Every finding on record at Glen Brook Rehabilitation and Healthcare Center

Based on review of clinical records, select facility policy, hospital records, and staff interview, it was determined the facility failed to ensure that care provided during the removal and replacement of an indwelling Foley catheter was documented in accordance with facility policy and professional standards of practice for one of three residents reviewed (Resident A1).Findings include: Review of the facility Indwelling Catheter use and Removal Policy last reviewed by the facility on March 27, 2026, indicated it is the facility policy to ensure that indwelling urinary catheters (thin, flexible tube inserted into the bladder to drain urine) that are inserted or remain in place are justified or removed according to regulations and current standards of practice. The facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: Insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures, response of the resident during the use of the catheter, and ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting, and addressing such changes. Catheter and drainage bags should be changed on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine fixed intervals are not recommended. Clinical record review revealed that Resident A1 was admitted to the facility on [DATE], with diagnoses which included anoxic brain damage (brain injury caused by a complete lack of oxygen) secondary to cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) and chronic respiratory failure (the lungs cannot properly provide the body with oxygen or remove carbon dioxide). A review of Resident A1's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 9, 2026, revealed that Resident A1 was severely cognitively impaired with a BIMS score of 4 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 through 7 indicates cognition is severely impaired) and was dependent on staff for all activities of daily living. A physician order initially dated April 23, 2025, noted an order for Foley catheter 16 Fr (external diameter of the catheter tube) 30 cc Balloon (inflatable sac located at tip of the catheter which holds approximately 30 ml of sterile water)for diagnosis of obstructive and reflux uropathy (condition where a blockage in the urinary tract stops urine from flowing out forcing it to back up into the kidneys). A physician's order initially dated November 17, 2025, directed staff to change the Foley catheter only as needed or when signs and symptoms of infection were present after obtaining a urine specimen. A physician's order dated February 24, 2026, revealed Resident A1 was admitted to hospice services with a diagnosis of anoxic brain damage.Review of the June 2026 Treatment Administration Record revealed documentation that Employee 1, an agency Licensed Practical Nurse (LPN), documented changing Resident A1's Foley catheter on June 29, 2026, at 11:46 PM. The effectiveness of the catheter change was documented as unknown.A corresponding nursing note entered by Employee 1 on June 29, 2026, at 11:46 PM documented only that the Foley catheter had been changed. The documentation did not identify the size of the catheter inserted, the clinical indication for the catheter change, the resident's condition before or after the procedure, the resident's response to the catheter change, whether urine drained following insertion to confirm catheter placement, or whether any complications were observed during or immediately after the procedure.Nursing documentation dated June 30, 2026, at 2:30 AM revealed a nurse aide reported bright red blood on the resident's bed pad. The Foley catheter tubing was draining bright red blood, and the resident stated he could not pee. Staff attempted to irrigate (flush) the catheter but were unsuccessful. Staff removed the Foley catheter, after which bleeding from the urethra (the tube that carries urine from the bladder out of the body) was observed. Staff applied pressure and ice without stopping the bleeding. The resident's oxygen saturation was 80 percent on room air. Oxygen was applied at 2 liters per minute. The resident appeared pale and restless. Staff were unable to obtain a blood pressure because of the resident's restlessness. Staff attempted to notify the resident's representative, left a voicemail message, notified the physician and hospice provider, and transferred the resident to the hospital by Emergency Medical Services. Review of hospital information dated June 30,2026, revealed the resident was evaluated at 3:38 AM. The resident was admitted to the hospital with a diagnosis of urethral bleeding secondary to traumatic Foley catheter placement (bleeding from the urethra potentially caused by injury during the insertion of a urinary catheter, which may be complicated by enlarged prostate or urethral strictures, a known challenge with difficult resident anatomy). During an interview on July 8, 2026, at 1:00 PM, the Director of Nursing was unable to provide documented evidence that staff performed and documented the Foley catheter change in accordance with facility policy and professional standards of practice, including documentation of the catheter size inserted, the clinical reason for changing the catheter, confirmation of catheter placement through urinary output, the resident's condition before and after the procedure, the resident's response to the procedure, or assessment for complications immediately following catheter insertion. 28 Pa. Code 211.5 (f)(ii)(iii)(ix) Medical records28 Pa. Code 211.10 (c)(d) Resident care policies28 Pa. Code 211.12 (c) (d)(1)(3)(5) Nursing services

Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication for one resident (Resident 7) and by failing to ensure the consistent implementation of a physician-ordered therapeutic positioning device for one resident (Resident 4), for two of 36 residents reviewed.Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) the registered nurse (RN) is to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records. A review of the facility policy titled Medication Administration last reviewed by the facility on January 6, 2026, revealed that medications are administered as ordered by the physician and in accordance with professional standards of practice. The policy required staff to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A review of the clinical record revealed Resident 7 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to a build-up of fluid in the lungs and surrounding body tissues), and chronic atrial fibrillation (an irregular heartbeat). A review of the physician's order dated January 9, 2026, directed staff to administer Midodrine HCl (medication used to treat low blood pressure) 5 mg by mouth three times a day for orthostatic hypotension (a sudden drop in blood pressure occurring within 3 minutes of standing or shifting to an upright position). The order specified to hold the medication if the systolic blood pressure was greater than 110 millimeters of mercury (mm/Hg). Systolic blood pressure is the top number in a blood pressure reading and reflects the pressure when the heart is actively pumping.A review of the January 2026 Medication Administration Record (MAR) revealed Midodrine was administered 31 times when the documented systolic blood pressure exceeded the physician-ordered hold parameter of 110 mm/Hg.The following blood pressure readings were documented at the time the medication was given:January 10, 2026 at 12:00 PM: 122/66 mm/HgJanuary 10, 2026 at 8:00 PM: 146/96 mm/HgJanuary 11, 2026 at 6:00 AM: 125/72 mm/HGJanuary 11, 2026 at 12:00 PM: 126/80 mm/HgJanuary 11, 2026 at 8:00 PM: 128/68 mm/HgJanuary 12, 2026 at 6:00 AM: 125/67 mm/HgJanuary 13, 2026 at 6:00 AM: 137/78 mm/HgJanuary 13, 2026 at 8:00 PM: 124/82 mm/HgJanuary 14, 2026 at 8:00 PM: 116/70 mm/HgJanuary 15, 2026 at 8:00 PM: 120/76 mm/HgJanuary 16, 2026 at 6:00 AM: 119/69 mm/HgJanuary 17, 2026 at 6:00 AM: 134/74 mm/HgJanuary 18, 2026 at 12:00 PM: 124/82 mm/HgJanuary 18, 2026 at 8:00 PM: 124/82 mm/HgJanuary 19, 2026 at 6:00 AM: 127/82 mm/HgJanuary 20, 2026 at 8:00 PM: 154/100 mm/HgJanuary 21, 2026 at 6:00 AM: 141/70 mm/HgJanuary 21, 2026 at 8:00 PM: 135/78 mm/HgJanuary 22, 2026 at 6:00 AM: 123/70 mm/HgJanuary 22, 2026 at 8:00 PM: 134/84 mm/HgJanuary 23, 2026 at 6:00 AM: 124/73 mm/HgJanuary 24, 2026 at 12:00 PM: 141/98 mm/HgJanuary 24, 2026 at 8:00 PM: 125/75 mm/HgJanuary 27, 2026 at 6:00 AM: 114/76 mm/HgJanuary 27, 2026 at 8:00 PM: 134/81 mm/HgJanuary 27, 2026 at 8:00 PM: 134/81 mm/HgJanuary 28, 2026 at 8:00 PM: 118/70 mm/HgJanuary 29, 2026 at 6:00 AM: 113/68 mm/HgJanuary 30, 2026 at 6:00 AM: 117/71 mm/HgJanuary 31, 2026 at 6:00 AM: 114/69 mm/HgJanuary 31, 2026 at 8:00 PM: 122/80 mm/HgA review of the February 2026 MAR revealed Midodrine was administered eight additional times when the documented systolic blood pressure exceeded 110 mm/Hg. The following blood pressure readings were documented at the time the medication was given:February 1, 2026 at 8:00 PM: 145/96 mm/HgFebruary 3, 2026 at 6:00 AM: 124/73 mm/HgFebruary 4, 2026 at 6:00 AM: 119/69 mm/HgFebruary 5, 2026 at 6:00 AM: 129/74 mm/HgFebruary 6, 2026 at 6:00 AM: 1122/67 mm/HgFebruary 9, 2026 at 8:00 PM: 122/84 mm/HgFebruary 10, 2026 at 6:00 AM: 1120/72 mm/HgFebruary 12, 2026 at 6:00 AM: 121/74 mm/Hg These findings demonstrated the medication was repeatedly administered outside of the physician-ordered parameters, contrary to facility policy and accepted standards of nursing practice. During an interview on February 27, 2026, at 9:00 AM, the Director of Nursing reviewed the above findings and confirmed that nursing staff failed to follow the physician's order by administering the medication outside the ordered parameters. A review of the clinical record revealed Resident 4 was admitted to the facility on [DATE], with diagnoses to include right femur (thigh bone) fracture (broken bone), lumbar disc degeneration (spinal discs in lower back lose water, elasticity and height, often causing chronic pain and stiffness), and muscle weakness. A review of the physician's order dated October 20, 2025, directed staff to provide a lateral support to the right side of the resident's wheelchair to promote proper positioning and stability. A lateral support is a padded L-shaped positioning device attached to the wheelchair to provide lateral stability, help maintain a neutral upright sitting position, and improve posture by supporting the torso. It prevents side-to-side leaning and fatigue. Observation on February 24, 2026, at 12:30 PM revealed Resident 4 seated in her wheelchair at the entrance to her room. She was leaning significantly over the right side of her wheelchair. The ordered lateral support was not attached to the wheelchair. The device was observed in a laundry basket on a chair in the resident's room. A second observation on February 26, 2026, at 1:10 PM, conducted in the presence of Employee 2 (Licensed Practical Nurse), confirmed the physician ordered lateral support was not in place on the resident's wheelchair. These findings demonstrated the facility failed to ensure nursing services were provided in accordance with physician orders and professional standards of practice. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on observations of resident pantry areas and staff interview, it was determined the facility failed to maintain equipment and environmental surfaces in a clean and sanitary condition in areas used for food and ice service to prevent the potential for microbial growth in food and beverages, increasing the risk of foodborne illness and waterborne pathogens in four of four resident pantry areas (East, North, Spruce and [NAME] pantries). Findings include: Observation on February 26, 2026, at 10:25 AM of the resident food pantry located on the East Wing nursing unit revealed the ice machine's condensation drain hose (a hose that transports moisture produced by the ice machine to a floor drain) was visibly soiled with a black substance. The ice dispenser contained a buildup of orange and gray substance and white mineral deposits (hard residue left behind from water) within and around the dispenser opening where ice is dispensed. The pantry sink contained a used food thermometer that was visibly soiled with an orange substance. Observation on February 26, 2026, at 10:40 AM of the resident food pantry located on the North Wing nursing unit revealed the ice machine's dispenser contained a thick white build-up of white substance around the dispenser opening. Observation on February 26, 2026, at 10:47 AM of the resident food pantry located on the Spruce nursing unit revealed the ice machine's condensation hose DrainGap fitting device (a component designed to create an air gap, which is an open space between the end of the drain hose and the floor drain that prevents contaminated water, sewage, or bacteria from flowing backward into equipment that produces ice) was in direct contact with the floor drain, eliminating the protective separation intended to prevent contamination. The floor drain and surrounding tiles were visibly covered with a wet black substance, and several floor tiles were broken and cracked. The pantry microwave contained an eight-inch rust-like area along the top left interior wall and two 1.5-inch rusted areas on the interior ceiling. Observation on February 26, 2026, at 11:01 AM of the resident food pantry located on the [NAME] nursing unit revealed the ice machine's condensation hose DrainGap fitting device was in direct contact with the floor and not aligned with the floor drain, eliminating the protective separation intended to prevent contamination. Evidence of water damage was observed to six floor tiles surrounding the drain area. The DrainGap condensation hose end piece and surrounding floor tiles were visibly soiled with a black substance. During an interview on February 26, 2026, at 1:45 PM the Nursing Home Administrator confirmed that the ice machines and microwave were not maintained in a sanitary manner. 28 Pa. Code 201.18 (e)(2.1) Management 28 Pa. Code 211.6 (f) Dietary Services

Based on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 36 residents sampled (Resident 13).Findings include: A review of the facility policy titled Restorative Nursing Program, last reviewed by the facility on January 6, 2026, revealed it is the policy of the facility to provide maintenance services (ongoing nursing support intended to preserve a resident's current physical abilities and prevent decline) and restorative services (structured nursing interventions designed to help a resident regain or improve functional abilities such as walking, transferring, or performing daily activities) designed to maintain or improve a resident's abilities to the highest practicable level. The policy indicates that residents, as identified during the comprehensive assessment process, will receive services from restorative aides (trained nursing assistants who provide restorative maintenance care under the supervision of licensed nursing staff) when they are assessed to have a need for restorative nursing services. A clinical record review revealed Resident 13 was admitted to the facility on [DATE], with diagnoses that include multiple sclerosis (a chronic autoimmune disease in which the body's immune system attacks the protective covering of nerves in the brain and spinal cord, which can cause weakness, problems with movement, balance, and coordination). A review of Resident 13's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 1, 2026, revealed that Resident 13 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). An occupational therapy Discharge summary dated [DATE], revealed discharge recommendations for Resident 13 to have a restorative range of motion program established, which includes bilateral upper extremities active range of motion (AROM, movement of a joint performed by the resident using their own muscle strength to move the body part through its normal range of movement) through all planes as tolerated, two sets of 10 repetitions daily to improve range of motion and maintain strength and joint integrity. A physical therapy Discharge summary dated [DATE], revealed discharge recommendations for Resident 13 to have a restorative nursing program, which includes bilateral lower extremity active range of motion and passive range of motion (PROM, movement of a joint performed by another person, such as nursing staff, who moves the resident's body part through its normal range of movement when the resident is unable to move it independently), manual stretches for improved range of motion, strength for bilateral lower extremities, and reducing the resident's risk for contractures. A review of the resident's care plan revealed that Resident 13 required a nursing maintenance program initiated on August 28, 2025. Interventions implemented for Resident 13 were to maintain or improve the present level of functioning include discussing nursing maintenance appropriateness and progress in interdisciplinary department meetings and active range of motion upper and lower body exercises daily. During an interview on February 24, at 11:36 AM, Resident 13 indicated that she is not receiving any therapy or restorative nursing services and is not encouraged or offered exercise daily. Resident 12 confirmed that she has a problem with her upper and lower body range of motion (ROM, the full, measurable distance and direction a joint or body part can move, ranging from bending to straightening). During an interview on February 24, at 11:40 AM, Resident 13's representative indicated that she was concerned the facility was not consistently implementing range of motion exercises with the resident. A review of the documentation survey report for January 28, 2026, through February 25, 2026, revealed Resident 13 refused or was not applicable for bilateral upper extremity active range of motion exercises on 17 occasions during the 30-day period. A review of the documentation survey report for January 28, 2026, through February 25, 2026, revealed Resident 13 refused or was not applicable for bilateral lower extremity active range of motion exercises on 17 occasions during the 30-day period. A review of the documentation survey report dated February 25, 2026, revealed that Resident 13 actively participates in bilateral lower and upper active range of motion exercises with Employee 1, Nurse Aide (NA). The documentation indicated Resident 13 completed 30 repetitions and spent 15 minutes completing the upper body exercises. Also, the documentation indicated Resident 13 completed 30 repetitions and spent 15 minutes completing the lower-body exercise. During an interview on February 26, 2026, at 10:02 AM, Resident 13 indicated that she did not receive or was offered 15 minutes of active upper body range of motion exercises or lower body range of motion exercises yesterday. Resident 13 reiterated she is not receiving any therapy or restorative nursing services and is not encouraged or offered exercise daily. Also, the resident confirmed that she is not refusing and did not refuse participation in these activities over the last 30 days. During an interview on February 26, 2026, at 10:50 AM, Employee 1, Nurse Aide (NA), confirmed that she documented Resident 13 received 15 minutes of active upper body range of motion exercises and lower body range of motion exercises on February 25, 2026. Employee 1, NA, indicated that the range of motion exercises occur when the resident is assisted with activities of daily life. Employee 1, NA, could not confirm that Resident 13 completed 30 repetitions and spent 15 minutes completing the lower body exercises and completed 30 repetitions and spent 15 minutes completing the upper body exercises. During an interview on February 26, 2026, at 12:05 PM, the above information was reviewed with the director of nursing (DON). The DON was unable to explain why the documentation survey report indicated that Resident 13 refused or was not applicable for bilateral lower and upper extremity active range of motion exercises on 17 occasions during the 30-day period. The facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for Resident 13. 28 Pa. Code: 211.5(f)(ii) Medical records. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(3)(5) Nursing services.

Based on a review of clinical records, investigative documentation provided by the facility, select facility policy, manufacturer guidelines, and staff interview, it was determined the facility failed to ensure appropriate prevention and management of a pressure injury for one of 36 sampled residents (Resident 9).Findings include: Review of the facility's Pressure Injury Prevention and Management policy, reviewed January 6, 2026, revealed that the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Interventions could include, but are not limited to, redistribution of pressure, minimizing exposure to moisture, and providing appropriate, pressure-redistributing support surfaces. Clinical record review revealed that Resident 9 had diagnoses including chronic kidney disease (a long-term medical condition in which the kidneys gradually lose the ability to filter waste and excess fluid from the blood) and a history of pressure injuries (damage to the skin and underlying tissue caused by prolonged pressure on the skin, most often over bony areas of the body). The resident also had an unstageable pressure ulcer (the wound is covered by dead tissue or scabbing that prevents healthcare staff from determining the full depth and severity of the wound until the tissue covering the wound is removed) on the coccyx (tailbone area located at the lower end of the spine). A review of Resident 9's quarterly Minimum Data Set assessment, MDS, a federally mandated standardized assessment process conducted periodically to plan resident care dated January 10, 2026, revealed that Resident 9 was severely cognitively impaired with a BIMS score of 1, (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information indicates a score of 0-7 indicates severe cognitive impairment). The MDS indicated the resident required staff assistance with mobility in bed and when transferring between bed and chair and had a Stage III pressure ulcer (a full thickness loss of skin where the underlying fat tissue may be visible and dead tissue may be present, although the depth of the wound can still be determined). Investigative documentation provided by the facility dated December 28, 2025, at 8:00 PM revealed staff identified a pressure ulcer on Resident 9's coccyx that measured 1 centimeter by 0.5 centimeter. However, the investigation failed to document the depth of the wound and failed to determine the stage of the pressure ulcer, which is a clinical method used to classify the severity and depth of a pressure injury. The investigation indicated the resident had a history of pressure injuries in the same location and that the previously healed area had reopened after healing on November 24, 2025. The facility identified potential contributing factors including immobility, incontinence (inability to control bowel or bladder function), and fragile skin. The investigative report included a staff statement indicating the resident was incontinent of bowel and bladder and that staff had attended to the resident two hours earlier. The report also indicated the resident spent time in both a chair and bed during the shift. However, the investigation did not include documentation describing the condition of the coccyx area prior to the identification of the pressure ulcer, did not describe the condition of the skin surrounding the wound, and did not determine whether preventative interventions identified in the resident's care plan were consistently implemented. The investigation also failed to determine whether a change in the resident's condition or care contributed to the reopening of the previously healed pressure injury. A Braden Scale assessment (a standardized assessment tool used to determine a resident's risk for developing pressure injuries by evaluating factors such as mobility, activity level, moisture exposure, and nutritional status) had been completed for Resident 9 on December 28, 2025. The assessment indicated Resident 9 was at very high risk for developing pressure injuries due to being chairfast, having limited mobility, and being constantly moist due to urinary incontinence. A review of the resident's care plan dated January 28, 2026, revealed interventions to prevent pressure injury development and promote wound healing. These interventions included staff repositioning the resident regularly while in bed and while seated in a chair to relieve pressure from vulnerable areas of the body. Staff task documentation for February 2026 indicated Resident 9 was to be repositioned every hour as part of pressure injury prevention measures. However, a review of staff task documentation from February 1, 2026, through February 26, 2026, revealed the repositioning documentation was blank and lacked evidence that staff completed or documented the required repositioning interventions. A review of Resident 9's February 2026 weight record revealed that on February 19, 2026, the resident weighed 99 pounds and on February 26, 2026, at 8:53 AM the resident weighed 98.5 pounds. The clinical record indicated the resident utilized a specialty therapeutic mattress identified as the Med-Aire Melody Alternating Pressure Low Air Loss Mattress to assist with pressure redistribution and wound healing to the resident's coccyx area. Manufacturer guidelines for the Med-Aire Melody Alternating Pressure Low Air Loss Mattress indicated the mattress is designed to distribute a resident's body weight across the support surface in order to reduce pressure on vulnerable areas and promote healing of pressure injuries. The manufacturer instructions indicated the mattress must be set according to the resident's current weight in order to ensure proper pressure redistribution and therapeutic function for wound healing. Observation of Resident 9's therapeutic mattress on February 26, 2026, at 9:15 AM and 2:15 PM, and again on February 27, 2026, at 10:20 AM, revealed the mattress weight setting was adjusted to 150 pounds. This setting was inconsistent with the resident's documented weight of 98.5 pounds. The mattress manufacturer indicated the system could accommodate residents weighing as little as 80 pounds. A review of a wound assessment dated [DATE], revealed the pressure ulcer on Resident 9's coccyx measured 2.0 cm by 1.0 cm by 0.20 cm and was identified as unstageable. During an interview on February 27, 2026, at 9:15 AM, the Director of Nursing was unable to provide evidence that the facility conducted a thorough investigation to determine whether pressure injury prevention interventions were consistently implemented. The Director of Nursing was also unable to provide documentation demonstrating that the resident's repositioning schedule had been followed or that the incorrect therapeutic mattress weight setting had been identified and corrected to ensure appropriate pressure redistribution and promote healing of the pressure injury. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of the Resident Assessment Instrument (RAI) Manual, clinical records, resident observation, and staff interviews, it was determined the facility failed to complete an accurate Minimum Data Set for one of 36 sampled residents (Resident 199).Findings include: A clinical record review revealed resident 199 was admitted to the facility on [DATE], with a diagnosis of urinary incontinence (the loss of control over one's urine). A review of a significant change Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 30, 2025, revealed that Resident 199 did not experience any limitation in range of motion (ROM) (referring to the full movement of a joint) in the upper extremities. MDS section GG-0115 (section related to functional abilities, the ability to perform tasks and activities necessary for daily living) indicated Resident 199 did not experience any limitation in moving one's shoulders, arms, elbows, wrist, hands, and fingers. Clinical record review revealed an evaluation by occupational therapy (certification period August 4, 2025, to October 25, 2025) and indicated Resident 199 had limited ROM in the right and left upper extremities including shoulders, elbows, wrists, and fingers. The therapy evaluation identified Resident 199 had bilateral hand contractures (permanent tightening of muscles, tendons, ligaments, or skin, which severely impacts joint mobility and function). The therapy evaluation revealed Resident 199 had a mobility performance score of 0. The mobility function score ranges from 0-12, 0 indicated the lowest level of function. Observation of Resident 199 while in bed, on February 24, 2026, at 10:45 AM revealed bilateral upper extremities (including elbows, wrists and fingers) with obvious joint deformities. The resident's elbows were observed in a fixed flexed position (permanently bent and unable to be straightened) held close to the chest. Both hands were observed in a closed, flexed position with the fingers tightly bent toward the palm. When asked, the resident was unable to open either hand or extend the arms. Dressings were observed in both hands and between the fingers. These observations were consistent with significant limitations in movement of the upper extremities (arms and hands). However, a review of the resident's Significant Change Minimum Data Set (MDS) assessment dated [DATE], Section GG0115, Functional Abilities and Goals indicated the resident did not have limitations with movement of the upper extremities. The observed physical limitations and therapy evaluation did not correspond with the MDS coding indicating no limitation. A review of the same significant change MDS dated [DATE], Section GG0120. Mobility Device (addressing devices used to assist with mobility such as walking), revealed Resident 199 uses a walker for mobility and ambulation. This information was inconsistent with the coding in Section GG0170, Mobility (which documents how a resident performs movement activities such as rolling in bed, sitting, standing, and transferring). Section GG0170 indicated the resident was dependent (helpers perform all of the effort, the resident does none of the effort to complete the activity) for multiple mobility activities, including rolling from left to right, sitting to lying, sitting to standing, and transferring from the bed to a chair. The coding in Section GG0170 further indicated the resident was unable to walk or move independently. The documentation indicating the resident used a walker for ambulation did not correspond with the resident's documented dependence for mobility and inability to walk. During an interview on February 25, 2026, at 1:45 PM, the Director of Nursing reviewed the above information and confirmed the MDS assessment data was inaccurate and did not accurately reflect Resident 199's limited upper extremity movement or the resident's mobility status. 28 Pa. Code 211.5(f)(iii) Medical records. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to afford a resident and their designated representative the right to participate in the development of the resident's plan of care for one resident out of 36 sampled residents (Resident 11).Findings include: A review of the facility policy titled Care Planning-Resident Participation, last reviewed by the facility on January 6, 2026, revealed it is the facility policy to support the resident's right to be informed of and participate in their care planning and treatment (implementation of care). The policy indicates the facility will notify the resident and/or resident representative of the risks and benefits of proposed care, treatment, and treatment alternatives or options. The facility will honor requests for care plan meetings and acknowledge requests for revisions to the person-centered plan of care. A clinical record review revealed Resident 11 was admitted to the facility on [DATE], with diagnoses that include acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). A review of Resident 11's quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 8, 2026, revealed that Resident 11 was cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates cognition is intact). During an interview on February 24, 2026, at 12:02 PM Resident 11 explained that she would like to receive more therapy and restorative services (nursing based exercises to help maintain or improve strength and movement) to address her deficits related to ambulation. Resident 11 indicated that she has not addressed the concern with the facility. A progress note dated February 25, 2026, at 1:42 PM indicated a care plan meeting was held on February 25, 2026, with the resident. No family present. The note indicated social services reviewed Resident 11's code status, diet, weights, meal consumption, transfer status, assistance with activities of daily living care, therapy status, and psychosocial needs. During a follow-up interview on February 26, 2026, at 10:10 AM, Resident 11 had no knowledge of a care plan meeting and was not invited to participate in a care plan meeting on February 25, 2026. She indicated that she has not discussed her therapy status, activities of daily care, and/or preferences of daily care with facility staff. She indicated that she has not had the opportunity to discuss her preferences for more therapy and restorative services to address her deficits related to ambulation. A clinical record review revealed no documented evidence the resident was notified that a care plan meeting was scheduled to occur on February 25, 2026. Also, a clinical record review revealed no documentation that Resident 11 was provided an opportunity to fully participate in establishing her expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. During an interview on February 27, 2026, at approximately 10:30 AM, the nursing home administrator (NHA) confirmed there was no documented evidence that Resident 11 or Resident 11's representative was invited to participate in the resident's care plan development. The NHA was unable to provide documented evidence the interdisciplinary team and Resident 11 met and provided Resident 11 an opportunity to fully participate in establishing her expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. The NHA was unable to provide a list of facility staff that met on February 25, 2026, as part of Resident 11's care plan meeting. The facility failed to ensure a person-centered care planning process was completed by failing to invite or include Resident 11 in the development of her goals and frequency of services, resulting in the resident's concerns regarding services for ambulation not addressed. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 36 residents sampled (Resident 141).Findings include: A review of Resident 141's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include mild neurocognitive disorder with behavioral disturbance (a slight, noticeable decline in cognitive abilities that does not significantly interfere with daily independence and is accompanied by agitation, irritability or mood changes) and cerebral infarction (stroke). A nursing progress note dated January 20, 2026, indicated staff notified the physician of Resident 141's increased confusion and incontinence (the inability to control bladder or bowel function). The physician ordered STAT (immediate) laboratory testing, including a complete blood count (CBC, a blood test that measures the number and types of blood cells and can help identify infection or inflammation), a basic metabolic panel (BMP, a blood test that measures electrolytes, kidney function, and blood sugar levels), a urinalysis (UA, a laboratory test that examines the appearance and chemical composition of urine to detect signs of infection or other medical conditions), and a urine culture and sensitivity test (C&S, a laboratory test that attempts to grow bacteria from a urine specimen to determine whether bacteria are present and, if so, which antibiotics would effectively treat the bacteria). A physician's order dated January 21, 2026, directed staff to administer Ceftriaxone Sodium Injection (a powerful, long-acting antibiotic used to treat severe bacterial infections). The order instructed staff to administer 1 gram intramuscularly (injection of medication into a large muscle to allow the medication to be absorbed into the bloodstream) once daily for three days. A laboratory report dated January 21, 2026, indicated the urine culture showed no significant growth, meaning the urine specimen did not contain enough bacteria to indicate an active urinary tract infection. Review of Resident 141's January 2026 Medication Administration Record (MAR, the clinical document used by staff to record medications administered to a resident) revealed staff administered one dose of Ceftriaxone on January 21, 2026, despite the urine culture showing no significant bacterial growth. The physician discontinued the Ceftriaxone order on January 22, 2026. A physician's order dated February 19, 2026, directing staff to obtain another urinalysis and urine culture and sensitivity test. An additional order dated February 20, 2026, directed staff to administer Ceftriaxone Sodium Injection 1000 milligrams intramuscularly once daily for a suspected urinary tract infection (UTI) followed by 500 milligrams intramuscularly on the second day and 500 milligrams intramuscularly on the third day. A laboratory report dated February 20, 2026, indicated the urine specimen showed multiple flora suggesting contamination (the presence of several different types of bacteria that likely entered the specimen during collection, which means the test result may not accurately represent bacteria present in the bladder) or colonization (bacteria present in or on the body without causing illness, symptoms, or tissue damage). The report recommended repeating the test if symptoms worsened. Review of the February 2026 MAR revealed staff administered Ceftriaxone on February 20, 2026, and again on February 21, 2026. Review of physician's orders indicated the medication was discontinued on February 20, 2026; however, staff administered an additional dose on February 21, 2026. During an interview on February 27, 2026, at 10:45 AM, the Infection Preventionist (IP) confirmed the resident's symptoms did not meet the McGeer Criteria (a standardized surveillance guideline used in long term care facilities to determine whether a resident has a true, symptomatic infection requiring treatment). The IP explained that the criteria help distinguish a true urinary tract infection from asymptomatic bacteriuria (the presence of bacteria in the urine without symptoms of infection). The IP acknowledged that the administration of Ceftriaxone was not clinically indicated and confirmed the resident received unnecessary antibiotic therapy that was not consistent with evidence-based infection control practices or antimicrobial stewardship principles (programs designed to ensure antibiotics are used only when medically necessary to reduce antibiotic resistance and prevent avoidable medication exposure). 28 Pa. Code 211.2(d)(3)(5) Medical Director 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on a review of pre-admission records, facility clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop a baseline care plan that documented interim, person-centered approaches to address the resident's identified fall risk for one of 36 sampled residents (Resident 14).Findings include: A review of the clinical record revealed Resident 14 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (lungs cannot deliver oxygen to the body). A review of Resident 14's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 6, 2025, revealed Resident 14 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; score between 0 and 7 indicate severe cognitive impairment). A review of Resident 14's pre-admission medical records revealed the resident experienced two falls in the weeks prior to admission. Documentation indicated a fall occurred at home on October 12, 2025, at 2:15 AM, and another fall occurred at home on October 16, 2025, at 3:00 AM. A review of the facility's Baseline Care Plan Policy, reviewed January 6, 2026, indicated the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. The policy explanation and compliance guidelines revealed that initial goals shall be established that reflect the resident's stated goals and objectives. The interventions shall be initiated that address the resident's current needs including any health and safety concerns to prevent decline or injury such as elopement, fall, or pressure injury risk as well as any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. The baseline care plan must be developed within 48 hours of the resident's admission. A review of nursing documentation dated November 4, 2025, at 1:43 AM revealed Resident 14 was observed in the hallway without clothing on the lower half of the body. The documentation indicated the resident wandered into other residents' rooms and went through other residents' belongings. Nursing staff attempted to redirect the resident using snacks, drinks, and activities such as coloring and folding laundry. The documentation indicated the resident required one-to-one supervision (continuous monitoring by a staff member assigned to observe the resident at all times) and returned to bed at approximately 5:00 AM. A review of nursing documentation dated November 8, 2025, at 7:00 AM revealed Resident 14 remained restless throughout the night. Documentation indicated that both non-medication interventions (such as activities, food, and providing a calm environment) and medication were not effective in reducing the resident's restlessness. The note indicated the resident required staff supervision for most of the night. A review of the clinical record revealed Resident 14 experienced a fall without injury on November 8, 2025, at 7:45 AM. Nursing documentation indicated the resident was confused and looking for socks at the time of the fall. The note further indicated the resident was wearing properly fitting, non-skid socks. Interventions initiated after the fall included checks by staff every 15 minutes from 7:00 PM through 9:00 AM for 72 hours, an evaluation by therapy, and neurological checks (assessments performed by staff to monitor a resident after a fall such as level of consciousness, alertness and the ability to move) in accordance with facility policy. A review of the baseline care plan initiated on October 31, 2025, indicated Resident 14 had safety risks, including falls, and documented the resident experienced multiple falls at home prior to admission. However, the baseline care plan lacked specific, resident-centered fall prevention interventions to reduce the resident's risk for falls during nighttime hours, despite documented falls occurring during nighttime hours prior to admission and observations of nighttime wandering and unsafe behaviors after admission. During an interview on February 27, 2026, at 10:15 AM, the Director of Nursing confirmed the baseline care plan for Resident 14 did not include individualized fall prevention interventions consistent with the resident's identified nighttime behaviors and fall risk and was not consistent with the facility's baseline care plan policy. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5(f)(iii) Medical records.

Based on review of clinical records and controlled drug records, and staff interview, it was determined the facility failed to implement procedures to promote accurate accounting and administration of controlled medications for two of 35 residents sampled (Residents 64 and 92). Finding include: A review of Resident 92's clinical record revealed a physician's order dated December 21, 2024, for Morphine Sulfate 15 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet by mouth every four hours as needed for severe pain. A review of the controlled substance record for Resident 92's Morphine Sulfate 15 mg (schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) showed that nursing staff signed out doses of the medication on the following dates and times: February 2, 2025, at 4:15 PM February 4, 2025, at 4:00 PM February 5, 2025, at 2:00 PM February 18, 2025, (time illegible) February 21, 2025, at 5:50 PM March 3, 2025, at 4:40 PM However, a review of Resident 92's Medication Administration Record (MAR) revealed there was no documentation indicating that the medication was administered to the resident on these dates and times A review of the clinical record revealed a physician's order dated for January 17,2025, for Resident 64 to receive Oxycodone HCL 5 mg. (Oxycodone is in a schedule II opiate narcotic medication) with instructions to administer one tablet every six hours as needed for moderate pain. A review of the controlled substance record for Resident 64's Oxycodone HCL 5 mg showed that nursing staff signed out doses of the medication on: March 4, 2025, at 8:15 PM March 5, 2025, at 5:00 PM However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record (MAR) on those dates and times. During an interview on March 21, 2025, at 9:30 AM, the Director of Nursing confirmed the discrepancies in the accounting and administration of opioid pain medications for Residents 64 and 92. 92. 28 Pa Code 211.5 (f)(xi) Medical records 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9(a)(1)(k) Pharmacy services

Based on a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 35 residents sampled (Residents 47, 48, and 140) and five out of nine residents interviewed during a resident group interview (Residents 10, 31, 49, 72, and 142). Findings include: A review of Resident Council meeting minutes dated February 11, 2025, revealed residents in attendance raised concerns regarding not being assisted out of bed to participate in activities. The residents indicated there was an issue with receiving staff assistance to get out of bed promptly. Also, residents in attendance raised concerns indicating call bells are not answered when residents ring for assistance. During a resident council meeting on March 19, 2025, at 10:00 AM, Residents 10, 31, 49, 72, and 142 expressed concerns about the timeliness of staff assistance when using their call bells. Resident 49 stated she rang her call bell for assistance the night before but did not receive help for over two hours. She needed medication for not feeling well and noted that this concern had been raised repeatedly in previous Resident Council meetings without improvement Resident 142 stated that staff often enter her room, turn off her call bell light, and leave without providing care. She recalled an incident where she soiled her bed and was left waiting for at least an hour after her call bell was silenced. She noted that delays are more frequent during the night shift Resident 10 stated he routinely waits 20 to 30 minutes for assistance and finds the prolonged delays frustrating. He reported that waiting excessive times for help has become a daily occurrence and it causes him frustration. Resident 72 and his roommate both reported 30-minute wait times for staff to respond to call bells. Resident 72 stated that these delays cause frustration and sadness and make him feel as though staff do not care about the residents Resident 31 indicated he frequently waits 30 minutes or more for care after using his call bell. He reported that staff sometimes respond after 15 minutes, turn off his call bell, and leave without assisting him, forcing him to ring for help multiple times before receiving care. A clinical record review revealed Resident 140 was admitted to the facility on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and difficulty in walking. A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 14, 2024, revealed that Resident 140 is severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). During an interview on March 18, 2025, at 12:05 PM, with Resident 140's Responsible Party, she indicated she has concerns regarding the timeliness of staff assisting Resident 140 with her toileting needs. She expressed that Resident 140 is frequently soiled upon arrival when she visits and that the staff may not be checking and changing Resident 140 as often as needed. She reported that Resident 140's husband, Resident 149, reported utilizing the call bell to obtain assistance for his wife, but that they wait an extended period of time, up to an hour, for staff to provide assistance. She continued to report the delay in care is most noted during the evening and night shifts. A clinical record review revealed Resident 48 was admitted to the facility on [DATE], with diagnoses that included stage 4 chronic kidney disease (severe kidney damage leading to waste and fluid buildup), and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). A review of an annual MDS dated [DATE], revealed that Resident 48 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates intact cognition). Interview on March 18, 2025, at 12:30 PM: Resident 48 reported excessive wait times for staff assistance. He recounted waiting 1.5 hours to be placed on a bedpan and another 1.5 hours to be removed from it. He also stated that because he requires assistance from two staff members, staff often respond to his call bell, say they will find a second staff member, and then never return. He reported these delays are most frequent during the second shift A clinical record review revealed Resident 47 was admitted to the facility on [DATE], with diagnoses that included chronic heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs). A review of an annual MDS dated [DATE], revealed that Resident 47 is moderately cognitively impaired with a BIMS score of 12 (a score of 8-12 indicates moderate cognitive impairment). During an interview on March 19, 2025, at 11:00 AM, Resident 47 indicated she experiences long wait times for care. She indicated she often waits 20 to 30 minutes or longer for staff to respond to her call bell after she rings for assistance. Resident 47 stated the long wait often occurs when she is ready to get out of bed in the morning. During an interview on March 21, 2025, at approximately 9:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect and provided care in a manner that promotes each resident's quality of life. The NHA and DON were unable to explain why multiple residents continued to report delayed response times and unmet care needs. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (d)(4) Nursing services.

Based on a review of clinical records and staff interview, it was determined the facility failed to offer and/or provide the influenza immunization, unless the immunization was medically contraindicated or the resident had already been immunized, for one out of the five residents sampled (Resident 58). Findings include: A review of the clinical record revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2025, revealed that Resident 58 is severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). A review of Resident 58's influenza immunization informed consent revealed Resident 58's resident representative acknowledged receiving information and education on the benefits and potential side effects of the influenza vaccine. Resident 58's representative authorized consent for Resident 58 to receive an influenza vaccine on January 29, 2025. A review of the clinical record revealed no documented evidence indicating Resident 58 received the influenza vaccine. During an interview on March 21, 2025, at approximately 9:30 AM, the Director of Nursing (DON) confirmed the facility failed to administer Resident 58's influenza vaccination. The DON confirmed it is the facility's responsibility to ensure residents are offered and/or provided the influenza immunization, unless the immunization was medically contraindicated or the resident has already been immunized. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(3) Nursing Services

Based on observation, review of clinical records, select facility policy, and staff interview it was determined the facility failed to consistently administer Oxygen (O2) as ordered for one out of 35 sampled residents (Resident 14). Findings included: Review of the facility Oxygen Administration Policy last reviewed April 17, 2024, indicated that oxygen is administered to residents who need it, consistent with professional standards, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. A review of the clinical record of Resident 14 revealed admission to the facility on [DATE], with diagnoses that include congestive heart failure (the heart muscle does not pump blood as well as it should). The resident had a current physician order initially dated December 16, 2024, for O2 at 2 liters per minute (L/min) continuous via nasal cannula for shortness of breath. An observation on March 19, 2025, at 10:15AM revealed Resident 14's O2 concentrator (machine delivering oxygen therapy) was turned on and running at 3 L/min which was not consistent with physician's orders. An observation on March 21, 2025, at 9:05 AM revealed Resident 14's O2 was turned on and again running at 3 L/min failing to follow physician's orders. Employee 1 (LPN) confirmed this observation. Interview with the director of nursing on March 21, 2025, at approximately 9:30 AM confirmed the physician's order for supplemental oxygen was not followed for Resident 14. 28 Pa. Code 211.10 (c) Resident Care Policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on observations, a review of clinical records and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included specific and individualized interventions to address a resident's involuntary movements for one out of five residents sampled for unnecessary medication (Resident 10). Findings include: A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder (a condition in which an individual has a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania, and a milder form of mania called hypomania). A clinical record review revealed an Abnormal Involuntary Movement Scale (AIMS- assessment tool used to screen for and assess the severity of tardive dyskinesia (TD), a movement disorder that can occur as a side effect of certain medications, particularly antipsychotics) dated September 23, 2024, indicated Resident 2 has an overall moderate level of severity of abnormal movements and mild incapacitation due to these abnormal movements. The assessment also indicates Resident 2 experiences moderate distress because of the involuntary movements. A clinical record review revealed Resident 2 has a physician's order to receive a Quetiapine Fumarate tablet (an antipsychotic medication that works by affecting the balance of certain chemicals in the brain, such as dopamine and serotonin) 50 mg, with directions to give 50 mg by mouth three times a day related to schizoaffective disorder initiated on January 9, 2025. A physician's order for hydroxyzine HCI oral tablet 10 mg with direction to give 10 mg by mouth every 6 hours as needed for anxiety or motor restlessness was initiated on March 17, 2025. A physician's order for lorazepam 0.5 oral tablet 0.5 mg with directions to give 1.5 tablets by mouth every 8 hours related to generalized anxiety disorder was initiated on July 16, 2024. During an observation on March 19, 2025, at 11:02 AM, Resident 2 was lying in bed, displaying an erratic rolling motion between her left and right sides. Concurrently, her arms were moving irregularly and unpredictably, with abrupt, jerky movements. Resident 2 did not appear to be in control of these movements. A clinical record review revealed no documented evidence the facility developed a care plan to include the resident's involuntary movements and the psycho-social distress the resident reported as a result of the involuntary movements as identified from the September 23, 2024, AIMS assessment. Following questions asked during the survey, Resident 2's care plan was updated to include a care plan focus that indicates she has a behavioral problem and mood problem related to medication-induced akathisia (a movement disorder characterized by an intense, subjective feeling of inner restlessness and an uncontrollable urge to move, often manifesting as pacing, fidgeting, or an inability to sit still, and is frequently a side effect of certain medications, particularly antipsychotics). During an interview on March 21, 2025, at approximately 9:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure each resident's comprehensive person-centered care plan includes identified problems and services that are to be provided to assist the resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The DON and NHA confirmed Resident 2's comprehensive person-centered care plan did not identify a problem with medication-induced involuntary movements or the psychosocial distress caused by the movements prior to inquiries made during the survey ending on March 21, 2025. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3) Nursing services

Based on a review of clinical records, the Resident Assessment Instrument (RAI), and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments accurately reflected the status of two residents out of 35 sampled (Residents 2 and 183). Findings include: According to the Resident Assessment Instrument (RAI) User's Manual (an assessment tool utilized to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan, and the RAI also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status) dated October 2024, Section A2105: Discharge Status indicates to review the medical record, including the discharge plan and discharge orders, for documentation of discharge location. This section indicates that if the resident is discharged to a private home, apartment, board and care, assisted living facility, group home, transition living, or adult foster care, then Code 01, home and community, should be encoded. Also, RAI Section I Active Diagnoses indicates to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. A clinical record review revealed Resident 2 was admitted to the facility on [DATE]. A review of the annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) Section I, Active Diagnoses, dated January 9, 2025, indicated Resident 2 has a psychotic disorder (other than schizoaffective and schizophreniform) diagnosis. A clinical record review revealed no documented evidence of a psychotic disorder other than schizoaffective disorders. During an interview on March 21, 2025, at approximately 9:30 AM, the Director of Nursing confirmed Resident 2's MDS dated [DATE], was not accurate. The DON confirmed there was no documented evidence Resident 2 had psychotic disorder diagnosis (other than schizoaffective disorder). A clinical record review revealed Resident 183 was admitted to the facility on [DATE], and discharged home to the community on February 4, 2025. A review of the discharge return not anticipated MDS, dated [DATE], Section A Identification Information; Subsection A2105 Discharge Status indicated Resident 182 was discharged to a short-term general hospital (acute hospital). A progress note dated February 7, 2025, at 4:41 PM revealed Resident 183 was discharged to home with belongings and medications by way of wheelchair through an external transport company. During an interview on March 21, 2025, at approximately 9:30 AM, the DON confirmed Resident 183's discharge return not anticipated MDS dated [DATE], was not accurate. The DON confirmed Resident 183 was discharged to home and not transferred to a community hospital. 28 Pa. Code 211.5 (f)(vi) Medical records. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to timely follow up with required dental services for one Medicaid payor source resident out of 35 residents sampled (Resident 10). Findings include: A clinical record review revealed Resident 10 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and mild protein malnutrition (inadequate intake of food, particularly protein and calories, resulting in a deficit in expected weight for age or height). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 3, 2025, revealed that Resident 10 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of the facility's census information revealed Resident 10 receives benefits through Medicaid (a social assistance program providing individuals comprehensive health and long-term care coverage). A progress note dated December 22, 2024, at 3:00 PM revealed that Resident 10 stated he has been missing his lower dentures for two months. A room search revealed the dentures were not able to be located. A progress note dated December 23, 2024, at 7:05 AM revealed Resident 10's representative contacted the facility and wished to speak with the facility about the resident's missing dentures. A progress note dated January 3, 2025, at 11:37 PM revealed an X-ray full series was performed regarding missing dentures. A review of Resident Council meeting minutes dated January 14, 2025, revealed Resident 10 indicated it is very hard for him to eat due to not having his new dentures. During an interview on March 19, 2025, at 10:30 AM, Resident 10 indicated he has not had dentures for three to four months. He expressed that he is upset the facility staff threw his dentures in the garbage. Resident 10 explained he has brought this issue up a few times with staff, but nothing has been done to help him get his new dentures. A clinical record review revealed no documented evidence the facility provided Resident 10 further assistance in attaining dental services to replace his missing dentures until inquiries made during the week of the survey ending on March 21, 2025. During an interview on March 21, 2025, at approximately 9:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were not able to provide evidence the facility ensured Resident 10 received dental services to replace his missing dentures. Following inquiries made during the survey, Resident 10 was scheduled for an appointment to receive additional dental services. The DON and NHA confirmed it is the facility's responsibility to ensure residents receive required dental services. 28 Pa. Code 211.12 (d)(3) Nursing services

Based on review of clinical records, select facility policy and incident reports, and staff interviews, it was determined that the facility failed to implement adequate safety measures, including sufficient staff supervision, for a resident identified as at high risk for falls to prevent falls for one resident out of 35 sampled (Resident 115). Findings include: A facility policy titled Falls Prevention Program, last reviewed by the facility in April 2024, revealed that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy indicates the facility will provide interventions as directed by the resident's assessment, including but not limited to assistive devices, increased frequency of safety monitoring rounds, scheduled ambulation or toileting assistance, and therapy services referrals. A clinical record review revealed Resident 115 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (a condition in which excessive worry causes clinically significant distress or impairment in social, occupational, or other areas of functioning) and insomnia (a sleep disorder that makes it hard to fall or stay asleep) and a history of falling. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 4, 2024, revealed that Resident 115 is severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A care plan revealed the resident has delirium or acute confusional episodes at times initiated on July 1, 2024, with a goal that she will be free from signs or symptoms of delirium (changes in behavior, cognitive function, communication level of consciousness, restlessness). Further clinical record review revealed Resident 115 is at risk for falls related to a history of falling, initiated on June 29, 2024. Her care plan indicates she will be free from injury with facility interventions including checking the resident every 15 minutes, anticipating the resident's needs, motion alarms, bilateral floor mats, and a position alarm to the resident's chair and bed to qalert staff of unsafe transfers. A clinical record review revealed Resident 115 experienced nine falls during her first month at the facility from June 29, 2024, through July 29, 2024. A Fall Risk assessment dated [DATE], identified Resident 115 as a high risk for falls. A clinical record review revealed Resident 115 experienced seven additional falls from August 26, 2024, through October 18, 2024. A review of facility investigations revealed that six of these falls were unwitnessed. A progress note dated August 26, 2024, at 12:15 AM, indicated Resident 115 was found on the floor of her room lying on her right side, incontinent, without complaints of pain or discomfort. The resident was assessed without injury. A progress note dated September 1, 2024, at 1:40 AM, indicated Resident 115 was found on the floor in her room. The note indicated that the resident was assessed without injury and assisted to the nursing station for monitoring. A progress note dated September 9, 2024, at 11:27 PM indicated Resident 115 was found on the right side of her bed on her buttocks with her back against the wall. The note indicated that the resident was assessed without injury, assisted into her wheelchair, and brought to the nursing station for monitoring. A progress note dated September 12, 2024, at 5:29 PM indicated Resident 115 was found on the floor near the nurse's station in front of her wheelchair. A small amount of blood was noted on the resident's hand and forehead. An additional progress note dated September 12, 2024, at 5:30 PM indicated Resident 115 was assessed with noted skin tears to her left temple measuring 0.1 cm x 3.0 cm x 0.1 cm and left posterior hand measuring 0.1 cm x 2.0 cm x 0.1 cm. The note indicated the resident reported striking her head against the floor during the event. The resident denied pain and was assessed without further injuries. A progress note dated September 22, 2024, at 11:45 AM, indicated Resident 115 fell out of her chair while sitting in front of the nurse's station. The note explained that her previous skin tear on her left hand began to bleed. The resident had no complaints of pain and was assessed without further injury noted. A progress note dated September 28, 2024, at 10:10 AM, indicated Resident 115 was found on the floor, laying on her right side by the nursing station. The note indicated the resident was assessed, and injuries noted included a skin tear to her right forearm and an abrasion on her right knee. Further clinical record review revealed no additional documented evidence describing Resident 115's right forearm skin tear or right knee abrasion. A progress note dated October 18, 2024, at 3:25 AM, indicated Resident 115 was found on the floor. The resident was assessed without injury and had no complaints of pain or discomfort. The facility failed to implement effective interventions and provide adequate supervision to prevent the resident's reoccurring falls. During an interview on October 25, 2024, at approximately 9:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed it is the facility's responsibility to ensure each resident receives adequate safety measures, including sufficient staff supervision to prevent falls. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident (Resident B1) out of two residents reviewed Findings include: A review of the facility policy titled Abuse, Neglect and Exploitation last reviewed by the facility on April 15, 2024, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebrovascular disease (stroke) affecting his left non-dominant side, muscle weakness, and abnormalities of gait and mobility. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 16, 2024, revealed that Resident B1 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment), had an impairment on one side of his upper extremity (arm) and lower extremity (leg), required substantial/maximal assistance to transition from sitting to lying in bed, and required total staff assistance to perform chair to bed and bed to chair transfers. A review of a physician's order dated July 3, 2024, revealed an order for the resident to transfer with two (2) staff assist and to use nonskid footwear. A review of the resident's [NAME] (a nursing information system used to obtain specific care information for each resident) revealed the resident required the assistance of two staff members and the use of nonskid footwear for all transfers to ensure safety. A nurses note dated December 9, 2024, at 7:45 PM indicated that the nurse was called to the Resident B1's room. Upon arrival, the resident was found lying on the floor next to the bed and a nightstand. The resident was lowered to the floor while the nurse aid was helping him transfer with assistance of one person. An assessment was completed with no visible injuries. A review of a facility investigative report dated December 9, 2024, revealed that Employee 1, nurse aide, lowered Resident B1 to the floor after she had transferred him with assist of one (1) despite the care plan requiring two-person assistance. A witness statement dated December 9, 2024, (no time indicated) provided by Employee 1, revealed that the resident had asked to go to bed. Employee 1 attempted to put him to bed on her own and he slid onto the floor. The statement indicated that the resident's transfer status required assistance of two (2) staff members. Employee 1 admitted in her statement that she was aware of the two-person transfer requirement but attempted the transfer alone. The resident slipped and was lowered to the floor. A witness statement dated December 10, 2024, (no time indicated) provided by Resident B1, stated I pushed the call button to go to bed. The girl came in and I told her I was ready for bed at 7:00PM. She was a big girl, German and Italian. She was nice. I told her she may need another person, but she said she can put me to bed by herself. She was not able to, and I fell. I did not get hurt. She was a nice girl and was just trying to help me. During an interview on January 9, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility staff failed to ensure that Resident B1 received the services necessary to prevent a fall during a transfer. The NHA confirmed that Employee 1, was aware that Resident B1's transfer was to be performed with two people but neglected to assure the presence of a second person and performed the transfer by herself, resulting in Resident 1's fall to the floor. The fall caused unnecessary risk and could have resulted in potential harm. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on a review of clinical records and staff interview, it was determined the facility failed to develop and/or implement a person-centered comprehensive care plan for three residents out of 35 sampled (Resident 103, 58, and 404). Findings include: A review of the clinical record revealed Resident 103 was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes and difficulty walking. A review of a bowel and bladder assessment dated [DATE], revealed the resident is always incontinent of urine and feces. A review of the resident's clinical record revealed the resident is on a two hour check and change program to check for incontinence. A review of the current resident's plan of care revealed the resident's care plan failed to identify the resident's bowel and bladder incontinence and interventions to address the resident's concerns. A review of Resident 58's clinical record revealed that the resident was admitted to the facility July 30, 2023, with diagnoses that included dementia with behavioral disturbances, muscle wasting and atrophy (is a progressive and degeneration or shrinkage of muscles or nerve tissues), lack of coordination, and difficulty walking. A review of the resident's comprehensive person-center care plan that for communication initiated on December 19, 2023, identified that Resident 58 was fluent in both Spanish and English and the resident's needs would be met. Planned interventions included to anticipate and meet the needs of the resident, communicate with family/resident PRN (as needed) about any suspected changes in expression/understanding, and observe for evidence that language expression/understanding is changing in relation to his dementia. Interviews with Employees 3 and Employee 4, both nurse aides (NA), on October 17, 2024, at 11:15 AM, revealed that Resident 58 had behaviors such as frequently self-transferring to the bathroom and resistive during care and the resident required Spanish speaking staff to translate care being rendered to deter escalating behaviors. Staff also reported the resident's family was present most afternoons and would translate for the resident and when there wasn't anyone readily available to translate for the resident, the staff would use translating devises to communicate. Resident 58's comprehensive plan of care failed to include intervventions required to effectively communicate with the resident. A review of the clinical record revealed Resident 401 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a brain disorder that causes problems with memory, thinking and behavior) and Depression (a mood disorder that causes a persistent feeling of sadness or loss of interest). A review of the documentation provided by the facility listed Resident 401 as Spanish speaking resident. An interview with Employee 1, a NA, on October 24, 2024, at 11:32 AM, revealed the facility had Spanish speaking staff members to help translate and that Resident 401 had been provided a 1:1 sitter (one staff member to one resident to ensure the safety of that resident) that was able to speak Spanish and communicate with Resident 401. An interview with Employee 2, a NA, on October 24,2024 at 11:40 AM, revealed the facility provided staff who did not speak Spanish a translation service so that staff was able to communicate with the resident. A review of Resident 401's care plan, last updated on October 14, 2024, determined the facility failed to develop a person-centered care plan that addressed the resident's inability to communicate with staff. Interview with the Nursing Home Administrator and Director of Nursing on October 25, 2024, at approximately 1:15 PM confirmed the facility failed to ensure that comprehensive care plans were developed to meet the residents specific needs. 28 Pa. Code 211.12 (d)(5) Nursing services

Based on a review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined the failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of one resident (Resident B1) out of two residents reviewed Findings include: A review of the facility policy titled Abuse, Neglect and Exploitation last reviewed by the facility on April 15, 2024, revealed it is the facility's policy to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed that Resident B1 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebrovascular disease (stroke) affecting his left non-dominant side, muscle weakness, and abnormalities of gait and mobility. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 16, 2024, revealed that Resident B1 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment), had an impairment on one side of his upper extremity (arm) and lower extremity (leg), required substantial/maximal assistance to transition from sitting to lying in bed, and required total staff assistance to perform chair to bed and bed to chair transfers. A review of a physician's order dated July 3, 2024, revealed an order for the resident to transfer with two (2) staff assist and to use nonskid footwear. A review of the resident's Kardex (a nursing information system used to obtain specific care information for each resident) revealed the resident required the assistance of two staff members and the use of nonskid footwear for all transfers to ensure safety. A nurses note dated December 9, 2024, at 7:45 PM indicated that the nurse was called to the Resident B1's room. Upon arrival, the resident was found lying on the floor next to the bed and a nightstand. The resident was lowered to the floor while the nurse aid was helping him transfer with assistance of one person. An assessment was completed with no visible injuries. A review of a facility investigative report dated December 9, 2024, revealed that Employee 1, nurse aide, lowered Resident B1 to the floor after she had transferred him with assist of one (1) despite the care plan requiring two-person assistance. A witness statement dated December 9, 2024, (no time indicated) provided by Employee 1, revealed that the resident had asked to go to bed. Employee 1 attempted to put him to bed on her own and he slid onto the floor. The statement indicated that the resident's transfer status required assistance of two (2) staff members. Employee 1 admitted in her statement that she was aware of the two-person transfer requirement but attempted the transfer alone. The resident slipped and was lowered to the floor. A witness statement dated December 10, 2024, (no time indicated) provided by Resident B1, stated I pushed the call button to go to bed. The girl came in and I told her I was ready for bed at 7:00PM. She was a big girl, German and Italian. She was nice. I told her she may need another person, but she said she can put me to bed by herself. She was not able to, and I fell . I did not get hurt. She was a nice girl and was just trying to help me. During an interview on January 9, 2025, at approximately 1:30 PM, the Nursing Home Administrator (NHA) confirmed that the facility staff failed to ensure that Resident B1 received the services necessary to prevent a fall during a transfer. The NHA confirmed that Employee 1, was aware that Resident B1's transfer was to be performed with two people but neglected to assure the presence of a second person and performed the transfer by herself, resulting in Resident 1's fall to the floor. The fall caused unnecessary risk and could have resulted in potential harm. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(1)(5) Nursing Services

Based on a review of the facility's abuse policy, clinical records and select investigative reports and resident and staff interviews it was determined that the facility failed to ensure that one resident (Resident 26) out of 35 sampled was free from physical abuse perpetrated by another resident (Resident 24), which caused Resident 26 to fall and sustain a traumatic hematoma to the forehead and facial bruising. Findings included: A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility April 15, 2023, revealed that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. A review of Resident 26's clinical record revealed admission to the facility on [DATE], with diagnoses, of dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 06. A review of Resident 24's clinical record revealed admission on August 2, 2023, with diagnoses, which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and oppositional defiant disorder. An admission MDS assessment dated [DATE], indicated that the resident was cognitively intact with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 13. A review of a nursing note dated September 30, 2023, at 7:35 PM, indicted that after dinner Resident 24 came out of the room and was yelling that another resident needs to sit in her chair. He began to accuse staff of not caring. He then verbalized I will sit outside of her door all night and watch her if you assh***s don't care. A review of a Social Services note dated October 13, 2023, 11:59 AM, revealed it was reported that Resident 24 was being unfriendly/name calling to fell ow peers during activities. Social Services reminded the resident about being respectful to fell ow peers, unfortunately he feels differently about the solution offered, indicating he feels it is his job to fix issues that arise. A review of a nursing note dated October 24, 2023, at 12:14 AM, revealed that Resident 24 was displaying aggressive behaviors and yelling at staff members. Not able to be re-directed, re-direction attempts were met with more aggression. A review of a nursing note dated October 29, 2023, at 1:31 PM, revealed that Resident 24 was upset and vocalizing his anger towards staff in hallway due to being placed on visual supervision post incident in the dining room during which Resident 26 sustained a fall with minor injury. Resident 24 stated that he is everyone's boss that work here. A nursing note dated October 29, 2023, at 2:30 PM, revealed a new order was obtained to send Resident 24 to hospital ER for evaluation. 911 was called after discussing with crisis center staff that resident needed to be evaluated. MD agreed resident transported to ER at this time. A nursing note dated October 29, 2023, at 12:05 PM, indicted that staff found Resident 26 sitting on dining room floor with 1.5 cm laceration to right forehead with swelling at laceration site. Resident also had 1cm x 0.5 cm red mark on right side of bridge of her nose. No other injuries were noted. The resident's glasses were lying on the floor next to her and were bent. Ice and a bandage were applied to the resident's forehead. Neuro checks were initiated. MD made aware with new orders received to send resident to the ER for evaluation. A review of the hospital emergency department provider note, dated October 29, 2023, indicated that {Resident 26} presented to the ER for a fall evaluation, and per emergency medical services (EMS) staff the resident got into a verbal and/or physical altercation with another resident at the facility. The ER discharge clinical impression was a fall, traumatic hematoma of forehead. A nursing note dated October 29, 2023, at 10:26 PM, indicted that Resident 26 returned to facility with dressing intact to a laceration to the forehead and bruising to right eye and on bridge of nose. No new orders were received. A review of facility provided investigation entitled fall dated October 29, 2023, 11:30 AM revealed that in the north dining room, Resident 26 was found on the floor with a 1.5 cm laceration right forehead with swelling, along with a red mark of the right side of the bridge of her nose. Resident 26 stated, that man hit me, causing her to fall. A review of witness statement dated October 29, 2023, from Employee 1, Licensed Practical Nurse (LPN), revealed that at approximately 11:15 AM while sitting at the nurses station I heard a women yelling for help. On my way to the dining room, I passed {Resident 24} who was stating 'I warned her, I warned her,' and then started humming. I didn't know what {Resident 24} was referring to at the time. When I got to the dining room, I saw {Resident 26} sitting on the floor with the right side of her forehead bleeding. A review of witness statement dated October 29, 2023, from Employee 2, Licensed Practical Nurse (LPN), revealed that this nurse went to the dining room at approximately 11:30 AM to assist. While assisting fell ow staff members, Resident 26 stated she was hit in the face, he just hit me. Review of facility provided document entitled Investigation dated October 29, 2023, (author unknown), revealed that at approximately 11:15 AM, a charge nurse heard a woman yelling for help. On her way into the dining room, she passed {Resident 24} stating that 'he warned her.' Upon entering the dining room Resident 26 was found on the floor with the right side of her head bleeding. At approximately 11:30 AM, as additional staff assistance was being provided, Resident 26 stated he just hit me. At this time no other resident, or male was in the dining room. Resident 24 (identified perpetrator) did enter the dining room, and Resident 26 (victim) started yelling at him and proceeded to stand. At that time, Resident 26 tried to hit Resident 24 and fell back onto the floor. Staff assumed it was Resident 24 who had struck her (Resident 26), however, Resident 24 (the identified perpetrator) denied hitting her (Resident 26). A review of information submitted dated October 29, 2023, submitted by the facility solely identified Resident's 26's fall but no reference to the resident's allegation of physical abuse by Resident 24. A discharge MDS assessment dated [DATE], indicated that Resident 24 displayed physical behavioral symptoms directed towards other including hitting, kicking, pushing, scratching, grabbing and abusing others on 1-3 days during the assessment look back period, and verbal behaviors such as threatening others, screaming at others, cursing at others on 1-3 days during the assessment look back period. A review of the coordinated at ED to Hosp - Admission, dated October 29, 2023, regarding Resident 24's admission indicated [AGE] year-old male presenting to emergency department for evaluation from nursing home after assaulting another resident. He was seen walking out of the dining room stating that he warned her that he was going to do it. The other patient was found on the dining room floor bleeding from her head. Interview with Resident 26 (victim) on December 7, 2023, at approximately 10:38 AM, revealed she had no specific recall of the altercation with Resident 24 resulting in her fall on October 29, 2023. Interview with Resident 24 (Perpetrator) on December 7, 2023, at approximately 10:45 AM, revealed that the resident confirmed that he did enter the dining room, where Resident 26 was seated that morning. His account of the incident was that she stood and tried to hit him, causing her to fall back onto the floor. Resident 24 further stated, he has been told the facility has video cameras that show he (Resident 24) swung and hit her (Resident 26). A review of a nursing note dated October 31, 2023, at 4:00 PM indicated that Resident 24 returned to facility via stretcher, accompanied by EMS transporters. He was awake and alert. Pleasant and cooperative. Offering no complaints of pain, discomfort, or distress. A new order was received for the antipsychotic drug, Seroquel 25 mg, 0.5 tablet by mouth twice a day. Appetite good for dinner. He accepted medications without incident. A review of Resident 24's care plan initiated October 24, 2023, and revised on November 1, 2023, revealed that the resident has behavior problems physically aggressive towards other residents (peers) and staff, verbally aggressive, threatening towards staff, verbally puts down fell ow peers. A review of a Social Services note dated November 1, 2023, 12:00 PM, revealed Social Services along with fell ow social service staff spoke to the resident at great lengths about his behavior and being respectful to fell ow peers and keeping hands to self. Resident informed social services that he will do what he wants and make his own rules. A review of a psychiatric evaluation and consultation of Resident 24 dated November 6, 2023, indicated that Resident 24 was seen for an early follow up due to a recent altercation with another resident on the unit. Per staff, patient was being antagonized by another resident on unit, and after multiple warnings by patient to stop being verbally antagonized, he struck resident resulting in other resident falling (Resident 26). A review of a Psychological Services Supportive Care Progress Note dated November 14, 2023, indicated that Resident 24 present as agitated and verbally aggressive. He continues to display aggressive behavior and aggressive language. Patient declines to change behavior despite being informed he is at risk of being removed from the facility. Patient continues to struggle with emotional regulation and anger management. During an interview with the Nursing Home Administrator (NHA) on December 7, 2023, at approximately 9:40 AM, and observation confirmed that video surveillance cameras are present in the north dining room and that they are functioning. After being shown the video camera is able to retrieve the date of October 29, 2023, the state survey team asked permission to view the footage of October 29, 2023, in north dining room, at approximately 11:30 AM. to view the incident between Resident 24 and Resident 26, but the NHA denied the request to allow the surveyors to view the video surveillance footage. During an interview with the NHA on December 7, 2023, at approximately 12:50 PM, confirmed the incident on October 29, 2023, which resulted in Resident 26's transfer to the ER for treatment of minor injuries and Resident 24's crisis admission for behavioral issues following an incident on October 29, 2023. Refer F 610 28 Pa. Code 201.18 (e)(1)(3) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12 (c)(d)(5) Nursing Services 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on a review of clinical records, select facility policy, and investigative reports, observations and resident and staff interviews, it was determined that the facility failed to provide necessary staff set-up and positioning assistance with eating as required by a resident to prevent an accident while eating resulting in a second degree burn for one (Resident 132) out of 35 residents sampled. Findings include: The American Burn Association ([NAME]) classifies burns by the depth of the wound: superficial skin injuries are classified as first-degree burns, partial-thickness skin injuries are classified as second-degree burns, and full-thickness skin injuries are classified as third-degree burns. According to the [NAME], in general, if a second-degree burn measures less than two to three inches (seven centimeters), it may be treated as a minor burn. A review of the facility policy titled Use and Storage of Food Brought in by Family or Visitors, implemented on April 15, 2023, indicated that it is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. The policy indicated that facility staff will assist residents in accessing and consuming food that is brought in by the resident and family or visitors if the resident is not able to do so on their own. A clinical record review revealed Resident 132 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and a right above the knee amputation and left below knee amputation. A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 17, 2023, revealed that Resident 132 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A physical therapy evaluation and plan of treatment dated November 12, 2023, indicated that Resident 132 was dependent on staff assistance bed mobility, for rolling left and right in bed, and dependent on staff to move from a lying position to a sitting position. Resident 132's plan of care initiated July 7, 2022, indicated that the resident had an ADL (activities of daily living) problem related to self-care deficits due to his bilateral amputations with planned interventions to provide the assistance of two people when moving or repositioning the resident in bed and that the resident requires set-up assistance by staff when eating and drinking. A review of the facility investigation report dated November 18, 2023, revealed that Resident 132 sustained a burn to his mid-chest. The report indicated that the resident was eating hot soup for dinner last evening, which he had ordered from an outside food delivery service, and some of the soup spilled on his chest. The report also indicated that Resident 132 did not tell anyone about the injury until a day after the incident. At the time of the survey ending December 8, 2023, there was no documented evidence that facility staff had provided Resident 132 with set-up assistance with eating the meal delivered to him and that staff had assisted the resident to a sitting position prior to the resident eating the soup according to the resident's assessed needs and care plan. A progress note dated November 18, 2023, at 5:43 PM indicated that this nurse was called to Resident 132's room due to a mark found on the resident's right upper chest. The entry indicated that the resident was alert and oriented and stated that he spilled some soup from last night's dinner on him but never informed anyone. The resident had a 1.0 cm x 3.0 cm superficial burn mark on his upper chest. The physician was notified. A witness statement dated November 19, 2023, completed by Employee 16, nurse aide, indicated that Resident 132 ordered take out delivery food for dinner on November 17, 2023. According to Employee 16's statement she did not heat up any food for him that evening. A witness statement dated November 21, 2023, completed by Employee 11, Registered Nurse, indicated that Employee 11 saw the food get delivered to Resident 132's room on the evening of November 17, 2023. Employee 11 indicated that she did not heat up the food for the resident and was not aware of any issues with his dinner. Neither the employee witness statements nor the facility's investigation identified who had delivered the food to the resident's room, whether it was facility staff or outside delivery person. A witness statement dated November 22, 2023, completed by Employee 15, nurse aide, indicated that Employee 15 did not warm any food up for Resident 132 on the evening of November 17, 2023, but she did report seeing a red mark on his chest while providing care (witness statement did not state when Employee 15 observed the red mark on the resident's chest). She stated that the resident told her it happened to him while he was eating soup. A review of Resident 132's treatment administration report for November 2023 indicated that the resident's chest burn was cleansed with normal saline solution, patted dry, and that triple antibiotic ointment was applied to the wound on November 19, 20, and 21, 2023, in accordance with a physician order initiated on November 18, 2023, and discontinued on November 22, 2023. Progress notes dated November 22, 2023, at 2:10 PM indicated that the consultant wound care provider saw the resident for a self-inflicted burn to his upper chest and that treatment was completed at bedside. The entry indicated that the resident's wound would be monitored until healed. The physician and the resident's representative were notified. The wound care consultant provider summary dated November 22, 2023, indicated that wound care was consulted for a partial-thickness burn to the resident's left chest. The wound was measured at 2.5 cm x 1.6 cm x 0.1 cm (4 square centimeters total) with a small serous exudate, and the tissue type is 100% dermis. A review of Resident 132's treatment administration report for November 22, 2023 indicated that the resident's chest burn was cleansed with normal saline solution, patted dry, and that Silvadene was applied to the wound. The wound was then covered with Dry Sterile Dressing (DSD) on November 22, 24, 25, 26, 29, and 30, 2023, in accordance with a physician order initiated on November 22, 2023. A wound care consultant provider summary dated November 30, 2023, indicated that wound care is consulted for a partial-thickness burn to the resident left chest. The wound was indicated as resolved as of that date. However, an observation on December 7, 2023, at 11:45 AM revealed a white bandage on Resident 132's right upper chest. Employee 3, Registered Nurse, removed the bandage, and the wound was observed measuring 2.6 cm x 1.5 cm. The resident's skin had dark pigmentation, and the wound was pink with a small amount of brown crust. The bandage had a scant amount of drainage. During an interview on December 5, 2023, at 11:45 AM, Resident 132 stated that he had soup delivered to the facility from an outside vendor a few weeks ago. He explained that nursing staff brought the cheese and broccoli soup to him when the soup arrived at the facility. Resident 132 said that staff delivered the food in a bag and put it on his bedside table. He stated that he was lying down in bed while he was eating and spilled soup on his chest. Resident 132 stated that he is unable to sit up in bed without staff assistance. Resident 132 explained that he didn't realize how hot the soup was at the time. He informed staff that he had sustained a burn the next day because it was painful. At the time of the interview, a white bandage was observed on the resident's left upper chest, measuring approximately four inches by four inches. During an interview on December 8, 2023, at 9:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide evidence that Resident 132 was assisted to a sitting position or provided with a meal setup consistent with the resident's plan of care prior to the resident eating food delivered from an outside source, which subsequently led to him sustaining a partial-thickness burn to his upper chest. Staff witness statements indicated awareness of the resident's food delivery arriving to his room for dinner on the evening of November 17, 2023, and the resident stated that staff dropped off the food at his bedside but there was no evidence that staff assisted the resident with the meal set-up and positioning to safely consume the food. The NHA and DON confirmed that it is the facility's policy to ensure that residents are protected from potential hazards and that food from outside sources is handled in a way to ensure the safety of the residents. 28 Pa Code 211.10 (a)(c) Resident care policies 28 Pa Code 211.12 (d)(3)(5) Nursing services

Based on a review of clinical records and select facility policy and staff and resident interviews it was determined that the facility failed to timely assess a resident's weight, progressive weight loss and potential contributing factors to decreased oral intake, and implement applicable interventions to deter further weight loss, which resulted in an undesirable significant weight loss for one resident (Resident 6) and failed to timely monitor nutritional parameters to assure accurate nutritional assessment of one resident out of 20 residents (Resident CR1). Findings include: A review of the facility policy entitled Weight assessment and intervention adopted by the facility March 31, 2021 revealed The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Procedures included: The nursing staff will measure resident weights on admission, the next day and weekly for 2 weeks, thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. The dietitian will respond within 24 hours of written notification. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month--5% weight loss is significant; greater than 5% is severe. b. 3 months--7.5% weight loss is significant; greater than 7.5% is severe c. 6 months--10% weight loss is significant; greater than 10% is severe. The policy indicated that interventions to include: a. Resident choice and preferences b. Nutrition and hydration needs of the resident c. Functional factors that may inhibit independent eating d. Environmental factors that may inhibit appitite of desire to participate in meals e. chewing and swallowing abnormalities and the need for diet modifications A review of the clinical record revealed that Resident 6 was readmitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a resident belonging list (resident inventory record) dated March 22, 2017, (initial admitted d) revealed Resident 6 had upper and lower dentures. A review of a Dietary Note dated February 10, 2021 at 1:18 PM revealed that the resident had a weight change. Weight (2/5) 144.8 pounds, (1/7) 145.5 pounds,(11/2) 145.5 pounds, (8/3) 147.2 pounds. An insignificant weight loss of 0.5% (0.7 pounds), an insignificant weight gain of 6.9% (9.3 pounds) x 3 months, and an insignificant weight loss of 1.6% (2.4 pounds) x 6 months. Remains on regular diet, regular textures, thin liquids. Fair PO (by mouth) intake. Average recorded meal intake (2/3-2/9) 52% of meals. Ensure [MEDICATION(S)] provided TID to supplement calorie and protein intake. No skin issues noted. Care plan updated. Will continue to follow. A nutritional data collection tool evaluation dated February 25, 2021, revealed that the resident weighed 144.8 pounds (lb) on February 5, 2021. The evaluation indicated that the resident's ideal body weight (IBW) was approximately 145 pounds. The evaluation noted that the resident was independent with feeding, consumed 50% of his meals and received a regular diet. A quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 22, 2021 revealed that Resident 6 was severely, cognitively impaired, required set-up assistance for meals, weighed 145 pounds and received a regular consistency diet. A review of the resident's Weights and Vitals Summary report revealed that the resident's weight on the following dates was noted as: March 2, 2021, 145.3 pounds; April 5, 2021, 143.1 pounds; No documented weight for May 2021; June 3, 2021, 136.2 pounds, a 6.9# weight loss (4.82%); July 2, 2021, 131.6 pounds, 4.6# weight loss; August 1, 2021 127.3 pounds, 4.3# weight loss; Between March 2, 2021 and August 1, 2021, Resident 6 lost 18 pounds or 12.39 % over 5 months, which was a significant severe weight loss. A review of physician orders dated March 18, 2021, revealed that [MEDICATION(S)] 7.5 mg, 1 tablet at bedtime for appitite stimulant was initiated. The [MEDICATION(S)] was discontinued on July 21, 2021. Corresponding medication administration records (MAR) for March 2021 through July 2021 indicated that Resident 6 received the [MEDICATION(S)] daily. A physician order dated March 31, 2021, was noted for the resident to receive a regular diet, regular texture with thin liquids. A physicians order dated May 18, 2021 was noted for the addition of the nutritional supplement Mighty shake (a liquid dietary supplement, protein and calorie dense) daily. A review of meal consumption records dated May 2021 revealed that the resident consumed 25% of breakfast and lunch on most days and 50% to 100% consumption of the dinner meal. There were multiple meals with no meal consumption recorded. A review of snack documentation for May 2021 revealed that the resident accepted a snack on most days, but multiple days lacked documentation of acceptance or refusal throughout the month with no documented consumption. A review of May 2021 Medication Admistration record revealed that the resident accepted the Mighty shake daily. Resident 6's diet was changed again, per a physician order dated May 30, 2021, to a regular diet, mechanical soft texture (A mechanical soft diet or soft food diet is a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food) with thin liquids. However, there was no documentation in the resident's clinical record regarding the reason for Resident 6's diet change on May 30, 2021. There was no documented evidence that the resident was experiencing chewing or swallowing difficulties requiring a mechanically altered diet. A physicians order dated June 10, 2021 was noted for the addition of Ensure (liquid dietary supplement) 120 cc with medication pass, nursing to document amount consumed. A review of a social services note dated June 14, 2021, at 7:42 PM revealed Follow up, resident dentures are missing, Consult requested for speech eval. Request made for a dental appointment to be scheduled. A review of meal consumption records dated June 2021 revealed that the resident consumed 0 % of breakfast and lunch and dinner from June 1, 2021 through June 16, 2021, and 0 % consumption or refusal of the dinner meal from June 17, 2021 to June 30, 2021. There were multiple meals with no meal consumption recorded. A review of snack documentation for June 2021 revealed that the resident accepted a snack on most days, but several days lacked documentation of acceptance or refusal. A review of June 2021 Medication Admistration record revealed that the resident accepted the Mighty Shake daily. Further review of the June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a facility rehabilitation services screening request to speech therapy dated June 15, 2021, revealed Resident reported with missing dentures. Staff reports resident eats what he wants, but never eats a lot. Resident resistant to staff intervention in room. Staff reports they give him Ensure when he does not eat his meal. Staff interviewed reported resident will not eat pureed foods. Resident's diet level down graded to mechanical soft when dentures first misplaced. Noted recommendations, as resident refused to allow speech therapy to interview or observe during by mouth intake. No speech services at this time. A review of a facility rehabilitation services screening request to speech therapy dated June 24, 2021 revealed resident refused to work with speech therapy, gibberish language with clear gestures to leave the room. Staff reports resident refuses solids until he receives his dentures. resident accepts puddings and ice creams. Comes to the desk for nutritional drinks. Recommending nutritional drinks and ice cream on all meal trays. A review of snack documentation for July 2021 revealed accepted on most days with multiple days with no documented acceptance or refusal. A review of July 2021 medication Admistration record revealed that the resident consumed Mighty Shake liquid supplement daily and 100 cc of Ensure (liquid dietary supplement) on most days. A review of meal consumption records dated July 2021 revealed that the resident consumed 0 % of breakfast, but six days lacked documentation of meal consumption, 0% at lunch, with no documented consumption on 7 days and and 5-25 %, 1-50%, and 1-75% consumption of the dinner meal. On four days the amount of dinner consumed was not recorded. The next dietary/nutrition note was dated August 11, 2021 4:33 PM and revealed and noted that the resident had a significant weight loss of 12% in six months and now weighted 127.3 lbs with a BMI (body mass index- body mass index is a value derived from the mass and height of a person) of 20.5 (In older adults it is often better to have a BMI between 25 and 27, rather than under 25. If you are older than 65, for example, a slightly higher BMI may help protect you from thinning of the bones). The resident's ideal body weight was noted as 142 lbs. The entry noted that some weight loss anticipated with aging process as body composition changes, goal is to preserve lean muscle mass and promote weight stability. The entry noted that the resident was able to feed self, usual intake at meals is poor. Supplements in place to increase kcal/protein density of diet with overall good acceptance. It was also noted that a Trial HS snack-monitor acceptance. Continue supplements to enhance intake as well. Tolerating diet as ordered with no chewing/swallowing difficulty noted. Liberalized diet remains appropriate to optimize intake. Will recommend weekly weights to closely monitor trend and reassess need for additional intervention as indicated. The nutrition note dated August 11, 2021, indicated that the resident had no chewing issues. However the resident had been missing his upper and lower dentures since at least June 14, 2021, per social service documentation. This resident's upper and lower dentures were noted to be missing at the time of the nutrition note. The resident's intake at meals continued to decline and/or fluctuate. Current physicians orders dated August 13, 2021, were noted for the resident to receive a regular diet, soft & bite Sized texture, thin Liquids consistency At the time of the survey ending August 19. 2021, there was no additional nutritional/dietary documention in the resident's clinical record. At the time of the survey ending August 19, 2021, the resident remained without dentures. A review of meal consumption records dated August 1, 2021, through August 19, 2021, revealed that the resident ate breakfast on only two days during the time period, ate lunch on one day, with the remaining days documented as 0% or refused. There were multiple meals with no consumption percentages documented. At the dinner meal the resident consumed only five meals, one at 25%, one meal at 50% and the remaining meals as 0% or refused. There were multiple meals with no documented consumption. A review of snack documentation for August 2021 revealed that the resident accepted a snack on 5 days, with the additional days refused up to August 19, 2021. A review of August 2021 medication admistration record that the resident consumed the Mighty Shake daily and his intake of the Ensure ranged from 25 cs to 240 cs. There was no documented evidence in the resident's clinical record at the time of the survey ending August 19, 2021, that the facility had identified and correlated the lack of the resident's upper and lower dentures with the resident's declining intake at meals beginning May 2021, through the time of the survey. A review of a dietary notes revealed no documented evidence in the resident's clinical record that the dietitian had addressed the resident's decreased intake by obtaining the resident's food preferences, as per facility policy, and had addressed the resident's missing dentures in relationship to diet consistency and food preferences. There was no documented evidence that the facility had responded to the resident's significant weight loss, identified on August 1, 2021, with additional interventions until August 11, 2021. An observation of the resident on August 19, 2021, at approximately 11:45 AM revealed that the resident was lying in bed. The resident's breakfast tray was on his overbed table, next to the bed and was uneaten. Observation of the meal revealed that the resident had been served an egg omelet, a round sausage patty, cut up in four equal pieces, each piece of the patty measured approximately 1.5 inches x 1.5 inches x 2 inches. A review of Resident 6's breakfast tray ticket (a paper form with the residents diet, diet texture along with the breakfast food items for this resident for meals) for August 19, 2021, breakfast meal revealed Diet: Regular, Diet, soft and bite sized. The noted food items included a diced sausage patty. During an interview at the time of the observation, Resident 6's speech was garbled, but when asked about his breakfast the resident stated I'm hungry. This surveyor then asked him if he had difficulty chewing his food and the resident said yes and pointed his fingers to the inside of his mouth multiple times, showing that he was edentulous (lacking teeth) Interview with the interim director of nursing on August 19, 2021, failed to provide documented evidence that the facility had timely acted upon the resident's missing dentures, resulting in decreased ability to chew, declining oral intake and significant progressive weight loss. The facility did not timely address the resident's severe weight loss identified on August 1, 2021. The facility added liquid nutritional supplements, but failed to identify and address the resident's underlying contributing factor to the weight loss and identify preferences for meals consistent with his chewing abilities until the resident's dentures are replaced. Review of Resident CR1's clinical record revealed admission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Weights and Vitals Summary report revealed that the resident's weight on the following dates was noted as: May 12, 2021 - 163.0 pounds; May 18, 2021 - 138.3 pounds; May 18, 2021 - 139.5 pounds (re-weight); a 23.5 pound/ 14.4% weight loss in 6 days. Review of Resident CR1's admission assessment dated [DATE], revealed that the resident was 70 inches tall and 163 pounds. There was no documented evidence that a re-weight on admission was obtained as outlined in the facility's weight policy. Review of Resident CR1's hospital discharge revealed that the resident weighed 163 pounds on May 2, 2021, four days prior to the surgical amputation of his left leg below the knee. Review of Dietary Note dated May 25, 2021, at 10:30 AM indicated that the weight decrease/loss since admission may be possibly related to the resident's BKA (below the knee amputation) and currently suffering from diarrhea. Interview with the Assistant Director of Nursing on August 19, 2021, at approximately 2:00 PM confirmed that the facility failed to obtain an accurate admission weight on Resident CR1 to assure an accurate assessment of the resident's nutrition and hydration needs and failed to implement the facility's weight policy. Refer F791, F805 483.25 Nutrition/Hydration Status Maintenance Previously cited 101/20 28 Pa Code 211.6(d) Dietary services Previously cited 10/1/20, 10/15/20, 11/24/20, 1/19/21, 5/27/21 28 Pa. Code 211.12(a)(c) Nursing services. Previously cited 8/23/19, 11/24/20, 1/19/21, 3/26/21, 5/27/21 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 8/23/19, 1/19/21, 3/26/21, 4/21/21, 5/27/21 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/23/19, 10/1/20, 11/24/20, 1/19/21, 3/26/21, 4/21/21, 5/27/21

Based on a review of clinical records and information submitted by the facility and staff interview, it was determined the facility failed to ensure that food was served in a form to meet the individual needs of one of two residents reviewed that resulted in actual harm to that resident (Resident 1) who required transfer to the emergency room and an endoscopic procedure for bolus retrieval of the food item (Tater tot). Findings include: A review of the clinical record revealed that Resident 1 had diagnoses, which included oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat). The resident's physician prescribed diet order dated March 31, 2021, was for a Regular diet, ground meat texture, thin liquids consistency, minced and moist textures. Review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed at specific intervals to identify specific resident care needs) dated April 15, 2021, indicated that the resident had a BIMS (brief screener that aids in detecting cognitive impairment) score of 1 (score of 0-7 is indicative of severe cognitive impairment), had no signs and symptoms of possible swallowing disorder, was independent in eating with set-up help for meals (includes cutting food to appropriate bite sizes), and was receiving a mechanically altered diet (require change in texture or liquids such as pureed foods or thickened liquids). Review of information submitted by the facility dated May 31, 2021, revealed that on May 30, 2021, during dinner Resident 1 was evaluated by nursing for vomiting small amounts and spitting up food. The resident's airway was assessed, and the resident was found to be breathing normal with no change in color and was not coughing. The [MEDICATION(S)] maneuver (first-aid technique for someone who is choking because food or another swallowed object is obstructing his or her airway. Using an upward abdominal thrust, the [MEDICATION(S)] maneuver compresses the lungs and forces air up into the windpipe {trachea} until the object causing the choking is ejected from the throat) was performed on the resident with no effectiveness. The physician was notified, and the resident was sent to the emergency room for evaluation. The information noted that the resident was served ground honey ham with gravy, Tater tots drizzled with ketchup, ice cream, milk, Mighty shake (a nutritional beverage), and a juice. Interview with the administrator on June 29, 2021, at 9:30 AM confirmed that the facility had completed an incident/accident report relating to this incident. Review of the hospital History and Physical dated May 30, 2021, revealed that the resident's chief complaint was unable to swallow saliva. The assessment and plan noted that patient with a foreign object, food bolus retained in the esophagus. Plan for RSI intubation (a form of anesthesia), EGD (endoscopic procedure that allows physician to examine esophagus and stomach), and admission for observation postoperatively. Review of the Operative Report dated, May 30, 2021, noted that the Postoperative Diagnosis was retained foreign object/food bolus in esophagus, Tater tot material. Interview with the food and nutrition services director on June 29, 2021, at approximately 10:00 AM revealed that when Tater tots are on the menu, the preparation includes deep frying the Tater tots for residents on regular textured diets and baking the Tater tots for those on a minced and moist textured diet (dental soft, mechanical soft diet) to provide for a softer product which can be mashed with a fork. The food and nutrition services director confirmed during interview that the facility had not determined at the time of resident's choking incident, the preparation method of the Tater tots served to Resident 1 or that the texture/form/moisture level of this food item was consistent with the resident's prescribed mechanically altered diet consistency, of ground meat texture, thin liquids consistency, minced and moist textures. The food and nutrition services director confirmed that the food and nutrition department did not did not evaluate the consistency/texture of the food item served at that meal as part of an investigation or root cause analysis of the resident's choking incident. Interview with the administrator on June 29, 2021, at approximately 11:00 AM failed to provide evidence that Resident 1 received food (Tater tot) in a form to meet the resident's needs for safe swallowing to prevent the resident from choking. The facility was unaware of the Tater Tots served to Resident had been baked or fried, and/or sufficiently moistened with ketchup to facilitate safe swallowing by the resident. The administrator failed to provide documented evidence of a complete facility investigation into the incident to assure that the appropriate texture/consistency and moisture level of the food item was consistent with the resident's diet order. 28 Pa. Code 211.6 (c) Dietary Services. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services

Based on a clinical records and manufacturer directions for use and staff interviews it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and resulted in the resident experiencing an unresponsive episode requiring a transfer to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of the clinical record revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses, which included Type 2 Diabetes Mellitus [an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream] and [CONDITION(S)] (a serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most [CONDITION(S)] individuals experience alternating episodes of [CONDITION(S)] and depression). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to manufacturer's product information, [MEDICATION(S)] Insulin (injected under the skin) is a long acting insulin used to treat Diabetes Mellitus. Long acting insulin takes 3-4 hours to get into the bloodstream to maintain a steady-state of glucose levels and prevent dangerous blood glucose spikes after meals. {After eating the pancreas releases a hormone called insulin. Insulin moves sugar (glucose) from the blood to the cells for energy or storage. If taking insulin, it may be needed at mealtime to help lower blood sugar after eating. Between meals insulin is needed in small amounts to help keep blood sugar stable which is the function of long acting insulin. With diabetes, the pancreas can't produce enough (or any) insulin, or the cells can't use it efficiently. To control blood sugar regular insulin injections are used to replace or supplement the normal function of the pancreas}. A review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to her meal intake record she consumed 100% of her breakfast that morning. According to the May 2021, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 50 mg was administered approximately 3 hours later than its scheduled administration time of 8:00 AM and this delay jeopardized the resident's health as the drug is used to manage blood sugar levels. [MEDICATION(S)] insulin 55 Units SQ was scheduled for administration prior to breakfast, at 7:30 AM, but was administered approximately 3 and one half hours later at 10:54 AM, which jeopardized the resident's health as this medication is also used to manage blood sugar levels. Meal intake documentation indicated that the resident refused her lunch meal on May 28, 2021. A Situation-Background-Assessment-Recommendation (SBAR-technique that provides a framework for communication between members of the health care team about a resident's condition. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of resident safety) note dated May 28, 2021, indicated that Resident 22 was transferred to the hospital May 28, 2021, due to decreased level of consciousness, unresponsive, and hypoglycemic (condition resulting when the blood glucose levels drop below the specified limits of 78-110 mg/dl). The resident's blood sugar was obtained prior to 4:00 PM and it was 26 mg/dl. At 3:58 PM [MEDICATION(S)] (medication is the same as the body's own [MEDICATION(S)], a natural substance that raises blood sugar by causing the body to release sugar stored in the liver. It is used to treat very low blood sugar/[CONDITION(S)]) was administered 1 ml via intramuscular injection for the low blood sugar. The resident was transferred to the hospital. A review of the hospital record revealed that the resident arrived at the hospital at 4:30 PM and EMS (emergency medical service) indicated that per the facility the resident was found unresponsive in bed with cold and clammy skin. Reportedly the resident received her insulin in the morning and refused to eat all day. EMS was unable to obtain IV (intravenous) access so no medication was administered in route to the hospital. The resident's blood sugar checks prior to arrival at the hospital were 38 mg/dl, 43 mg/dl and 48 m/dl. In the emergency department she was provided fluids by mouth. Hospital documentation at 4:53 PM indicated that multiple attempts to gain IV access were unsuccessful. The resident was provided with a meal at 6:00 PM and her blood sugars returned to normal. The resident returned to the facility at approximately 8:30 PM the same day. Interview with the Administrator on June 29, 2021, at 11:00 AM confirmed that the facility failed to ensure Resident 2 was free of significant medication errors, which resulted in Resident 2 experiencing an unresponsive episode requiring hospitalization and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) ) Nursing services

Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff interviews, it was determined that the facility failed to provide staff supervision as planned to monitor the activities and whereabouts of a resident with known unsafe exit seeking behaviors to prevent additional attempts to leave the facility unsupervised, which threatened the resident's safety and increased the resident's risk for accidents and bodily injury or harm for one of seven residents identified at risk for elopement. The facility further failed to promptly identify the failure of assigned staff to provide the planned one on one supervision and relied on the facility's alarm system to prevent future unsupervised exits from the facility, which placed residents in immediate jeopardy of future unsupervised exits and elopements from the facility and the likelihood of serious bodily injury, harm or death (Resident 1). Findings included: A review of the facility policy, dated July 2017, entitled, Safety and Supervision of Residents, indicated the facility strives to make the environment as free from accident hazards as possible. Residents safety and supervision and assistance to prevent accident are facility-wide priorities. As an Individualized, Resident-Centered Approach to Safety the care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive devices. The policy also indicates Systems Approach to Safety include the type and frequency of resident supervision may vary among residents and over time for the same resident. The facility's policy dated March 2019, entitled, Wandering and Elopements, revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If the resident is identified at risk for wandering, elopement or other safety issues, the residents' care plan will include strategies and interventions to maintain the residents' safety. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE]. The resident's diagnoses included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 1's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2021, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 6 (a score of 0 -7 indicates severe impaired cognition) and was noted to be wandering the unit four to six days during the look back period (time period during which the resident's condition or status is captured by the MDS assessment). A review of physician's orders initially dated December 29, 2020, indicated that the resident was to receive one to one observation by staff for safety. A review of nursing progress notes dated February 9, 2021, at 1:25 PM revealed that one to one observation, was available that day and that the resident became increasingly agitated and exit seeking. A review of nursing progress notes dated February 17, 2021, at 2:57 PM revealed that the resident asked staff multiple times how to leave the facility and tried to pack her belongings to leave. Nursing noted that the resident was confused part of the day and needed to leave to go to work. Nursing notes dated February 20, 2021, at 7:10 PM indicated that the resident had self-removed the wander guard (device to alarm the facility if the resident tries to leave) that was located on her left ankle. Nursing noted that on February 23, 2021, at 8:54 AM the resident was on one to one observation and exhibiting exit seeking behaviors. The resident was stating that she needed to get out of the facility. On February 28, 2021, at 2:16 PM, nursing noted that the resident continued to have exit seeking behaviors and [MEDICATION(S)] (antianxiety medication) was administered. A review of nursing progress notes for the month of March 2021, revealed 14 instances during which the resident displayed exit seeking behaviors. Nursing progress notes dated April 1, 2021, at 6:59 PM indicated that the resident remained on observations. The resident was combative with staff and attempted three times to open the emergency exit door at the end of the nursing unit halls. The resident was physically abusive to staff when attempting to redirect her from the exits. The resident was able to open the exit door to the parking lot. Nursing progress notes dated April 5, 2021, at 10:57 PM indicated that the resident was observed with exit seeking behavior on the nursing unit at 7:30 PM. When staff attempted to redirect the resident the resident stated, I want to die. The resident asked another staff member present at that time, can you kill me? Nursing noted that the resident was not on one to one observation at that time. The resident continued to exit seek with staff by her side almost opening a fire exit door. A review of the facility's documentation of the One to One observation of the resident staff conducted from March 25, 2021 to April 20, 2021, revealed that over the 27 days of documentation provided by the facility, the physician ordered one to one observation was not completed on 23 days during that time frame. Review of information submitted by the facility on April 7, 2021, revealed that Employee 3 LPN (license practical nurse) reported to the Nursing Home Administrator (NHA) that Employee 4 personal care aide companion hit Resident 1 while trying to prevent the resident from exiting the facility. While Employee 3 was escorting Employee 4 from the unit the resident was able to exit the facility out of the door at the end of the hall. A written statement from an interview that was completed with Employee 4 on April 7, 2021, revealed that the employee stated she was unaware that Resident 1 had exited the facility and stated that it must have happened after she left the unit. A written statement from Employee 5 NA (nurse aide) dated April 7, 2021, revealed that the employee called the supervisor from the desk to inform supervisory staff of the incident that occurred with Employee 4 hitting Resident 1. Employee 5 stated he looked down the hall and the resident was standing by the door. The employee further stated he was on the phone and then when he looked down the hall again the resident was gone. The employee stated that he then went down the hall and out the door and found the resident in the employee parking lot. A written statement from Employee 7 LPN (no date or time) indicated that on April 7, 2021, the employee was driving out of the employee parking lot and found Resident 1 on the road. The employee further stated that the resident was ambulating with her rolling walker when Employee 5 approached the resident and convinced her to go back into the facility. An interview with the NHA on April 21, 2021, at approximately 2:30 PM confirmed that the facility failed to provide adequate supervision of a resident with known exit seeking behavior and a physician order for one to one observation to prevent the resident from exiting the facility without staff supervision placing the resident at risk for accidents and injury. Observation of video footage conducted by surveyors in the presence of the Nursing Home Administrator during the survey ending April 21, 2021, at 3:28 PM revealed that on April 7, 2021, at 4:29 PM the resident was unsupervised at the end of the hall of the nursing unit pushing on the handle of the exit door. The resident continually pushed on the door, stopped for a moment, looked around and continued to push on the handle of the exit door. The resident was observed to open the door and while unsupervised, the resident exited the building alone. A review of a timeline of the event provided by the facility from the security camera footage revealed the following: 4:29:02 PM Camera 24 showed Employee 3 and Employee 4 walk down the hall leaving the resident unsupervised at the exit door. 4:29:30 PM the resident opened the exit door and left the facility unsupervised by staff. 4:29:37 PM the door closes behind the resident. 4:30:27 PM Employee 5 exits the facility through door looking for the resident. The above findings were cited as deficient facility practice during the abbreviated survey ending April 21, 2021. The facility submitted a plan of correction for the cited deficiency, which was to be completed by May 16, 2021. According to the facility's plan of correction the facility was to implement the following steps: 1. Resident 1 remains in the facility on 1:1, as needed, with anxiety and exit seeking behaviors; resident's plan of care reviewed and updated with diversional interventions regarding exit seeking behaviors. Resident will receive therapeutic service by a contracted License Clinical Social Worker regarding episode of physical abuse 2. Facility residents were evaluated for exit seeking behaviors and use of EXI (audible alarm that sounds when a resident wearing the signaling devise approaches a door alarmed with this system) alarm device. Any resident identified will have plan of care updated with diversional activities to divert exit seeking behaviors and will be monitored by staff as needed. At the time of the revisit survey ending May 27, 2021, the facility had identified six other residents, Residents 7, 8, 9, 16, 17 and 18, with exit seeking behaviors at risk for elopement. A review of this resident's clinical record completed on May 26, 2021, during the revisit survey, revealed nursing progress notes dated April 29, 2021, which indicated that the resident was very agitated and seeking to exit the building. She was redirected multiply times. At 1:15 AM the resident tried to exit the building through the fire exit door at the North B hallway, while a nurse aide was redirecting her, but it was unsuccessful. The resident stepped out of the door, but did not get any further, as a nurse aide and the RN supervisor were successfully able to redirect the resident to return into the facility. Nursing documentation dated April 29, 2021, at 10:10 PM revealed that, 1:1 observation continued with resident. The resident was observed walking continuously in the hallways. The resident made several attempts to exit the building via the fire door exit on the North B hallway. The nurse aide was able to redirect the resident safely away from exit door. Nursing documentation dated May 2, 2021, at 10:35 AM indicated that the resident was agitated wanting to leave. The resident called her granddaughter to see if she was coming to pick her up. The resident was yelling at staff and wanted to call the police. The resident pushed staff trying to get out of door. Therapy and nursing tried to calm her down without any relief. Nursing documentation at 11:20 AM revealed that the resident had increased agitation, was verbally aggressive towards staff, especially with the companion who was observing her on 1:1. The resident was yelling and calling staff, cows and, scumbags. The resident elbowed the companion in the side and tried to ram her with the walker. The physician ordered an antianxiety medication, but the resident was too agitated to take the medication. The facility sent the resident to the hospital for an evaluation at 4:16 PM and the resident was returned by 7:00 PM the same date. At the hospital she received [MEDICATION(S)] 50 mg (antipsychotic drug) by mouth, which was then ordered for administration at the skilled nursing facility on that date, [MEDICATION(S)] 12.5 mg by mouth twice a day. Nursing documentation dated May 3, 2021, at 11:02 PM indicated that the resident, while on 1:1 supervision, was sleeping in bed when she rolled over and fell on to the floor. The assigned staff companion was in the resident's room to witness the fall. The resident complained of pain to both elbows and knees and sustained a new skin tear to her left knee. Nursing documentation revealed that the resident was maintained on 1:1 staff observation and continued with exit seeking behaviors on May 6, 2021, May 8, 2021, and May 12, 2021. Documentation from the facility's interdisciplinary team dated May 13, 2021, at 3:15 PM revealed that the team determined that the resident was agitated by the constant supervision by the companion. The team determined that the facility will only initiate 1:1 supervision with excessive anxiety, aggression and exit seeking behaviors. Progress notes dated May 19, 2021, written by Social Services at 11:31 AM indicated that Resident 1 was ambulating about the facility with companion (1:1 staff member), voicing that she wants to go home. Social Service encouraged this resident to go outdoors into the courtyard for fresh air. She did decline and continued to ambulate about the facility with companion. Nursing documentation dated May 22, 2021, indicated that at 2:00 PM the resident came out of her room with some of her belongings, stating she was ready to go home. After a short conversation, nursing noted that the resident, tranquilly returned her belongings to her room. Nursing documentation dated May 24, 2021, at 11:37 AM revealed that Social Service staff along with the administrator were notified that the resident exited the facility through the doors on the North unit C hallway. The resident was not on 1:1 observation at the time. The 1:1 had been discontinued on May 13, 2021. One to one was only to be implemented for excessive anxiety, aggression and exit seeking behaviors. Social Service staff and the administrator went outside, the resident was observed with two nurses. The resident went back into the facility with Social Service and the administrator. The resident was described as talkative and pleasant. She did not display any aggressive behaviors at the time. She came back inside the facility and assisted to put her belongings in her room. The resident sat by the table at the nurses' station to rest. She later was observed walking with staff in the halls. The resident was placed on 1:1 staff observation. Nursing documentation dated May 24, 2021, at 2:47 PM by Employee 1 a licensed practical nurse (LPN) noted that, this nurse was called to C-hall while the resident was just opening the door. Two nurse aides were with resident right outside the door. The resident prior to incident was walking up and down the halls, not exit seeking at that time. An interdisciplinary note of May 24, 2021, indicated that the previous, 1:1 observation were no longer in place. The 1:1 observation were only to be in place if she was showing increased agitation and exiting seeking behaviors. As a result of this exit attempt on May 24, 2021, the facility placed the resident back on 1:1 continuous observation. Observation of video footage conducted by surveyors in the presence of the Nursing Home Administrator on May 26, 2021, at 11:00 AM revealed that on May 24, 2021, the resident was unsupervised at the end of the hall of the nursing unit pushing on the handle of the exit door. The resident continually pushed on the door, stopped for a moment, looked around and continued to push on the handle of the exit door. The resident was observed to open the door and while unsupervised, the resident exited the building alone. A review of a timeline of the event on May 24, 2021, provided by the facility from the security camera footage revealed the following: (the clock on the camera was off by one hour, the real time should have been 9:00:06 AM). 8:06:54 AM showed Resident 1 wearing a coat pushing her rollator walker with multiple belongings on top of it, (unable to view exactly what these items were) ambulating unsupervised down the C hallway toward the exit door, she was unsupervised; Employee 2, a nurse aide, was observed to walk pass the resident, look at the resident and then continue in the opposite direction of the resident out of the sight of the camera; 8:07:19 AM - she pushed on the door handle. 8:07:30 -AM - pushed down again on the door handle. 8:07:40 AM - held door handle down. 8:07:57 AM - exited through the door out of the view of the camera. 8:08:06 AM - observed Employee 6, housekeeping supervisor, running down hallway turned around and appeared to yell for help. Interview with Employee 6 on May 26, 2021, at 11:30 AM revealed that at the time the resident exited the door, this employee was in the bathroom on the unit. He stated he heard the alarm sounding and when he exited the bathroom went toward the sound when he observed Resident 1 exit through the door at the end of the C hallway. Observation of this door on the C hallway on May 26, 2021, at 11:00 AM accompanied by the NHA and Social Worker revealed that once the bar on this fire exit door is pressed, within 3 second a loud alarms sounds to alert staff that the door is being opened. After 15 more seconds the door releases and it is unlocked and exit through this door to the outside parking lot is likely. The alarm remains sounding until a code is entered to disarm the alarm. According to the video surveillance footage and timing of the facility's door alarm system, the door alarm was sounding on May 24, 2021, from approximately 8:07:19 AM when she first pressed the door until she actually crossed over the threshold of the open door at 8:07:57 AM. It was not until 8:08:06 AM when Employee 4 ran down the hallway. There was no staff in the area to respond prior to Employee 4 responding even though the alarm was sounding within seconds after the door handle was pressed. The resident was then placed on 1:1 observation after this incident. On May 25, 2021, nursing documentation revealed that at 2:12 PM the resident remained on 1:1 with the staff member as the resident walked up and down the hallways trying to get out of the door and also hit this staff member. Observation of the North unit on May 26, 2021, at 9:20 AM revealed that Resident 1 was currently on 1:1 observation. The resident's room door was closed. The surveyor knocked and after receiving no reply, opened the door of the room and observed the resident lying on her bed. Employee 9, a nurse aide in training/companion assigned to provide 1:1 observation of the resident, was seated in a chair. Employee 9 was slouched in the chair. The employee's mask was underneath her nose and the employee was observed to be asleep. The surveyor entered the resident's room again at 9:30 AM, 9:40 AM and 9:50 AM and observed Employee 9 asleep. The employee did not awaken during the surveyor's repeated entry and exits from the resident's room. Resident 1 would have been able to leave the room unsupervised during the 30 minutes Employee 9 was observed sleeping. The surveyor informed the facility's administrator that Employee 9, the staff member assigned to provide 1:1 observation of this resident with exit seeking behavior, remained asleep for at least 30 minutes as observed. As a result of the facility's failure to promptly identify and act upon the issues, which allowed Resident 1 to successfully exit from the facility unsupervised, which included alarms and the failure of staff to meet the resident's individualized needs for supervision of exit seeking behaviors, at the time of the survey, Immediate Jeopardy to the health and safety of the residents of the facility was identified. The Nursing Home Administrator was notified of the immediate jeopardy and provided the IJ Template on May 26, 2021, at 11:55 AM. The facility's immediate action plan provided to the survey team at 4:00 PM on May 26, 2021, was as follows: Employee noted sleeping was immediately terminated. Another staff member was placed on 1:1 with the resident 10:00 AM on 5/26/2021. Resident involved having room changed to new Unit in a private room with 1:1. Care plan updated for continuous 1:1 supervision. Family notified and agreed. Facility designee checked all alarmed doors for functioning, 5/27/2021. No other residents have been affected at this time. All residents to be evaluated for wandering/exit seeking with plan of care adjusted as needed. Any resident identified for high risk wandering/exit seeking to have care plan updated to ensure safety. Completed by 5/27/2021. All staff educated on 1:1 duties and responsibilities to ensure resident safety during supervision. All staff educated on resident (CC - care cards - a working tool used by direct care staff detailing resident care needs) plan of care for 1:1 supervision as on Care Plan Facility staff educated on timely response to exit door alarms. Facility staff educated on elopement drill policy and procedure. Staff education to be completed by 5/27/2021. Timeline: 5/26/2021 10:00 AM NHA/DON arrive to resident's room removed aide and assigned another aide to the resident, aide that was noted to be sleeping was immediately terminated. 12:00 PM team completing wandering evaluations and updating care plans as needed 12:15 PM RP (Responsible Party) notified of room change to the Spruce unit and agreeable 1:50 PM Resident transferred to Spruce unit 2:00 PM -3:30PM staff facility education on 1:1, elopement drills, responding to exit door alarms, team calling staff not currently on site; reconciling staff education 2:53 PM- exit alarm response time test North B hall 3:40 PM elopement drill During the onsite visit to the facility on [DATE], verification of the implementation of the facility's corrective action plan was completed by a tour of the facility, observation of staff supervision of Resident 1, inspection of exit doors, review of documentation of the completed staff education and interview with the NHA. The Immediate Jeopardy was lifted on May 27, 2021, at 1:45 PM. 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices Previously cited 101/20, 3/26/21, 4/21/21 28 Pa Code 201.18(e)(1) Management Previously cited 8/23/19, 10/1/20, 11/24/20, 3/26/21, 4/21/21 28 Pa Code 201.18(e)(3) Management Previously cited 10/1/20, 10/15/20, 11/24/20, 4/21/21 28 Pa Code 207.2(a) Administrators Responsibility Previously cited 7/22/20, 10/1/20, 11/24/20, 1/19/21 28 Pa Code 211.12(a)(c)(d)(5) Nursing Services Previously cited 8/23/19, 10/1/20, 11/24/20, 1/19/21, 3/26/21, 4/21/21 28 Pa Code 211.12(d)(3) Nursing Services Previously cited 8/23/19, 11/24/20, 1/19/21, 3/26/21, 4/21/21

Based on observations, a review of clinical records, resident incident/accident reports, information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision as planned to monitor a resident with known unsafe behavior to prevent an unsupervised exit from the facility and threat to the resident's safety while ambulating outside the facility for one resident (Resident 3) out of 7 reviewed. Findings included: A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE]. The resident's diagnoses included Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 3's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2021, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 6 (a score of 0 -7 indicates severe impaired cognition) and was noted to be wandering the unit four to six days during the look back period. A review of physician's orders initially dated December 29, 2020, indicated that the resident was to receive one to one observation by staff for safety. A review of nursing progress notes dated February 9, 2021, at 1:25 PM revealed that one to one observation was available that day and that the resident became increasingly agitated and exit seeking. A review of nursing progress notes dated February 17, 2021, at 2:57 PM revealed that the resident asked staff multiple times how to leave the facility and tried to pack her belongings to leave. Nursing noted that the resident was confused part of the day and needed to leave to go to work. Nursing notes dated February 20, 2021, at 7:10 PM indicated that the resident had self-removed the wander guard (device to alarm the facility if the resident tries to leave) that was located on her left ankle. Nursing noted that on February 23, 2021, at 8:54 AM the resident was on one to one observation and exhibiting exit seeking behaviors. The resident was stating that she needed to get out of the facility. On February 28, 2021, at 2:16 PM, nursing noted that the resident continued to have exit seeking behaviors and [MEDICATION(S)] was administered. A review of nursing progress notes for the month of March 2021 revealed 14 instances during which the resident displayed exit seeking behaviors. Nursing progress notes dated April 1, 2021, at 6:59 PM indicated that the resident remained on observations. The resident was combative with staff and attempted three times to open emergency exit door at end of the nursing unit halls. The resident was physically abusive to staff when attempting to redirect her from the exits. The resident was able to open the exit door to the parking lot. Nursing progress notes dated April 5, 2021, at 10: 57 PM indicated that the resident was observed with exit seeking behavior on the nursing unit at 7:30 PM. When staff attempted to to redirect the resident the resident stated I want to die. The resident asked another staff member present at that time, can you kill me? Nursing noted that the resident was not on one to one observation at that time. The resident continued to exit seek with staff by her side almost opening a fire exit door. A review of the documentation of the One to One observation of the resident staff conducted from March 25, 2021 to April 20, 2021, revealed over that of the 27 days of documentation provided by the facility the physician ordered one to one observation was not completed on 23 days during that time frame. Review of information submitted by the facility on April 7, 2021, revealed that Employee 3 LPN (license practical nurse) reported to the Nursing Home Administrator (NHA) that Employee 4 personal care aide companion hit Resident 3 while trying to prevent the resident from exiting the facility. While Employee 3 was escorting Employee 4 from the unit the resident was able to exit the facility out of the door at the end of the hall. Employee 3 did not submit a written statement to the facility regarding the incident of physical abuse of the resident at the time of the investigation. A written statement from an interview that was completed with Employee 4 on April 7, 2021, revealed that the employee stated she was unaware that Resident 3 had exited the facility and stated that it must have happened after she left the unit. A written statement from Employee 5 NA (nurse aide) dated April 7, 2021, revealed that the employee called the supervisor from the desk to inform supervisory staff of the incident that occurred with Employee 4 hitting Resident 3. Employee 5 stated he looked down the hall and the resident was standing by the door. The employee further stated he was on the phone and then when he looked down the hall again the resident was gone. The employee stated that he then went down the hall and out the door and found the resident in the employee parking lot. A written statement from Employee 7 LPN (no date or time) indicated that on April 7, 2021, the employee was driving out of the employee parking lot and found Resident 3 on the road. The employee further stated that the resident was ambulating with her rolling walker when Employee 5 approached the resident and convinced her to go back into the facility. Observation of video footage conducted by surveyors in the presence of the Nursing Home Administrator on April 21, 2021, at 3:28 PM revealed that on April 7, 2021, at 4:29 PM the resident was unsupervised at the end of the hall of the nursing unit pushing on the handle of the exit door. The resident continually pushed on the door, stopped for a moment, looked around and continued to push on the handle of the exit door. The resident was observed to open the door and while unsupervised, the resident exited the building alone. A review of a timeline of the event provided by the facility from the security camera footage revealed the following: 4:29:02 PM Camera 24 showed Employee 3 and Employee 4 walk down the hall leaving the resident unsupervised at the exit door; 4:29:30 the resident opened the exit door and left the facility unsupervised by staff; 4:29:37 the door closes behind the resident; 4:30:27 Employee 5 exits the facility through door looking for the resident. An interview with the NHA on April 21, 2021, at approximately 2:30 PM confirmed the facility failed to provide adequate supervision of a resident with known exit seeking behavior and a physician order for one to one observation to prevent the resident from exiting the facility without staff supervision placing the resident at risk for accidents and injury. 28 Pa Code: 201.19(e)(1) Management 28 Pa Code:201.18(e)(3) Management 28 Pa. Code: 211.12(a)(c)(d)(3)(5) Nursing Services

Based on observation, a review of clinical records, information submitted by the facility, select resident incident/accident and investigative reports, video surveillance footage and staff and resident interview, it was revealed that the facility failed to ensure that one resident out of 7 sampled was free from physical abuse, which caused psychosocial harm and humiliation (Resident 3). Findings include: A review of the facility policy entitled, Abuse Prevention Program, reviewed by the facility February 24, 2021, revealed it is the policy of the facility for residents to have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Further it was indicated the administration will protect the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the clinical record revealed that Resident 3 was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 6, 2021, indicated that the resident was severely cognitively impaired and wandered the unit four to six days during the assessment look back period. Review of information submitted by the facility dated April 7, 2021, revealed that Employee 3 LPN (License Practical Nurse) reported to the Nursing Home Administrator (NHA) that Employee 4, Personal Care Aide Companion, hit Resident 3 while trying to prevent the resident from exiting the facility. A review of an investigative report of alleged abuse, neglect and misappropriation of property report form for investigation of alleged abuse, neglect and misappropriation dated April 21, 2021, revealed that when the facility reviewed the video surveillance footage from the camera in the hall of the nursing unit in the presence of local police investigating the incident, the facility was able to substantiate that Employee 4 physically abused the resident and terminated Employee 4 for resident abuse. Employee 3 did not submit a written statement to the facility regarding the incident at the time of the investigation. The facility did not have any documentation, at the time of the survey ending April 21, 2021, that an interview was conducted with the resident at the time Employee 3 had reported the allegation of abuse to the NHA. A review of a written statement of an interview conducted with Employee 4 dated April 7, 2021, revealed that the employee was walking with Resident 3. The resident was pushing on the door. The employee was trying to prevent the resident from pushing the door and the resident then became mad. The resident grabbed the employee's arm. The employee indicated that she grabbed the resident's arm and stated, let the f*** go of me now. Employee 4 further stated that she didn't realize she raised her fist at the resident, but verified that she did physically push the resident off of her. Observation of Resident 3 on April 21, 2021, at approximately 8:50 AM revealed that the resident was resting with her eyes closed. The resident woke momentarily, but appeared too tired to talk to the surveyor. Employee 1, a companion, stated the resident hasn't been sleeping at night due to her, husband cheating on her in her mind. Employee 1 stated the resident is very confused and not aware of what is going on. The surveyor attempted to conduct an interview with the resident, which was unsuccessful. A phone interview was conducted with Employee 3 on April 21, 2021, at 2:36 PM. The employee stated she was at her medication cart at the end of the hall and saw Resident 3 and Employee 4 walk past her and were standing by the door that exits the building. Employee 3 stated that the resident was trying to exit the facility, pushing on the door to leave. Employee 4 stood between the door and the resident. Employee 3 stated she saw Employee 4 forcefully push the resident. At that time Employee 3 heard the resident state, you cannot hit me. Employee 3 then heard Employee 4 tell the resident, B**** I will knock you the F*** out. Employee 3 then indicated that she separated the resident and Employee 4 and walked Employee 4 to the nursing station. Employee 3 stated she was given no direction by supervisory or administrative staff on what to do in such a situation. Employee 3 stated at that time she called 911 to report abuse because she was afraid the facility was not going to report the incident and was concerned about her nursing license being in jeopardy. Observation of video footage conducted by surveyors in the presence of the Nursing Home Administrator on April 21, 2021, at 3:28 PM revealed that on April 7, 2021, at 4:27 PM Resident 3 and Employee 4 walked down the hallway of the nursing unit and stopped at an exit door. Employee 3 was seen by the medication cart. The resident reached to push on the exit door, when Employee 4 placed her arm across the door to prevent the resident from pushing on the door. The resident grabbed Employee 4's arm. Employee 4 was then seen on the video pulling her arm away from the resident. Employee 4 then used her forearms and pushed the resident. Employee 3 approached and separated the resident and Employee 4. Employee 3 walked away with Employee 4 and left the resident alone by the exit door. A review of Resident 3's clinical record revealed no documentation that the resident was assessed for injuries after the observed physical abuse occurred or an assessment of the resident's psycho-social needs to ascertain if the resident had any fear or mental anguish from the abuse. Review of Employee 4's personnel record revealed that the employee's first day worked at the facility was February 22, 2021. Employee 4's personnel record revealed that abuse training was provided on February 9, 2021, but no training was provided to the employee on how to care for residents with dementia. The facility's complete abuse investigative report dated April 21, 2021, noted that a police investigation was performed by the local police and was concluded. A review of Magisterial District Judge Criminal Docket issued April 13, 2021, revealed Employee 4 was issued a summons for charges of harassment by physical contact. The court is currently awaiting a plea from Employee 4 as of the time of the survey ending April 21, 2021. Interview with the NHA on April 21, 2021, at approximately 6:15 PM, confirmed Resident 3 had been physically abused by Employee 4, a companion, while providing 1:1 observations of the resident. Applying the reasonable person concept, in the case of Resident 3, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused and harassed by Employee 4, Resident 3 would have suffered psychosocial harm and humiliation. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(e)(1) Management Previously cited 8/23/19, 10/1/20, 11/24/20, 3/26/21 28 Pa. Code 201.18(e)(3) Management Previously cited 9/1/20, 10/1/20, 10/15/20, 11/24/20 28 Pa. Code 201.29(a) Resident rights Previously cited 8/23/19, 11/24/20, 3/26/21 28 Pa. Code 201.29(c) Resident rights Previously cited 8/23/19, 3/26/21 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services Previously cited 8/23/19, 10/1/20, 11/24/20, 1/19/21, 3/26/21 28 Pa. Code 211.12 (d)(3) Nursing services Previously cited 8/23/19, 1/19/21, 3/26/21

Based on a review of clinical records and select incident reports and staff interview it was determined that the facility failed to provide sufficient staff supervision to prevent a fall resulting in minor injury to one of 24 residents reviewed (Resident 80) Findings include: A review of clinical record revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses which includes dementia with behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling. A Quarterly Minimum Date Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 2, 2021, indicated that the resident was severely cognitively impaired and needed extensive assistance with bed mobility, transfers, and toileting. A review of a fall risk assessment dated [DATE], revealed that the resident was at high risk for falls. A review of the resident's plan of care indicated that the resident was a fall risk with a planned intervention initially dated May 30, 2020, for supervision while in the bathroom. A review a facility incident report dated March 16, 2021, at 9:29 PM, revealed that Employee 1 failed to supervise Resident 80 while the resident was in the bathroom and the resident fell . Employee 1 left the resident on the toilet alone in the bathroom. Although Resident 80 was cognitively impaired, Employee 1 instructed the resident to pull the call bell when she was ready to get up from the toilet. Employee 1 went back into the bathroom to check on the resident and found Resident 80 on the floor in the bathroom. The resident had sustained an abrasion to her sacrum (area where the tailbone is located) as a result of the fall. A review of Employee 1's witness statement revealed that the employee confirmed that she left the resident alone in the bathroom to care for another resident. When she returned to the bathroom the resident was sitting on the floor next to the toilet. An interview with the NHA (nursing home administrator) on March 25, 2021, at approximately 10:00 AM confirmed the facility failed to provide necessary supervision as required for a resident who was a fall risk resulting in a fall with minor injury. 28 Pa Code 211.12 (a)(d)(5) Nursing services 28 Pa Code 211.12(c) Nursing services 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(3) Nursing services

Based on review of clinical records and facility provided documentation and staff interviews it was determined that the facility failed to provide timely and necessary treatment as recommended to promote healing of a skin tear, which deteriorated into a significant skin ulcer/wound for one resident out of six residents reviewed (Resident 15). Findings included: A review of the clinical record of Resident 15 revealed admission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 2, 2020, indicated that the resident was cognitively impaired, needed extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene (combing hair, brushing teeth, shaving, applying makeup etc.) and was at risk for developing pressure sores. A review of Resident 15's care plan (a tool used by staff to direct the care needed for the specific resident) dated March 22, 2021, indicated that interventions to maintain skin integrity planned were to keep the resident's skin clean and dry, use lotion on dry skin and on March 24, 2021, an air mattress on the resident's bed, pressure reduction mattress and cushion in chair. A review of the clinical record revealed a wound care specialist note dated March 2, 2021, identifying an initial examination of a new left thigh skin tear measuring 1.5 cm length (l) x 2.0 cm width (w) x 0.1 cm depth (d); 3 square cm, without drainage and no odor. The recommended instruction (treatment) was Xeroform (a dressing used to cover and protect wounds) daily and PRN (as needed if soiled or dislodged). A head to toe weekly skin check sheet dated March 6, 2021, indicated that the resident's skin integrity was intact, but the resident had an, existing wound vac and skin tear on left buttock wound on heels existing. A review of nursing progress notes revealed no documentation regarding a skin tear on the resident's left buttock or how the resident had sustained the skin tear. A wound care specialist note dated March 9, 2021, noted no change to the new left thigh skin tear measuring 1.5 cm x 2.0 cm x 0.1 cm (d), 3 sq cm without drainage and no odor. The recommended instruction (treatment) was Duoderm or boarder foam (a dressing used to cover and protect wounds) twice a week and PRN. A wound care specialist note dated March 16, 2021, noted that the resident's left thigh skin tear had deteriorated and now measured 3.0 cm x 4.0 cm x 0.1 cm; 9 sq cm without drainage and no odor. The recommended instruction (treatment) remained Duoderm or boarder foam (a dressing used to cover and protect wounds) twice a week and PRN. A wound care specialist note dated March 23, 2021, noted that the resident's left thigh skin tear continued to deteriorate, and now measured 5.0 cm x 4.0 cm x 1.5 cm; 20 sq cm with scant drainage and mild odor, 60 % granulation tissue (new connective tissue) and 40 % slough (dead tissue). The new recommended instruction (treatment) was the use of a wound vac (vacuum assisted closure VAC - is a method of decreasing air pressure around a wound to assist in healing). A review of the resident's Treatment Administration Record (TAR) for March 2021, revealed that a treatment to cleanse the skin tear on buttocks with normal saline solution (NSS) and apply Duoderm dressing Tuesday and Saturdays and PRN for soilage was initiated on March 17, 2021. The March 2021, TAR noted the treatment had first been applied to the resident's wound on March 20, 2021. The facility had not been provided the treatments recommended/instructed by the wound care care physician and the resident's skin tear continue to deteriorate. Interview with Employee 5, (RN, Wound care nurse) on March 25, 2021, at approximately 2:00 PM, revealed that the resident's left thigh skin tear was a new skin injury found during routine wound rounds on March 2, 2021, which had deteriorated. Employee 5 also confirmed there was no documentation in the nursing progress notes of the new skin tear and the facility had conducted an investigation to the origin/cause of the skin injury. Employee 5 verified that there was no documented evidence of any treatment being applied to the new left thigh skin tear from March 2, 2021, until March 20, 2021, 18 days after the skin tear was found. Employee 5 further confirmed that the head to toe weekly skin check form dated March 6, 2021, was inaccurately completed by nursing staff indicating that the resident's skin was intact and that no new skin issue was noted. An interview with the Nursing Home Administrator (NHA) on March 26, 2021, at approximately 12:45 PM, confirmed that at the time of survey the facility was unable to provide evidence that the resident received timely and necessary treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 483.24 Quality of Care Previously cited 9/28/18, 4/10/19 28 Pa. Code 211.5(f)(g) Clinical Records Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 1/19/21 28 Pa. Code 211.5(h) Clinical Records Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services. Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 11/24/20, 1/19/21 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 1/19/21 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/28/18, 12/1/18, 8/23/19, 1/19/21

Based on a review of clinical records, observations, staff and resident interviews it was determined that the facility failed to timely and consistently provide recommended treatment and services, consistent with professional standards of practice, to prevent new pressure sore development, promote healing and prevent worsening of existing pressure sores, which resulted in the development of multiple pressure sores and related pain to one of four residents sampled with pressure sores (Resident 16). Findings include: According to the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians ([ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean would environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. A review of the facility's policy entitled Wound Care Policy last revised by the facility January 2021, indicated that the facility will identify factors that place the residents at risk for the development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds and to promote a monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. The facility's risk identification and assessment consists of : completing a Braden scale on admission, quarterly and with a change in condition, document all wounds, identify risk factors and implement appropriate interventions, conduct weekly wound rounds and update the care plan, as needed. A review of the clinical record revealed that Resident 16 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This may be due to injuries, underlying conditions, or problems with the legs and feet). A review of an admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 18, 2021, revealed that Resident 16 was at risk for developing pressure sores and required assistance of two staff members for activities of daily living to include bed mobility, transfers and toilet use. Section M0150 (skin section) of the resident's MDS indicated that the resident was at risk for pressure ulcers and two Stage III pressure ulcers were present upon readmission to the facility. Section M1200 (skin and ulcer/injury treatment) indicated that no preventative measures, such as pressure reducing device for bed or chair, or a turning and repositioning program were put into place. The resident also had an indwelling urinary Foley catheter in place and was frequently incontinent of bowel. There was no bowel program being used to manage the resident's bowel incontinence. A review of the resident's Braden scale assessment (a tool developed to assess a patient's risk of developing a pressure ulcer) dated February 1, 2021, revealed a score of 16, indicating that the resident was at risk for developing pressure sores. A Braden assessment dated [DATE], revealed a score of 14, indicating that the resident was now at moderate risk for developing pressure sores and an assessment dated [DATE], revealed a score of 15, indicating the resident was at risk for developing pressure sores. There was no documented evidence provided at the time of the survey ending March 26, 2021, that a Braden scale assessment had been conducted upon the resident's readmission to the facility on [DATE], according to facility policy. A review of an admission/readmission evaluation, section C-skin integrity, dated January 28, 2021, revealed that the resident's skin color was normal for ethnic group, skin temperature, warm and dry, skin turgor, normal. There were no areas documented on the form to indicate any skin issues found on the resident's during this admission/readmission evaluation, although the MDS assessment of January 18, 2021, indicated that the resident had two Stage III pressure sores. This admission/readmission evaluation did not address the healing status of the Stage III pressure sores or their location. A review of a wound care note dated March 3, 2021, revealed a new wound was found during wound rounds by the wound care physician specialist and the wound nurse. The wound area measured 2 cm x 1 cm x 0.1 cm and was identified as Stage II pressure ulcer to the resident's perineum (the space between the anus and scrotum in the male) wound bed contained slough and the wound edges were epithelializing. The recommendations made by the wound care physician specialist included to apply [MEDICATION(S)] and towel, change daily and prn (as needed), low air mattress, turn and reposition and provide incontinence care. A review of the facility's treatment and task administration record report dated March 2021, revealed that the wound care physician specialist's recommendations made during wound rounds of March 2, 2021, to include a low air mattress were not implemented by the facility until March 25, 2021. There was no also no documented evidence that wound care specialist physician's recommendation of turning and repositioning the resident had been implemented. The facility treatment and task administration report revealed the use of bilateral bed enablers for improved mobility, to be implemented on March 24, 2021. The report documented that the enablers were in place. However, an observation was made on March 26, 2021, at 12:45 PM, of the maintenance staff member installing the bed enablers on the resident's bed. A review of documentation of the resident's weekly skin checks dated March 9, 2021, March 16, 2021, and March 21, 2021, failed to identify the Stage II pressure sore found during wound rounds on March 2, 2021, to the resident's perineum. According to Employee 5, RN Wound Care Nurse, the weekly skin checks are completed by nursing staff by gathering information from the shower checks. Each week the registered nurses are required to conduct body checks on each resident. A review of documentation provided by the facility of the resident's skin monitoring/shower review dated March 22, 2021, revealed no new areas of skin impairment/damage. The documentation was signed by a nurse aide and a charge nurse. The facility was unable to provide any other skin monitoring/shower review documentation that would reflect the perineum pressure sore found during wound rounds on March 2, 2021. Employee 5 stated that the facility did not investigate the potential origin of the Stage II pressure sore to the resident's perineum in an attempt to ascertain how the breakdown occurred and to address any potential contributing factors Observation of the resident on March 26, 2021, at 1:45 PM, revealed the resident was lying in his bed, on his back. During observation of the resident's perineal pressure sore on March 26, 2021, at 12:48 PM, Employee 5 stated that she was made aware at change of shift of another pressure sore that had been found by an employee on the previous shift. The facility had not evaluated the potential cause of this new wound. Observation revealed that when Employee 5, removed a dressing from the resident's right buttocks, she caused a skin tear to the residents right buttocks. The wounds observed during this treatment observation were four areas on the resident's sacrum, a skin tear to his right buttocks, two shearing areas to his right buttocks and a shearing area to the resident's left upper thigh. During observation of the wound dressing the resident stated that he was in pain. When asked the location of his pain the resident stated that he had pain in his right knee and his right heel. At this time, the resident was wearing heel bows to both feet while in bed. Employee 8 (nurse aide) then removed the heel bow to the resident's right heel, revealing a dark colored wound to his heel approximately the size of an oval sized quarter. By the end of the survey on March 26, 2021, the facility had not determined the cause of the wound to the resident's right heel. Review of the resident's comprehensive care plan to address pressure ulcers dated February 9, 2021, revealed interventions planned for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility was unable to demonstrate the consistent implementation of prescribed approaches and sufficient preventative measures upon admission. The facility failed to timely identify declines in the resident's skin integrity and failed to promptly implement adequate measures to prevent the development of new pressure sores on the resident's buttocks, sacrum and thigh areas for a resident identified at risk for pressure sore development. During an interview with the Nursing Home Administrator on March 26, 2021, at 11:10 AM, she was unable to provide evidence that the recommendations by the wound care physician specialist of turning and repositioning the resident and a low air loss mattress was promptly implemented to promote healing and prevent worsening of pressure sores for Resident 16 and to prevent additional pressure sores from developing. 483.25(b)(1)(i)(ii) Treatment/Services to prevent/heal pressure ulcers Previously cited 1/19/21 28 Pa. Code 211.5(f)(g) Clinical Records Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 1/19/21 28 Pa. Code 211.5(h) Clinical Records Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services. Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 11/24/20, 1/19/21 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 9/28/18, 12/1/18, 4/10/19, 8/23/19, 1/19/21 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/28/18, 12/1/18, 8/23/19, 1/19/21

Based on review of clinical records, documentation submitted by the facility and select resident incident/accident, observation and staff and resident interviews, it was determined that the facility failed to consistently implement safety measures to prevent significant injury and recurrence of similar accidents and injuries for one resident sampled (Resident 129) out of 24 sampled. Findings include: A review of the clinical record revealed that Resident 129 and documentation submitted by the facility dated June 12, 2015, revealed that on June 11, 2015, at 3:30 PM Resident 129, who is alert and oriented, was being transported from his room to the shower room via a wheelchair. The resident's left leg became caught between the two wheels on the left side of the chair causing a laceration. He was transported to the emergency room and received stitches (19 stitches) to his left calf. The documentation submitted by the facility indicated that the facility planned to update the resident's plan of care to include the use of bilateral legrests for transport by staff. At the time of the survey ending August 21, 2015, there was no evidence that the resident's plan of care had been updated to include the use of the legrests during staff transport. Nursing documentation dated June 11, 2015, at 11:30 PM, revealed that the resident was being wheeled in the hallway to the shower room. He was holding his legs up and the resident's left leg came down and hit his calf off the wheelchair, where the leg rests attaches. The resident received a laceration on the left calf, a dressing was applied and he was taken to the hospital ER. He returned with 19 stitches in the calf, and a new order for Keflex (antibiotic) every 6 hours for ten days. Subsequent nursing documentation on June 12, 2015 at 2:27 PM revealed that the area on the left calf was assessed at 20 cm x less than 0.1 x less than 0.1 cm. The laceration was closed with 19 stitches. Review of an INVESTIGATION OF INCIDENT dated June 11, 2015, at 3:30 PM, revealed a written statement provided by Licensed Practical Nurse (Employee 1) which indicated that a nurse aide came to the desk stating the resident was bleeding. The Nurse Aide was taking the resident for a shower in wheelchair without the legrests attached. The resident could not hold his foot up any longer, it stuck to the floor and the resident's legs got caught on the wheelchair where legs attach causing a laceration. A dressing was applied and the resident was taken to the emergency room . A written statement provided by the Nurse Aide (Employee 2) dated June 11, 2015, revealed that he was attempting to give the resident his shower. He was taking the resident to the shower room and did not put his foot pedals on and the back of the resident's calf muscle was sliced open. He also indicated that he was wheeling the resident down the hall in his wheelchair to the shower room and footrests were not on his wheelchair and the resident's foot got stuck on the floor and the joint where you attach the foot rests to the wheelchair, which caused his skin tear and the muscle was visible. A written statement dated June 12, 2015, which was provided by the Assistant Director of Nursing, revealed that the resident had informed her that I usually don't wear shoes when they are pushing me down the hall, just my socks. But when this happened I had sneakers on. I usually hold my feet up, but they got heavy and I couldn't hold them up anymore. When I put my foot down it got stuck. An observation was conducted on August at approximately 9:55 AM with respect to the location of the resident's room in conjunction to the central bathing area, which revealed that both were the last rooms directly at the opposite ends of the hallway. During an interview on August 21, 2015, at approximately 10:00 AM with Resident 129, he stated that on the day he was injured he went to the bathroom just prior to staff pushing him in the wheelchair from the bathroom to the shower room. He stated that when he came out of the bathroom, the nurse aide pushed him in his wheelchair to take him to the shower room. He stated that he was wearing sneakers and could not hold his feet up because his feet were heavy from the sneakers. He put his foot down and his leg got caught under the wheelchair where the leg rest attachment was located. Review of Physical Therapy treatment notes, which immediately preceded this incident which occurred on June 11, 2015, revealed that on June 10, 2015, the resident was identified as a fall risk and had safety awareness risks. He was being treated for [REDACTED]. There was no documented evidence available for review that therapy assessed the resident's potential need for legrests during transport by a staff person in light of the resident's condition. Interview with the Physical Therapist (Employee 3) on August 21, 2015, at approximately 10:40 AM revealed if a resident required footrests for transport a physician's orders [REDACTED]. Additionally, review of the resident's current comprehensive plan of care which was initiated on April 22, 2015, revealed that the resident was a risk for falls, had ADL deficits, chronic pain, neuropathy, and altered respiratory status related to Congestive Heart Failure/COPD. There was no documented evidence that the facility had care planned for the resident's use of legrests on the wheelchair for transport before this incident or after the incident with significant injury. An interview with the Director of Nursing on August 21, 2015 at approximately 1:15 PM revealed that the resident self propels at times within the facility without the legrests on and does not have a physician's orders [REDACTED]. 483.25(h)Accidents Previously cited 7/25/14 28 Pa Code 211.12(a)(c)(d)(1)(3)(5) Nursing services. Previously cited: 7/24/14, 9/25/14.

Based on review of clinical records and select facility policy and resident and staff interview it was determined that the facility failed to assess and monitor one resident's indwelling urinary catheter for proper functioning to prevent complications, pain and infection (Resident 62) and failed to fully evaluate declines in urinary continence and implement individualized approaches to restore normal bladder function to the extent possible for four of 24 residents sampled (Resident 24, 34, 38, and 47) Findings include: A review of the clinical record of Resident 62 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set Assessment (MDS - federally mandated standardized assessment completed at specific intervals to define resident care needs) dated July 7, 2015, revealed that the resident was cognitively intact and was able to make her needs known. The resident required extensive assistance from staff for activities of daily living (dressing, grooming, bathing and hygiene, bed mobility and transfer). The resident had a indwelling urinary foley catheter (a rubber or silicone flexible tube inserted into the bladder through the urethra (pathway from the meatus (opening) into the bladder) for the purpose of draining urine. Review of physician orders [REDACTED]. Review of nursing documentation dated August 1, 2015, at 2:31 a.m., revealed that at 10:30 p.m., on July 31, 2015, the resident requested pain medication. The charge nurse explained to the resident that she had just received pain medication at 10:00 p.m. on July 31, 2015. A review of the narcotic record revealed that the resident received [MEDICATION NAME] 10 mg at 9:00 p.m., on July 31, 2015, for pain on a scale of 7-10 level. The resident stated that she had a concern about her kidney not working properly as she only has one left and it felt strange like a trickling feeling every 10-15 minutes. The charge nurse asked her if she had pain or burning and the resident stated no. The charge nurse documented that the resident's foley catheter was patent and draining clear yellow urine. The charge nurse further informed the resident that she would make the physician aware of her concerns in the morning. At 1:15 a.m., on August 1, 2015, the resident had called the on-call nurse at the hospital and then called 911 to dispatch an ambulance to the facility. The physician and resident's husband were made aware according to nursing documentation. Review of a Late Entry nursing note dated August 1, 2015, at 8:59 a.m., revealed that at 1:10 a.m. on August 1, 2015, the charge nurse notified the Registered Nurse that the resident was having a hard time explaining what she was feeling, but it felt like a trickling sensation every so often. The charge nurse informed the RN that the resident's foley catheter was in place and provided the RN the resident's medical history. The charge nurse also stated that she was on the phone with the nurse at the hospital. The RN and charge nurse went to assess the resident's foley catheter and the situation, emergency medical services-EMS had already been called were en route to the facility. Further review of nursing documentation dated 9:02 a.m., on August 1, 2015, as a Late Entry revealed that the resident's husband and son arrived at the facility at 6:45 a.m. on August 1, 2015, and voiced concerns as to what had happened to warrant the resident's EMS transfer to the hospital. The RN explained the situation as understood and told the resident's family that someone would contact them with further information. Continued review of nursing documentation dated August 1, 2015, at 9:06 a.m., revealed that the resident returned to the facility at 7:50 a.m. on August 1, 2015. The resident stated that the foley (catheter) was exchanged (removed and replaced) because it was clogged. Interview with Resident 62 on August 20, 2015 at 10:24 a.m., revealed that the resident stated that she kept yelling and yelling help me since her return from the oncologist appointment around 4:00 p.m. on July 31, 2015. The resident stated that the nurses at the facility never looked at the foley catheter to see if it was blocked. The resident further stated that the pain was severe and lasted until I got to the hospital. When the nurse at the hospital tried to flush the foley catheter it was blocked. The resident stated that as soon as the nurse removed the foley catheter, the urine came gushing out and the pain was instantly relieved. Review of documentation from the hospital emergency room dated August 1, 2015, revealed that the resident had a urinary output of 500 cubic centimeters (cc) noted as a large amount of clear yellow urine. The resident was placed on a broad spectrum antibiotic, [MEDICATION NAME]-[MEDICATION NAME] 800-160 mg twice a day for seven days. Instructions were also sent back to the facility with the resident for care of a foley catheter. Interview with the director of nursing (DON) on August 20, 2015 at 1:50 p.m., confirmed that the facility's nursing staff had not assessed the resident's foley catheter for patency and the only assessment for pain was conducted at 9:00 p.m., on July 31, 2015, when the narcotic pain medication was given to the resident. Review of the facility Incontinence Evaluation and Management dated as reviewed, May 2015, indicated that all residents admitted with any urinary incontinence and any resident who has a significant change related to incontinence will be assessed to ensure appropriate treatment and services to prevent urinary tract infections and to restore as much bladder function as possible are in place. A review of the clinical record revealed that Resident 24 had current [DIAGNOSES REDACTED]. An annual Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively intact, dependent on staff for most activities of daily living (ADLs - the basic tasks of everyday life, such as eating, bathing, dressing, toileting and transferring) and was occasionally incontinent of bladder. A quarterly MDS assessment dated [DATE], indicated that the resident was cognitively intact, dependent on staff for most activities of daily living and was now frequently incontinent of bladder. A review of Resident 34's clinical record revealed current [DIAGNOSES REDACTED]. An annual MDS assessment dated [DATE], indicated that the resident was moderately impaired cognitively, dependent on staff for most activities of daily living and was now frequently incontinent of bladder. A review of the clinical record of Resident 38 revealed current [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], indicated that the resident was severely impaired cognitively, dependent on staff for most activities of daily living and was now occasionally incontinent of bladder. There was no evidence that the facility acknowledged the declines of bladder function reflected on the MDS assessments of Residents 24, 34, and 38. There was no documented evidence that the facility evaluated each of these resident's bladder status and management in response to the declines and had developed and implemented individualized measures to restore normal bladder function to the extent possible for Residents 24, 34, and 38. Review of Resident 24's plan of care also revealed no evidence that the resident's bladder incontinence was addressed. Clinical record review revealed that Resident 47 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident required staff assistance for toileting and was frequently incontinent of urine. Further review of the clinical record revealed no documented evidence that an assessment was completed upon admission to assess the resident's bladder incontinence. Interview with the Director of Nursing on August 21, 2015, at 9:30 a.m., failed to provide evidence that the facility had assessed, evaluated and consistently implemented individualized continence management plans designed to maintain or improve Residents 24, 34, 38 and 47's bladder functions to the extent practicable. 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services. Previously cited 7/25/14, 9/25/14 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan. Previously cited 7/25/14, 9/25/14 28 Pa. Code 211.5(f)(g)(h) Clinical records Previously cited 7/25/14

Based on review of the clinical records and staff interviews it was revealed that the facility failed to timely identify skin impairment and provide necessary treatment and services to promote wound healing and prevent worsening for one resident out of five sampled (Resident A1). Findings include: A review of Resident A1's clinical record revealed that on January 31, 2011 the resident's wife requested that a nurse examine the resident's right hand, as it was noted that the resident's hand was [MEDICAL CONDITION]. When the resident's sweatshirt was removed it was noted that the resident's right hand was red, warm to touch with +2 to +3 [MEDICAL CONDITION] (swelling) from the hand to the right elbow. An open area was also noted to the right elbow. A review of the resident's Wound/Skin Care Management Documentation Form dated January 31, 2011, revealed that the facility identified this impaired area as a Stage II wound measuring 1.6 cm x 2.0 cm x 0.1 cm with a scant amount of yellow exudate. On January 31, 2011, The resident's attending physician was notified and [MEDICATION NAME] mg twice daily (antibiotic). An order to cleanse the right elbow with wound cleaner, apply Santyl and cover with an [MEDICATION NAME] four by four and Kling daily and as needed. A review of the resident's treatment records revealed that the treatments were not completed on February 2, 3, 4, 5, 2011. When interviewed on February 28, 2011 at 1:45 p.m., the Director of Nursing Services was unable to explain why the resident's wound treatments had not been completed as ordered. A review of nursing progress notes revealed that on February 6, 2011, the resident's family had concerns to facility staff regarding the resident's persistent right arm [MEDICAL CONDITION]. When assessed on that date in response to the family's concern, the nurse documented that the resident's arm appeared to have more swelling and discomfort. There was no description of the condition of the open area to the resident's elbow. According to review of nursing progress notes, on February 7, 2011, the resident's treatment was completed and the area was described as a "crater like" opening 1.7 cm round with a pink base and slough perimeter. Serous/purulent drainage was observed. A red, warm [MEDICAL CONDITION] area surrounded the elbow. [MEDICAL CONDITION] was noted from the resident's elbow to his fingers. The resident's attending physician was notified on February 7, 2011, and ordered the resident transferred to the emergency room , where he was sent for direct admission to the Intensive Care Unit of the hospital. A review of the hospital admission records revealed that he was admitted for aggressive wound care and [MEDICATION NAME] antibiotic therapy related to a septic Olecranon Bursitis (inflammation of the fluid filled sac at the pointy end of the elbow). A culture and sensitivity of the resident's elbow was obtained on February 7, 2011, and was positive for [MEDICAL CONDITION]. The resident required an Incision and Drainage debridement of the area. 483.25 Quality of Care previously cited 9/17/10 28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing Services. previously cited: 9/17/10, 9/2/10. .