC for the reason of consult by the nurses. Unit Clerk will review the order in PCC and schedule the appointment, notify the resident representative with the date and time, schedule the escort if needed, and transportation. Unit clerk or designee will write a note under consultation confirming the appointment, responsible party notification and transportation notification. In an interview with Resident R142 on September 17, 2024, at 1:45 p.m., the resident stated that they had checked her hearing a while ago and told her she was getting a hearing aide, and that she never got one. Review of clinical documentation for Resident R142 revealed that she was admitted to the facility on [DATE], and had diagnoses of cognitive communication deficit. Further review revealed a March 16, 2023, audiology consult which recommended a hearing aide evaluation and that the patient agreed. Review of Resident R142's physician orders revealed an April 15, 2024, order for Audiology and Ear, Nose and Throat (ENT) consult, evaluation, treatment as ordered by physician services, over a year later. Continued review of Resident R142's record revealed that the ENT consultation was done May 14, 2024, which indicated treatment was partial debridement of both ears and recommended debridement of both ears and an Audiology consult. Interview with Unit Clerk, Employee E14, on September 19, 2024, at 1:50 p.m. revealed that she was still following up with Audiology for that status of the hearing aids for Resident R142, and that Resident R144 is also waiting for Audiology for his hearing aids. Review of Resident R144's clinical documentation revealed that he was admitted on [DATE], with diagnosis to include having a stoke with aphasia (comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). Review indicated that Resident R144 had an ENT consult on April 6, 2023, which stated that the patient was cleared for hearing aids. A May 8, 2023, Audiology consult revealed hearing loss in both ears and recommended an ENT consult. Further review of Resident R144's clinical record revealed that the ENT consult was not done until April 3, 2024, which recommended an Audiology evaluation. An August 21, 2024, social services note indicated that an amplifier was added to Resident R144's room phone and that he was to be seen by Audiology on the next September 5, 2024, visit. No further documentation was available as to the status of Resident R144's hearing aids. Interview with Unit Clerk, Employee E14, on September 19, 2024, at 1:50 p.m. revealed that she had just called Audiology about the status of Resident R144's hearing aids and that they were to get back to her. Review of clinical documentation for Resident R53 revealed that she was admitted to the facility on [DATE], and had diagnosesof type 2 diabetes with diabetic retinopathy of the right eye. In an interview with Resident R53 on September 18, 2024, at 12:07 p.m., she stated that an outside care company is paying for my glasses. I've had my appointment back in May and I'm waiting for my new glasses. My friend bought the ones I'm wearing. The resident stated that she required bifocals to correct both near and far vision, but that her current pair were non-prescription reading glasses. Continued review of the clinical record revealed a nursing note signed by Registered nurse, Employee E16, on May 16, 2024, which stated Resident seen in house by optometry, N/O (new order) for new prescription glasses. Review of a consultation note from the consultant optometrist, Employee E17, dated May 15, 2024, revealed that it included an updated prescription for eyeglasses and stated that glasses were required and to encourage full-time use for distance and reading. Review of a document titled Eyeglass Dispense Log which listed all residents who received new glasses between January 20, 2024, and September 19, 2024, revealed that the resident was not documented as having received her eyeglasses. In an interview with the Director of Nursing, Employee E2, on September 19, 2024, at 1:34 p.m., she stated that the outside service paying for the glasses has a process, and that the prescription was sent to them. A subsequent interview with Employee E2 at 1:56 p.m. confirmed that the resident's new eyeglasses had not yet been delivered. No evidence was provided that the facility attempted to follow up with the service to ensure that the needed glasses were delivered in a timely manner. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E9). Findings include: An interview on September 17, 2024, at 10:30 a.m. with Employee E4, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on September 19, 2024, at 11:30 a.m. with the Administrator, the FSD's personnel file was reviewed, and his qualifications were discussed which revealed he had been working at the facility for many years, was promoted to FSD over a year ago and was not a Certified Dietary Manager or Certified Food Manager. The Administrator confirmed that the FSD had not completed these requirements. The Nursing Home Administrator was unable to provide evidence that the FSD was Certified, and therefore unqualified to direct the dietary department. 28 Pa. Code 211.6(c)(d) Dietary services 28 Pa Code 201.18(e)(1)(6) Management

Based on review of facility policy, clinical record review and interview with staff, it was determined that facility failed provide resident with pressure injury measures to prevent the development or worsening of pressure injury for one resident. (Resident R1) Findings include: Review of facility policy on wound prevention and maintenance guidelines revealed that under section Policy: It is the policy for this facility that all residents are assessed for skin risk, using the Braden Scale, and that residents at risk, including those with pressure injury, will have appropriate plans of care implemented. Under section Purpose: To provide at-risk residents with pressure reducing or relieving surfaces and devices to reduce the mechanical forces of pressure, shear, friction and/or moisture, which contribute to tissue breakdown. Under section Procedure: #4. Based on the assessment and Braden Scale, a licensed nurse will initiate treatment with appropriate pressure redistribution and devices. #8. Products vary greatly in their ability to reduce pressure, shear, friction, and moisture. Care should be taken to match product efficiency with elder needs. A. Full Therapy Beds (pressure relief), i. Low air loss therapy, ii. Alternating air Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses of Pressure Ulcer (damage to the skin and/or underlying soft tissue) to Sacral Region, Type Two Diabetes Mellitus (failure of the body to product insulin), Hypertensive Heart Disease with Heart Failure, Unspecified Dementia (irreversible, progressive degenerative disease of the brain), Hypertension ( high blood pressure), Hyperlipidemia (high cholesterol). Review of Resident R1's admission Minimal Data Set (MDS- assessment of resident's care needs) dated March 23, 23, 2023, section C0500 BIMS (Brief interview for mental status) revealed that resident scored 7 suggesting that Resident R1 was severely impaired in cognition. Section G ADL (Activities of Daily Living) revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility. Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 (full thickness loss of skin, slough and/or eschar may be visible but does not obscure the depth of tissue loss) pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's quarterly MDS assessment dated [DATE], section C0500 BIMS revealed that resident scored 4 suggesting that Resident R1 was severely impaired in cognition. Section G ADL revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's quarterly MDS assessment dated [DATE], revealed that section C 0500 BIMS, revealed that resident scored 3 suggesting that Resident R1 was severely impaired in cognition. Section G ADL revealed that Resident R1's required extensive assistance with two staff assistance with bed mobility. Section M0100(A) revealed that resident had pressure ulcer, Section M0150 revealed that resident was at risk for developing pressure ulcer/injury, M0210 revealed that resident had unhealed pressure ulcer injury, Section M0300 C revealed that resident had one stage 3 pressure that was present on admission, M1200C revealed that resident was not on a turning and position program. Review of Resident R1's current care plan revealed that Resident R1 had a plan of care for: risk for/ actual impairment to skin integrity related to coccyx stage 3 pressure injury -discoloration to both heels. Further, review of the care plan revealed intervention to Off-load pressure to affected areas, reposition patient at least every 2 hours while in chair/bed and continue repositioning in accordance to assessed needs. Review of Resident's R1's wound/skin nutrition note dated June 6, 2023, revealed that Resident R1 was seen on June 2, 2023, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with one of the treatments as follow: Continue re- positioning in accordance to assessed needs. Further review of resident's R1's wound/skin nutrition notes revealed that Resident R1 was seen on June 7, 2023, June 14, 2023; June 21, 2023; June 28, 2023; July 10, 2023; July, 12, 2023 and July 19, 2023, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with treatments as follow: Offload pressure to affected areas: re- positing patient at least every 2 hours while in chair/bed. Continue repositioning in accordance to assessed needs. Wound/skin nutrition note dated July 31, 2023, revealed that Resident R1 was seen, for weekly wound rounds by wound team including Nurse practitioner/consultant for Stage 3 pressure and full thickness ulceration of the coccyx with recommendation to continue: Off-load pressure to affected areas: reposition patient at least every 2 hours while in chair/bed Continue re- positioning in accordance to assessed needs and low air loss support surface. Review of Resident's R1's Wound Nurse skin impairment tracking note dated August 2, 2023, revealed Additional findings include full-thickness wound of the right heel measuring 5.0 x 3.5 x 0.0 cm. Purple / maroon localized area of discolored intact skin with blood-filled blister roof. With recommendations/plan to continue: Low-air loss support surface and, turn every 2 hours. Wound/skin nutrition note dated August 11, 2023, revealed that Resident R1 was seen, for weekly wound rounds for Stage 3 pressure and full thickness ulceration of the coccyx with recommendation to continue: Off-load pressure to affected areas: reposition patient at least every 2 hours while in chair/bed Continue re- positioning in accordance to assessed needs. Review of wound note from wound consultant dated August 23, 2023, revealed that Resident R1 was seen by wound consultant with recommendation for turning/repositioning precautions per protocol. Wound note from wound consultant dated August 30, 2023; September 6, 2023; September 13, 2023, and September 20, 2023, revealed that Resident R1 was seen by wound consultant. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, continue with turning and repositioning schedule per protocol for pressure prevention. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring Length: 4.00 cm, Width: 2.50 cm, Depth: 2.50 cm. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring: Length: 4.80 cm, Width: 2.50 cm, Depth: 2.50 cm. Review of wound assessment dated [DATE], revealed that Resident R1 had a stage 3 sacral pressure ulcer measuring, Length: 4.80 cm, Width: 2.90 cm, Depth: 2.50 cm Nurses note dated September 22, 2023, 11:46 a.m. revealed that the resident was out of the facility to surgical appointment to wound clinic accompanied by daughter in stable condition at 9:06 a.m. no distress noted at this time. Review of resident's clinical record revealed no documented evidence that resident was turned and re-position at least every two hours while in chair/bed daily. Interview with Licensed nurse, Employee E3 conducted on October 12, 2023, at 11:18 am confirmed that Resident R1 required extensive assistance with two people assist with bed mobility as indicated on the Admission MDS assessment dated . Further, Employee E3 confirmed that Resident R1 was not on a turning and positioning program. Interview with Licensed nurse, Employee E4 conducted on October 12, 2023 at 11:38 a.m. revealed that Resident R1's sacral pressure ulcer was getting larger and that Resident R1 had developed arterial ulcers to her lower extremities. Further Employee E4 also confirmed that Resident R1 was on a low air loss mattress. Further interview with Wound Care Nurse confirmed that Resident R1 was not placed on a turning and position program. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive, person-centered care plan related to behaviors, wound treatment and communication for two of 37 residents reviewed (Residen R36, and R149). Findings Include: Review of facility policy Resident Centered Care Planning revealed individual treatment goals should be identified. These goals should be resident specific, reasonable, and measurable. The plan of care should be revised whenever appropriate to reflect the resident's current needs. Review of facility policy titled Resident Centered Care Planning, dated January 2018, revealed that Long term care interdisciplinary assessments will be initiated within 24 hours and completed between 7 and 14 days of admission, and Individual treatment goals are identified. These goals are resident specific, reasonable, and measurable. Each resident's plan of care identifies goals that: Reflect the resident's unique needs/strengths/preferences .[and] Identify specific, individualized interventions/approaches, as well as Services and care are identified and planned to meet the resident's problems, needs and goals. Review of clinical documentation revealed that resident R36 was admitted to the facility on [DATE], with diagnoses including, but not limited to, pressure ulcer of sacral region, stage 4, end stage renal disease, and type 2 diabetes mellitus with diabetic chronic kidney disease. A physician order was reviewed dated January 13, 2023, which stated Check NPWT Negative Pressure Wound Therapy, also known as a wound vac- a treatment in which the wound is packed with foam and then a vacuum is applied to control moisture and drainage in order to improve wound healing) to Sacrum and right ischum for placement and functionality every shift. Foam should be collapsed, machine setting @125 mmHg continuous: charger in place. Review of the resident's care plan revealed that as of February 9, 2023, no care plan had been developed for the resident's wound vac. Interview with the Director of Nursing, employee E2 on February 9, 2023, at 12:30 p.m. revealed that the resident's wound vac had been present since admission and he confirmed that a care plan should have been developed for it, but that it had not been. Review of clinical documentation revealed that resident R149 was admitted to the facility on [DATE], with diagnoses including, but not limited to, unspecified hearing loss, unspecified ear, malignant neoplasm of prostate, and anxiety disorder. Interview with the responsible party for R149 on February 9, 2023, at 10:24 a.m. revealed that the resident is profoundly deaf and requires an interpreter to accompany him to physician appointments. Review of the resident's care plan revealed that a care plan for interpreter services was not developed before February 9, 2023. Interview with the Director of Nursing, employee E2 on February 9, 2023, at 12:30 p.m. revealed that the was receiving interpreter services, and that a care plan should have been developed for it, but that it had not been prior to the survey. 28 Pa Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to ensure necessary care and services were provided related to nail care for one of one resident reviewed with a hand contracture (Resident R68). Findings include: Review of facility policy Bathing/Showering revelaed each resident should have a shower/bath schedule. The purpose is to maintain and encourage proper hygiene and identify any skin abnormalities. Procedures for bathing included to provide nail care, wash hands with soap and warm water, and to document in the electornic medical record. Review of Resident R68's clinical record revealed a Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 8, 2022, which indicated the resident was admitted to the facility on [DATE], and had diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), malnutrition (lack of sufficient nutrients in the body), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), muscle weakness, and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). Further review of the MDS assessment revealed that the resident had functional limitation in range of motion on one side of the upper extremity (shoulder, elbow, wrist, hand), and required extensive assistance of two-persons for personal hygiene. Review of Resident R68's Occupational Therapy (OT) Evaluation and Plan of Care dated February 26, 2021, revealed the resident was referred for therapy due to worsening contracture of the right hand. Review of Resident R68's OT discharge summary dated April 5, 2021, revealed limited progress was made due to the resident's severe cognitive decline and pain to right hand. The resident would clench hand and was not able to tolerate range of motion. Occupational therapy coordinated with nursing and decided that a protective sleeve should be worn as Resident R68 was unable to tolerate a palm guard (hand splint which is a thicker material that is used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture). Review of Resident R68's care plan, revised October 5, 2022, revealed the resident had decreased strength of right upper extremity. The resident had contractures to the right hand with limited ability to flex pointer finger and thumb. Review of Resident R68's care plan date-initiated January 16, 2022, revealed the resident had a history of and resolved skin tear to the right-hand palm on January 16, 2022, related to moisture, sharp fingernails and hand contracture. Interventions dated January 16, 2022, incldued daily inspection of the palm of the hands, wash inside the hands, keep dry, and to keeps nails short/trimmed. Review of Occupational Therapy screening dated January 18, 2022, by occupational therapist, Employee E5, revealed Resident R68 was screened by OT and therapy was not warranted secondary to abrasion and resident's resistance. Resident R68 was referred to nursing until abrasion was resolved. Review of Resident R68's clinical record revealed a physician order dated July 15, 2022, for a protective sleeve to the right hand, remove for daily hygiene, passive range of motion (achieved when an outside force, such as a therapist, exclusively causes movement of a joint), and skin checks. Review of Resident R68's clinical record revealed a progress note that the resident was assessed on September 2, 2022, by the physician, Employee E15. Review of Employee E15's assessment indicated the resident had no recent behavioral issues. Continued review of the assessment revealed no documented evidence of reference to the resident's right-hand contracture. Continued review of Resident R68's clinical record revealed the next progress note was dated September 30, 2022, by Registered Nurse Supervisor (RN), Employee E3. Employee E3 indicated that the care nurse reported a foul odor coming from Resident R68's right hand. Upon assessment, Resident R68's right hand was contracted to all digits and presented as a fist. The RN supervisor and charge nurse were able to assess the right hand with difficulty and observed an open area with a foul smell. It appeared that Resident R68's fingernails were elongated and penetrating the skin to cause the open area as the right hand was balled in a fist. Review of Resident R68's clinical record revealed the physician was made aware and gave new orders to send the resident to the hospital. Review of Resident R68's hospital records dated September 30, 2022, revealed the resident presented to the emergency room for a wound check. Review of hospital records revealed the wound developed an unknown amount of time ago due to the resident's fingernails growing too long because the hand was chronically contracted. The physician assessed the area and noted the wound was small with no drainage but did have a foul smell, so it was covered with Doxycycline (antibiotic). Review of the skin assessment revealed the area was identified as a small 1.5-centimeter (cm) laceration on the right palm, with a foul smell, and appeared chronic. Review of the facility investigation revealed a statement by nurse aide, Employee E7, dated September 30, 2022. It was revealed this nurse aide was the resident's assigned care giver on September 28, 2022, on the 7:00 a.m. to 3:00 p.m. shift. Review of statement by Employee E7 revealed this nurse aide was unable to open her hand, therefore did not see open area. Interview on February 9, 2023, at 8:52 a.m. with Director of Therapy, Employee E5, revealed Resident R68's clenching of right hand was a combination of behavior and contracture. Interview on February 9, 2023, at 11:36 a.m. with restorative aide, Employee E6, confirmed that Resident R68 was resistive to care. Continued interview revealed it was hard to trim Resident R68's nails on the right hand because the resident would refuse to open her hand. Interview on February 9, 2023, at 11:45 a.m. with Registered Nurse, Employee E4, revealed the resident was resistive to care and would refuse nail care of the right hand. Continued interview revealed nursing aides were not always letting licensed nursing staff know when the resident would refuse. Therefore, the facility implemented a physician order for nail care status post skin breakdown identified on September 30, 2022. Review of Resident R68's entire clinical record revealed no documented evidence of refusals for nail care to right hand. Interview on February 9, 2023, at 12:07 p.m. with nurse aide, Employee E7, confirmed Resident R68 would refuse nail care. Continued interview with Employee E7 revealed a nurse would attempt to assist in trimming nails and the resident would still refuse. Review of Resident R68's nursing Kardex (communication tool for nursing staff related to patient care summary) revealed nail care was intended to be completed on the resident's shower days. Review of Resident R68's clinical record revealed the resident had a scheduled shower day with subsequent nail care on September 29, 2022. Tasks were signed out as completed by nurse aide, Employee E9. Interview on February 9, 2023, at 12:54 p.m. with nurse aide, Employee E9, confirmed that nail care was not completed on Resident R68's right hand on September 29, 2022. Continued interview revealed nail care was only able to be completed on the resident's left hand. Employee E9 reported that the resident would make a clenched fist of the right hand and not allow staff to complete nail care. 28 Pa. Code 201.29(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for two of three resident's reviewed. (Resident R125 and R26). Findings include: Review of facility policy Weight and Nutrition Management revealed if the dietitian determines that a high protein supplement is warranted, a physician order must be obtained, nursing staff should document percent consumed in the electronic medication administration record (MAR), and the dietitian will review percent consumed. Review of Resident R125's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 10, 2022, revealed the resident was admitted to the facility on [DATE], and had diagnoses of protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), muscle weakness, dysphagia (swallowing difficulty), cerebrovascular attack (stroke - an interruption in the flow of blood to cells in the brain), and cognitive communication deficit. Further review of the MDS revealed the resident had a tube feeding (delivery of nutrition formula via a tube feeding directly into the stomach) and received 25% or less of total calories, and 500 cc/day or less of average fluid intake via the tube feeding. Review of Resident R125's comprehensive care plan, date-initiated December 28, 2020, revealed the resident had potential nutritional problem related to dysphagia, protein calorie malnutrition, and history of need for PEG tube (percutaneous endoscopic gastrostomy- feeding tube insertion through the skin and the stomach wall) as primary source of nutrition. Review of Resident R125's clinical record revealed a progress note by the Registered Dietitian, Employee E8, dated October 4, 2022, that the resident's family had requested discontinuation of the tube-feeding, although the resident's food intake varied from 25-100%. Further review of Resident R125's clinical record revealed the Registered Dietitian ultimately discontinued the resident's tube feeding formula on October 10, 2022, secondary to excellent intakes and stable weight. Tube-feeding water flushes continued to maintain patency of the tube-feeding. Review of Resident R125's weight summary revealed a gradual, continuous weight loss status post discontinuation of the resident's tube feeding. Further review revealed Resident R125 had a significant weight loss of 8.6% in three months (10/4/2022 weight 144.2-pounds; 01/15/2023 weight 131.8-pounds). Review of Resident R125's clinical record revealed a progress note by the Registered Dietitian dated January 17, 2023, that confirmed the resident had a significant weight loss in three months. The Registered Dietitian noted that the resident's intakes were variable from 25-100%, which was below her usual baseline. The Registered Dietitian subsequently recommended Ensure Clear (liquid nutritional supplement) three times per day. Interventions included monitoring intake and weight to promote weight stability. Review of Resident R125's weight summary revealed the resident continued to have a continuous, gradual weight loss status post implementation of the supplement, with a documented weight of 126.2 pounds on February 5, 2023. Review of Resident R125's medication administration record revealed no documented evidence nursing was documenting percent consumed of the nutritional supplement. Review of Resident R125's clinical record revealed no monitoring of Resident 125's meal and nutritional supplement consumption by the Registered Dietitian between January 17, 2023, and February 7, 2023. Interview with the Registered Dietitian, Employee E8, on February 9, 2023, at 11:04 a.m. confirmed resident R125 would have benefited from increased monitoring. Review of Resident R26's Significant Change MDS dated [DATE], revealed the resident was readmitted from the hospital on December 29, 2022, and had diagnoses of dementia (progressive loss of intellectual functioning), depression (loss of interest in activities, causing impairment in daily life), diabetes mellitus (affects how the body uses blood sugar), and gastrointestinal hemorrhage (internal bleeding of the digestive tract). Continued review of the MDS revealed the resident had a weight of 117-pounds and had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight loss program. Review of Resident R26's clinical record revealed a physician order dated December 30, 2022, for Glucerna (specialized oral nutritional supplement designed to help people with diabetes manage blood sugar) three times per day. Review of Resident R26's nutrition assessment dated [DATE], by the Registered Dietitian, Employee E8, revealed the resident consumed 25-100% of most meals and accepts Glucerna three times per day. Continued review of nutrition assessment confirmed the resident had a significant weight loss of -8.2% in 30-days (01/09/2023 weight 117.4-pounds; 12/6/2022 weight 128-pounds) and interventions included to monitor intake, weight, and encourage resident to consume adequate intake of meals for weight stability. Observations during the lunch time meal service on February 6, 2023, revealed Resident R26 did not eat any of her lunch or drink the two milks on the lunch tray. Interview with nursing assistant, Employee E11, at on February 6, 2023, at 1:30 p.m., confirmed Resident R26 did not eat lunch and will only drink the milk when she wanted to. Review of Resident R26's weight summary revealed the resident had a continuous, gradual weight loss from January 11, 2023, with a documented weight of 110.1 pounds on February 5, 2023. Review of Resident R26's nursing Kardex for percentage of food eaten at meals revealed the resident had poor-variable intakes that ranged from 0-75%. Review of Resident R125's medication administration record revealed no documented evidence nursing was documenting percent consumed of the ordered nutritional supplement. Review of Resident R125's clinical record revealed no monitoring of Resident 125's weight and food consumption by the Registered Dietitian between January 11, 2023, and February 5, 2023. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (c)(5) Nursing Services

Based on review of hospital records, review of clinical records, and staff interview, it was determined the facility failed to ensure treatment recommendations from the hospital were reviewed and implemented for one of 37 residents reviewed (Resident R68). Findings include: Review of Resident R68's clinical record revealed a Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated November 8, 2022, which indicated the resident was admitted to the facility on [DATE], and had diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions), malnutrition (lack of sufficient nutrients in the body), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), muscle weakness, and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). Further review of the MDS assessment revealed that the resident had functional limitation in range of motion on one side of the upper extremity (shoulder, elbow, wrist, hand), and required extensive assistance of two-persons for personal hygiene. Review of Resident R68's care plan, revised October 5, 2022, revealed the resident had decreased strength of right upper extremity. The resident had contractures to the right hand with limited ability to flex pointer finger and thumb. Review of Resident R68's clinical record revealed a progress note dated September 30, 2022, by Registered Nurse (RN) Supervisor, Employee E3, that indicated the care nurse reported a foul odor coming from Resident R68's right hand. Upon assessment, Resident R68's right hand was contracted to all digits and presented as a fist. The RN supervisor and charge nurse were able to assess the right hand with difficulty and observed an open area with a foul smell. It appeared that Resident R68's fingernails were elongated and penetrating the skin to cause the open area as the right hand was balled in a fist. Review of Resident R68's clinical record revealed the physician was made aware and gave new orders to send the resident to the hospital. Further review of Resident R68's clinical record revealed the resident returned from the hospital the same day, September 30, 2022, with no discharge instruction/no treatment order. Resident R68 was assessed by the wound nurse, Employee E10, on October 1, 2022, who noted that the resident returned to the facility on [DATE], with no discharge paperwork. Employee E10 reached out to the hospital who reported the electronic medical record system was down and Employee E10 was subsequently unable to review discharge orders. Interview on February 9, 2023, at approximately 9:00 a.m. with the Director of Nursing, Employee E2, revealed the facility did not obtain hospital discharge paperwork for Resident R68 from the September 30, 2022 hospitalization , until February 8, 2023. Review of Resident R68's hospital records dated September 30, 2022, revealed the resident presented to the emergency room for a wound check. Further review of hospital records revealed the wound developed an unknown amount of time ago due to the resident's fingernails growing too long because the hand was chronically contracted. The physician assessed the area and noted the wound was small with no drainage but did have a foul smell, so it was covered with doxycycline (antibiotic). Review of the discharge disposition revealed medication changes included doxycycline hyclate (antibiotic medication used to treat different bacterial infections) 100 milligrams oral 2 times daily. Review of Resident R68's entire clinical record revealed no documented evidence the physician addressed or or implemented medication recommendations from the hopsital. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of six residents reviewed (Resident R1). This failure resulted in an Immediate Jeopardy situation for Resident R1 who was rough handled and hit by a nurse aide. Findings include: Review of facility policy, Abuse Prohibition dated last revised March 9, 2021, revealed, Residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be abused by anyone, including, but not limited to, facility staff. Continued review revealed that physical abuse includes, but is not limited to, hitting, slapping, pinching, kicking, etc. Further review revealed that, Situations of abuse, neglect, and/or misappropriation of property will be identified and corrected. This includes an analysis of . the supervision of staff to identify inappropriate behaviors, such as . rough handling. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated May 26, 2022, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of dementia with behavioral disturbance (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities with behaviors that may include aggression, wandering and hoarding), anxiety disorder (intense, excessive, persistent worry or fear), persistent mood disorder (a long-term form of depression) and senile degeneration of the brain (a decrease in cognitive abilities or mental decline). Continued review revealed that the resident was severely cognitively impaired. Review of Resident R1's care plan, dated initiated July 4, 2020, revealed that the resident had behaviors including physical and verbal aggression. Interventions included: anticipate needs, provided tasks to distract and engage, caregivers to provide opportunity for positive interaction, stop and talk to the resident, redirect out of arms reach of other residents, approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, minimize potential for disruptive behaviors by offering tasks which divert attention, monitor behavior episodes and attempt to determine underlying cause, and reassure resident of his safety during his stay at the facility. Review of nursing notes revealed an incident note, dated August 22, 2022, at 2:27 p.m. which indicated that at 8:55 a.m. Resident R1 was in an altercation with a staff member and the resident reported, She hit me, I swung (demonstrated with his left hand) and I pushed her away. Interview on August 29, 2022, at 11:54 a.m. Housekeeper, Employee E11, stated that on the morning of August 22, 2022, she was in the dining room cleaning and sweeping. Employee E11 stated that she observed Nurse Aide, Employee E13, forcefully pull and peel Resident R1's hands off of a table, Nurse Aide, Employee E13 then proceeded to drag the chair that Resident R1 was seated in and positioned the chair against the wall. Resident R1 began to hit Nurse Aide, Employee E13 and Nurse Aide, Employee E13 responded by hitting Resident R1 back. Employee E11 stated that she was standing right next to the resident and staff member at the time and had a direct line of sight of the altercation. Housekeeper, Employee E11 stated that Resident R1 remained seated in the chair during the altercation and that she observed Nurse Aide, Employee E13 punch Resident R1 in the chest with both hands with closed fists. Housekeeper, Employee E11 adamantly described that she saw Employee E13's hands make physical contact with Resident R1's chest while she was punching him. Housekeeper, Employee E11 then left the dining room to get assistance from nursing staff. Interview on August 29, 2022, at 11:22 a.m. with Registered Nurse, Employee E12, stated that she heard Housekeeper, Employee E11 yell out they're fighting. Registered Nurse, Employee E12 stated that she then entered the dining room and observed Nurse Aide, Employee E13 using her hands to pin Resident R1's hands and arms over his chest. Registered Nurse, Employee E12 instructed Nurse Aide, Employee E13 to step away. Registered Nurse, Employee E12 stated that as Nurse Aide, Employee E13 stepped away, Employee E13 pushed a table against Resident R1, impeding his ability to move or get up. Registered Nurse, Employee E12 informed Nurse Aide, Employee E13 that she cannot do that, Employee E13 then proceeded to grab a chair and put it in front of the table. Registered Nurse, Employee E12 escorted Nurse Aide, Employee E13 out of the dining room and dismissed her from duty. Registered Nurse, Employee E12 stated that Resident R1 reported to her that Nurse Aide, Employee E13 hit him. Registered Nurse, Employee E12 stated that upon assessment Resident R1 had a one centimeter scratch on the back (dorsal) of his left hand. Employee E12 stated that she did not understand why Nurse Aide, Employee E13 engaged in a physical altercation with Resident R1 and reported that Nurse Aide, Employee E13 had opportunities to step back, walk away or call for help that could have avoided the altercation. Review of facility documentation submitted to the Department of Health dated August 23, 2022, at 4:40 a.m. revealed that Resident R1 was allegedly hit by nurse aide, Employee E13. Review of facility documentation revealed a witness statement, dated August 22, 2022, regarding the incident, from Housekeeper, Employee E11 which noted, She [Nurse Aide, Employee E13] pulled the table back and then they were fighting . she handled it wrong the way she pulled the chair back and then she hit him . she was punching him in his chest. Continued review of facility documentation revealed a witness statement, dated August 22, 2022, regarding the incident, from Registered Nurse, Employee 12 which noted, Housekeeper [Employee E11] informed this writer that someone was fighting in the dining area/multipurpose room. Upon entering the room, once I looked to the right, observed staff member [Nurse Aide, Employee E13] with resident pinning his arm across his chest while sitting in a stationary chair . Asked resident what occurred, he stated, 'She hit me, I swung (demonstrated with his left hand) and pushed her away.' This writer did observe [Nurse Aide, Employee E13] attempt to use the table to impede resident from standing up from chair. After assessing resident, [Resident R1] had a 1 c.m. [one centimeter] scratch on mid-dorsal hand. Further review of facility documentation revealed a witness statement, dated August 22, 2022, regarding the incident from Nurse Aide, Employee 13 which noted, I was putting resident in the chair and resident started hitting me and the housekeeper call the nurse and she seen the whole thing. Interview with the Director of Nursing and Assistant Director of Nursing on August 29, 2022, at 11:10 a.m. revealed that Nurse Aide, Employee E13 was still on suspension and that the investigation was still in progress. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from a nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on August 29, 2022, at 2:44 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 1. The nurse aide was removed from resident area and her statement was obtained. A subsequent question and answer session was conducted to clarify details of the concern. 2. The policy on prohibition of abuse, exploitation, and neglect, including rough handling was reviewed with the nurse aide. She was suspended pending the outcome of the investigation. 3. The resident was assessed for injury and observed with a small scratch to his left dorsal hand. A full skin assessment, with specific attention to chest and torso was completed. No other injury was identified. 4. The housekeeper who witnessed the incident was interviewed and provided a statement. A subsequent question and answer session was conducted followed by a reenactment of the incident. 5. The residents present in the main lounge exhibited no signs of distress and no behavior changes were observed. 6. Education on facility policy on prohibition of abuse, including rough handling will be provided for all working staff, approximately 80%, during this week by Wednesday, August 31st, 2022. All other staff will receive education at start of shift prior to initiating their assignment. 7. In-person General staff meeting for nursing and non-nursing staff was conducted by ANHA and ADON on August 25th and 26th for all shifts with evidence of staff participation via sign-in sheets where resident rights and facility protocol on prohibition of abuse, neglect, exploitation, and included rough handling. 8. Administration, social workers, and unit managers will conduct a whole house audit to ensure that residents have not experienced abuse or have any physical or psychosocial signs of abuse by Wednesday, August 31st, 2022. 9. Additional resident council meetings will be scheduled for August 30, 2022, to re-educate residents on resident rights and facility protocol on prohibition of abuse, neglect, and exploitation, including rough handling. 10. The abuse investigation will be concluded by Wednesday, August 31, 2022. Facility will continue to review during monthly QAPI (Quality Assurance Plan Improvement), next scheduled on September 13, 2022, any new incidents and audits related to resident rights and abuse. Review of facility documentation revealed that the corrective action plan was immediately initiated. Audits were initiated to screen residents for abuse. Residents were interviewed by facility staff and resident council meetings were conducted. Abuse and neglect were discussed, reporting procedures were explained and residents were assured of their safety. Residents expressed no concerns and no further occurrences of abuse. Facility in-services for staff were promptly initiated and included abuse and neglect and reporting requirements. Examples of abuse reviewed included rough handling, shoving, scratching and hitting. Interviews were conducted on August 30, 2022 between 1:10 p.m.-2:00 p.m. & 3:05 p.m.-3:40 p.m. with staff from various departments. All staff reported that they received the in-service training. It was confirmed during the interviews that they were able to recognize signs of resident abuse, that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process. Staff reported that they were knowledgeable and sufficiently prepared to manage residents with behaviors in a safe manner. Interviews conducted on August 30, 2022 1:10 p.m.-2:00 p.m. & 3:05 p.m.-3:40 p.m. with residents from all nursing units reported that they had no concerns related to staff or care. Residents denied any concerns of abuse and reported that they felt safe at the facility. The Immediate Jeopardy was lifted on August 30, 2022, at 4:15 p.m. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29 (c) Resident rights 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services

Based on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of six residents reviewed (Resident R1). This failure resulted in an immediate jeopardy situation for Resident R1 who was hit on the back of the head by a nursing staff. Findings include: Review of facility policy, Abuse Prohibition dated last revised March 9, 2021, revealed that, Residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents will not be abused by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Continued review revealed that physical abuse includes, hitting, slapping, pinching, kicking, etc. Review of Resident R1's significant change MDS (Minimum Data Set - a periodic mandatory assessment) dated April 27, 2022, revealed that the resident was admitted to the facility December 22, 2014, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that the resident required extensive assistance from staff with bed mobility, transfers and hygiene. Further review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of three, which indicated that Resident R1 was severely cognitively impaired. Review of progress notes revealed a nurses note, dated April 30, 2022, at 5:59 a.m. which indicated that at 5:00 a.m. Employee E22, licensed nurse, heard Resident R1 yell out. Employee E5 went to the resident's room and observed a nurse aide leaning over [Resident R1] and punched her with a closed fist in the back of the head. Employee E22 noted that Resident R1 was medicated for complaints of pain to her head and face, swelling was noted to the resident s right eye and bruises noted to bilateral wrist area. Review of facility documentation submitted to the Department of Health dated April 30, 2022, at 1:41 p.m. revealed that Resident R1 was allegedly hit by a nurse aide, Employee 21. Review of facility documentation revealed a witness statement regarding the incident from Employee E22, which noted, At 5:00 a.m. I heard [Resident R1] yell out, I just saw her CNA (nurse aide) take her into her room, I immediately walked into [Resident R1's] room and I saw the CNA [Employee E21] punch [Resident R1] in the back of the head. [Resident R1] was laying in the bed at the time of the incident. Continued review of facility documentation revealed a witness statement regarding the incident from Employee E25, licensed nurse, which noted, Resident noted with some redness surrounding right eye and slight swelling. Resident reported pain touching her forehead . [Resident R1] states she was hit on her head, back and stomach. Continued review of facility documentation revealed a witness statement regarding the incident from Employee E23, licensed nurse. Employee E23 noted that, upon speaking to the resident she verbalized that she hit her three times in the face, once in the eye and two times in the mouth chin area. Employee E23 noted that he saw the area around the right eye socket reddening and signs of swelling to the area. Employee E23 further noted that he took a statement from resident's roommate. Continued review of facility documentation revealed a witness statement, dated April 30, 2022, from Resident R3. Resident R3 noted that she slept in the same room as Resident R1 and that she over heard the care nurse fussing at the resident and heard the care nurse strike my roommate with three pops sounds and overheard her tassling. Interview on June 9, 2022, at 3:12 p.m. Resident R3 stated that she recalled the incident and confirmed that she heard Employee E21 hit Resident R1 three times. Review of Resident R1's physician evaluation, dated May 2, 2022, revealed that the resident was evaluated for follow-up after the reported altercation. The physician noted that the resident was unable to recall the incident due to her advanced dementia. The physician noted that the resident was thin, frail and that [CONDITION(S)] (redness) was noted along the resident's right periorbital (eye socket) region. Interview on June 9, 2022, at 4:01 p.m. the Nursing Home Administrator (NHA) confirmed that the allegation of physical abuse was substantiated and that Employee E21 was terminated from her position at the facility. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified for failure to ensure that a resident was free from physical abuse from a nursing staff. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, on June 9, 2022, at 4:01 p.m. On April 30, 2022, the facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 1. The aide was removed from the facility and suspended pending investigation on April 30, 2022. 2. The local authorities were notified within two hours of observed incident on April 30, 2022. 3. Message was left on the Pennsylvania Depart of Aging elder abuse hotline within two hours of incident on April 30, 2022. 4. Message was left with Philadelphia Corporation for Aging protective services on April 30, 2022. 5. An event report was submitted via Pennsylvania Department of Health event report website on April 30, 2022. 6. The resident's physician was notified. Orders were given to initiate neurological checks and to monitor for pain on April 30, 2022. 7. The resident's guardian was notified on April 30, 2022. 8. Other residents in aide's assigned area were interviewed to identify any concerns regarding care. No other concerns were identified on April 30, 2022. 9. Statements were obtained from staff with relevant knowledge regarding incident on April 30, 2022. 10. Security footage was reviewed to validate the reported timeframe of events on April 30, 2022. 11. The aide subsequently submitted to an interview on May 2, 2022. The allegation was substantiated and the aide was terminated. 12. The facility policy on prohibition from abuse was reviewed on May 4, 2022. 13. A facility-wide directed education including all departments regarding facility policy on prohibition from abuse, including physical, was initiated on May 4, 2022. The education was recorded and training continued through May 8, 2022, for all staff. Any staff not scheduled to work during this time were scheduled to complete education. 14. An audit was initiated, including review of electronic health record, weekly, to identify and monitor resident behavior that may identify abuse per CMS (Center of Medicare and Medicaid) regulation related to resident freedom from abuse and neglect. 15. Plan of corrections reviewed during Quality Aassurance Performance Improvement (QAPI) meeting in May 2022 including freedom from abuse, neglect and exploitation. 16. Next QAPI is scheduled June 21, 2022. 17. Facility continues to review resident rights during monthly resident council meeting, on admission, and during quarterly resident care conferences. Residents are encouraged per policy to immediately report allegations of abuse, neglect and exploitation. Review of facility documentation revealed that the corrective action plan was immediately developed and initiated April 30, 2022. Audits were initiated to monitor residents and resident behaviors. The facility reviewed their policy related to abuse. Review of Directed in-service training related to abuse was completed with staff from all departments. Interviews were conducted with staff from various departments. All staff reported that they received the in-service training. It was confirmed during interview that they were able to recognize signs of resident abuse and that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process. The Immediate Jeopary was lifted on June 9, 2022. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on the review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to ensure that residents were free from sexual abuse which resulted in actual harm to Resident 51 who was sexually assaulted by Resident R42 for one of 33 residents reviewed. (Resident R51). Findings include: Review of the facility policy title Freedom from Abuse, Neglect and Exploitation last revised January 2022 revealed that The facility must ensure that all residents are free from abuse, neglect and exploitation. Continued review of the policy indicated that Sexual abuse is nonconsensual sexual contact of any type with a resident. Review of Resident R42's clinical record revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R51's annual Minimum Data Set (MDS- assessment of resident's care needs) dated November 30, 2021, revealed a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Further review of the assessment revealed that the resident required extensive assistance of person for bed mobility and transfers; limited assistance for ambulation and no upper or lower extremities impairments. The resident did not exhibit any behaviors. Review of Resident R42's Significant Change MDS dated [DATE], revealed the resident now needed extensive assistance with one person assisting him with bed mobility, transfers locomotion on and off the unit, dressing. The resident was not steady and was only able to stabilize himself by staff assistance with walking and transfers and used a walker and a wheelchair for mobility. Review of Resident R42's care plan revealed that a care plan was developed for behaviors, initiated on June 15, 2020, and last reviewed February 14, 2022, for Behaviors or wandering into other residents' rooms. Physical/Verbal aggression towards residents. Rummaging. Removing door name tags. Relocating personal and other resident clothing and behaviors and/or wandering belongings from their room/closet/drawers. Two goals were included that the resident would not have altercations with other residents by next review date and would have fewer episodes of wandering into other residents' rooms, (no more than 7 times weekly). The interventions used for these behaviors, included staff to intervene as necessary to protect the rights and safety of others. Remove the resident and take him elsewhere. Provide the resident one to one supervision as needed. Redirect the resident out of arms reach of another resident. Assist the resident, as tolerated, to the dining room for observation. Review of nursing note dated February 3, 2021, stated that Resident R42 was found sleeping with a female resident in her bed. Further review of facility documentation stated the security cameras revealed that Resident R42 had been in the female's room for almost an hour. The facility identified the female resident with severe cognitive impairment and used a wheelchair for mobility. The report continued, that the charge nurse noticed the female resident's door was slightly closed, when the charge nurse approached the room, she saw Resident R42 in bed with the female resident. Facility's documentation stated the follow-up action plan, would be that Resident R42 was monitored for behaviors at 30- minute intervals. During an interview on April 6, 2022, at 1:15 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), related to the Resident R42 found in another female resident's bed on February 3, 2021, the DON stated that wandering was A natural thing for those residents, even if they go into someone else's room. Residents take their clothes off in the hallway - jump in other people's beds. He (Resident R42) thought it was his wife. We try to redirect the residents but there is no need for a 1:1. The DON further indicated Resident R42 was continually directed by staff and that the intervention of 30- minutes monitoring was only for nine shifts until February 6, 2021. Review of Resident R42's nursing note dated March 23, 2021, revealed, Resident R42 and a female resident were both found naked in her room. Review of facility's investigation revealed that Resident R42 was in the female resident's room for 23 minutes before being discovered by a nurse aide. Continue review described the female resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility action plan reported , Resident 42 to be placed on a 1:1 and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R42's care plan revealed that a new intervention was initiated on March 27, 2021, which included Resident on 1:1 behavior monitoring and a consultation for Psychiatry. Review of Resident R42's psychiatric consultation dated April 2, 2021, revealed that the resident was ordered the anti-depressive medication [MEDICATION(S)] 50 milligrams, to be used at night for the resident's increased libido and was instructed to Continue with the 1:1 monitoring. Review of nursing notes revealed that the last note that indicated Resident R42 was on 1:1 monitoring was on April 20, 2021. Review of nursing note dated June 20, 2021, at 2:50 p.m. indicated that Resident R149 was in bed and calling out for the nursing staff to come into her room and remove Resident R42. Resident R42 wandered into Resident R149's room and was touching her breast. The nursing assistant reported that Resident R42 was observed standing inside Resident R149's room. Resident R42 was escorted from the bedroom and was placed on close monitoring. Review of the facility's investigation revealed Resident R42 would be placed on a 1:1 and another psychiatric evaluation was scheduled for June 22, 2021. Review of the facility documentation revealed that August 13, 2021, was the last documentation for 1:1 monitoring due to positive effects from the increase in [MEDICATION(S)]. Review of the January 7, 2022, progress notes revealed Resident R42 wandered in the night and needed constant redirection. Review of the January 8, 2022, progress note revealed Resident R42 needed to be redirected countless times. Review of Resident R42's nursing note dated January 27, 2022, at 7:00 a.m. revealed that the nursing unit manager noted, I was waved down the hallway by a CNA, (nursing assistant) who was standing outside [room XXX]. Upon entrance into the room, I witnessed Mr. (Resident R42) dismounting [Resident 51] who resides in the door bed (bed closest to door). [Resident 51] was observed lying supine with her gown above her pelvic area, there was an undergarment on the floor. [Resident R51] was observed in no acute distress and when asked Are you okay?, she replied, I am sorry. [Resident R51] given emotional support. [Resident R42)] had his pants around his ankles and with slippers off. [Resident R42's] genitals were not observed and no observations of body fluids. [Resident R42] pulled up his pants and put on his slippers and walked out the door. [Resident R42] was assisted back to the dining room, a supervised area. Review of the facility's documentation revealed that security footage showed Resident R42 ambulating on the unit entering [Resident R51] room at 6:55 a.m. on January 27, 2022, and being found by the nursing assistant at 7:00 a.m. Continued reviewed revealed that orders were received from the physician for Resident R42 to go to a behavioral health facility for psychiatric evaluation. The facility indicated that Resident R51 was diagnosed with Alzheimer's Disease with severe cognitive impairment and needed total assistance with activities of daily living. Review of the witness statement from the nursing assistant who first saw Resident R42 stated, When I walked past [room XXX] I saw [Resident R42] on top of [Resident 51] pants down to his knees. He was humping on her. She had on a gown and her brief was on the floor. I didn't notice if his penis was erect or not. [Resident R42] was not saying anything, [female resident] was not screaming or talking. I called for help and did not leave until someone came. Interview on April 6, 2022, at 1:15 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) related to the Resident R42 revealed that wandering was, A natural thing for those residents, even if they go into someone else's room. Residents take their clothes off in the hallway - jump in other people's beds .We try to redirect the residents but there is no need for a 1:1. The facility failed to ensure that Resident 51 was free of sexual abuse from Resident 42 who wandered into Resident R51 and performed a sexual act to Resident R51. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on the review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to ensure adequate supervision to Resident R42 which resulted in actual harm to Resident 51 who was sexually assaulted by Resident R42 for one of 33 residents reviewed (Resident R51). Findings include: Review of Resident R42's clinical record revealed the diagnoses of Dementia (a condition characterized by progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking), wandering (a person with dementia roams around and becomes lost and confused), [CONDITION(S)] (cannot sleep at night), and left eye [CONDITION(S)]. Review of Resident R42's Minimum Data Set (MDS- assessment of resident care needs) dated January 12, 2021, revealed that the resident did not use any assistive devises when walking, he was independent in bed mobility, transfers, and walking in his room and needed supervision when walking in the corridor (with no physical help from staff). Review of Resident R42's care plan revealed that a care plan was developed for behaviors, on June 15, 2020, and last reviewed February 14, 2022, titled Behaviors or wandering into other residents' rooms. Physical/Verbal aggression towards residents. Rummaging. Removing door name tags. Relocating personal and other resident clothing and behaviors and/or wandering belongings from their room/closet/drawers. The two goals included on the care plan were that the resident would not have altercations with other residents by next review date and would have fewer episodes of wandering into other residents' rooms (no more than 7 times weekly). The interventions used for these behaviors, included staff to intervene as necessary to protect the rights and safety of others. Remove the resident and take him elsewhere. Provide the resident one to one supervision as needed. Redirect the resident out of arms reach of another resident. Assist the resident, as tolerated, to the dining room for observation. Review of nursing note dated February 3, 2021, stated that Resident R42 was found sleeping with a female resident in her bed. Further review of facility documentation stated the security cameras revealed that Resident R42 had been in the female's room for almost an hour. The facility identified the female resident with severe cognitive impairment and used a wheelchair for mobility. The report continued, that the charge nurse noticed the female resident's door was slightly closed, when the charge nurse approached the room, she saw Resident R42 in bed with the female resident. Facility's documentation stated the follow-up action plan, would be that Resident R42 was monitored for behaviors at 30- minute intervals. During an interview on April 6, 2022, at 1:15 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) related to the Resident R42 found in another female resident's bed on February 3, 2021 the DON stated that wandering was A natural thing for those residents, even if they go into someone else's room. Residents take their clothes off in the hallway - jump in other people's beds. He (Resident R42) thought it was his wife. We try to redirect the residents but there is no need for a 1:1. The DON further indicated Resident R42 was continually directed by staff and that the intervention of 30- minutes monitoring was only for nine shifts until February 6, 2021. Review of Resident R42's nursing note dated March 23, 2021, revealed, Resident R42 and a female resident were both found naked in her room. Review of facility's investigation revealed that Resident R42 was in the female resident's room for 23 minutes before being discovered by a nurse aide. Continue review described the female resident with a diagnosis of dementia with severe cognitive impairment, non- verbal and rarely understood. The facility action plan reported , Resident 42 to be placed on a 1:1 and an order for a psychiatric consultation was obtained. Review of Resident R42's care plan revealed that a new intervention was initiated on March 27, 2021, which included Resident on 1:1 behavior monitoring and a consultation for Psychiatry. Review of Resident R42's psychiatric consultation dated April 2, 2021, revealed that the resident was ordered the anti-depressive medication [MEDICATION(S)] 50 milligrams, to be used at night for the resident's increased libido and was instructed to Continue with the 1:1 monitoring. Review of nursing notes revealed that the last note that indicated Resident R42 was on 1:1 monitoring was on April 20, 2021. Review of nursing note dated June 20, 2021, at 2:50 p.m. indicated that Resident R149 was in bed and calling out for the nursing staff to come into her room and remove Resident R42. Resident R42 wandered into Resident R149's room and was touching her breast. The nursing assistant reported that Resident R42 was observed standing inside Resident R149's room. Resident R42 was escorted from the bedroom and was placed on close monitoring. Review of the facility's investigation revealed Resident R42 would be placed on a 1:1 and another psychiatric evaluation was scheduled for June 22, 2021. Review of Resident R42's care plan revealed a new intervention dated June 20, 2021, that included, If reasonable discuss my behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable. Review a Resident R42's psychiatric evaluation dated July 1, 2021, revealed that the resident's [MEDICATION(S)] was increased. Review of the facility documentation revealed that August 13, 2021, was the last documentation for 1:1 monitoring due to positive effects from the increase in [MEDICATION(S)]. Review of Resident R42's Significant Change MDS dated [DATE], revealed the resident now needed extensive assistance with one person assisting him with bed mobility, transfers, locomotion on and off the unit, dressing. The resident was not steady and was only able to stabilize himself by staff assistance with walking and transfers and used a walker and a wheelchair for mobility. Review of the January 7, 2022, nursing note revealed Resident R42 wandered in the night and needed constant redirection. Review of the January 8, 2022, nursing note revealed Resident R42 needed to be redirected countless times. Review of Resident R42's nursing note dated January 27, 2022, at 7:00 a.m. revealed that the nursing unit manager noted, I was waved down the hallway by a CNA, (nursing assistant) who was standing outside [room XXX]. Upon entrance into the room, I witnessed [Resident R42] dismounting [Resident 51] who resides in the door bed (bed closest to door). [Resident 51] was observed lying supine with her gown above her pelvic area, there was an undergarment on the floor. [Resident R51] was observed in no acute distress and when asked Are you okay?, she replied, I am sorry. [Resident R51] given emotional support. [Resident R42] had his pants around his ankles and with slippers off. [Resident R42's] genitals were not observed and no observations of body fluids. [Resident R42] pulled up his pants and put on his slippers and walked out the door. [Resident R42] was assisted back to the dining room, a supervised area. Review of the facility's documentation revealed, that security footage showed Resident R42 ambulating on the unit entering [Resident R51] room at 6:55 a.m. on January 27, 2022 and being found by the nursing assistant at 7:00 a.m. Continue reviewed of facility's documentation revealed that orders were received from the physician for Resident R42 to go to a behavioral health facility for psychiatric evaluation. Further, the facility indicated that Resident R51 was diagnosed with Alzheimer's Disease with severe cognitive impairment and needed total assistance with her activities of daily living. Review of the witness statement from the nursing assistant who first saw Resident R42 stated, When I walked past [Room XXX] I saw [Resident R42] on top of [Resident 51] pants down to his knees. He was humping on her. She had on a gown and her brief was on the floor. I didn't notice if his penis was erect or not. [Resident R42] was not saying anything, [Resident 51] was not screaming of talking. I called for help and did not leave until some came. The facility failed to ensure proper supervision and monitoring of Resident R42 who was identified with a history of wandering into other female residents' room and exhibiting sexual behaviors resulting in actual harm to Resident R51 who was sexually assaulted by Resident R42. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review, review of facility policies and procedures, facility documentation and staff interview, it was determined that the facility failed to provide an environment that was free from abuse and neglect. Findings include: A review of Resident RCL's clinical record revealed the resident was admitted to the facility in [DATE], with [DIAGNOSES REDACTED]. (percutaneous endoscopic gastrostomy tube) - a feeding tube placed through the abdominal wall into the stomach for nutrition/fluids). A review of the Resident RCL1's Minimum Data Set assessment (MDS-a periodic review of the resident's needs) dated [DATE], showed a BIMS (Brief Interview for Mental Status-a brief screening tool that aids in detecting cognitive impairment) score of 99 which indicated that the resident was unable to complete the interview. Further review revealed that Resident RCL1 was 67 inches tall, weighed 199 pounds, and required the extensive assistance of two staff for bed mobility and transfers and Resident RCL1 was care planned for assist of one for showers. Further review of Resident RCL1's closed record revealed on [DATE] at 4:40 p.m., Resident RCL1 fell from shower gurney and was sent to . Medical Center. A facility investigation indicated that Employee E2, Nursing Assistant, had showered Resident RCL1 and requested for Employee E3, Licensed Nurse, to come to the shower room to perform a skin assessment as per the facility policy, Bathing/Showering Policy dated [DATE] and reviewed [DATE]. Employee E3 declined to come to the shower room and perform the skin assessment. At that point, Employee E2 logrolled (to move without flexing the spine) Resident RCL1 away from her to dry her back. Resident RCL1 fell over the rail of the shower gurney and onto the tiled shower floor. The staff responded to this incident, treated resident who was bleeding from her mouth and above the left eye and the resident was placed in her chair and returned to her room. The responsible party and the physician were notified. Employee E2 was suspended pending investigation. An interview on [DATE] at 10:30 a.m. with Employee E1, Nursing Home Administrator, confirmed that Employee E2 placed Resident RCL1 on the shower gurney and that Employee E2 was aware that the shower gurney was missing one of the four pins located on the four corners of the shower gurney bed rail. The plastic pins secure the pvc (poly-vinyl chloride) railing surrounding the shower bed. An investigation was conducted and it was determined that Employee E2 would be re-educated on checking equipment before using it and on the proper technique of rolling residents toward you and not away from you. Review of the nurses' progress note dated [DATE], revealed, Resident RCL1 was admitted to the trauma unit with [DIAGNOSES REDACTED]. The resident was readmitted to the Germantown Home on [DATE], at 4:00 p.m. with an inoperable left iliac (crest of the hip bone) and acetabulum (socket of the hip) fracture and six sutures to left forehead. Review of Resident RCL1's physician's orders [REDACTED]. Further review of Resident RCL1's record revealed that the physician, consulted with family and they agreed to send her to the hospital. Review of the nursing progress note dated [DATE], at 10:25 p.m., revealed Resident RCL1, was observed with a missing front tooth. A chest X-ray and cervical neck X-ray were ordered to rule out aspiration pneumonia. The resident was prescribed [MEDICATION NAME] (an antibiotic) 500 mg. every day for 7 days. Review of nursing progress note of [DATE], revealed, Resident with ,[DATE] % pulse ox on O2 @ (at) 6 liters. The physician recommended the family visit at this time. Facility contacted Resident RCL1's responsible party and daughter stated, 'I have seen my mother bounce back after antibiotic therapy.' Review of nursing progress note of [DATE], charge nurse found a tooth on resident's gown. Review of physician's progress note of [DATE], stated, resident's condition declining. Review of nursing progress notes of [DATE] revealed, blood pressure low and shortness of breath noted. Pulse ox -92% on 6 liters of oxygen. Peg tube leaking and replaced. Further review of Resident RCL1's closed clinical record on [DATE] revealed a nurses' progress note which stated, Large amount of tube feed seeping from peg insertion site. Also, tube feed coming from mouth. Also, peg tube site with new wound 2.0 (centimeters) x 2.0 x 0.1 full thickness MASD (moisture associated skin damage.) Resident discharged to . Hospital with [DIAGNOSES REDACTED]. Review of Resident RCL1's closed clinical record revealed a physician's discharge summary dated [DATE].(Resident RCL1) .She had been having a steady decline after sustaining a fall that resulted in a fracture. She developed aspiration pneumonia for which she was treated. Her feeding tube started to malfunction and she was sent to . Hospital for a possible replacement, however, she was placed on [MEDICATION NAME] drip for comfort care and she expired on Sunday in the hospital with her family. An interview on [DATE] at 1:00 p.m. with Employee E1, Nursing Home Administrator, confirmed that Resident RCL1, did have loosening of the front teeth as a result of the fall from the shower bed. A dental consult was ordered and completed on [DATE]. The dentist recommended extraction of twelve teeth. The resident's responsible party did not consent to the recommendation. The facility failed to provide goods and services that are necessary to attain or maintain physical, mental and psycho-social well-being by placing one resident on a damaged shower gurney resulting in actual harm when the resident fell from the gurney, resulting in an inoperable left iliac and acetabulum fracture, six sutures to the left forehead and loose teeth with a transfer to the hospital. Refer to F323. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 201.29(j) Resident rights Previously cited [DATE] 28 Pa. Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE]

Based on clinical record review, review of facility policies and procedures, facility documentation and staff interview, it was determined that the facility failed to provide adequate monitoring and supervision for one resident (Resident RCL1) out of three residents reviewed which resulted in actual harm of a fracture and hospital transfer. Findings include: A review of Resident RCL's clinical record revealed the resident was admitted to the facility in [DATE], with [DIAGNOSES REDACTED]. (percutaneous endoscopic gastrostomy tube) - a feeding tube placed through the abdominal wall into the stomach for nutrition/fluids). A review of the Resident RCL1's Minimum Data Set assessment (MDS-a periodic review of the resident's needs) dated [DATE], showed a BIMS (Brief Interview for Mental Status-a brief screening tool that aids in detecting cognitive impairment) score of 99 which indicated that the resident was unable to complete the interview. Further review revealed that Resident RCL1 was 67 inches tall, weighed 199 pounds, and required the extensive assistance of two staff for bed mobility and transfers, however, Resident RCL1 was care planned for assist of one assist for showers. Further review of Resident RCL1's closed record revealed on [DATE], at 4:40 p.m., Resident RCL1 fell from shower gurney and was sent to .Medical Center. A facility investigation indicated that Employee E2, Nursing Assistant, had showered Resident RCL1 and requested for Employee E3, Licensed Nurse, to come to the shower room to perform a skin assessment as per the facility policy, Bathing/Showering Policy dated [DATE] and reviewed [DATE]. Employee E3 declined to come to the shower room and perform the skin assessment. At that point, Employee E2 logrolled (to move without flexing the spine) Resident RCL1 away from her to dry her back. Resident RCL1 fell over the rail of teh shower gurney and onto the shower floor. The staff responded to this incident, treated resident who was bleeding from her mouth and above the left eye and the resident was placed in her chair and returned to her room. The responsible party and the physician were notified. Employee E2 was suspended pending investigation. An interview on [DATE] at 10:30 a.m. with Employee E1, Nursing Home Administrator, confirmed that Employee E2 placed Resident RCL1 on the shower gurney and that Employee E2 was aware that the shower gurney was missing one of the four pins located on the four corners of the shower gurney bed rail. The plastic pins secure the pvc (poly-vinyl chloride) railing surrounding the shower bed. An investigation was conducted and it was determined that Employee E2 would be re-educated on checking equipment before using it and on the proper technique of rolling residents toward you and not away from you. Review of nurse's progress note, dated [DATE], revealed Resident RCL1 was admitted to a trauma unit with [DIAGNOSES REDACTED]. The resident was readmitted to Germantown Home on [DATE] at 4:00 p.m. with an inoperable left iliac (crest of the hip bone) and acetabulum (socket of the hip) fracture and six sutures to left forehead. Review of Resident RCl1's physician orders [REDACTED]. Further review of Resident RCL1's record revealed that, physician consulted with family and they agreed to send her to the hospital. Review of the nursing progress notes, dated [DATE], revealed at 10:25 p.m., revealed Resident RCL1 was observed with a missing front tooth. A chest X-ray and cervical neck X-ray were ordered to rule out aspiration pneumonia. The resident was prescribed Levaquin (an antibiotic) 500 mg. every day for 7 days. Review of the nurses' progress notes of [DATE] revealed, Resident with ,[DATE] % pulse ox on O2 @ 6 liters. Physician recommended family visit at this time. Resident RCl1's responsible party was contacted and daughter stated, 'I have seen my mother bounce back after antibiotic therapy.' Review of the nurses' progress note of [DATE], revealed, charge nurse found a tooth on resident's gown. Review of the physician's progress note of [DATE] stated, resident's condition declining. Review of the nurses' progress note of [DATE] revealed, blood pressure low and shortness of breath noted. Pulse ox -92% on 6 liters of oxygen. Peg tube leaking and replaced. Further review of Resident RCL1's closed clinical record revealed on [DATE], a nursing progress note that stated, Large amount of tube feed seeping from peg insertion site. Also, tube feed coming from mouth. Also, peg tube site with new wound 2.0 (centimeters) x 2.0 x 0.1 full thickness MASD-moisture associated skin damage. Resident discharged to . Hospital with [DIAGNOSES REDACTED]. Review of Resident RCL1's closed clinical record revealed a physician's discharge summary dated [DATE], which stated, She had been having a steady decline after sustaining a fall that resulted in a fracture. She developed aspiration pneumonia for which she was treated. Her feeding tube started to malfunction and she was sent to . Hospital for a possible replacement, however, she was placed on morphine drip for comfort care and she expired on Sunday in the hospital with her family. An interview on [DATE] at 1:00 p.m.with E1, Nursing Home Administrator, confirmed that Resident RCL1 did have loosening of the front teeth as a result of the fall from the shower bed. A dental consult was ordered and completed on [DATE]. The dentist recommended extraction of twelve teeth. The resident's responsible party did not consent to the recommendation. The facility failed to provide adequate monitoring and assistance to prevent an accident resulting in harm to one resident, including an inoperable left iliac and acetabulum fracture, six sutures to the left forehead and loosened teeth. 42 CFR 483.25(d)(1)(2) Accident Hazards/Supervision/Devices Previously cited [DATE] (At 42 CFR 483.25(h)) 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 207.2(a) Administrator's responsibility 28 Pa.Code 211.10(d) Resident care policies Previously cited [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE]

Based on clinical record review, interviews with staff, and reviews of facility policy and procedures it was determined that the facility failed to assess, monitor or implement interventions for the prevention of pressure sore development for one of two residents reviewed (Resident Cl1). Findings include: The comprehensive Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated February 23, 2015, for Resident Cl1 indicated that the resident was readmitted to the facility on [DATE]. This assessment also indicated that Resident Cl1 was able to express ideas and wants and had clear comprehension skills. The assessment further indicated that Resident Cl1 required extensive physical assist of two persons for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed). Resident Cl1 was noted as incontinent (having no or insufficient control) of urine and bowel. The resident's weight was entered as 229 pounds and height 62 inches. The assessment indicated that the resident was not on a physician prescribed weight loss regimen. The assessment indicated that Resident Cl1 was at risk for developing pressure ulcers and that this resident had no pressure ulcers (injuries to the skin and the underlying tissue resulting from prolonged pressure on the skin. Pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and the tailbone). The assessment indicated that a diuretic (a medication that promotes the production of urine) medication was being administered to Resident Cl1. According to the facility's current policy and procedure entitled, Wound Prevention and Treatment Program, reviewed 2007, the facility's nursing staff are required to assess all residents and determine those at risk for skin breakdown and pressure ulcer development. This policy guides the nursing staff to prevent pressure ulcer formation. The policy states that the licensed nurse was required to observe/assess each resident's skin integrity two times a week. There was no documentation to indicate that Resident Cl1's skin integrity was being evaluated consistently, twice a week for the months of April and May 2015. The lack of assessment, monitoring and care planning of Resident Cl1's skin condition and needs during the months of April and May 2015 was confirmed during an interview with the Director of Nursing at 1:00 p.m., on August 10, 2016. According to the facility policy and procedure entitled, Wound Prevention and Treatment Program nutrition was a risk factor to be evaluated. The, Wound Prevention and Treatment Program policy indicated that the nursing and dietary staff were required to observe/assess each resident's usual food intake daily, at each meal. There was no documentation to indicate that Resident Cl1's usual daily food intake was being evaluated, monitored and assessed. The lack of assessment, monitoring and care planning for Resident Cl1's nutritional needs for March, April and May 2015 was confirmed during an interview with the Registered Dietitian at 2:00 p.m., on August 10, 2016. Clinical record documentation dated February 23, 2015, indicated that Resident Cl1's weight was 229 pounds. On March 16, 2015, the weight was recorded at 210 pounds, a significant unintentional weight loss of 19 pounds which was a 5% weight loss over one month. Significant unintentional weight loss creates loss of lean body mass. This lean body mass provides the majority of the body's protein; in accordance with the Dietary Manual for Pressure Ulcer Prevention, Becky Dorner and Associates, 2008. Review of the recorded daily meal intakes for Resident Cl1 for March 2015, indicated that this resident's food intake was inadequate. There was no documentation to indicate that the nursing staff had alerted the Registered Dietitian about Resident Cl1's poor food consumption. The nutrition progress note dated March 19, 2015 indicated that an [MEDICATION NAME] level was obtained for Resident Cl1. The [MEDICATION NAME] value is a laboratory value used to evaluate the body's blood protein stores. [MEDICATION NAME] values are often used for assessment purposes to indicate the body's ability to repair damaged skin. The value reported for Resident Cl1 was low at 3.2 gm/dl (grams/deciliter - normal is 3.5 to 5.5 gm/dl). A dietary progress note entered on March 16, 2015, indicated that resident Cl1 was ordered a Mighty (house) Shake. According to the facility's dietary formulary, this supplement contained 200 calories and 7 grams of protein per four fluid ounces. The care plan was to administer the supplement twice a day. A dietary progress note dated March 31, 2015, indicated that the nutrition care plan was to continue the Mighty (house) Shake, no sugar added, however, there was no documentation to indicate that Resident Cl1 was accepting/consuming this dietary supplement as ordered by the physician. The recorded usual food intakes for Resident Cl1 for the month of April 2015 indicated that this resident's food intake was inadequate. On May 4, 2015, Resident Cl1's weight was recorded at 206 pounds and on May 18, 2015, it was 203 pounds. The nursing progress notes dated April 5, 2015, indicated that Resident Cl1's skin was intact. The nursing progress notes on April 16, 2015, indicated that Resident Cl l's toe nail, on the right foot, was completely off. On May 12, 2015, the nursing progress notes indicated that Resident Cl1 was found to have a 6.0 cm (centimeter) by 13.0 cm by 0.1 cm sacral (the triangular bone located at the coccyx (tailbone) forming the posterior boundary of the pelvis) pressure ulcer having serosaguinous (containing serum and blood) drainage, an odor, necrotic tissue (black, brown, tan tissue that adheres firmly to the wound bed or ulcer edges) and slough (yellow or white tissue that adheres to the ulcer bed in clumps). On May 13, 2015, the physician was notified of Resident Cl1's pressure ulcer and ordered Dakin's solution (a bleach/water solution) and Santyl (a [MEDICATION NAME] agent to remove dead tissue). Clinical record documentation by the consulting Wound Specialist for Resident Cl1 on May 27, 2015, indicated that the sacral pressure ulcer had deteriorated to a full thickness ulceration measuring 7.5 cm by 11 cm by 3.0 cm, was odorous and contained serosanguineous drainage. The resident's [MEDICATION NAME] had decreased to 2.8 gm/dl. The clinical record documentation indicated that Resident Cl1 was discharged from the facility to the hospital for scheduled surgical debridement (removal of dead or damaged skin) of the sacral pressure ulcer on May 29, 2015. The facility failed to assess, monitor, implement and plan care to prevent the development of pressure ulcers and promote the healing and repair of skin for Resident Cl1. This lack of care resulted in actual harm, the development of an avoidable pressure ulcer that required surgical interventions for Resident Cl1. 28 Pa. Code 201.18(b)(1)(3)(d) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.11(a)(b)(c) Resident care plan 28 Pa. Code 211.12(c)(d)(1)(2)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 02/19/16