Every finding on record at Green Meadows Nursing & Rehabilitation Center

Based upon review of facility policy and procedure, review of facility documentation and clinical record review, it was determined that the facility failed to ensure residents were free from significant medication errors, resulting in actual harm to one resident (Resident R1), who required treatment with Narcan and hospitalization. This was identified as past non-compliance for Resident R1.Findings include: Review of undated facility policy and procedure titled Medication Administration revealed identify resident by photo in the MAR (medication administration record). Review of Resident R1's diagnosis list revealed diagnoses including Pulmonary Fibrosis (lung disease where tissue deep in the lungs becomes thick, stiff, and scarred over time), Transient Cerebral Ischemic attack (temporary blockage of blood flow to part of the brain that causes sudden stroke-like symptoms), Thyrotoxicosis (serious health condition caused by too much thyroid hormone in the blood), and type 2 Diabetes Mellitus (chronic condition where the body resists insulin or does not make enough of it, causing high blood sugar). Review of facility documentation titled, Medication Error Reporting Form dated July 7, 2026, reveals on July 7, 2026, at 10:00 a.m., Resident R1 was not properly identified during a medication pass. Further review of facility documentation revealed medications were given to Resident R1 as:Norvasc 5 mg (prescription calcium channel blocker used to treat high blood pressure and chest pain)ASA 81 mg (Aspirin; over the counter medication used to prevent blood clots, heart attacks, and ischemic strokes)Cymbalta 60 mg (prescription medication that works by increasing specific natural chemicals in the brain and spinal cord that regulate mood and pain signals)Metformin 500 mg (prescription medication used primarily as a first-line treatment for type 2 diabetes to lower blood sugar levels)Eliquis 5 mg (prescription blood thinner used to prevent and treat dangerous blood clots)Keppra 750 mg (prescription anticonvulsant medication used to treat various types of seizures)Ativan 0.5 mg (prescription benzodiazepine medication that slows the central nervous system to treat anxiety disorders, insomnia caused by stress, acute seizures, and alcohol withdrawal, or to provide sedation before surgery)Metoprolol 50 mg (prescription beta-blocker used to lower blood pressure, treat chest pain, manage heart failure, and improve survival after a heart attack)Oxycodone 10 mg (strong prescription opioid medicine used to treat moderate to severe pain when other non-opioid treatments do not work well enough)Tylenol 1000 mg (over the counter medication that acts as a pain reliever and fever reducer to treat headaches, muscle aches, arthritis, and cold symptoms)Gabapentin 500 mg (prescription medication used to treat partial seizures and nerve pain from shingles)Pantoprazole 40 mg (prescription proton pump inhibitor used to decrease stomach acid production) Further review of facility documentation revealed statement by Nursing Orientee Employee E1, I was passing medications during training, and my trainer handed me the residents medication. I approached the resident sitting by the window who I believed was (Resident R2) and introduced myself saying hey (Resident R2) I have your meds the resident noded as I proceeded to pas her the meds, I came to realize I gave the wrong meds and reported the incident to my trainer immediately. Further review of facility documentation dated July 7, 2026, revealed statement by Nursing Preceptor Employee E2, Nurse trainer gave nurse trainee medication for a resident. Medication was given in medication cup poured by trainer. Trainee gave the medication to the wrong resident. Nurse trainer stood by med cart as trainee gave medication. Review of facility documentation Additional Questions for Statements, revealed statement by Nursing Preceptor Employee E2, Why did you pour the medications and not administering them? I was showing the orientee how to pour the meds and going over each medication. What direction did you give the orientee? I showed her the medications, the name of the resident, and the area in the room where the resident was at. Did you tell the orientee who the resident was prior to giving the medications? Yes, I told her the name and pointed to the door side of the room. What did you do after the med error was discovered? I told the unit manager, then I took vital signs. Further review of facility documentation Additional Questions for Statements, revealed statement by Nursing Orientee Employee E1, Why didn't you pull your own medications to administer? She was pouring the medications and showing me each medication. I didn't question it. Did you check patient identifiers prior to giving medications? I asked the resident's name and she said nothing. I had looked at the door and saw the resident's name. I thought the resident was at the window. Review of Nurse Practitioner Progress Note dated July 7, 2026, at 9:09 a.m., revealed, LATE ENTRY: Today the patient was urgently evaluated for an acute change in mental status after nursing reported decreased responsiveness. Upon arrival to the room, the patient was found lying in bed, markedly lethargic, difficult to arouse, and unable to answer questions or follow commands. She was drifting in and out of sleep with minimal response to verbal and tactile stimulation. At the time of assessment, respirations were even and unlabored with a respiratory rate of 16 breaths/min, and heart rate was 66beats/min. Due to concern for possible opioid-induced CNS (central nervous system) depression [occurs when opioid drugs slow down brain activity], a verbal order was given for immediate administration of Narcan [prescription rescue medication that rapidly reverses the effects of opioid overdose]. Following the initial dose, the patient demonstrated partial improvement by opening her eyes spontaneously and briefly tracking staff; however, she remained significantly lethargic, nonverbal, and unable to meaningfully interact or follow commands. Respiratory status and vital signs were closely monitored while the patient remained under continuous nursing observation. The PCP [Primary Care Physician] arrived at the facility subsequently and was provided a verbal report regarding the patient's acute change in condition, assessment findings, and response to the initial dose of Narcan. Review of Nurses Note dated July 7, 2026, at 2:19 p.m., revealed, Received report resident was lethargic. This nurse went to assess resident with MD [Doctor of Medicine]. Vital signs taken and WNL [within normal limits]. Resident AAOx1 [alert and oriented to person] and lethargic, eyes opening to verbal commands but resident nonverbal. Neurochecks [assessment of neurological systems] were initiated. Resident had emesis [vomiting] and MD ordered to send resident to ER [emergency room] for further evaluation. 911 was called and daughter notified. Review of hospital documentation titled Discharge summary, dated [DATE], revealed,Problem List on the Day of discharge: 1. Toxic metabolic encephalopathy [brain dysfunction caused by systemic illness, organ failure, toxins, drugs, or chemical and electrolyte imbalances in the body]. This is secondary to medications (Resident R1) wrongly received as well as pneumonia [infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus] .2. Sepsis [medical emergency that occurs when the body has an extreme, harmful response to an infection] present on admission associated with acute hypoxemic respiratory failure [sudden, life-threatening condition where the lungs cannot transfer enough oxygen into the blood] from aspiration pneumonia [lung infection that occurs when food, liquid, vomit, or saliva enters your airways or lungs] 4. Nausea and vomiting. This is likely secondary to ingestion of multiple medications that were given to her mistakenly . Further review of hospital documentation dated July 10, 2026, revealed a brief hospital course stating, (Resident R1) . was admitted on [DATE] for altered mental status [sudden or gradual change in thinking, awareness, attention or level of consciousness] following inadvertent administration of another resident's morning medications at (Resident R1's) skilled nursing facility. (Resident R1's) acute presentation included encephalopathy [disease, damage, or malfunction of the brain], vomiting, and subsequent aspiration, leading to right lower lobe pneumonia and acute hypoxic respiratory failure. Diagnosis was supported by CT (computed tomography scan, a medical imaging test that combines specialized x-ray equipement with computer processing to generate detailed, cross-sectional slice images of bones, blood vessels, and soft tissues inside the body) chest showing right lower lobe and right middle lobe airspace disease consistent with pneumonia (infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus), and chest x-ray revealing patchy airspace opacity at the right lung base. Pulmonary and infectious disease consultants confirmed aspiration pneumonia . Altered mental status was attributed to toxic metabolic encephalopathy from the medication error and pneumonia . experienced nausea and vomiting, likely related to the medication ingestion . Review of Nurses Note dated July 10, 2026, at 1:40 p.m., revealed, Resident returned from [local] hospital with dx (diagnosis) of RLL (right lower lobe) PNA (pneumonia). Interview with the Nursing Home Administrator and Director of Nursing on August 4, 2026, at 1:30 p.m. confirmed Employee E1 and Employee E2 failed to ensure Resident R1's was free from significant medication errors by verifying the identity of the resident prior to medication administration, resulting in subsequent transfer to the emergency room and admission to the hospital. The facility self-identified deficient practice at the time of the incident on July 7, 2026. The facility implemented a corrective action plan of staff education regarding the 9 Rights of Medication Administration. The facility's immediate action plan included:The Director of Nursing provided one-on-one education to the involved and preceptor and orienting nurse regarding the rights of medication administration. The Director of Nursing completed one-on-one medication administration competency assessment with both nurses. Facility policies and procedures related to 9 rights of medication administration were reviewed.The Director of Nursing and designee(s) will educate LPN/RN's about the 9 rights of medication administration, and to ensure no medications are left at bedside. Director of Nursing/Designee and/or pharmacy consultant will conduct random medication administration observations to ensure that licensed nurses are following the 9 rights of medication administration which includes the right resident, x 7 days, then the following will be weekly x4 then monthly audit x2 then quarterly until compliance is sustained. Audit report will be submitted to QA committee. The corrective action plan was completed on July 8, 2026, and verified through review of education documentation, interviews, and observation.The facility failed to ensure residents were free from significant medication errors, resulting in actual harm to Resident R1, who required treatment with Narcan and subsequent hospital admission for antibiotics and supplemental oxygenation. This was identified as past non-compliance for Resident R1, based on facility self-identification of deficient practice and subsequent completion of a corrective action plan.28 Pa. Code 211.9 (a)(1)(c)(d) Pharmacy Services28 Pa. Code 211.10 (c) Resident Care Policies

Based on clincal record review, observations, and staff and resident interviews it was determined the facitliy failed to provided services that meet professional standards for one of one residents reviewed. (Resdient 1)Findings include:Review of facility's policy Medication Administration, stated .18 Administer medications as ordered in accordance with manufacturer specifications.19 Observe resident consumption of medication.Review of Resident 1's diagnosis sheet revealed diagnoses type 2 diabetes (insufficient production of insulin, causing high blood sugar) and chronic systolic(congestive)heart failure (excessive body/lung fluid caused by a weakened heart muscle).Observations were made in Resident 1's room on June 29, 2026, at 9:43 am, of a cup filled with medications set on the table in front of Resident 1.Interview with Resident 1 on June 29, 2026, at 9:43am, stated I did not know the medication was there.Review of Resident 1's active care plan failed to reveal a care plan for self-administration of medication.Observations made with the Director of Nursing on June 29, 2026, at 10:12am confirmed the cup filled with medications set on the table should not have been left in front of Resident 1. Interview with Director of Nursing on June 29, 2026, at 10:12am revealed that the nurses are expected to observe resident consumption of medication.Review of physician orders revealed the following medications were administered on June 29, 2026:Prednisone Oral Tablet 5mg (inflammatory, autoimmune, and allergic conditions)Aspirin Low Dose Oral Tablet Delayed Release 81mg (used to treat pain and reduce fever or inflammation.)Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (used to reduce stomach acid); Ezetimibe Oral Tablet 10mg (cholesterol medication)Mycophenolate Mofetil Oral Capsule 250mg (prevent organ transplant rejection and treat certain autoimmune)Clopidogrel Bisulfate Oral Tablet 75 mg (antiplatelet medication used to prevent blood clots)Isosorbide Dinitrate Oral Tablet 10mg (medication used to prevent and treat angina by dilating blood vessels)Tums Oral Tablet Chewable 500 mg (Antacid)Lamotrigine Oral Tablet 150 mg (used to treat epilepsy and stabilize mood in bipolar disorder)Tacrolimus Oral Capsule 1 mg (used to prevent organ rejection in transplant patients)Amoxicillin-Potclavulanate Oral Tablet 875-125mg (prescribed to treat bacterial infections); Doxycycline Hyclate Oral Capsule 100 mg (an antibiotic used to treat a wide range of bacterial infections)Sertraline HCl Oral Tablet 100mg (treats depression, anxiety and other mental health conditions). Review of Resident 1's Medication Administration Record (MAR) dated June 29, 2026, revealed that the Registered Nurse Employee 3 administered the above medication and failed to observe Resident 1's consumption of the medication.Interview with the Nursing Home Administrator on June 29, 2026, at 2:00pm confirmed the above findings.28 Pa. Code 211.12(d)(5) Nursing services.

Based on observations and staff interviews it was determined that the facility failed to provide hydration for fifteen of thirty-two rooms on the 1st floor dementia care unit.Observations made of resident rooms on December 8, 2025, December 9, 2025, and December 10, 2025, revealed rooms 100 through 115 had no cups of fresh water for resident's hydration or the cups were dated between November 14, 2025, and December 1, 2025. Rooms 116 through 132 were observed to have currently dated cups with fresh water.Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of rooms [ROOM NUMBERS] revealed cups of water dated November 14, 2025. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of room [ROOM NUMBER] revealed a cup of water dated December 1, 2025.All remaining rooms between 100 and 115 had no water cups.Interview on December 10, 2025, at 12:43 p.m., with Registered Nurse Employee E4, E4 confirmed knowledge of rooms 100 through 115 not having fresh water with properly dated cups. Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 10, 2025, at 1:30 p.m., when the above information was presented, the NHA and DON denied knowledge of residents not receiving fresh hydration daily and stated they would investigate the matter.28 Pa. Code 211.10 (c) Resident care policies28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations and staff interviews it was determined that the facility failed to provide privacy curtains for three of thirty-two resident rooms and failed to provide clean privacy curtains for eighteen of thirty-two resident rooms located on the 1st floor dementia care unit.Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 3 rooms with missing privacy curtains. Observations made on December 8, 2025, December 9, 2025, and December 10, 2025, of resident rooms on the 1st floor dementia care unit revealed 18 rooms with privacy curtains that were soiled or had brown stains on them.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 11, 2025, at 10:58 a.m., when the above information was presented, the NHA stated the facility was in the process of remodeling the 1st floor and new privacy curtains have already been ordered for all rooms. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to ensure appropriate advance directives regarding code status were in place for one of 33 residents reviewed. (Resident 114)Findings include:Review of Resident 114's clinical record revealed a physician's order dated October 18, 2025, stating Resident 114 was a Full Code.Review of Resident 114's current care plan revealed Resident 114 had a Full Code Status.Review of a Physician's Order for Life Sustaining Treatment (POLST) signed by Resident 114 and dated November 7, 2025, revealed Resident 114's wishes to have a Do Not Resuscitate status.Interview with the Director of Nursing on December 11, 2025, at 10:00 a.m. confirmed that Resident 114's clinical record did not concur with the POLST signed by Resident 114. 28 Pa. Code 201.14(a) Responsibility of LicenseePreviously cited 10/9/202428 Pa. Code 211.12(c)(d)(3) Nursing ServicesPreviously cited 10/9/2024, 4/30/2025

Based on observations, interviews and record reviews it was determined that the facility failed to provide an assistive device for one of seven residents investigated, (Resident 7).Review of Resident 7's physician orders revealed an order for regular diet, regular texture, thin consistency [NAME] Cup (a spill-proof drinking cup with a secure lid and J-shaped handle) built up fork and spoon dated May 21, 2025.Review of Resident 7's care plan revealed a care plan for nutritional problem or potential nutritional problem related to need for assist with meals, intellectual disability, and weight stable.Review of Resident 7's face sheet revealed medical diagnoses that include Encephalopathy (a group of conditions that cause brain dysfunction).Observations made of Resident 7 on December 8, 2025, December 9, 2025, and December 10, 2025, during lunch service revealed the resident drinking from a regular cup with a straw.Interview on December 10, 2025, at 12:43 p.m., with Unit Manager Registered Nurse Employee E4, E4 confirmed knowledge of resident not drinking from a Kennedy cup as per physician order.Interview conducted with Nursing Home Administrator (NHA) and Director of Nursing (DON) on December 10, 2025, at 12:48 p.m., when the above information was presented, the NHA and DON denied knowledge of the resident not utilizing a Kennedy cup. Interview conducted on December 11, 2025, at 10:58 a.m., with the DON who stated that a new order of Kenndy cups had been received and were now available for Resident 7's use. 28 Pa Code 201.18 (b)(1) Management 28 Pa Code 211.10 (d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined that the facility failed to ensure appropriate monitoring for side effects and effectiveness were completed for the use of an anti-depressant medication for one of 33 records reviewed (Resident 35).Findings include:Review of Resident 35's diagnosis list revealed a diagnosis of major depressive disorder.Review of Resident 35's physician's orders dated November 27, 2025, revealed an order for Mirtazapine (antidepressant) to be administered for treatment of Resident 35's depression.Further review of Resident 35's clinical record failed to reveal evidence of monitoring for side effects of the anti-depressant medication and failed to reveal documented evidence of the effectiveness of the anti-depressant medication.Interview with the Director of Nursing on December 11, 2025, at 11:00 a.m. confirmed that no monitoring for side effects of the anti-depressant medication was conducted and further that no monitoring of the effectiveness of the medication was conducted. 28 Pa. Code 211.12(c)(d)(3) Nursing ServicesPreviously cited 10/9/2024, 4/30/2025

Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 33 residents reviewed (Resident 29)Findings include:Review of Resident 29's admission MDS (Minimum Data Assessment - periodic assessment of resident needs) dated November 30, 2025, section H, Bladder and Bowel, indicated that the resident had an indwelling catheter (flexible tube that carries fluids into or out of the body).Further review of the clinical record no evidence that the resident had an indwelling catheter.Interview with the licensed staff E3 on December 11, 2025, at 10:45 a.m. confirmed that the resident did not have an indwelling catheter and that the MDS was coded incorrectly.28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for two of four residents reviewed (Residents 1 and 3). Findings include: Review of Resident 1's clinical record revealed Resident 1 was admitted [DATE], with diagnoses of but not limited to hypertension (high blood pressure), hyperlipidemia (high levels of fats in the blood), COPD (chronic obstructive pulmonary disease - progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and surgical aftercare following aortocoronary bypass graft (heart bypass surgery - procedure to restore blood flow to areas of the heart), Review of physician's admissions orders revealed a start date of March 30, 2025, for the following medications: Metoprolol Succinate ER (extended release) 50 MG (milligrams), one tablet by mouth twice a day for hypertension (high blood pressure), Spironolactone Oral Tablet 25 MG, one tablet by mouth one time a day for Hypertension, Ezetimibe Oral Tablet 10 MG one tablet by mouth one time a day for hyperlipidemia (high cholesterol), Anoro Ellipta Inhalation Aerosol one puff inhale orally one time a day for COPD/shortness of breath/wheezing, guaifenesin ER Oral Tablet 600 mg one tablet by mouth two times a day for cough/acute bronchitis, Clopidogrel Bisulfate Oral Tablet 75 mg one tablet by mouth one time a day for ASHD (ateriosclerotic heart disease)/history of long term anticoagulant (blood thinner) use, and Viactiv Calcium Immune Oral Tablet Chewable one tablet by mouth one time a day for supplement. Review of the March 2025 Medication Administration Record (MAR) revealed that the above medications were not administered as ordered. Review of orders administration note of March 30, 2025, revealed staff were waiting for delivery for the above medications. Review of Resident 3's clinical record revealed that Resident was admitted [DATE], with a diagnosis of , but not limited to hypopituitarism (decreased secretion of one of the hormones normally produced by the pituitary gland). Review of physician admission orders revealed a start date of April 16, 2025, for Desmopressin Acetate Oral Tablet 0.1 MG one tablet by mouth two times a day for hypopituitarism and Hydrocortisone Oral Tablet 5 MG 0.5 tablet by mouth two times a day for hypopituitarism. Review of the April 2025 MAR revealed that the above medications were not administered as ordered. Review of orders administration note of April 16, 2025, revealed staff were awaiting pharmacy. Interview with the Director of Nursing on April 30, 2025, at 12:15 p.m. confirmed that Residents 1 and 3 did not receive their medications as ordered because they were not available from the pharmacy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 10/9/24

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food in the dry storage located next to the main kitchen. Findings include: Review of the facility's policy entitled, Labeling and storage, dated 2017, revealed that All food should be dated upon receipt before stored, food labels must include the food item name, and the use-by date . Observations during the tour of the main kitchen on October 6, 2024, at 9:12 a.m., revealed the following: Observation of the dry storage 2 area, noting eight opened bags of uncooked pasta without a label and use-by date and were nor properly sealed. Interview conducted on October 6, 2024, at 9:15 a.m., with the Dietary Director E3 confirmed the eight bags of uncooked pasta should have had a label with the name of the item and a use-by date. E3 also stated the above items should have been properly sealed. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, observation, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to one of seven residents reviewed for catheters (Resident 94). Findings include: Review of facility policy, Catheter Care, implemented March 1, 2024, revealed: Catheter care will be performed every shift and as needed by nursing personnel .Document care and report any concerns noted to the nurse on duty. Observation of Resident 94 on October 7, 2024, at approximately 12:30 p.m. revealed the resident had a suprapubic catheter (tube that drains urine from the bladder through a small incision in the abdomen). Review of Resident 94's clinical record failed to reveal documented evidence that staff were providing catheter care. Interview with the Director of Nursing on October 9, 2024, at approximately 11:15 a.m. confirmed there was no documented evidence of catheter care for Resident 94's suprapubic catheter. 28 Pa Code 211.12(d)(5) Nursing Services

Based on clinical record review and staff interview it was determined the facility failed to report results for laboratory studies to the ordering physician timely for one of 40 residents reviewed. (Resident 22) Findings Include: Review of Resident 22's Physician orders revealed an order dated September 11, 2024 for a UA C+S (test of urine to determine if there is a Urinary Tract Infection). Review of Resident 22's Laboratory report for the UA C+S revealed the report was final and was reported on September 15, 2024. Review of Resident 22's Progress Notes revealed a nursing entry on September 18, 2024 stating the results were posted and reported to the physician who ordered antibiotics to treat the urinary tract infection. Interview with the DON on October 9, 2024 at 11:30 a.m. confirmed the results were final on September 15, 2024 but not reported to the physician for orders to begin treatment until September 18, 2024. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on clinical record and facility documentation review and resident/staff interview, it was determined that the facility failed to timely treat a burn and failed to follow a physician medication parameter for two of 33 residents reviewed (Residents 32 and 58). Findings include: Interview with Resident 32 on November 28, 2023, at 9:10 a.m. revealed the resident had a burn on her abdomen from spilling coffee in September. Review of Resident 32's progress notes revealed a nurse's note dated September 10, 2023, at 10:31 a.m. which stated: notified by aide that resident had a skin area on upper abdomen. Upon arrival to room, this nurse noted 4x4 gauze pad on abdomen and once removed, a slightly red non-opened area noted (measured 4cm W x 4 1/2 L). Resident stated 'I burnt myself with coffee on [September 8] a blister appeared and it popped [September 9, 2023.]' Nursing supervisor notified. Cleansed area with [normal saline], applied [triple antibiotic ointment], and covered with bordered gauze. Review of facility documentation revealed on September 8, 2023, at approximately 11:00 a.m., the resident spilled coffee on herself during a coffee social witnessed by Employee E3. Review of facility documentation dated September 12, 2023, revealed Employee E3 received individualized education for failing to report the burn to nursing. Review of facility witness statement from nurse aide Employee E4 revealed on September 8, 2023, the employee noticed a blister on Resident 32's abdomen while putting the resident to bed. Nurse aide Employee E4 notified licensed nurse Employee E5 about the area. Review of facility documentation dated September 12, 2023, revealed licensed nurse Employee E5 failed to assess Resident 32 after nurse aide Employee E4 notified them about the area. Review of Resident 32's September 2023 Treatment Administration Record revealed that a treatment was not started on the burn until September 10, 2023. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Employee E3's failure to report the burn initially and licensed nurse Employee E5's failure to assess Resident 32 resulted in a two-day delay in treating Resident 32's burn. Review of Resident 58's physician order dated October 25, 2023, revealed an order for Midodrine (medication to treat low blood pressure that causes severe dizziness and fainting) HCL Oral tablet 5mg given two tablets by mouth three times a day for Orthostatic Hypotension (A form of low blood pressure that happens when standing up from sitting or lying down). Give if blood pressure is less than 95/60 mmHg. Review of Resident 58's October 2023 Medication Administration Record (MAR) revealed that from October 25, 2023, until October 30, 2023, the medication Midodrine was administered to the resident seven times with a blood pressure above 95/60 mmHg. Interview with the Director of Nursing on November 30, 2023, at 10:00 a.m., confirmed that Resident 58 was administered with Midodrine outside of the ordered blood pressure parameter. The facility failed to follow Resident 58's physician's order regarding blood pressure parameters for Midodrine medication. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services

Based on clinical records facility documentation review and staff interview, it was determined that the facility failed to timely assess a resident's skin impairment and inform the physician of a newly found skin impairment for one of six residents reviewed (Resident 58). Findings include: Review of Resident 58's clinical records revealed resident was admitted to the facility with a diagnosis of Malignant Prostate Cancer, Diabetes, and Severe Protein Calorie Malnutrition. The admission skin assessment dated [DATE], revealed no skin impairment in the resident's midback area. Review of facility documentation, and staff statement dated November 7, 2023, revealed that on November 3, 2023, a bandage gauze dressing was observed on the resident's upper back which was not present during initial assessment. Review of Resident 58's clinical records failed to reveal a completed skin assessment of the mid-upper back upon observing a bandage gauze dressing on November 3, 2023. Review of Resident 58's clinical records, Physician's order, revealed no treatment order the resident's mid-upper back wound on November 3, 2023. Interview was conducted with the Director of Nursing on November 30, 2023, at 10:00 a.m. The DON was unable to provide documented evidence that Resident 58's mid upper back skin was assessed on November 3, 2023, after observing a bandage dressing. The DON also confirmed that although a bandage dressing was observed on the resident's upper mid back, there was no physician's order for a wound treatment on Resident 58's mid-upper back on November 3, 2023. The facility failed to assess Resident 58's skin and notify the physician upon observing a bandage dressing to the resident's upper mid back on November 3, 2023. 28 Pa Code 211.5 (f) Clinical records 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, it was determined that the facility failed to ensure one of 33 residents reviewed was free of unnecessary medications (Resident 137). Findings include: Review of Resident 137's physician's orders revealed an order dated May 20, 2021, to evaluate for verbal and non-verbal signs and symptoms of pain every shift. Review of Resident 137's July 2023 Medication Administration Record (MAR) revealed the resident reported no pain a total of 78 times. Review of Resident 137's August 2023 MAR revealed the resident reported no pain a total of 48 times. Review of Resident 137's September 2023 MAR revealed the resident reported no pain a total of 42 times. Review of Resident 137's October 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's November 2023 MAR revealed the resident reported no pain a total of 50 times. Review of Resident 137's clinical record revealed a nurse's note on November 24, 2023, at 8:39 a.m. which stated that the resident approached this writer stating she will not take any of her prescribed medications unless a provider re-enters a script for Percocet [(narcotic pain reliever.)] When asked if resident was experiencing discomfort, she states I don't think you need to worry about that. I have been taking Percocet for longer than you have been alive. You just do what [you] need to do if you want me to take the medication you want me to take. I need those Percocets. Discussed risks of non-compliance with all medications and [resident] disregarded education stating Just get my Percocet. MD (Medical Doctor) aware of resident request and refusals of all other medications and will assess med regimen. Awaiting return call from provider. Further review of Resident 137's progress notes revealed a nurse's note on November 24, 2023, at 8:47 a.m. which stated that the physician called back and wrote an order for Percocet 5-325 milligrams (mg) every 8 hours as needed for 14 days. Interview with the Director of Nursing on November 30, 2023, at approximately 11:45 a.m. confirmed that Resident 137's refusal to take other medication unless provided with Percocet was not an appropriate reason to continue the resident on narcotic pain medication. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of the facility's policy and clinical records, resident and staff interviews, it was determined that the facility failed to timely and comprehensively assess and provide treatment to residents multiple pressure wounds for two of five residents (Residents 1 and 371) and resulted in harm of a declined condition of wounds for one resident (Resident 371). Findings include: Review of the facility's policy and procedures titled Wound Prevention and Management, dated February 6, 2022, revealed wound treatments will be provided under the physician's orders, including the type of dressing and frequency of dressing change. Treatment decisions will be based on the etiology of the wound (pressure injuries, surgical, incidental, and atypical) and characteristics of the wound (pressure injury stage, size, exudate, location of the wound, and presence of pain). The facility will follow specific physician orders for providing wound care, treatments will be documented on the Treatment Administration Record (TAR). Review of Resident 371's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated December 17, 2022, revealed resident was cognitively intact. The same MDS revealed resident required extensive two people assistance with bed mobility. Review of the hospital records dated December 13, 2022, revealed problem list including Osteomyelitis (infection in the bone), Cellulitis (bacterial skin infection), and diabetic ulcer of the left heel associated with Diabetes Mellitus, with bone involvement without evidence of necrosis. Review of nursing progress notes dated December 14, 2022, at 10:49 a.m., revealed Resident 371 was admitted to the facility from the hospital with a diagnosis of Cellulitis, and Osteomyelitis, all medication orders were reviewed by the on-call physician. Review of Resident 371's diagnosis list revealed Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Peripheral Vascular Disease (PVD -blockage or narrowing of the blood vessels outside of the heart and brain that worsens over time), and Osteomyelitis of the foot. Review of the nursing progress notes dated December 15, 2022, at 3:21 p.m., revealed Resident 371 had multiple open areas: a wound to the left ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone), left buttock, right buttock, right low back, left heel, right great toe, and redness to groin all open areas. Review of Resident 371's care plan goal for skin integrity initiated on December 15, 2022 revealed interventions of encourage good nutrition and hydration, follow facility protocols for treatment, and LAL (Low Air Loss)mattress. Clinical record reviews failed to reveal the above mentioned wounds were present upon admission. Further review of clinical record failed to reveal the wounds identified on December 15, 2022, were comprehensively assessed upon identification. Interview with the Director of Nursing (DON) conducted on January 20, 2023, revealed that upon admission, a head-to-toe skin assessment should be completed on every resident. Any identified open skin area will include location, size, color, and presence of drainage and odor. The DON confirmed that the admission skin assessment was not completed. The DON confirmed that the identified wounds noted on December 15, 2022, were not comprehensively assessed. Review of physician orders dated December 15, 2022, revealed the following treatment orders: Normal saline solution (NSS) or wound cleanser to the left ischium, right and left buttock, cover with dressing everyday shift; and Cleanse right low back with NSS or wound cleanser, apply bordered foam dressing everyday shift. Review of the December 2022 Treatment Administration Record (TAR) revealed that the left ischium, right and left buttock, and right low back wound treatment order was not administered until the morning of December 17, 2022; two days after the wound was identified. Review of the wound care consult dated December 20, 2022, revealed the following: Right lower back, full-thickness ulceration, 2.5 x 0.6 x 0.1 cm (centimeter) in size, 10% deep purple, 30% slough (non-viable yellow, tan, gray, green, or brown tissue; usually moist, can be soft, stringy, and mucinous in texture) with serous drainage, the wound was identified as an Unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer secondary to a slough; Left ischium, full thickness ulceration measures 6.0 x 7.5 x 0.1 cm, 10% deep purple with serous drainage, the wound was identified as Unstageable pressure ulcer; Left buttock, full thickness ulceration, measures 5.0 x 7.0 0.1 cm, 20% deep purple, 20% slough with serous drainage, the wound was identified as Unstageable pressure ulcer; and Right buttock, full thickness ulceration, measures 4.2 x 5.0 x 0.1 cm, 60% slough with serous drainage, the wound was identified as Unstageable pressure ulcer. The recommended treatment was to clean the right lower back, left ischium, and right and left buttock with NSS or wound cleanser, apply medical grade honey to wound bases daily and as needed cover with a dry dressing, and monitor the site for signs and symptoms of infection-bogginess, drainages, and erythema. Review of the physician order dated December 21, 2022, revealed an order to clean the right low back, left ischium, and right and left buttock with NSS or wound cleanser, apply Medihoney and cover with dressing everyday shift. Review of the December 2022 and January 2023, TAR revealed wound treatments for the right low back, left ischium, and right and left buttock were not completed on the following dates: December 22, 23, 25, 26, 29, 30, 31, 2022, and January 2, 2023. Interview with Resident 371 conducted on January 19, 2023, at 1:00 p.m. confirmed the wound treatments were not administered daily. The Resident stated that the wound treatment was spotty. Interview conducted with the Director of Nursing on January 20, 2023, at 9:00 a.m., revealed the DON was unable to provide rationale or documentation for wound treatments not being done on the above-mentioned dates. Further review of Resident 371's clinical records failed to reveal the physician was notified of the missed wound treatments. Review of the wound care consults dated January 3, 2023, revealed: Left ischium wound measures 6.3 cm (centimeter) x 7.0 x 0.1 cm, 50% deep purple, the wound was still identified as unstageable stage secondary to slough and had declined; the Left buttock wound measures 4.2 x 7.0 x 0.1 cm, 50% deep purple, identified as an unstageable stage, and had declined due to discoloration; Right buttock wound measures 2.1 x 3.3 x 0.1 cm, moderate serosanguinous drainage, the wound was still identified as unstageable stage and had declined; the Right lower back wound was resolved. The Medihoney wound treatment order was continued. Review of the January 2023 TAR revealed from January 3, until January 12, 2023, left ischium, right and left buttocks did not have documented treatment for four days (January 4, 5, 7, and 11). The above information was conveyed to the Director of Nursing on January 20, 2023, at 11:00 a.m. The facility failed to timely assess and provide treatment to resident 371's left ischium, right low back, right and left buttock wounds resulting in the harm of a declined wound condition of the left ischium, right and left buttock wounds. Review of Resident 1's progress notes revealed a nursing entry dated| October 4, 2022 at 9:33 p.m. stating resident returned to this facility via stretcher, came from the hospital. Physical assessment found the following: Bruises on both arms upper and lower from the IV lines, wound on the left side of his buttock. It was covered with dressing. Further review of Resident 1's clinical record revealed no other documentation on the buttock wound when readmitted from the hospital on October 4, 2022. Further review of Resident 1's clinical record revealed a skin evaluation was completed on October 6, 2022 and October 10, 2022. Both skin evaluations indicated the resident had a current impairment but no measurements or description of the wound. Review of Resident 1's Wound CRNP (Certified Registered Nurse Practitioner) consultation report dated October 13, 2022 revealed staff reported resident returned from hospital with a dressing on his left buttock early last week full thickness ulceration of the left buttock measuring 6.5 x 8.0 x 0.1 centimeters, wound base 100% slough (dead tissue) and firm. Scant nonodorous serous (clear and watery) drainage Diagnosis: suspect soft tissue abscess of the buttock. Interview with the Director of Nursing on January 20, 2023 at 10:00 a.m. confirmed there was no complete documentation of Resident 1's wound when readmitted from the hospital on October 4, 2022 until seen by the CRNP on October 13, 2022. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/21, 11/1/22

Based on facility policy and procedure review, observations, and staff interview it was determined the facility failed to date multidose insulin vials on one of three units. (2nd floor) Findings Include: Review of facility policy titled, Vials and Ampules of Injectable Medications revealed, opening a vial triggers a shortened expiration date that is unique for that product. The date opened, and this triggered expiration date are both important to be recorded on multi-dose vials. At a minimum, the date opened must be recorded. Guidelines recommend discarding multi-dose vials at 28 days after opened. Observation of the Middle medication cart on the second floor on [DATE] at 9:15 a.m. revealed two Lantus (long acting insulin) insulin pens, one Novolog (short acting insulin) pen, one Basaglar (long acting insulin) insulin pen, one Lantus insulin vial, 2 Humalog (short acting insulin) insulin vials, and a Novolog vial all undated. Further observations of the Middle medication cart revealed an undated Lantus insulin vial for a resident that was discharged on [DATE]. Further observations of the Middle medication cart revealed a Levemir (long acting insulin) vial dated [DATE] from a resident who was discharged on [DATE]. Interview with Licensed Nursing Employee E5 on [DATE] at the time of the observations confirmed the vials were undated and should have been dated the day they were opened and the vials that were dated were expired and should have been discarded. Observation of the North medication cart on the second floor on [DATE] at 9:30 a.m. revealed one vial of Lantus insulin that was undated. Interview with licensed Nursing Employee E6 at the time of the observation confirmed the insulin vial should have been dated when opened. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing Services

Based on clinical records review, staff, and resident interviews, it was determined that the facility failed to follow a physician's order regarding multiple diabetic ulcer treatments for one of the five residents reviewed (Resident 371). Findings include: Review of Resident 371's diagnosis list revealed Diabetes (A group of metabolic disorders characterized by a high blood sugar level over a prolonged period), Peripheral Vascular Disease (PVD -A blockage or narrowing of the blood vessels outside of the heart and brain that gets worse over time), and Osteomyelitis (Bone infection) of the foot. Secondary to Review of the wound care consult dated December 20, 2022, revealed resident was admitted to the facility on [DATE], for rehabilitation, acute admission secondary to acute Osteomyelitis. Current treatment includes IV (Intravenous - medication administered through a vein) antibiotic for 40 days. The same consult revealed the presence of a diabetic foot ulcer on the left 1st MTP (Metatarsophalangeal- located in the forefoot where the metatarsal and phalanx meet), right 1st MTP, right 2nd MTP, right 4th MTP, and right 5th MTP. The same consult revealed Osteomyelitis of the 4th and 5th MTP. Review of the Physician's Order Sheet (POS) dated December 21, 2022, revealed an order to cleanse diabetic ulcer to the left 1st MTP, right 1st, 2nd, 4th, and 5th MTP with NSS (Normal Saline Solution) or wound cleanser, apply Betadine to wound base and leave open to air everyday shift. Review of the December 2022 MAR revealed that the treatment order was not done on December 22, 23, 25, 26, 29, 30, and 31. Interview with Resident 371 was conducted on January 19, 2023, at 1:00 p.m. Resident 371 confirmed that the wound treatment was not being done daily. The Resident stated that the wound treatment was spotty. Interview with the Director of Nursing (DON) on January 20, 2023, at 9:00 a.m., was conducted. The DON was unable to provide a reason or documentation for wound treatment not being done on the above-mentioned dates. The facility failed to follow the physician's order for Resident 371 diabetic foot ulcers. 28 Pa. Code 201.18(b)(1) Management Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.5(f) Clinical records Previously cited 12/16/21, 11/1/22 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 12/16/21, 11/1/22

Based on review of facility policy, resident and staff interview, and clinical record review, it was determined that the facility failed to provide documented evidence that consisted, adequate catheter care was provided to prevent urinary tract infections for one of two residents reviewed (Resident 24). Findings include: Review of facility policy, Foley (Indwelling Urinary) Catheters and Care, effective date September 2020, revealed: Catheter care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter .Routine meatal care is performed daily and as needed. Interview with Resident 24 on January 18, 2023, at 11:56 a.m., revealed the resident had a foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine) and was complaining of burning pain at the catheter site due to having a urinary tract infection (UTI). Further interview with Resident 24 revealed that staff were not consistent with providing catheter care. Review of Resident 24's clinical record revealed a physician's order dated January 17, 2023, for levofloxacin (antibiotic) 250 milligrams one tablet by mouth at bedtime for seven days for UTI. Further review of Resident 24's physician's orders, Medication Administrator Records, Treatment Administration Record, and care plan failed to reveal evidence that the resident was receiving routine catheter care. Interview with nurse aide Employee E4 on January 20, 2023, at 11:56 a.m. revealed the aide's responsibility to Resident 24's catheter was to empty it and report the output to nursing. Interview with licensed nurse Employee E5 on January 20, 2023, at 11:50 a.m. revealed it is nursing's responsibility to perform catheter care. Employee E5 confirmed there was no evidence in Resident 24's clinical record that staff were performing routine catheter care to Resident 24. The above findings were discussed with the Director of Nursing on January 20, 2023 at approximately 1:30 p.m. 28 Pa Code 211.12(d)(5) Nursing Services

Based on facility policy review, observation, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and address weight loss in one of seven residents reviewed for nutrition (Resident 20). Findings include: Review of facility policy, Nutrition, effective date February 2, 2022, revealed: Each resident will be weighed upon admission and re-admission weekly for 4 weeks during the resident's stay .Weight variances will be reviewed by dietician and [interdisciplinary team] .If a resident refuses to be weighed refusal will be noted in the electronic medical record .The Dietitian/designee will reassess the nutritional needs and intakes of any resident with a significant weight change .Interventions will be evaluated, documentation made in the electronic medical record, and the resident's plan of care updated. Observation of Resident 20 on January 17, 2023, at 12:49 p.m. revealed the resident had a jejunostomy tube (J-tube) (soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine). Review of Resident 20's clinical record revealed diagnoses including, but not limited to, Dysphagia (difficulty swallowing) and Spastic Quadriplegia Cerebral Palsy (disorder that affect a person's ability to move and maintain balance and posture; spastic quadriplegia is the most severe form and affects all four limbs, the trunk, and the face.) Further review of Resident 20's clinical record revealed the resident was readmitted to the facility following a prolonged hospital stay on July 13, 2022, where the resident first received the J-tube. Review of Resident 20's weights revealed a weight was not obtained on Resident 20's readmission from the hospital until July 22, 2022, where the resident was documented as weighing 140.2 pounds (lbs.) The next weight recorded in Resident 20's clinical record was on August 8, 2022, where the resident was documented as weighing 145.3 lbs. The next weight recorded in Resident 20's clinical record was on September 6, 2022, where the resident was documented as weighing 121.1 lbs., a 19.98% loss in one month. Further review of Resident 20's weights revealed the next weight obtained was on September 20, 2022, where the resident was documented as weighing 122.2 lbs. Review of Resident 20's progress notes revealed a weight change note on September 26, 2022 from the dietitian, Employee E3, which stated: Last three hospital visits were due to J-tube dislodgement (8/31), hematuria and UTI [(blood in urine and urinary tract infection)] 9/3 and then J-tube not flushing 9/8-9/9. Weight fluctuations difficult to explain, some error may be a cause as well as prolonged hospitalization and fluid shifts may be a factor with surgery and new J-tube. Currently, res. is at a desirable weight and goal would be to stabilize at this time. Review of Resident 20's hospitalization s revealed the resident went to the hospital August 31, 2022, and returned the same day due to j-tube dislodgement. The resident transferred to hospital again on September 3, 2022 and returned the same day with a diagnosis of UTI. The resident went out again September 8, 2022, and returned September 9, 2022, due to j-tube dislodgement. Further review of Resident 20's progress notes revealed weight change notes from Employee E3 on September 28, 2022 which stated that the physician and resident's responsible party were notified of the resident's weight loss, which was first documented on September 6, 2022; 22 days prior to notification. Further review of Resident 20's progress notes revealed a physician's note on September 30, 2022 which stated: Weight fluctuating but no change clinically. Further review of Resident 20's weights revealed that on November 10, 2022, the resident weighed 122.1 lbs. On December 14, 2022, the resident weighed 112 pounds which is an 8.27 % loss in one month. There were no weights documented between the November 10th and December 14th weights, despite the resident being hospitalized on [DATE] and readmitted to the facility November 28, 2022. Review of Resident 20's progress notes revealed a weight change note from the dietitian, Employee E3, on December 28, 2022, 14 days after the resident's significant weight loss was first documented, which attributed the resident's weight loss to multiple hospitalization s. Review of Resident 20's hospitalization s revealed the resident went to the hospital November 13, 2022 and returned the same day for j-tube dislodgement. The resident went to the hospital again on November 24, 2022 for j-tube dislodgement and returned November 28, 2022 with diagnoses of covid-19 and UTI. The resident went to the hospital again on December 7, 2022, and returned December 8, 2022, for j-tube dislodgement. Further review of Resident 20's progress notes revealed progress notes from the dietitian, Employee E3, on December 30, 2022, stating they notified the physician and responsible party of the resident's weight loss. Interview with Employee E3 on January 20, 2023, at 11:23 a.m. confirmed readmission weights and reweights for Resident 20 were not done in a timely manner. Employee E3 stated that Resident 20 refuses weights at times, though refusals were not documented in the resident's clinical record. The facility's failure to obtain readmission weights and weekly weights for four weeks, reweights in a timely manner, and the delays in addressing Resident 20's weight loss were discussed with the Director of Nursing on January 20, 2023, at 1:30 p.m. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on review of clinical records and staff interviews, it was determined that the facility failed to develop comprehensive care plans to address the individual needs of five out of 24 residents reviewed (Residents F10, I5, M6, N5, and CL3) which resulted in actual harm to one resident (Resident F10) who sustained a [MEDICAL CONDITION] and fibula of the right leg during a transfer. Findings include: Review of Resident F10's [DIAGNOSES REDACTED]. Review of Resident F10's quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident needs), dated January 5, 2017, Section G, Functional Status, Section G0110 B, Transfer Status, revealed that Resident F10 required the extensive assistance of two persons for transfers. Section G0300, Balance During Transition and Walking, assessed the resident as not steady and only able to stabilize with staff assistance for surface to surface transfer. Further review of Resident F10's quarterly MDS, Section G0400, Functional Limitation in Range of Motion, revealed that Resident F10 had upper extremity and lower extremity impairment on both sides of the body. Review of Resident F10's December 2016 physician's orders [REDACTED]. Review of Resident F10's nursing notes dated March 2, 2017, revealed that at approximately 3:25 p.m. on March 2, 2017, Resident F10 was sitting in a wheelchair crying and requesting to be returned to bed. Licensed Nurse, Employee E10, requested Resident F10's assigned caregiver to return the resident to the bed. Further review of Resident F10's nursing notes revealed that at approximately 5:30 p.m., Resident F10's husband approached Employee E10 and stated that per Resident F10, when the assigned caregivers transferred the resident into the bed, they bumped Resident F10's right leg into the side of the bed and Resident F10 was now complaining of pain. Employee E10 followed the resident's husband into the room to assess the resident. The resident's right knee was observed to be swollen and warm to touch. Further review of the nursing note indicated that the physician was made aware and stated, new order given for STAT (immediate) x-ray to right knee femur (thigh bone), tibia (shin bone) and fibula (calf bone). Nursing supervisor and Director of Nursing went into resident's room to asked her what happen, resident replied that when nursing assistants were transferring her from wheelchair to bed, they bumped her right leg on the side of the bed but she didn't feel it and at the same time the nursing assistant were not aware of bumping her right leg on the side of bed. Review of the X-ray report dated March 1, 2017, revealed that Resident F10 sustained a fracture (a break) of the tibia and fibula (two bones located in the lower portion of the leg) of the right leg. Further review of nursing note dated March 2, 2017 noted that a physician's orders [REDACTED]. The resident left the facility approximately at 10:00 p.m. via stretcher escorted and transported by emergency medical personnel. Further review of Resident F10's clinical record revealed that the facility failed to update Resident's F10 active care plan in directing the nursing staff to transfer the resident via a Hoyer lift during all transfers per physician's orders [REDACTED].>Review of the information dated March 1, 2017, submitted by the facility confirmed that the physician's orders [REDACTED]. to transfer, eat, bed mobility, ambulation, toileting and devices) to be used by the caregivers. An interview with the Director of Nursing on March 27, 2017, at approximately 11:00 a.m. confirmed that the physician's orders [REDACTED]. The facility failed to update the Resident F10's plan of care and care card for transfer status and by two nursing assistants transferring Resident F10 without the use of a Hoyer lift, as ordered by the physician, which resulted in nursing staff bumping Resident F10's right leg into the side of the bed and the resident sustaining a right leg [MEDICAL CONDITION] and fibula during a transfer. Review of Resident M6's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident M6's nursing notes dated January 3, 2017, documented that the resident was being treated for [REDACTED]. Review of the physician's progress note dated March 16, 2017, documented that Resident M6 was noted for a few days with classic grouped blisters on the left buttock dermatone (an area of skin that is mainly supplied by a single spinal nerve) and was diagnosed with [REDACTED]. Review of Resident M6's current plan of care revealed that there was no plan of care developed regarding the resident's [DIAGNOSES REDACTED]. An interview with the Director of Nursing on March 27, 2017, at approximately 12:00 p.m. confirmed that Resident M6's comprehensive care plan was developed on March 27, 2017, to include those focus areas regarding Diabetes Mellitus, impairment to skin integrity related to shingles, and limited mobility, and pressure ulcer development related to history of pressure ulcers. Review of the [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the clinical record failed to reveal that a care plan was developed to address symptoms of [MEDICAL CONDITION], to manage care during and after a [MEDICAL CONDITION] including physician notification, and to educate the resident and family about the condition and care. Review of the [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the clinical record failed to reveal a care plan developed to address the administration, care, and maintenance for the PEG tube for this resident which was discussed with the NHA on March 27, 2017, at 1:30 p.m. Review of [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of clinical record failed to reveal that care plans were developed for the [MEDICAL CONDITION] or the [MEDICAL CONDITION] machine maintenance and care which was discussed with the Nursing Home Administrator on March 23, 2017, at approximately 2:00 p.m. The facility failed to ensure that the plans of care for Residents F10, M6, CL3, I5, and N5 were developed to address all the individual needs of these residents. 42 CFR 483.20(d), 483.20(k)(1) Develop Comprehensive Care Plans Previously cited 06/24/15, 11/20/15 28 Pa. Code 201.18(a) Management Previously cited 06/24/15, 01/15/17 28 Pa. Code 201.18(b)(1) Management Previously cited 06/24/15, 11/20/15, 05/09/16, 01/15/17 28 Pa. Code 201.18(b)(3) Management Previously cited 06/24/15, 05/09/16, 01/15/17 28 Pa. Code 211.5(f) Clinical records Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 05/09/16 28 Pa. Code 211.10(a) Resident care policies Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15 28 pa. Code 211.11(a)(c) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 06/24/15, 11/20/15 28 Pa. Code 211.12(c) Nursing services Previously cited 06/24/15, 09/04/15, 11/20/15, 05/09/16, 01/15/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 01/15/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 05/09/16, 01/15/17

Based on clinical record review, review of facility documentation and staff interview, it was determined that the facility failed to ensure that interventions developed were fully implemented and in place to ensure the safety of the residents for one of 24 residents reviewed, which resulted in actual harm to one resident (Resident F10) who sustained a fracture of the tibia and fibula of the right leg during a transfer. Findings include: Review of Resident F10's [DIAGNOSES REDACTED]. Review of Resident F10's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated January 5, 2017, Section C, Cognitive Patterns, assessed the resident with a BIMS score of 13 out of 15 (Brief Interview for Mental Status - a tool used to assess a resident's cognitive status) which identified the resident as cognitively intact. Section G, Functional Status, and Section G0110 B, Transfer Status, revealed that Resident F10 required the extensive assistance of two persons for transfer. Section G0300, Balance During Transition and Walking, assessed the resident as not steady; only able to stabilize with staff assistance for surface to surface transfer. Further review of Resident F10's quarterly MDS assessment, Section G0400, Functional Limitation in Range of Motion, revealed that Resident F10 had upper extremity and lower extremity impairment on both sides of the body. Review of Resident F10's December 2016 physician's orders [REDACTED]. Review of Resident F10's active plan of care failed to reveal that the Hoyer lift was to be used at all times for Resident F10's transfers as ordered by the physician. Review of Resident F10's nursing notes dated March 2, 2017 at 12:27 a.m., revealed that at approximately 3:25 p.m. on March 1, 2017, Resident F10 was sitting in a wheelchair crying and requesting to be returned to bed. Licensed Nurse, Employee E10, requested Resident F10's assigned caregiver to return the resident to bed. Further review of Resident F10's nursing notes revealed that at approximately 5:30 p.m., Resident F10's husband approached Employee E10 and stated that per Resident F10, when the assigned caregivers transferred the resident into bed, they bumped Resident F10's right leg into the side of the bed and Resident F10 was now complaining of pain. Employee E10 observed Resident F10's right knee to be swollen and warm to touch. Review of the March 2017 physician's orders [REDACTED]. Review of the X-ray report dated March 1, 2017, revealed that Resident F10 sustained a fracture (a break) of the tibia and fibula of the right leg. Review of the facility's investigation into Resident F10's injury revealed a statement obtained by Licensed Nursing staff, Employee E13, which noted that Resident F10 stated during an interview that she was not transferred back into bed via a Hoyer lift, during both 7-3 and 3-11 shifts. The statement further noted, the nursing assistant was unaware the resident struck her right knee against her bed during the transfer. Review of statements obtained from both nursing assistants, Employee E11 and Employee E12, revealed that Employee E11 stated when the resident was transferred by Employee E11 and Employee E12, the resident complained of pain and asked the nursing assistants to notify the Licensed Nurse that she wanted a pain medication. An interview with the Director of Nursing on March 27, 2017, at approximately 11:00 a.m. confirmed that the physician's orders [REDACTED]. [REDACTED]. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 06/24/15, 11/20/15, 01/15/17 28 Pa. Code 201.18(b)(1) Management Previously cited 06/24/15, 11/20/15, 05/09/16, 01/15/17 28 Pa. Code 201.18(b)(3) Management Previously cited 06/24/15, 05/09/16, 01/15/17 28 Pa. Code 201.18(e)(1) Management Previously cited 06/24/15 28 Pa. Code 211.5(f) Clinical records Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 05/09/16 28 Pa. Code 211.10(a) Resident care policies Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15 28 Pa. Code 211.10(c) Resident care policies Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 05/09/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/24/15, 10/09/15, 11/20/15 28 pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 06/24/15, 11/20/15 28 Pa. Code 211.12(c) Nursing services Previously cited 06/24/15, 09/04/15, 11/20/15, 05/09/16, 01/15/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 01/15/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/24/15, 09/04/15, 10/09/15, 11/20/15, 05/09/16, 01/15/17

Based on clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to ensure that care and services were provided for a resident with a [MEDICAL CONDITION] which resulted in actual harm by the resident pulling out the [MEDICAL CONDITION], becoming unresponsive, and required emergency medical services for one resident (Resident L1), failed to ensure that the physician's orders [REDACTED]. Findings include: Review of Resident L1's [DIAGNOSES REDACTED]. and is often fatal if not treated immediately), anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety), depression (the major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine) and the resident had a pacemaker (a surgically implanted electronic device to stimulate the heartbeat). Review of Resident L1's nursing notes revealed that on [DATE], Resident L1 removed the [MEDICAL CONDITION]. Nursing staff were unable to replace the [MEDICAL CONDITION] at that time and Resident L1 was subsequently transferred to the hospital emergency room for replacement of the [MEDICAL CONDITION]. Further review of Resident L1's nursing notes revealed that on [DATE], Resident L1 returned to the facility with the [MEDICAL CONDITION] in place. Immediately after returning to the facility, Resident L1 made another attempt to remove the [MEDICAL CONDITION]. Continued review of the nursing notes indicated that physician's orders [REDACTED]. Review of Resident L1's nursing notes revealed that on [DATE], at approximately 9:00 a.m. Resident L1 was found unresponsive in bed with the [MEDICAL CONDITION] pulled out. Further review of Resident L1's nursing notes revealed that Resident L1 was found with the [MEDICAL CONDITION] not present and the notes stated, Resident was without pulse or respirations. The facility's immediate action included calling emergency medical services, replaced [MEDICAL CONDITION] at [MEDICAL CONDITION] site and began ventilating with ambu bag (a resuscitator bag used to assist ventilation) and oxygen. Another nurse began CPR (cardio-pulmonary resuscitation - an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing) after 2 rounds of CPR resident and (had) a pulse. Continue ventilating until resident began breathing on her own but continued with oxygen support. Resident L1 was transferred to the hospital on [DATE], by emergency services. Further review of Resident L1's nursing notes dated [DATE], revealed no documented evidence that the resident's left hand mitt was in place during morning nursing rounds. An interview with the Physical Therapist, Employee E7, on [DATE], at approximately 2:00 p.m. revealed that Employee E7 arrived in Resident L1's room on [DATE], at 7:00 a.m. to begin therapy treatments. Employee E7 revealed that upon Employee E7's arrival in Resident L1's room, the resident was observed not to have the mitt on the left hand. An interview with the Nursing Home Administrator and the Director of Nursing on [DATE], at approximately 11:00 a.m. confirmed that the mitt was not on Resident L1's left hand as ordered by the physician. The facility failed to apply a mitt to Resident L1's left hand as ordered by the physcian to inhibit any attempts at removing the [MEDICAL CONDITION] which resulted in actual harm by the resident pulling out the [MEDICAL CONDITION], becoming unresponsive, requiring cardio [MEDICAL CONDITION] resuscitation, ventilation and oxygen; subsequently, Resident L1 was transferred to the hospital via emergency medical services. Review of Resident F1's [DIAGNOSES REDACTED].) Review of the physician's orders [REDACTED]. Review of Resident F1's nursing notes dated [DATE], documented that the resident's Accucheck measured 267 mg/dl, a nursing note dated [DATE], documented that the resident's Accucheck measured 226 mg/dl and a nursing note dated [DATE], documented that the resident's Accucheck measured 178 mg/dl. Review of the Resident F1's entire clinical record revealed no documented evidence that the resident's physician was notified when the resident's weekly Accucheck measured greater than 170 on the above stated dates. An interview with the Director of Nursing on [DATE], at 10:15 a.m. confirmed that the nursing staff failed to follow the physician's orders [REDACTED]. Review of Resident F5's [DIAGNOSES REDACTED]. Review of Resident F5's [DATE] physician's orders [REDACTED]. Review of Resident F5's [DATE] Medication Administration Record [REDACTED]. Further review of Resident F5's [DATE] MAR indicated [REDACTED]. The above information was conveyed to the Director of Nursing on [DATE], at approximately 11:10 a.m. 42 CFR 483.24 Provide Care/Services for Highest Well Being Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE] 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.10(c) Resident care policies Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(3) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]

Based on review of the facility's policy, review of clinical records, observations and interviews with staff, it was determined that the facility failed to ensure that all staff were educated on how to evacuate a bariatric (extreme obesity), non-ambulatory resident from the third floor of the building, placing the health and safety of the residents in an Immediate Jeopardy situation for four residents (Residents I123, K163, K172, and J151). The facility failed to provide a safe environment for residents of the third floor by securing resident care equipment that had the potential to burn residents and the facility failed to provide residents with safe access entering and exiting the second floor nursing unit to the main foyer area of the building in order to prevent accidents/injuries. Findings include: Review of facility policy entitled, Bariatric Resident Evacuation Policy effective April 2006, revealed that the procedure to remove a bariatric resident's bed from the resident's bedroom in an emergency is to collapse the bed. The procedure stated to, Remove both head boards and foot boards, remove the mattress extenders on each side. Pull the knob or pull string under each bed extender (located under bed frame), push in extender at the same time until flush with the bed frame, and push the bed through the door. According to the National Institutes of Health report, Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel, 2013 indicated that a person with a body mass index (BMI - measure of body fat based on height and weight) equal to or greater than 40 exhibits extreme obesity. Residents I123, K163, K172 and J151 resided on the 3rd floor of the facility. The 2nd floor is at ground level. Review of Resident I123's quarterly Minimum Data Set assessment (MDS - an assessment of resident care needs and status) dated March 2, 2015, revealed that the resident was non-ambulatory. Review of the vital sign record revealed that the resident was 5 feet 2 inches tall with a weight of 224.4 pounds on June 10, 2015, resulting in a calculated BMI of 41.0. Observation on June 23, 2015, at 12:00 p.m., and on June 24, 2015, at 10:00 a.m., revealed the resident was in a bariatric bed on the third floor. Review of Resident J151's discharge MDS assessment dated [DATE], revealed that the resident was non-ambulatory. Review of the vital sign record revealed that the resident was 6 feet tall and weighed 401.6 pounds on June 12, 2015, resulting in a calculated BMI of 64.5. Observation on June 24, 2015, at 11:00 a.m., revealed that Resident J151 had a bariatric bed on the third floor, but was not in the bed. Review of Resident K163's quarterly MDS assessment dated [DATE], revealed that the resident was non-ambulatory. Review of the vital sign record revealed that the resident was 5 feet 6 inches tall and weighed 319.8 pounds on June 5, 2015, resulting in a calculated BMI of 51.6. Observation on June 23, 2015, at 2:00 p.m., Resident K163 was observed in a bariatric bed on the third floor waiting to be assisted for incontinence care. Review of Resident K172's face sheet revealed that the resident was admitted on [DATE]. Review of the vital signs record revealed a height of 5 feet 11 inches and a weight of 324.0 pounds on June 18, 2015, resulting in a calculated BMI of 45.2. Observation of the resident on June 24, 2015, at approximately 11:30 a.m., revealed that the resident was in a bariatric bed on the third floor, getting ready for a transfer to a hospital stretcher. Emergency Medical Technicians were observed at this time setting up the stretcher to accommodate a bariatric patient with metal side extensions. Interview with Licensed Staff, Employee E12, on June 18, 2015, at 12:55 p.m., revealed that the bariatric beds do not collapse and do not go through the resident room doors. The employee also revealed that they would utilize sheet blankets to lower the resident to the floor and evacuate in that manner out of room. Interview with Licensed Nurse, Employee E13 on June 18, 2015, at 4:50 p.m., revealed that the bariatric beds do not collapse and they do not fit through the doors. Interview with the Nursing Home Administrator (NHA) on June 23, 2015, at 8:30 a.m., revealed that the bariatric beds do collapse and that sheets would be used to evacuate the residents down the stairs. Interview with Nurse Aides, Employee E14 and Employee E15, on June 23, 2015, at 9:00 a.m., revealed that the bariatric beds do not go through the resident room doors and that they would utilize 4 people to lower the resident to the floor with sheets or blankets and evacuate them out of the room. Interview with the Maintenance Assistant, Employee E8, on June 23, 2015, at 9:05 a.m., revealed that the bariatric beds will lower, but will not fit through the door. Staff would use sheets to lower the resident to the floor. Employee E8 indicated that the door frame opening is 36 inches and the bariatric beds are 42-48 inches wide. Interview with the Maintenance Director, Employee E11, on June 23, 2015, at 9:45 a.m., revealed that all beds go through the door, including the bariatric beds, which collapse. Employee E11 indicated that in-services were done with staff to educate them on collapsing the beds. Observation of Maintenance Director, Employee E11 on June 23, 2015, at 11:20 a.m., revealed the employee demonstrating collapsing the bariatric bed in room 328. Employee E11 indicated that usually two people are needed to help hold the mattress in while going out the door. Observation and confirmation by Employee E11 revealed that the bed would not go through the door. Employee E11 stated he would need a wrench to remove the side rails in order for the bed to go through the door. Interview with Regional Consultant, Employee E16, on June 23, 2015, at 12:05 p.m., revealed that the facility does not use maxi-slides (a flat sheet sliding system designed to transfer a resident from the bed to a wheelchair/stretcher) because the weight capacity for that system is 400 pounds. Interviews with two Licensed Nurses, Employee E12 and Employee E13, and two Nurse Aides, Employee E14 and E15, (at the date and times stated above) who worked on the third floor along with the two maintenance staff, revealed that the staff did not know how to remove a bariatric bed with a non-ambulatory resident from a resident room in an emergency. The NHA was informed on June 23, 2015, at 12:25 p.m., that the health and safety of these residents was in Immediate Jeopardy due to the facility's failure to educate the staff and provide directions for the safe evacuation of the resident using a bariatric bed in the event of a fire or other emergency requiring evacuation. Measurements of the bariatric bed in room 328 obtained on June 23, 2015, at 12:45 p.m., in the presence of the Maintenance Director, Employee E11, revealed that the bed and the mattress was 48 inches wide and the footboard was 38 inches wide. The bed had side rails. When the bed frame collapsed, it was measured at 39 inches but the side rails were still in place and the bed would not go thru the door frame that was approximately 41 inches. Later, Employee E1 stated that the side rails needed to be removed to allow the bed to go through the door frame and the mattress would have to be bent when going through the opening. Interview with Maintenance Director, Employee E11, on June 23, 2015, at 12:50 p.m., revealed that there were different types of bariatric beds. Employee E11 indicated that the bariatric bed in room 202 was the type that the headboard and footboard would have to be removed for the bed to go through the door. Employee E11 was not aware of how staff would know that they needed to do that in order to move the bed. Employee E11 again stated that in-services were done in the past, but could not provide dates of in-services that demonstrated the breakdown of the beds and the staff who actively participated. Interview with the NHA on June 23, 2015, at 1:00 p.m., revealed that fire safety was covered in new hire orientation, but could not provide evidence that the breakdown of bariatric beds was covered or that there was ongoing training for the staff. Interview with the NHA on June 24, 2015, at 12:00 p.m., revealed that bariatric evacuation was covered in the fire/disaster drills, but was not sure if bariatric beds were ever evacuated during these drills. Review of the fire/disaster drills from May 2014 through May 2015, revealed no evidence that bariatric beds were evacuated as part of these drills. The facility submitted and implemented an acceptable plan of action and the Immediate Jeopardy was removed on June 24, 2015, at 12:35 p.m. The action plan included procedures on how to collapse all makes/models of bariatric beds. The procedure will be secured to the back of the bed's headboard. Interviews and demonstration by the nursing staff on June 24, 2015, showed that nursing staff were trained in the procedure to remove bariatric beds and the Immediate Jeopardy was removed. Observation on June 18, 2015, at 11:55 a.m., of the 3rd floor opened and unlocked North Shower Room revealed that a towel warmer was observed outside the shower stall and the towel warmer was, on and hot to touch. No residents were observed in the room at the time. An interview with the NHA on June 18, 2015, in the afternoon, revealed that she was not aware of any policy regarding the towel warmer. Review of the Resident Census and Condition Sheet for the Third Floor Nursing Unit revealed that 56 residents were on the unit and nine residents had a [DIAGNOSES REDACTED]. The towel warmer was not secured and had the potential to burn residents. Observation on June 19, 2015, revealed that the towel warmer was disengaged. Observation on June 18, 2015, upon the initial tour of the facility, revealed that when you enter the facility through the front doors which are automatic electronic doors, you walk into a small foyer area. Looking forward you can see a set of double doors that did not have a latching/releasing system to open the doors and had a large decorative wreath on each door. The set of double doors was the entry point into the Second Floor Nursing Unit which was at ground level. Coming onto the unit from the foyer/reception area, the double doors have a vertical handle on each door that a person would pull towards himself/herself to enter the unit. Coming out of the unit into the foyer/reception area, a person would push the door to exit since there was no handles on this side of the doors to pull them open. Both doors have a small, vertical narrow window on the upper inner part of each door that cannot be utilized to see through it by a person in a wheelchair due to it being too high. This would limit the residents on both sides of the door to see if there was a person on the other side of the door which when a resident comes from the Second Floor Nursing Unit to the foyer, there was a possibility of hitting a person with the door while exiting the unit. Observation on June 18, 2015, at 3:30 p.m., revealed a male resident in a wheelchair attempting to enter the Second Floor Nursing Unit, struggling to grab the door to open it towards him. The resident continued to struggle to try to open the door while moving backwards allowing the door to open so he could enter the unit. Observation on June 19, 2015, at 10:30 a.m., revealed a male resident in a wheelchair trying to exit the Second Floor Nursing Unit and also had a small cup of water in his right hand. The resident also had noticeable hand tremors and was slightly agitated. He was attempting to push open the left side door (which was the side people entering on the unit from the other side, which he was not able to see) with his left hand and maneuver his wheelchair with his feet. After attempting to open the door by himself, a male physical therapy staff member walked up and assisted the resident. Observation on June 19, 2015, at 1:30 p.m., revealed a female resident in a wheelchair attempting to enter the Second Floor Nursing Unit on the left side of the doors (which is the door the people would use to exit the unit, causing her not to know if there was someone on the other side of the door). The female resident was trying to maneuver the wheelchair with her right hand and open the door with her left hand with arm fully extended, causing the wheelchair to get stuck between the two doors. The resident needed to maneuver herself multiple times to get through the doors and enter the unit. Observation on June 23, 2015, at 2:00 p.m., revealed a male resident in a wheelchair with his right leg elevated straight out on the leg rest, attempting to grab hold of the door handle on the right side to enter the unit. This action to attempt to grab the handle caused the resident to overextend his arm and lean forward to be able to pull the door forward. A nursing staff member was coming out of the other door and then assisted the resident on the unit. Observation on June 23, 2015, at 2:15 p.m., revealed a male resident in a wheelchair with severe kyphosis (a severe curvature of the spine causing noticeable deformity and limited range of motion in the neck and shoulders) and had oxygen tubing in his nose delivering oxygen from a tank on the back of his wheelchair. The male resident was attempting to enter the unit from the foyer on the left side door and was hyperextending his right arm and body, pulling on his oxygen tubing, trying to grab the door handle. While trying to grab door handle to pull door forward to open, he maneuvered the wheelchair with his left hand causing difficulty and hyperextension forward. Observation on June 24, 2015, at 10:00 a.m., revealed a male resident in a wheelchair trying to enter the unit from the foyer area trying to grab the right door handle and use his left hand to maneuver his wheelchair back and forth to accommodate the door opening towards him to allow access to the unit. This maneuvering took multiple times with the wheelchair initially getting stuck in the small open area between both doors and causing him to continually shift the wheelchair to get around the doors. Interview with the NHA on June 22, 2015, at 12:00 p.m., confirmed that there was no significant purpose that the doors entering the Second Floor Nursing Unit from the foyer/receptionist area were kept closed and did not have any devices (wall plate, electronic sensor) to help wheelchair bound people to enter and exit the Second Floor Nursing Unit. The facility failed to ensure that residents were provided with safe access in entering and exiting the Second Floor Nursing Unit to the main foyer area of the building in order to prevent accidents. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 9/19/14, 7/11/14, 6/3/14. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 9/19/14, 7/11/14, 6/3/14, 6/24/13. 28 Pa. Code 201.18(b) (1)(3) Management Previously cited 9/19/15, 7/11/14, 6/3/14, 6/24/13. 28 Pa. Code 201.18(e) (1) Management Previously cited 7/11/14, 6/3/14, 6/24/13. 28 Pa. Code 201.20(a )(c) (d) Staff development 28 Pa. Code 211.10(a) Resident care policies Previously cited 7/11/14, 8/21/13, 6/24/13. 28 Pa. Code 211.12(c) Nursing services. Previously cited 7/11/14, 6/3/14, 4/22/14, 8/21/13, 6/24/13. 28 Pa. Code 211.12(d) (1) Nursing services. Previously cite 9/19/14, 7/17/14. 7/11/14, 6/3/14, 8/21/13, 6/24/13. 28 Pa. Code 211.12(d) (5) Nursing services. Previously cite 9/19/14, 7/17/14, 7/11/14, 4/22/14, 8/21/13, 6/24/13.

Based on review of facility policies and procedures, clinical records, facility documentation, observations, resident and facility staff interviews, and manufacturer guidelines for use of treatment products, it was determined that the facility failed to timely identify, accurately assess, monitor and provide the necessary care and treatment to prevent further decline and to promote healing for four of eleven residents reviewed with pressure ulcers (Residents I6, I10, K2 and K20) resulting in actual harm to three residents (Residents I6, K2, and K20). Findings include: Review of facility policy and procedure entitled, "Skin and Wound Management", revised May 2010, indicated that the registered or licensed nurse was responsible for the evaluation of each resident to determine resident risk for skin compromise or for the presence of pressure ulcers with the purpose that residents receive care and services necessary to regain optimal skin integrity. If skin compromise occurred, evaluations were conducted by the interdisciplinary team to ensure appropriate measures were in place to minimize further compromise and in aid in healing. Procedure Steps 1-6 indicated that the residents would be monitored weekly for skin integrity and documentation would be completed on the Treatment Administration Record. Upon discovery of a resident with impaired skin, the registered nurse supervisor or licensed nurse unit manager would assess the wound and determine if it was a pressure ulcer and then initiate the appropriate treatment. The physician would be notified to include treatment changes or orders and the care plan would be updated. Procedure Step 7 indicated that weekly rounds would be completed by the Director of Nursing/or designee, licensed nurse unit manager and CRNP (Certified Registered Nurse Practitioner) where applicable, would review results of treatment and evaluate interventions/wound progress. The Wound Status Report in step 3 indicated that if the resident was not seen on wound rounds by the wound consultant nurse practitioner (CRNP), weekly measurements were obtained by the facility wound team and entered into the residents' medical record. During a review of Resident I6's electronic clinical record accompanied by Licensed Nurse, Employee E1, and the Director of Nursing (DON) on July 7, 2014, at approximately 4:00 p.m., both nurses confirmed that the resident's weekly wound consultant progress notes regarding the resident's wounds were not accessible to the staff or the surveyor in the electronic record. The only electronic medical record wound report for both the staff and the surveyor to review on July 8, 2014, was a wound assessment note dated April 24, 2014. Employee E1 and E9 both confirmed that Resident I6 was seen weekly for wound management, but the wound nurses' progress notes were not timely uploaded for the weekly wound visits into the electronic record. In addition, Employee E1 reported when the wound nurses' notes were scanned in the electronic system, the notes were coded: review pending. Employee E1, further explained that status: review pending alerted the unit manager to review these documents for accuracy and check physician's orders for any recommendations. Interview with Resident I6 on July 7, 2014, at 5:30 p.m., revealed that the resident was concerned about the wound dressing changes to the left foot. Resident I6 alleged that the licensed staff were not changing the wound dressing to the resident's left foot as ordered, but alleged that the staff were documenting the resident was refusing the wound dressing changes. Review of Resident I6's current [DIAGNOSES REDACTED]. Review of Resident I6's quarterly resident assessment of care needs dated June 17, 2014, indicated that the resident was cognitively intact, was at risk for development of a pressure ulcer (open wound due to pressure) and had one unhealed Stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed) and a [MEDICAL CONDITION]. Review of Resident I6's podiatry examination note dated May 22, 2014, documented that the resident's chief concern was a new blister to the left heel. Podiatry described the left heel with a large blister that measured 3 centimeters x 4 centimeters. Resident I6's two week follow up podiatry examination dated June 10, 2014, documented the resident with a Stage II left heel wound that measured 3 centimeters x 2 centimeters and recommended [MEDICATION NAME] ointment (used to treat bacterial infections) two times daily. Review of Resident I6's Treatment Administration Record from May 23, 2014 through July 3, 2014, documented that the resident's left heel was being treated with [MEDICATION NAME] ointment two times daily. There was no documentation of weekly wound assessments or monitoring of the condition of Resident I6's left heel wound bed as per wound status report policy and procedure after podiatry visits on May 22, 2014, and follow up examination on June 10, 2014, for dates reviewed May 22, 2014, through July 2, 2014, at 1:00 p.m. The facility failed to assess the appropriateness for the use of [MEDICATION NAME] ointment until July 3, 2014. Facility documentation dated July 2, 2014, at 1:00 p.m., indicated that Resident I6 was noted to have an open area to the left heel measuring 1.6 centimeters by 0.9 centimeter. Review of Licensed Nurse, Employee E14's written statement dated July 2, 2014, documented that Resident I6 was noted to have an open blister on the left heel. Review of Resident I6's wound consultation examinations, revealed that since March 6, 2014, the resident was receiving weekly wound management visits for a [MEDICAL CONDITION] of the left plantar foot (fibrous knot (nodule) in the arch of the foot.) Review of the wound consultant notes failed to include any documentation of a blister or open wound to Resident I6's left heel until a formal examination visit on July 3, 2014. Resident I6's July 3, 2014, wound consultant examination documented the resident with a full thickness unstageable wound of the left heel (full thickness tissue loss in which the base of the ulcer is covered by slough (separation of dead tissue from living tissue) and/or eschar (dry scab, dead tissue in the wound bed)) that measured 2.5 centimeters by 1.0 centimeters by 0.1 centimeter and the wound base was described with 20% slough and the periwound (tissue surrounding wound) was macerated (distortion of skin; separating away). The wound consultation note dated July 10, 2014, described Resident I6 with a Stage III full thickness wound to the left heel (full thickness tissue loss, subcutaneous fat may be visible. Slough may be present) that measured 1.5 centimeters by 0.6 centimeters by 0.1 centimeters. The Director of Nursing, on July 10, 2014, at approximately 2:30 p.m., failed to provide any explanation to the surveyor as to why the wound team or wound consultant would not observe or evaluate a blister and subsequent open wound to the left heel when Resident I6's left foot was currently receiving wound team management for the left plantar foot ulceration. The facility failed to follow its policy and procedure by not responding to the initial identification of an intact blister to Resident I6's left heel on May 22, 2014, and an open wound on June 10, 2014. The facility failed to assess and monitor the resident's skin for any necessary changes in treatment to prevent further breakdown until the skin was compromised, on July 2, 2014, and a change in treatment with the identification of a unstageable full thickness pressure ulcer of the left heel, resulting in actual harm to Resident I6. Review of manufacturer prescribing instructions for [MEDICATION NAME] Santyl ointment (an ointment that removes dead tissue) indicated that this ointment should not be used in [MEDICATION NAME] with a wound dressing that would contain silver, as silver, a heavy metal could inactivate [MEDICATION NAME], the active enzyme in [MEDICATION NAME] Santyl ointment. In addition, to determine the proper amount of [MEDICATION NAME] Santyl ointment to prescribe for wound therapy per application, the wound size along with the duration of treatment to achieve proper wound debridement should be known. In addition, the manufacturer recommended that [MEDICATION NAME] Santyl should be appropriately applied to the wound from a medicine cup using an applicator. Review of manufacturer characteristics of Calcium Alginate Silver (keeps tissues moist during healing) dressing, indicated that both calcium and silver were used in this dressing product. Review of Resident I6's wound consultation examinations for unstageable, full thickness left heel wound, dated July 3, 2014, and July 10, 2014, revealed the plan for treatment to the wound included for staff to: Cleanse the site with normal saline or wound cleanser. Apply [MEDICATION NAME] Santyl ointment, then Calcium Alginate to wound base daily and as needed and cover with gauze. However, review of Resident I6 physician's treatment order, electronically entered on July 3, 2014, and electronically signed by physician on July 4, 2014, indicated an order for [REDACTED]. Review of the facility policy entitled, "Hand Washing/Hand Hygiene," indicated that all staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other residents, staff and visitors. Procedure indicated that employees would wash hands for at least 15 seconds, using antimicrobial or non-antimicrobial soap and water, both before and after changing a wound dressing, before handling clean or soiled dressings, after handling used dressings, contaminated equipment and after removing soiled gloves. The procedure also included for staff to vigorously lather hands with soap and rub them together, creating friction to all skin surfaces, for at least 15 minutes under a moderate stream of running water. Rinse hands thoroughly under running water and dry hands with paper towels and then turn off faucets with clean, dry paper towel. Observation of Resident I6's pressure ulcer treatment of [REDACTED]. Employee E14 organized Resident I6's wound treatment supplies on the over bed table which included: bottle of Dakin's 0.125 % solution; pile of gauze; opened 30 gram tube of Santyl ointment; Calcium Alginate Silver dressing pad and A&D skin moisturizing ointment. Employee E14 failed to provide any non saline solution or skin prep, as ordered. Observation of Resident I6's lower legs during this time on July 8, 2014, revealed bilateral legs wrapped with elastic ace bandages. Employee E14 proceeded to remove the ace bandage wrapping from the resident's left leg and subsequently removed the kling bandage that covered the left foot, further exposing a dressing pad which covered the heel wound. Employee E14 confirmed for the surveyor that Resident I6 was going to be observed for treatment to the left heel wound and four additional wounds which included: one wound of the right shin; two wounds of the left shin and a diabetic ulcer of the left foot plantar. After removing the soiled gloves, Employee E14 proceeded to wash hands for approximately six seconds (and not the recommended minimum of 15 seconds). Employee E14 applied clean gloves and then proceeded to cleanse five of five wounds using the Dakin's solution. Employee E14 started with the resident's left heel, proceeded to the plantar, then to the left shin and finally with the wound of the right shin. By failing to change gloves between each wound cleansing, there was a potential for cross contamination of these wounds. Employee E14 made no effort to elevate the resident's left heel to observe the wound bed or perimeter area of the wound during the cleansing step. The surveyor was also unable to observe the left heel wound and did inform Employee E14 of this concern. Employee E14 discarded the soiled gloves and proceeded with hand washing for approximately nine seconds (and not the recommended minimum of 15 seconds). After applying clean gloves, Employee E14 moisturized the resident's left leg and then the right leg with A&D ointment. After removing the soiled gloves, Employee E14 proceeded with a hand washing step which was completed within ten seconds, again failed to wash hands for a minimum of 15 seconds. Employee E14 then opened one package of Calcium Alginate Silver dressing pad, and dispensed one gram (as calculated by employee) of Santyl ointment which was placed on the center area of the Calcium Alginate Silver pad dressing, and then applied these products to the left heel wound. Employee E14 confirmed that the facility had provided training for the one gram dosing and application of Santyl. During this heel wound treatment, the surveyor was again unable to observe the bed or perimeter of the wound and inquired of Employee E14 of the same concern. Employee E14 confirmed that the left heel wound was not completely visible to this employee and confirmed that a wound mirror would not be used to further observe the wound to left heel. Employee E14 explained to the surveyor that not being able to observe the entire wound was not a concern for this employee because there was a wound nurse who looked at the resident's wounds every week. An interview with Employee E14 on July 8, 2014, at 12:30 p.m., confirmed that this employee had previously completed treatment to Resident I6's wounds on the calendar date of July 6, 2014. Employee E14 also confirmed that the employee probably should have discarded the soiled gloves and applied new gloves between each wound to prevent cross contamination. Employee E14 also reported that this employee received inservice training from the facility on how to determine proper dose and application procedures for the Santyl ointment, and that 1 gram of ointment was the proper dose for this wound. Review of Resident I6's Treatment Administration Record for dates July 3, 2014, through July 11, 2014, documented that the resident's left heel was being treated with Dakin's solution, rinsed with non saline solution, Santyl ointment and than Calcium Alginate with silver and skin prep to peri wound. Employee E14 failed to use proper handwashing technique during the wound dressing treatment to prevent cross contamination. Employee E14 failed to thoroughly observe Resident I6's heel wound to assess for any changes in the wound bed or perimeter area. Employee E14 failed to follow Santyl manufacturer recommended instructions for the proper amount that was to be used as it related to the size of the wound and proper application; failed to follow Santyl manufacturer prescribing instructions which indicated that this ointment was not to be used in [MEDICATION NAME] with a wound dressing which contained silver. Employee 14 failed to follow physician order for [REDACTED]. Interview with Licensed Nurse, Employee E1, on July 10, 2014, at approximately 10:00 a.m., confirmed that during the application of Santyl ointment to a wound, the staff should use an applicator to apply usually thickness of a nickle on the wound not on the dressing. Review of Resident K2's clinical record indicated that the resident was readmitted to facility on May 20, 2014. Review of Resident K2's admission assessment of care needs, dated May 27, 2014, indicated for bed mobility and transferring the resident required the assistance of two staff and had no existing pressure ulcers, but was at risk for developing pressure ulcers. Resident K2's nurses' note, dated May 22, 2014, at 10:41 a.m., documented that during skin assessment, the heels were noted to be boggy (feeling as though filled with fluid) and the current order for skin prep (liquid film forming dressing applied to intact skin) one time daily was changed to skin prep every shift. Review of facility documentation dated June 9, 2014, at 6:30 p.m., documented that resident K2 was observed with a Stage II right heel wound (ulcer involving the top layer of skin). Documentation further indicated that a contributing factor was that the resident does not move on their own while in bed. Documentation stated that the resident complained of heel pain. The nurses' note dated June 9, 2014 documented a Stage II right heel wound and that the left heel was red. Nurses' note, dated June 9, 2014, further documented that the right heel area was cleansed with non-saline solution and triple antibiotic ointment and a clean dry dressing was applied; and would continue to monitor. Review of Resident K2's physician progress notes [REDACTED]. The physician's progress note dated June 19, 2014, described the resident with possible heel pain and the right heel and left heel were soft with bruising and the right heel was opened and measured 2.5 centimeters. The plan for treatment was documented same as 6/15/2014. Physician's progress note, dated June 22, 2014, described Resident K2 with possible heel pain, the right and left heels soft with bruising and the right heel open 2.5 centimeters, and the plan of treatment was documented to include skin prep. Review of the physician's treatment orders for June 2014, revealed no documented evidence that the facility obtained a treatment order, on June 9, 2014, for triple antibiotic ointment and clean dry dressing applied to Resident K2's Stage II pressure ulcer of the right heel. Interview with Employee E1 on July 10, 2014, at 12:00 p.m., indicated that Resident K2's Stage II pressure ulcer to the right heel was being treated with triple antibiotic ointment upon discovery of the wound, on June 9, 2014 and continued for dates June 9, 2014 through June 26, 2014. However, review of the resident's Treatment Administration Record for June 2014, accompanied by Employee E1 on July 10, 2014, at 12:30 p.m., confirmed there was no documentation that the resident was ordered or being treated with triple antibiotic ointment for dates June 9 through June 26, 2014. Review of Resident K2's nurses' notes dated June 11, 2014, through June 13, 2014; June 21, 2014 through June 23, 2014; June 26, 2014 and July 7, 2014, documented that Resident K2's skin was intact. The facility failed to accurately assess and describe Resident K2's skin. In contrast, the wound team note signed June 12, 2014, documented a right heel wound was unstageable (full thickness tissue loss), 100% yellow/brown slough (yellow/brown dead tissue separating from living tissue) 2.0 x 2.5 x 0.2 cm (centimeters) and scant serosangineous (bloody) drainage. Documentation also indicated resident had a Stage I left heel ulcer (intact skin with non-blanchable redness). The nurses' note dated June 26, 2014, at 10:06 a.m., documented that Resident K2 was seen by the wound team and the right heel measured 1.8 centimeters by 1.6 centimeters by 0.2 centimeters and the current treatment was to continue. The nurses' note, dated July 7, 2014, at 10:42 p.m., documented as a late entry for date July 3, 2014: seen by wound team and right heel measured 2 x 1.5 x 0.2 cm (centimeters) 100% brown eshcar (dry scab, dead tissue in wound bed). Review of Resident K2's wound consultant documentation, dated July 10, 2014, described resident's foot wound as Unstageable pressure ulcer, full thickness wound of the right heel, 1..5 x 1.0 x 0.2 cm (centimeters); wound base 100% soft escar." (Escar -dry scab tan or black in wound bed, dead tissue). The facility failed to follow the policy and procedure by not accurately monitoring the skin for the potential development of breakdown. When the skin was compromised, the facility failed to ensure that necessary and appropriate treatment was provided to a Stage II pressure ulcer of the right heel which progressed to an unstageable wound, resulting in actual harm to Resident K2. Review of Resident K20's clinical record revealed a [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The admission nursing notes dated June 5, 2014, identified an open area on the right ear pinna (external part of ear). There were no measurements provided in this note and there was no further documentation of this wound until June 19, 2014 (14 days after admission). The wound consult note dated June 19, 2014 described the right ear as a partial thickness ulceration measuring 1.5 centimeters by 1.0 centimeter by 0.1 centimeter with a wound base that is 100% [MEDICATION NAME] tissue (tissue that covers the surface). Resident K20's physician order dated June 17, 2014, indicated to cleanse the outer right ear with normal saline solution and apply triple antibiotic ointment leaving the area open to the air. The Treatment Administration Record listed this treatment as initiated June 19, 2014. The resident's admission Minimum Data Set (MDS-an assessment of the residents status and care needs) assessment completed on June 10, 2014, indicated that the resident was at risk for pressure ulcer development. The assessment did not identify the ear wound. An interview on July 11, 2014, at 9:00 a.m. with Employee E1 confirmed that the facility failed to obtain a treatment when the right ear wound was identified on admission and failed to measure and monitor the right ear wound until 14 days after the wound was identified. This resulted in actual harm to the resident by failing to provide a treatment to the wound timely. Review of Resident I10's [DIAGNOSES REDACTED]. Review of Resident I10's wound consult by the wound Certified Registered Nurse Practitioner (CRNP) dated March 13, 2014, revealed the resident had a Stage II pressure ulcer of the right lateral (outside) heel that resolved and a new wound order to apply skin prep (a protective film) for 14 days then change to A&D ointment. Review of nurses' note dated March 17, 2014, at 2:00 p.m., revealed the right heel wound had reopened. A review of the podiatry consultation note dated March 17, 2014, revealed the resident had a wound on the right lateral heel that measured 0.5 centimeters x 0.3 centimeter x 0.1 centimeter, and continue the wound care as ordered. Review of Resident I10's entire clinical record revealed there was no documentation of the size or description of the right lateral heel wound from March 17, 2014 until April 30, 2014, (a period of 34 days), when the resident was seen by the consultant podiatrist. A review of the April 30, 2014, podiatry consultation note revealed the wound was debrided (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) and the wound now measured 0.4 centimeters x 0.8 centimeter x 0.2 centimeter. The podiatrist recommended the resident to have the wound cleansed with normal saline, apply [MEDICATION NAME] (a wound dressing), and foam (a protective covering) every other day. The physician ordered this treatment on April 30, 2014. The podiatry consult notes dated May 5, 2014, and May 12, 2014, described the right lateral foot wound as improved. The next documentation of the wound was June 19, 2014, by the wound CRNP, who described the wound as closed (healed). The physician continued the wound treatment as ordered for normal saline, apply [MEDICATION NAME] and foam every other day. There was no additional documentation of the right lateral foot wound until July 7, 2014, when the podiatrist's consult note stated a stable wound and 0.5 centimeter x 0.2 centimeter open. Interview with Licensed Nursing Employees E1 and E8 on July 11, 2014, at 8:50 p.m., confirmed that there was no documentation on the size and description of the wound for Resident I10 for the days between March 17, 2014 to April 20, 2014, from May 12, 2014 to June 19, 2014, and from June 19, 2014 to July 7, 2014. Resident I10's right lateral foot wound was not monitored or described weekly as per facility policy. Cross Reference F309 and F441 28 Pa. Code: 201.18(b)(1)(e)(1) Management Previously cited 06/03/2014, 04/22/2014, 06/24/2013, 01/24/ , 01/04/2013, 11/06/2012 28 Pa. Code: 211.5(f)(g) Clinical records Previously cited 04/22/2014, 06/24/2013, 10/25/2012, 06/25/2012 28 Pa. Code: 211.10(c)(d) Resident care policies Previously cited 04/22/2014, 06/24/2013, 01/24/2013, 11/06/2012 28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 04/22/2014, 08/21/2013, 06/24/2013, 01/24/2013, 11/06/2012, 10/25/2012, 06/25/2012

Based on observations and interviews with facility staff, it was determined that the facility failed to ensure that the resident's environment remained free from potential accident hazards related to storage of medications and treatment supplies for two of three nursing units observed (Nursing Units Second and Third). Findings include: During an observation of the medication administration pass on the second floor on July 8, 2014, at 8:40 a.m., a Licensed Nurse, Employee E2, proceeded to leave two medicine cups one containing five tablets and another with 30 milliliters of Lactulose (a non-digestible sugar) on top of the medication cart, which she left unattended and out of site, while going to the medication room to obtain a bottle of Vitamin B-1100 milligram tablets. It was confirmed by Licensed Nurse, Employee E2, at the time of the observation that medication should not be left on top of cart when not visible to employee. During an observation of the second floor medication administration pass on July 8, 2014, at approximately 9:00 a.m., a Licensed Nurse, Employee E3, proceeded to leave a box of Brimonidine 0.2% eye drops (used to treat glaucoma) on top of the medication cart and left the cart unlocked and unattended and out of site, in search of a box of tissues. It was confirmed by licensed nurse, Employee E3, at the time of the observation, that medications should not be left on top of cart when the cart is not visible to staff and cart should be locked. Observation of a wound dressing treatment to third floor Resident I6, on July 8, 2014, at 11:30 a.m., revealed that after Licensed Nurse, Employee E14 collected the treatment products from the cart, the employee walked away from the cart which was observed by the surveyor as unsecured, with the key still in the lock. The treatment cart remained unsecured with the key in the lock until approximately 11:45 a.m. At 12:15 p.m., an unidentified licensed staff requested, to borrow the treatment cart key, but Employee E14 directed this staff to the treatment cart where the key remained in the lock. This employee removed treatment products from the treatment cart, failed to lock the cart and failed to remove the key and further failed to inform Employee E14 that the cart was unsecured. At the conclusion of the treatment observation to Resident I6, at 12:30 p.m., Employee E14 was observed walking away from the unsecured treatment cart. After observing a treatment to second floor Resident H7's right scapula (shoulder blade) wound on July 10, 2014, at approximately 2:05 p.m., a Licensed Nurse, Employee E4, left the treatment cart unlocked and out of site in front of the medication room while proceeding to throw trash away in the soiled utility room and wash their hands in the central bathing room. It was confirmed by Employee E4, at the time of the observation, that the treatment cart should be locked when not in view or not in use. The facility staff failed to ensure medication anf treatment supplies were safely secured and stored to prevent unauthorized persons or residents from taking items from the carts. F323 483.25(h) Quality of Care Previously cited 6/03/2014 28 Pa. Code: 201.14 (a) Responsibility of licensee. Previously cited 06/03/2014, 06/24/2013 28 Pa. Code: 201.18 (b)(3) Management Previously cited 06/03/2014, 06/24/2013 28 Pa Code: 201.18(e)(1) Management Previously cited 06/03/2014, 06/24/2013, 01/24/2013 28 Pa. Code: 211.12 (d)(1)(3) Nursing services Previously cited 08/21/2013, 06/24/2013, 01/24/2013, 11/06/2012, 10/25/2012, 06/25/2012

Based on observation, review of clinical records, facility documentation and staff interview, it was determined that the facility failed to ensure the safety for one of 17 residents reviewed during the provision of care which resulted in actual harm to the resident (Resident E7). Findings include: Review of the September 2014, physician's orders [REDACTED]. Review of the quarterly Minimum Data Set assessment (MDS- assessment of resident status and care needs) completed on August 5, 2014, identified Resident E7 with short term and long term memory impairment. The resident was also identified as being totally dependent for bed mobility and transfers, requiring the assistance of two people, as having no ambulatory capabilities and functional limitations of both the upper and lower extremities. Review of Resident E7's care card which documented directions in regard to the care given by the nursing staff revealed that the resident required a two person assist for positioning and transfers, was unable to bear weight and was identified with hand contractures. Review of the nursing documentation dated September 12, 2014, revealed that on September 11, 2014, at approximately 7:30 p.m., Nursing Assistant, Employee E2, was proving evening care to Resident E7. The resident was positioned on their left side and rolled from the bed and fell on to the floor, face down, sustaining two lacerations on the right side of their face. The physician was notified at the time of the fall by a Licensed Nurse and a physician's orders [REDACTED]. Further review of the nursing documentation revealed that the resident returned to the facility from the hospital on September 12, 2014, at 1:15 a.m., with 18 sutures to their right eye brow. Review of the facility's investigation of the incident dated September 12, 2014, revealed that the resident was assessed at a moderate risk for falls and was completely bed fast. The investigation confirmed that Resident E7 required the assistance a two people for bed mobility and that the fall occurred while Employee E2 was providing incontinence care to the resident without the assistance of another staff person. Review of the statement provided by Employee E2 confirmed that the fall occurred while the resident was being washed in bed. During the care, Employee E2 was holding the resident with one hand and wiping the resident when the resident felt out of bed. An interview conducted on September 19, 2014, at 2:00 p.m., with the Director of Nursing (DON) revealed that, upon investigation into the fall incident, it was revealed that Employee E2 was in an orientation period and Employee E2 failed to review the resident's care card prior to providing evening care to Resident E7. The DON confirmed that the resident required the assistant of two staff persons for bed mobility. Observation conducted on September 18, 2014, at 10:15 a.m., of Resident E7 revealed that the resident had a dressing between the right eye and the hair line, covering part of the eyebrow. An interview conducted with Licensed Nurse, Employee E1, on September 18, 2014, at 10:15 a.m., revealed that Resident E7 had sutures on the side of the right eye and that the resident was scheduled to have the sutures removed on September 19, 2014. Observations conducted on September 19, 2014, at 11:15 a.m., in the company of Employee E1, confirmed the presence of the sutures on the resident's right eyebrow. The facility failed to ensure the safety of the resident while the resident was receiving care in bed from the facility's nursing staff resulting in actual harm to Resident E7. 42 CFR 483.25(h) Free Of Accident Hazards/Supervision/Devices. Previously cited 11/06/2012, 06/10/2013, 07/11/2014. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 03/20/2013, 06/24/2013, 07/11/2014. 28 Pa. Code 201.18(b)(1) Management. Previously cited 6/25/2012, 11/06/2012, 01/24/2013, 03/20/2013, 06/24/2013, 07/11/2014. 28 Pa. Code 201.18(b)(3) Management. Previously cited 06/25/2012, 11/06/2012, 03/20/2013, 06/24/2013, 07/11/2014. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 01/24/2013, 06/10/2013, 06/24/2013, 04/22/2014, 07/11/2014. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 06/25/2012, 10/25/2012, 11/06/2012, 01/24/2013, 03/20/2013, 06/24/2013, 08/21/2013, 07/11/2014, 07/17/2014. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/25/2012, 06/24/2013, 07/11/2014. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 06/25/2012, 10/25/2012, 11/06/2012, 01/24/2013, 03/20/2013, 06/10/2013, 06/24/2013, 08/21/2013, 04/22/2014, 07/11/2014, 07/17/2014.

Based on a review of policy and procedures, clinical record review, facility documentation, and staff interviews it was determined that the facility failed to administer medications in accordance with the physician's orders [REDACTED]. (Residents: R1). Findings include: Review of Resident R1's annual comprehensive assessment dated [DATE] indicated that the resident had [DIAGNOSES REDACTED]. Review of the facility's policy, Administering Medications, dated March 2012 indicated that any individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking the resident's identification band and verifying their face with a photograph within the medical record. A review of a Resident R1's nursing notes revealed a note dated January 13, 2013 at 9:48 a.m. that the resident was found unresponsive to verbal and tactile stimulation and was sent to the hospital. Review of hospital records within the resident's chart indicated a nursing note at 9:43 a.m. that the resident had arrived at the emergency room . The nurse further documented that the resident's respirations were shallow and ineffective on admission. A hospital respiratory therapist at 9:50 a.m. documented that the resident had been successfully intubated (the insertion of a plastic pipe down the trachea that assists in breathing for a person who has stopped breathing on their own. That breathing device is then connected to a ventilator or a mechanical device that produces respirations when the person cannot breathe on their own). Review of facility documentation regarding a medication error on January 13, 2013, revealed that in the afternoon of January 13, 2013 a nurse approached a facility doctor at Chester Valley Nursing and Rehabilitation and reported that she may have given Resident R1 another resident's medication. Further investigation into this error report indicated that Employee E1, a licensed LPN, gave resident R1 medications that she was not usually taking including [MEDICATION NAME] 40 mg (a diuretic), [MEDICATION NAME] 8 mg (a drug used to treat the symptoms of [MEDICAL CONDITION]), [MEDICATION NAME] 20 mg (a medication used to lower high blood pressure), and [MEDICATION NAME] 300 mg (a medication used to decrease the symptoms of [MEDICAL CONDITION]). Further review of the medication error report revealed on January 15, 2013 the facility documented that Employee E1, was reeducated regarding the identification of each resident prior to administering medications. A review of physician progress notes [REDACTED]. The note further indicated that the resident was hospitalized for [REDACTED]. The physician also documented that the nurse had confused two residents who had the same last name, causing the medication error to occur. 28 Pa. Code: 201.18(b)(1)(e)(1) Management Previously cited 11/6/12 28 Pa. Code 211.10(d) Resident care policies Previously cited 11/6/12, and 6/15/12 28 Pa. Code: 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/6/12, 10/25/12, and 6/15/12