Every finding on record at Greenfield Healthcare and Rehabilitation Center

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to notify the resident's representative of a change in condition timely for one of two residents reviewed (Closed Record Resident CR2). Findings include: The facility policy entitled Notification of Changes dated 11/01/25, revealed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change in requiring such notification. Circumstances requiring notification include: Accidents - resulting in injury. Potential to require physician intervention. Resident CR2's clinical record revealed an admission date of 6/22/26, with diagnoses that include hemiplegia and hemiparesis following cerebral infarction (the loss of movement or weakness on one side of body, occurring on the side opposite of the brain damage), dysphagia (difficulty of swallowing), hyperlipidemia (high cholesterol in the blood), and high blood pressure. Resident CR2's fall incident report and unwitnessed fall investigation dated 7/21/26, with time of fall at 7:45 p.m. revealed notification of resident representative/family at 10:47 p.m. on 7/21/26, approximately 3 hours after the fall. Resident CR2's clinical record revealed progress notes dated 7/21/26, revealed CR2 was transferred to the hospital related to above noted unwitnessed fall at 8:45 p.m. Resident CR2's clinical record revealed progress notes dated 7/22/26, 10:09 a.m. with a documented discussion, They were concerned that they weren't contacted sooner between nursing administration and family, that confirmed that family was not contacted in a timely manner, when Resident CR2 had a fall and was transferred to the hospital on 7/21/26. During an interview on 8/21/26, at 9:50 a.m. the Director of Nursing (DON) confirmed that the facility lacked evidence that the resident representative/family was provided timely notification of Resident CR2's fall and transfer to hospital on 7/21/26. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12 (d)(1)(5) Nursing services

Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide care by not getting residents out of bed for one of 39 residents (Resident R1). Findings include: No policy provided for residents to be out of bed dressed in their own clothing of choice daily. Resident R1's clinical record revealed an admission date of 9/26/25, with diagnoses that include dementia (a disease of the brain that affects behavior and mood), lower back pain, cognitive communication deficit (impaired thinking and processing affecting what a person desires to verbalize), and high blood pressure. The Minimum Data Set (MDS-periodic review of resident care needs) Section GG0170- Mobility dated 7/23/26, indicated that Resident R1's Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) is dependent on staff to do all the effort of the transfer. Section C0500 - Cognitive BIMS (Brief Interview for Mental Status) score dated 7/23/26, indicated that Resident R1's BIMS was 7/15 which is indicative of severe cognitive impairment. Resident R1's care plan dated 4/22/26, revealed Resident R1 was at risk for dehydration related to fluid deficit, insufficient intake, diuretic use, dementia, and constipation and with interventions to encourage resident to get out of bed for meals. Resident R1's clinical record lacked evidence of physician orders or progress notes to indicate that Resident R1 refused to get out of bed to a chair or was contraindicated to get out of bed to a chair. Observations on 8/18/26, at 11:50 a.m. revealed Resident R1 lying in bed with a hospital gown on. During an interview with Resident R1 and the Director of Nursing (DON) at time of observation, Resident R1 verbalized I am not in bed when asked if he/she would like to get out of bed. Interview with Nursing Assistant (NA) Employee E1 on 8/18/26, at 11:55 a.m. revealed Resident R1 did not have a chair to get out of bed. NA Employee E1 further revealed that Resident R1 has not been out of bed for over a month since NA Employee E1 has worked at the facility. Further observations with the DON revealed no chair in Resident R1's room or near his/her room for Resident R1 to get out of bed. An interview with the DON on 8/18/26, at 12:00 p.m. revealed that he/she was unaware of any clinical reason for Resident R1 to not get out of bed, and that a chair should be available for all residents to get out of bed daily as tolerated. The DON further indicated that all residents should be dressed in their own clothing attire and not a hospital gown during the daytime hours, unless it is the resident's desire to be in a hospital gown. An interview with the Therapy Director Employee E2 on 8/18/26, at approximately 2:00 p.m. revealed Resident R1 was evaluated by therapy services in 4/2026, and is able to be out of bed to a chair with no contraindications and was provided a wheelchair for such purpose. 28 Pa. Code 201.4 (a) Responsibility of licensee28 Pa. Code 211.5 (f)(ix) Medical records28 Pa. Code 211.11 (d)(e) Resident care plan

Based on review of facility policy, manufacturer's guidelines, facility records, clinical records and staff interview, it was determined that the facility failed to monitor interventions and complete assessments for a resident at risk for elopement (an at-risk individual leaving a supervised care setting without staff knowledge) (Resident R1).Findings include: Review of a facility policy entitled Elopement and Wandering Residents dated 1/16/26, indicated Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. and Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. Review of manufacturer's guidelines for wander guard (a device with a small box on a plastic bracelet placed on an at-risk wandering person to alert the staff if that person attempts to exit the facility without staff supervision) indicated Test each signaling device before use. Thereafter, test the device daily and record the results in the resident's records. Review of Resident R1's clinical record revealed an admission date of 12/10/24, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), gastroesophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and weakness. Review of elopement investigation for Resident R1 revealed that on 4/16/26, the facility's wander guard alarm was sounding, and he/she was found outside of the facility. Review of Resident R1's Care Plan revealed a plan of care for elopement with an intervention for a wander guard, check placement and function every shift dated 12/10/25. Review of Resident R1's January, February, March, and April 2026, treatment administration records lacked evidence of a wander guard being checked for placement and function from 1/1/26, through 4/16/26. Review of Resident R1's physician orders lacked evidence of an order for a wander guard from 1/1/26, through 4/16/26. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of resident care needs) dated 2/3/26, revealed under section P0200 Alarms E. Wander/elopement alarm was answered Not used. Review of Wandering Risk Assessment completed on Resident R1 revealed it was completed on 12/11/24. The clinical record lacked evidence that another wander risk assessment was completed throughout Resident R1's stay as the policy indicated. During an interview on 4/22/26, at 12:45 p.m. the Director of Nursing confirmed that Resident R1's clinical record lacked evidence that interventions for elopement risk were being monitored, that wander risk assessments were not completed throughout Resident R1's stay, and that Resident R1's wander guard should have been checked every shift. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding showers for one resident reviewed (Resident R1).Findings include: Review of facility policy entitled Documentation in Medical Record dated 1/16/26, indicated Documentation shall be completed at the time of service. and Documentation shall be accurate, relevant, and complete. Review of Resident R1's clinical record revealed an admission date of 12/10/24, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and weakness. Review of Resident R1's shower task (an area in point of care where the nursing assistants document showers) revealed Resident R1 was to receive a shower every Monday and Friday. Further review revealed for the month of April 2026, the shower task lacked documentation that a shower was provided on 4/3/26, 4/10/26, 4/13/26, 4/17/26, and 4/20/26. During an interview on 4/22/26, at 12:45 p.m. the Director of Nursing confirmed that Resident R1's clinical records did not have complete documentation regarding showers and that showers should be done as scheduled in the resident's task and documented when completed. 28 Pa. Code 211.5(f)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on review of facility policy, review of clinical and facility records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure Resident R6 was free of neglect during care, which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and shock (a life-threatening medical emergency caused by inadequate blood flow to tissues resulting in oxygen not getting to organs of body resulting in potential organ failure and death) for one of 17 residents reviewed (Resident R6). Findings include: A facility policy entitled, Abuse, Neglect and Exploitation, dated 11/01/25, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A facility policy entitled, Safe Resident Handling/Transfers, dated 11/01/25, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Two staff members must be utilized when transferring residents with a mechanical lift. Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]). Resident's R6's Minimum Data Set (MDS - periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 9/29/25, revealed Resident R6 was dependent for transfers (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity). Resident R6's task order summary (a program used by nursing staff to verify transfer orders) revealed task order reviews dated 9/24/25, 9/25/26, and 9/26/25, all indicating Resident R6 was dependent for transfers. Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm. Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, Resident sent out to ER [emergency room] today after fall. Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25. Facility provided documentation, Corrective Action Form, dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident - [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers]to transfer resident by [herself/himself] instead of using assist of two. Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date [DATE]), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]. Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head. Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall. Interview with the Nursing Home Administrator (NHA) on 1/26/26, at 2:55 p.m. confirmed that Resident R6 was transferred via a Hoyer lift on 9/29/25, by NA Employee E6, which resulted in a fall with substantial harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist. The NHA further confirmed that Resident R6 was dependent for transfers and required a Hoyer lift and a two person assist for all transfers, however on 9/29/25 Resident R6 was transferred with only one person and Hoyer lift which resulted in Resident R6's fall and substantial harm of laceration and fractures. The facility failed to ensure that Resident R6 was free from neglect which resulted in actual harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist from a fall from a Hoyer lift. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy, review of facility documentation and clinical records, review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2025 (RAI-assessment guide used to plan the provision of care for residents), and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall for one of 17 residents (Resident R6), which resulted in actual harm of a laceration to the left posterior head, fracture of left pubic bone with a two part fracture that extended into the pubic symphysis (the front and lower part of left hip bone which separated and fractured), left scapholunate ligament tear (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and shock (a life-threatening medical emergency caused by inadequate blood flow to tissues resulting in oxygen not getting to organs of body resulting in potential organ failure and death). Findings include: A facility policy entitled, Safe Resident Handling/Transfers dated 11/01/25, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Two staff members must be utilized when transferring residents with a mechanical lift. Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]). Resident's R6's Minimum Data Set (MDS - periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 9/29/25, revealed Resident R6 was dependent for transfers (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity). Resident R6's task order summary (a program used by nursing staff to verify transfer orders) revealed task order reviews dated 9/24/25, 9/25/26, and 9/26/25, all indicating Resident R6 was dependent for transfers. Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm. Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, Resident sent out to ER [emergency room] today after fall. Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25. Facility provided documentation, Corrective Action Form, dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident - [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [a mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two. Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date [DATE]), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]. Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head. Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall. Interview with the Nursing Home Administrator (NHA) on 1/26/26, at 2:55 p.m. confirmed that Resident R6 was transferred via a Hoyer lift on 9/29/25, by a single staff member, NA Employee E6, which resulted in a fall with substantial harm of a laceration to his/her posterior head, fracture of pelvis, and injury to his/her wrist. The NHA further confirmed that Resident R6 was dependent for transfers and required a Hoyer lift and a two person assist for transfers, however on 9/29/25 Resident R6 was transferred with only one person via a Hoyer lift, which resulted in Resident R6's fall and substantial harm of laceration and fractures. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5)

Based on review of facility policy, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure expired medications were discarded in a timely manner in two of two medication carts reviewed (West North Cart and East North Cart).Findings include: A facility policy entitled, Labeling of Medications and Biologicals dated 11/01/25, revealed Labels for multi-use vials must include: All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies (shorter or longer) date for that opened vial. Manufacturer's guidelines for Humalog insulin (a fast-acting insulin used to manage blood sugar levels in people with diabetes), revealed that after opened vials and pre-filled pens should be discarded after 28 days. Manufacturer's guidelines for Lantus insulin (a long-acting insulin used to manage blood sugar levels in people with diabetes), revealed that after opened vials and pre-filled pens should be discarded after 28 days. Observation on 1/24/26, at 4:15 p.m. of the [NAME] North medication cart revealed an open vial of Lantus with an open date of 12/26/25, therefore the medication was expired. This was witnessed and confirmed at that time by Licensed Practical Nurse (LPN) Employee E5. Observation on 1/24/26, at 4:29 p.m. of the East North medication cart revealed an opened Humalog vial with an open date of 12/18/25, and two open vials of Lantus, one with an open date of 12/21/25, and the other with an open date of 12/26/25, therefore the medications were expired. This was witnessed and confirmed at that time by LPN Employee E4. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure physician's orders and residents Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments) were consistent and failed to ensure that the resident/responsible party were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment for six of 20 residents reviewed (Residents R1, R5, R7, R30, R50 and R62).Findings include: Review of facility policy entitled Communication of Code Status dated [DATE], indicated It is the policy of this facility to adhere to residents' rights to formulate advance directives. The facility will follow facility policy regarding a resident's right to request. to formulate an Advance Directive/POLST. Review of Resident R1's clinical record revealed an admission date of [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and general anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R1's clinical record revealed a physician's order for Full Code (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) dated [DATE]. Review of resident R1's POLST revealed DNR (do not resuscitate allow natural death). Review of Resident R5's clinical record revealed an admission date of [DATE], with diagnoses that included surgical care following surgery on the digestive system, enterocolitis due to clostridium difficile (an intestinal inflammation caused by toxins from a bacteria usually after antibiotics that change the normal gut bacteria), convulsions (involuntary, rapid muscle contractions causing violent, uncontrollable shaking of the body), and atrial fibrillation (a rapid, irregular heartbeat caused by disorganized electrical signals of the atria, heart's upper chambers). Review of Resident R5's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment. Review of Resident R7's clinical record revealed an admission date of [DATE], with diagnoses that included hypertension (high blood pressure), COPD, and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked). Review of Resident R7's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment. Review of Resident R30's clinical record revealed an admission date of [DATE], with diagnoses that included hypertension, weakness, and hyperlipidemia (high cholesterol). Review of Resident R30's clinical record revealed a physician's order for DNR dated [DATE]. Review of Resident R30's POLST revealed Full Code. Review of Resident R50's clinical record revealed an admission date of [DATE], with diagnoses that included protein calorie malnutrition, iron deficiency, and major depressive disorder. Review of Resident R50's clinical record lacked evidence that he/she and/or his/her representative were provided with written information on advanced directives or assisted with the opportunity to formulate advanced directives regarding life sustaining treatment. Review of Resident R62's clinical record revealed an admission date of [DATE], with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia. Review of Resident R62's clinical record revealed a physician's order for Full Code dated [DATE], the clinical record lacked evidence he/she and/or his/her representative were provided with written information on advance directives or assisted with the opportunity to formulate advance directives regarding life sustaining treatment. During an interview on [DATE], at 2:20 p.m. Registered Nurse Employee E1, revealed that during an emergent situation the staff refer to the POLST book to determine resident life sustaining wishes. He/she confirmed that Residents' R1 and R30's physician's orders and POLST were not consistent with one another and that Residents R5, R7, R50, and R62's clinical records lacked evidence reflecting their and/or their representative's wishes for advanced directives and that the clinical records should reflect resident's current wishes. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that the physician signed and dated all orders during visits for seven of 20 residents reviewed (Residents R1, R7, R8, R10, R11, R30, and R62). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 11/1/25, indicated The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Sign and date all orders. Review of Resident R1's clinical record revealed an admission date of 8/11/23, with diagnoses that included chronic obstructive pulmonary disease (COPD-when your lungs do not have adequate air flow), bipolar disorder (a mental illness that causes extreme mood swings with emotional highs and emotional lows), and general anxiety disorder (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R1's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of Resident R7's clinical record revealed an admission date of 3/26/25, with diagnoses that included hypertension (high blood pressure), COPD, and cerebral infraction (also known as a stroke it occurs when blood flow to part of the brain is blocked). Review of Resident R7's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension. Review of Resident R8's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of Resident R10's clinical record revealed an admission date of 5/10/23, with diagnoses that included diabetes, hyperlipidemia (high cholesterol), and hypertension. Review of Resident R10's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of Resident R11's clinical record revealed an admission date of 8/30/24, with diagnosis that included chronic respiratory failure (a condition where your lungs don't exchange air properly), obstructive sleep apnea (a condition when a person repeatedly stops and starts breathing when they are sleeping), and hyperlipidemia. Review of Resident R11's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of Resident R30's clinical record revealed an admission date of 7/6/24, with diagnoses that included hypertension, weakness, and hyperlipidemia. Review of Resident R30's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. Review of resident R62's clinical record revealed an admission date of 10/17/25, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia. Review of Resident R62's clinical record revealed that his/her physician orders were signed and dated 10/30/25, and not again until 1/26/26, which is beyond the required 60 days. During an interview on 1/26/26, at 2:35 p.m. Registered Nurse Employee E2 confirmed that physician orders for Residents R1, R7, R8, R10, R11, R30, and R62 were not reviewed and signed by the physician in the required 60 days and confirmed that physician orders should be reviewed and signed with every physician visit on admission then every 30 days for the first 90 days then every 60 days. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(i) Medical records

Based on review of clinical records, resident interviews and staff interviews, it was determined that the facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least 60 days thereafter for three of 17 residents reviewed (R8, R11, and R62). Findings include: Review of facility policy entitled Physician Visits and Physician Delegation dated 11/1/25, indicated The physician should: See resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. Date, write and sign a progress note for each visit. Sign and date all orders. During an interview on 1/25/26, at approximately 10:30 a.m. Resident R8 expressed that he/she has not seen his/her physician face to face since he/she was admitted to the facility. Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Review of Resident R8's clinical record lacked evidence that Resident R8 was seen by his/her physician every 60 days as required. Resident R11's clinical record revealed an admission date of 8/30/24, with diagnoses that included chronic respiratory failure (a long term condition where the lungs cannot exchange oxygen and carbon dioxide adequately), hypertensive heart disease with heart failure (a condition resulting from chronic uncontrolled blood pressure), chronic obstructive pulmonary disease (COPD - a lung disease caused by airway damage and inflammation causing breathing issues), and protein calorie malnutrition (a deficiency of protein intake leading to impaired growth, muscle wasting and weakened immunity). Resident R11's clinical record revealed a progress note dated 1/09/26, at 3:51 p.m. related to refusal of medications, . you say the doctor ordered it but I want to know WHAT doctor. Review of Resident R11's clinical record lacked evidence that Resident R11 was seen by his/her physician every 60 days as required. During an interview on 1/25/26, at 9:40 a.m. Resident R11 indicated that he/she has not seen their physician, and no physician has assessed him/her while being a resident at the facility. Review of resident R62's clinical record revealed an admission date of 10/17/25, with diagnosis that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident R62's clinical record lacked evidence that he/she was seen by his/her physician every 30 days for the first 90 days after admission as required. During an interview on 1/26/26, at 2:35 p.m. Registered Nurse Employee E2 confirmed that the clinical records lacked evidence that Resident's R8, R11, and R62 were seen by their physician as required. He/she also confirmed that all residents should be seen by their physician every 30 days for the first 90 days then every 60 days thereafter. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.5(f)(ii)(vii) Medical records

Based on resident and staff interviews, and review of resident council minutes and grievances, and review of nursing staffing documentation, it was determined that the facility failed to provide sufficient nursing staff and services to promote the physical and mental well-being and meet the needs for six of 20 residents interviewed (Residents R6, R8, R9, R30, R53, and R57). Findings include: Interviews during the Resident Council meeting on 1/25/26, between 12:00 p.m. and 12:30 p.m., revealed Residents R8, R9, R30, R53, and R57, in attendance stated the call bells are not answered in a timely manner with all indicating they wait greater than 30 minutes. Resident R30 had concerns related to staff not responding to his/her call bell timely and it took hours for call bell response on 1/14/26, which resulted in him/her soiling his/her brief (incontinence product). Resident R9 had concerns related to staff responding timely to their call bell to close their bathroom door. Resident R9 indicated that he/she can transfer themselves to the toilet independently, however, cannot shut the bathroom door afterwards. He/She further indicated that it takes a very long time for staff to respond to his/her call bell, and he/she typically sits on toilet with door open allowing the roommate to see. Resident R9 indicated that the lengthy call bell response time is due to lack of staffing. Review of resident council minutes for November 2025, December 2025, and January 2026, revealed the following: On November 26, 2025, there were 13 residents in attendance that indicated they would like staff to answer call bells in a timely manner.On December 16, 2025, there were 10 residents in attendance that indicated call bell response times continued to be an issue.On January 20, 2026, there were 10 residents in attendance that indicated residents would like management to do an audit on call bell response times, because it continued to be an issue.Review of the Grievance Logs from June 2025, through December 2025, revealed a grievance related to call bell response time on 11/9/25.Review of facility nursing staffing documents for day of a fall incident, 9/29/25, which involved Nursing Assistant (NA) Employee E6 participating in a transfer of Resident R6 utilizing a two-person mechanical lift independently, which resulted in injury to Resident R6 falling out of the mechanical lift, it was revealed that the hours of direct resident care was below 3.2 minimum per patient per day (PPD) at 3.16 PPD, and NA staffing shortages for the dayshift where the NA ratios were not met with 6.59 NA worked and 7.0 were required for a census of 70 residents. During an interview on 1/27/26, at 9:50 a.m. the Nursing Home Administrator (NHA) confirmed that the facility does not have sufficient nursing staff and services to promote the physical and mental well-being and meet the needs of the residents. The NHA further confirmed that nursing hours for 9/29/25, day of Resident R6's fall incident, was below state mandated levels. Refer to F686 and F600. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (East and [NAME] Unit). Findings include: Facility policy, Enhanced Barrier Precautions, dated 11/01/25, revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Implementation of Enhanced Barrier Precautions - Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. High contact resident care activities include: Dressing-Bathing-Transferring-Providing hygiene-Changing linens-Changing briefs or assisting with toileting-Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripheral inserted central catheter (PICC) lines-midline catheters-Wound care: any skin opening requiring a dressing. Observations on 1/23/26, and 1/24/26, revealed no educational signage or PPE maintained for EBP for residents with indwelling devices, wounds, or infections throughout the facility. During an interview on 1/25/26, at 12:00 p.m. Registered Nurse (RN) Employee E1 confirmed that no EBPs are maintained throughout the facility for residents with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents. RN Employee E1 further indicated that the facility did have EBPs maintained, but the facility no longer has the EBPs in place. During an interview on 1/25/26, at 12:00 p.m. Licensed Practical Nurse (LPN) Employee E4 confirmed that no EBPs are maintained for residents on the East Unit with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents. During an interview on 1/25/26, at 2:10 p.m. LPN Employee E3 confirmed that no EBPs are maintained for residents on the [NAME] Unit with indwelling devices, chronic wounds, or infections, and staff does not utilize PPE during high contact care for these residents. During an interview on 1/25/26, at 2:15 p.m. the Nursing Home Administrator confirmed the facility lacked signage and PPE readily available when providing care for residents with indwelling devices, chronic wounds, or infections, who should have EBP maintained. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of facility policy, clinical records, resident and staff interviews, it was determined that the facility failed to provide a bath/shower as resident preference for two of 20 residents reviewed (Residents R8 and R62).Findings include: Review of facility policy entitled Resident Showers dated 11/1/25, indicated Residents will be provided showers as per request or as per facility schedule. and Document resident shower in point of care if refused, given, or bed bath given. Review of Resident R8's clinical record revealed an admission date of 1/14/22, with diagnoses that included chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body), diabetes (a health condition that is caused by the body's inability to produce enough insulin), and hypertension (high blood pressure). Interview with Resident R8 on 1/26/26, at approximately 10:30 a.m. revealed that he/she stated, I have not received a shower in weeks, it would be nice to get a shower and not just washed up in the bathroom. Review of resident R8's bath/shower documentation for 1/1/26, through 1/25/26, revealed he/she was scheduled for a bath/shower on Tuesday/Friday on the daylight shift. Further review revealed on 1/6/26 no shower was documented, on 1/9/26, 1/13/26, 1/16/26, 1/20/26, and 1/23/26, N/A (not applicable) was documented. Review of Resident R62's clinical record revealed an admission date of 10/17/25, with diagnoses that included gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), hypertension, and hyperlipidemia (high cholesterol). Interview with Resident R62 on 1/25/26, at approximately 3:15 p.m. revealed that he/she stated, I have not taken a shower in a long time, I wash up in the bathroom in the morning, but I would really like to get a shower every other day if not every day. Review of Resident R62's clinical record for bath/shower documentation lacked evidence of a bath/shower schedule for Resident R62. During an interview on 1/26/26, at 3:00 p.m. the Nursing Home Administrator confirmed that Residents R8 and R62's clinical records lacked evidence of showers/baths being given as residents' preferences. He/she also confirmed that shower/baths should be given per resident request/schedule. 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policy, review of clinical and facility records, and resident and staff interviews, it was determined that the facility failed to complete a thorough investigation related to falls for one of 17 residents reviewed (Resident R6). Findings include: Review of facility policy, Fall Prevention Program dated 11/01/25, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]). Facility provided documentation of an incident report for Resident R6 dated 9/29/25, at 6:50 a.m. revealed nursing description dated 9/29/25 5:54 p.m. - Entered resident room, observed resident on floor. Resident stated he/she hit his/her head. Skin assessment done on resident, observed laceration to back of head, and abrasions to right arm. Bruising to left hand. Resident bleeding from laceration on back of head and on right arm. Assisted to resident to bed using mechanical lift. Vital signs obtained, within normal limits. Wound care done on laceration on abrasions. Resident stated he hit his head during fall. Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, Resident sent out to ER [emergency room] today after fall. Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25. Facility provided documentation, Corrective Action Form, dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident - NA [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two. Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date [DATE]), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]. Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head. Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall. Interview on 1/27/26, at 11:00 a.m. the Nursing Home Administrator (NHA) confirmed that the incident report and investigation of Resident R6's fall from a Hoyer lift on 9/29/25, was incomplete and lacked evidence of a complete timely investigation which included, but not limited to, witness statements, nursing response to a resident falling from a Hoyer lift including response to a staff member utilizing a Hoyer lift independently resulting in a resident's fall from the Hoyer lift, fall assessment, and notification of physician and family at time of fall. The NHA further confirmed it is the responsibility of the facility to ensure all incidents, including falls, are investigated and documented thoroughly in a timely manner. There was no evidence that the facility thoroughly investigated the fall incident involving Resident R6 falling out of a Hoyer lift on 9/29/25. 28 Pa. Code 201.14(a)(c) Responsibility of licensee 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations and interviews, it was determined that the facility did not ensure the garbage and refuse was disposed of properly for one dumpster. Findings include: No facility policy provided. Observations on 1/24/26, at 5:15 p.m. revealed the dumpster open, without a full lid to secure the top of the dumpster, allowing garbage to be freely exposed. During an interview on 1/24/26, at 5:15 p.m. the Dietary Manager confirmed that the top of the dumpster was open without a lid, allowing the garbage to be freely exposed. He/She further confirmed that the dumpster lids should always be closed and tightly fitted when not in use to prevent insect/rodents to be attracted to area. 28 Pa. Code 201.18(b)(3) Management

Based on review of facility policy and review of clinical and facility records and resident and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to falls for one of 17 residents reviewed (Resident R6). Findings include: Review of facility policy entitled, Fall Prevention Program dated 11/01/25, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Resident R6's clinical record revealed an admission date of 2/08/25, with diagnoses that included shock, closed head injury (occurs when a sudden, violent impact to the head damages the brain without breaking the skull), fall, left scapho-lunate dissociation (a wrist injury involving bones of wrist that separate due to a tear in the connecting ligament), and closed fracture dislocation of left pubis symphysis with diastasis (the front and lower part of left hip bone which separated and fractured creating a diastasis [a widened gap]). Resident R6's clinical record revealed a nutritional progress note dated 9/29/25, at 12:02 p.m. which stated, Resident sent out to ER [emergency room] today after fall. Resident R6's clinical record lacked evidence of further progress notes related to a fall on 9/29/25. Facility provided documentation, Corrective Action Form, dated 10/03/25, revealed Nursing Assistant (NA) Employee E6 with a Final Written/Discharge warning for Nature of Infraction - Any deviation from a resident's course of treatment that creates the risk of/or results in serious or substantial harm to resident. Willful or reckless in attention to the needs of a resident. Description: Description of Incident - NA [NA Employee E6] did not follow transfer order for a resident as evidenced by using Hoyer lift [mechanical lift utilized in lifting a person who is dependent for assistance with transfers] to transfer resident by [herself/himself] instead of using assist of two. Resident R6's clinical documentation dated 10/02/25, (hospital admission date 9/29/25, and discharge date [DATE]), revealed progress notes from his/her hospitalization which indicated Resident R6 remained critically ill at this time after being dropped from a Hoyer lift approximately five feet. Progress notes stated, Currently treating this patient for fall from Hoyer lift on anticoagulants [blood thinning medication], scalp laceration with bleeding, left pubic symphysis fracture, left scapholunate ligament tear, hypotension [low blood pressure] and shock requiring vasopressors [medications used to raise low blood pressure] and fluid. V. tach [ventricular tachycardia - life-threatening heart rhythm disorder], hypokalemia [low potassium in blood]. Interview with Resident R6 on 1/25/26, at 9:55 a.m. revealed that he/she was dropped from a Hoyer lift a few months ago and received a laceration to his/her head. Resident R6 stated, I was lifted up and fell out of the lift. I hit the floor hard (rubbing the back of his/her head) and got a terrible gash to the back of my head. Resident R6 further indicated that only one NA assisted him/her during the time of fall from the Hoyer lift, and he/she was transferred to the hospital and stayed several days related to the fall. During an interview on 1/26/26, at 2:55 p.m. the Nursing Home Administrator (NHA) confirmed that Resident R6's clinical record lacked evidence of the nursing response to Resident R6's fall from a Hoyer lift on 9/29/25, including nursing assessment of resident and actions, fall assessment, and notification of physician and family. The NHA further confirmed it is the responsibility of the facility to ensure all documentation of resident care, including falls, is accurate and complete in each resident's clinical record. 28 Pa. Code 211.5(f)(ii)(iii) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and infection control documentation, and staff interview, it was determined that the facility failed to develop and implement an antibiotic stewardship program. Findings include: Review of the facility policy Antibiotic Stewardship Program, dated 11/01/25, revealed it is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Medical Director, Director of Nursing, and Consultant Pharmacist serve as the leaders of the Antibiotic Stewardship Program and receives support from the Administrator and other governing officials of the facility. The Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' efforts by working with the following partners: Infection Preventionist-Consultant Laboratory-State and Local Health Departments. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. The program includes antibiotic use protocols and a system to monitor antibiotic use. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. New or changed orders for antibiotics based on the antibiotic timeout recommendations will be obtained from the practitioner. At least annually or per facility policy, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical, and nursing staff, resident and family council, and the Quality Assessment and Assurance (QAA) Committee. At least annually or per facility policy, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report (i.e antibiotic report card) to improve prescribing practices and resident outcomes. Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families. The elements of the program and associated protocols are reviewed on an annual basis and as needed as part of the facility's review of the overall infection prevention and control program. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to Action plans and/or work plans associated with the program-Assessment forms-Antibiotic use protocols/algorithms-Data collection forms for antibiotic use, process, and outcome measures-Antibiotic stewardship meeting minutes-Feedback reports-Records related to education of physicians, staff, residents, and families-Annuals reports. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings. From 1/24/26, through 1/27/26, no evidence of the above noted facility Antibiotic Stewardship program was provided for review. During an interview on 1/26/26, at 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c)(d)(3) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 29 residents reviewed (Closed Record Residents CR1, CR2, and CR3). Findings include:A facility policy entitled Baseline Care Plan dated 11/01 /25, revealed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. The baseline care plan will be developed within 48 hours of a resident ' s admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, Preadmission Screening and Resident Review (PASARR) recommendation, if applicable. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/resident representative can understand. The summary shall include, at a minimum, the following: The initial goals of the resident, A summary of the resident ' s medications and dietary instructions, Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.Resident CR1's clinical record revealed an admission date of 9/18/25, with diagnoses that included chronic kidney disease (a condition where the kidneys cannot remove waste and balance fluids), hemiplegia and hemiparesis following cerebral infarction (paralysis, muscle weakness affecting one side of the body after a stroke), and diabetes mellitus (a condition when your blood sugar is too high), and chronic obstructive pulmonary disease (COPD - a group of respiratory conditions that involve shortness of breath, a persistent cough, and excess mucus).Resident CR2 ' s clinical record revealed an admission date of 9/19/25, with diagnoses that included morbid obesity (a person who is severely overweight), diabetes mellitus, hyperlipidemia (high levels of fat, including cholesterol and triglycerides, in the blood), and obstructive sleep apnea (a sleep disorder where the airway at times collapses during sleep causes disruption in the breathing pattern of a person).Resident CR3 ' s clinical record revealed an admission date of 10/23/25, with diagnoses that included severe protein-calorie malnutrition (a condition when a person does not consume enough protein and calories to meet their body ' s needs), dysphagia (difficulty swallowing), gastroparesis (a delay in the movement of food from the stomach to the small intestine), and diverticulitis of intestine (inflammation or infection of small pouches that form in the wall of the intestine).Review of the clinical records for Residents CR1, CR2, and CR3 lacked evidence that a baseline care plan was initiated, or a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Residents CR1, CR2, and CR3 and/or their representative.During an interview on 11/03/25, at approximately 3:40 p.m. the Nursing Home Administrator confirmed there was no evidence that a baseline care plan was initiated, or a copy of the baseline care plan including physician orders with medications, dietary orders, therapy services, were provided to Resident CR1, CR2, and CR3 and/or their representative.28 Pa. Code 211.10(c) Resident care plan28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for four of four residents reviewed for hospitalization (Residents R2, R5, R6, and R7).Findings include: Facility policy entitled Bed-Hold Notice dated 1/7/26, indicated that It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The policy further states In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative., The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or representative in the resident's file and/or medical record. and The facility will provide this information to all facility residents, regardless of their payment source. Facility policy entitled Transfer and Discharge (including AMA [against medical advice]) dated 1/7/26, indicated that for a transfer to another provider, for any reason, the following information must be provided to the receiving provider: contact information for the practitioner responsible for care of resident, resident representative information, advanced directive, information necessary to meet the resident's needs, special instructions and/or precautions for ongoing care, and care plan goals. Resident R2's clinical record revealed an admission date of 3/26/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Epilepsy (a chronic brain disorder which a group of nerve cells or neurons will sometimes send wrong signals and cause a seizure which temporarily affects your consciousness, muscle control, and behavior), and Stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times, but not always leading to permanent disabilities). Resident R2's clinical record revealed a progress note dated 12/8/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R2's clinical record also lacked evidence indicating that Resident R2 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Resident R5's clinical record revealed an admission date of 6/22/16, with diagnoses that included Epilepsy, Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn), and Paraplegia (the loss of the ability to move, and sometimes to feel anything in the legs or lower body, typically caused by a spinal injury or disease). Resident R5's clinical record revealed a progress note dated 12/26/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R5's clinical record also lacked evidence indicating that Resident R5 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Resident R6's clinical record revealed an admission date of 12/2/24, with diagnoses that included Encephalopathy (a group of conditions that cause problems with the brain that can appear as confusion, memory loss, and personality changes), High Blood Pressure and Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Resident R6's clinical record revealed a progress note dated 11/24/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R6's clinical record also lacked evidence indicating that Resident R6 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Resident R7's clinical record revealed an admission date of 6/15/24, with diagnoses that included Schizoaffective Disorder (a mental health condition that can be a mix of symptoms such as hallucinations [seeing things or hearing voices that other don't], delusions [believing things that are not real or true], and depression [persistent feeling of sadness loss of interest in activities once enjoyed]), Epilepsy, and GERD. Resident R7's clinical record revealed a progress note dated 11/5/25, 11/17/25, and 12/29/25, indicating transfers to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R7's clinical record also lacked evidence indicating that Resident R7 and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. During a telephone interview on 1/8/25, at approximately 11:09 a.m. the Nursing Home Administrator and Director of Nursing confirmed that Residents R2, R5, R6, and R7's clinical records lacked evidence that necessary clinical information was communicated to the receiving health care provider and lacked evidence that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3)(2) Resident rights

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to transcribe and act upon physician orders for medications ordered at time of admission for one of six residents reviewed (Resident R2) and failed to follow physician's orders regarding the administration of seizure medications for one of five residents reviewed (Resident R2).Findings include: Facility policy entitled Medication Orders dated 1/7/26, indicated for written transfer orders sent with a resident by a hospital or other health care facility the facility will Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete, or the date signed is different from the date or admission. If the order is unsigned, or signed by another physician, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending physician before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Resident R2's clinical record revealed an admission date of 3/26/25, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), Epilepsy (a chronic brain disorder which a group of nerve cells or neurons will sometimes send wrong signals and cause a seizure which temporarily affects your consciousness, muscle control, and behavior), and Stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times, but not always leading to permanent disabilities). Resident R2's clinical record revealed discharge instructions dated 3/26/25, from a local hospital that included Aspirin 81 milligrams (mg) by mouth every morning and Cholecalciferol (Vitamin D3) 50 micrograms (mcg) by mouth daily. Facility physician orders between 3/26/25, and 1/7/26, lacked evidence of Aspirin 81 mg and Cholecalciferol 50 mcg being ordered per the hospital discharge instructions. Medication Administration Records (MAR) between 3/26/25, and 1/7/26, lacked evidence of Aspirin 81 mg and Cholecalciferol 50 mcg being administered per hospital discharge instructions. Clinical record progress notes completed at time of admission lacked evidence that Resident R2's physician was notified and/or made any changes to the hospital discharge instructions. Resident R2's clinical record revealed discharge instructions dated 3/26/25, from a local hospital that included Clonazepam (medication used to treat seizures) 0.5 mg every twenty-four hours as needed (prn) for seizures. Facility physician orders indicated Clonazepam 0.5 mg every twenty-four prn for seizures. Clinical record progress notes dated 12/8/25, at 8:06 a.m. indicated that the nurse was called to residents' room at approximately 6:20 a.m. due to resident being found on the floor. Resident R2 stated he/she had a headache and later also complained of lightheadedness and stated he/she got dizzy. Resident R2 was assisted to bed and placed on a bedpan. When aide returned to room to assist Resident R2 off the bedpan, Resident R2 was having seizure like activity and upon observation resident was noted to have had a 13-minute (approximate) seizure At approximately 7:05 a.m. Resident R2 was starting to have another seizure that lasted approximately one minute. Clinical record progress notes and MAR lacked evidence that Clonazepam 0.5 mg every 24 hours prn for seizures was administered per physician orders. Findings of the facility not following physician orders and not administering Aspirin 81mg by mouth every morning and Cholecalciferol 50 mcg by mouth daily since time of admission and not following physician orders related to not administering Clonazepam 0.5 mg every twenty-four hours prn for seizures on 12/8/2025 when Resident R2 was having a seizure were reviewed with the Nursing Home Administrator and Director of Nursing on 1/08/2026 at 11:05 a.m. 28 Pa. Code 211.5(f)(i)(x) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of clinical records, facility documentation, facility policy, hospital records, and staff interviews, it was determined that the facility failed to adequately assess, monitor and implement interventions to promote wound healing that resulted in actual harm of worsening pressure ulcers for one of 18 residents reviewed (Resident R61). Findings include: The facility policy, Pressure Injury/Skin Breakdown - Clinical Protocol, dated 1/28/21, revealed that the physician will write orders and identify medical interventions related to wound management. Resident R61's clinical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of clinical notes for Resident R61 showed that upon admission, he/she had a 2.0 X 2.0 centimeter (cm) wound on the coccyx (small triangular bone forming the lower extremity of the spinal column) which was a Stage 2 (partial-thickness loss of skin, presenting as a shallow, open wound that has broken through the skin). The January 2021, Treatment Administration Record (TAR) revealed for a dressing change to the coccyx to cleanse wound with normal saline, pat dry, apply dressing, every day. This was ordered on 1/16/21 and discontinued 1/21/21. The signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January TAR failed to reveal that the dressing change occurred. A progress note dated, 1/21/21, stated that the area to coccyx was open and measured 9.0 X 4.5 cm and the entire wound bed was slough (necrotic tissue) and had a foul odor. Review of a progress note dated, 1/25/21, stated that the coccyx wound still has a foul odor, measures 9.0 X 5.0 cm and the wound bed had slough and necrotic tissue. In addition, the progress note stated that Resident R61 needed constant reminders to stay on his/her hips to relieve pressure to the coccyx. During an interview on 5/21/21, at 10:00 a.m., the Director of Nursing stated that there was not a certified wound nurse at the facility. Therefore, the facility consults with Wound Health Solutions (WHS) for their wound management. Review of WHS documentation dated 1/29/21, revealed an evaluation of Resident R61's coccyx/sacrum wound. It measured 9.0 X 8.0 X 0.1 cm and was unstageable (full-thickness skin and tissue loss where the tissue damage within the ulcer cannot be confirmed because the wound bed is covered by slough or necrotic tissue). In addition, new orders from WHS were to cleanse the coccyx/sacrum area with ¼ strength Dakin's Solution daily, apply skin prep to peri wound skin, apply Santyl Ointment to wound base daily, apply calcium alginate over top daily and as needed, cover with bordered foam dressing, change daily and as needed. This order was listed on the February TAR with a start date of 2/1/21, and a discontinue date of 3/30/21. Review of WHS documentation dated 2/4/21, revealed that the coccyx/sacrum wound measurements were 8.5 X 7.5 X 0.8 cm and was unstageable. In addition, new orders from WHS were to place on hold, the order for Santyl and calcium alginate. Review of the February TAR failed to reveal that the order had been placed on hold. The new order indicated to cleanse affected area ¼ Dakin's solution every day, apply skin prep to peri wound skin, apply Dakin's moistened kerlix to wound base twice a day and PRN (as needed), cover with a bordered foam dressing. Review of the February TAR failed to reveal this new order. Review of WHS documentation dated 2/11/21, revealed that the coccyx/sacrum wound measurements were 9.0 X 4.5 X 1.0 cm with 2.0 cm undermining (destruction of tissue or ulceration extending under the wound edges so that the pressure ulcer is larger at its base than the skin surface) and was unstageable. In addition, new orders from WHS were to place on hold, the order for Santyl and calcium alginate. Review of the February TAR failed to reveal that this order had been placed on hold. The new order indicated to cleanse affected area ¼ Dakin's solution every day, apply skin prep to peri wound skin, apply Dakin's moistened kerlix to wound base twice a day and PRN, cover with a bordered foam dressing. There was no evidence found of this order on the February TAR. Review of WHS documentation dated 2/18/21, revealed that the sacrum wound measured 9.0 X 4.2 X 1.5 cm with a 3.0 cm undermining and was a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendons, ligaments, or bone). New orders from WHS for the sacrum wound were to discontinue current treatment. Review of the February TAR failed to reveal that this order had been discontinued. Start this order, cleanse affected area ¼ Dakin's solution every day, apply skin prep to peri wound skin, apply Dakin's moistened kerlix to wound base twice a day and PRN, cover with a bordered foam dressing. Review of the February TAR showed that the facility did start a new order on 2/19/21, to apply ¼ Dakin's gauze packing twice a day and cover with an abdominal pad. Review of WHS documentation dated 2/18/21, revealed that new wound of the right trochanter (hip area) was identified which measured 7.0 X 3.0 X< (less than) 0.1 cm and was unstageable. New orders from WHS for the right trochanter wound were to cleanse affected area with normal saline only, apply skin prep to peri wound skin daily, apply Santyl Ointment, nickel thickness, to wound base daily and PRN, cover with a bordered dry dressing. In addition, an X-ray was recommended to the sacrum to rule out [CONDITION(S)] (inflammation of bone caused by infection) since the bone was exposed and to order a new low-air loss bed with bed extender to accommodate patient's height. The February 2021, TAR showed that the facility did start a new order on 2/19/21, to apply Santyl and foam dressing, needs X-ray of sacrum and extended bed one time a day for wound care. Review of Resident R61's progress notes revealed that the X-ray showed no [CONDITION(S)] or significant bony deformity noted. The bed had been ordered and received per Resident R61 confirmation on 5/20/21, at 1:00 p.m. Review of WHS documentation dated 3/4/21, revealed that the sacrum wound measured 6.6 X 3.5 X 1.0 cm with 1.6 cm undermining and was a Stage 4. The right trochanter wound measured 5.2 X 1.6 X <0.1 cm and was unstageable. Review of WHS documentation dated 3/9/21, revealed that the sacrum wound measured 6.2 X 3.5 X 1.0 cm with 1.5 cm undermining and was a Stage 4. The right trochanter wound measured 5.0 X 1.8 X <0.1 cm and was unstageable. Review of WHS documentation dated 3/18/21, revealed that the sacrum wound measured 5.2 X 2.5 X 1.0 cm and 2.0 cm undermining and was a Stage 4. The right trochanter wound measured 5.2 X 1.9 X <0.1 cm and was unstageable. The WHS sacrum/coccyx wound orders dated 3/4/21, 3/9/21, and 3/18/21, were to continue orders to cleanse affected area with ¼ Dakin's solution every day, apply skin prep to peri wound skin, apply Dakin's moistened kerlix to wound base twice a day and PRN, cover with a bordered foam dressing. The March 2021 TAR showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ Dakin's solution, apply Santyl and collagen alginate, cover with dry dressing daily. Another order was ¼ Dakin's gauze packing twice a day and cover with abdominal pad. The WHS right trochanter wound orders dated 3/4/21 and 3/9/21 were to continue orders to cleanse affected area with normal saline only, apply skin prep to peri wound skin daily, apply Santyl Ointment, nickel thickness, to wound base daily and PRN, cover with a bordered dry dressing. On 3/18/21, WHS stated to continue above orders but add calcium alginate. The March 2021 TAR showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Another order on 3/23/21, was to apply Santyl and calcium alginate and foam dressing. Review of Resident R61's progress notes revealed that the resident was sent on 3/23/21, to the emergency room for a right hip infection/foul smell and was admitted to the hospital. The hospital notes showed that during the hospital admission, he was diagnosed with [CONDITION(S)]. Resident R61's progress notes showed that on readmission back to the facility on [DATE], wound measurement of the sacrum/coccyx wound was 6.5 X 2.5 X 0.75 cm and was unstageable. The right trochanter wound measured 3.8 X 1.5 X 1.2 cm and was a Stage 4. Review of Resident R61's clinical record revealed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R61's progress notes revealed that on 4/5/21, Resident R61 had an appointment to attend the wound clinic at a local hospital. However, the transport van brought a wheelchair and not the required stretcher for the resident. After talking with the wound clinic and getting a later appointment, Resident R61 refused to go. Review of Resident R61's progress notes revealed that there was no evidence that the facility reconsulted WHS for Resident R61 from 3/30/21 to 5/5/21, a period of 36 days. The progress notes revealed that there were no assessment/evaluations found by facility staff regarding Resident R61's wounds during that time. In addition, there was no evidence found in the progress notes that the facility tried to get another appointment at wound clinic for Resident R61. The facility's failure to follow WHS's orders for wound management from 1/29/21, until 3/23/21, a period of 54 days, resulted in actual harm of worsening pressure ulcers for Resident R61. In addition, the facility's failure to adequately monitor and assess pressure ulcers from 3/30/21, until 5/5/21, a period of 36 days, resulted in actual harm of worsening pressure ulcers for Resident R61. 42 CFR 483.25 Quality of Care 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to accurately assess, care plan, and institute measures to prevent the development of a pressure ulcer associated with the use of an immobilizer/brace, resulting in actual harm for one of 21 residents reviewed (Resident CR21). Findings include: The facility policy entitled, Pressure Ulcer Review dated 08/03/15, stated that for residents identified as, at risk for skin breakdown, a care plan should be developed identifying risk factors and associated interventions, and that weekly assessments should be conducted to include, but not limited to the site, stage, dimensions and description. The policy further indicated that pressure ulcers should be documented on the care plan. Resident CR21's admission Minimum Data Set assessment (MDS - periodic assessment of resident care needs) dated 2/06/15, revealed that Resident CR21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment further indicated that Resident CR21 had limited range of motion in a lower extremity, required the extensive assistance of staff for bed mobility, transferring and toileting, and had no current pressure ulcers but was assessed as high risk for their development. Nurses' notes dated 1/30/15, indicated that Resident CR21 was admitted from an acute care facility with a [MEDICAL CONDITION] tibia (major weight bearing bone of the lower leg), with no weight bearing to be placed on the extremity. The note lacked any reference to an immobilizing device (a splint to prevent motion or bending) to the right lower leg. On 2/02/15, three days after admission, the nurses' notes first referenced that an immobilizer was present on Resident CR21's right lower extremity. The nurses' notes from 2/02/15 through 2/20/15, revealed documentation indicating that the right lower leg immobilizer was, in place on 22 occasions (2/04/15; 2/05/15; 2/06/15 - documented twice; 2/08/15; 2/09/15; 2/10/15; 2/11/15; 2/12/15 - documented twice; 2/13/15; 2/14/15 - documented twice; 2/15/15; 2/16/15; 2/17/15; 2/18/15 - documented twice; 2/19/15 - documented three times; and 2/20/15) but lacked documentation related to the brace's use, fit, or removal for care. The admitting physician's orders [REDACTED].>An initial physician's progress note dated 2/02/15, indicated that Resident CR21 had a large brace on the right knee and that the resident stated it is, hurting and is out of wack. Resident CR21's initial care plan related to pressure ulcer development, dated 1/30/15, identified risk factors for skin breakdown as bed mobility problems and bowel incontinence, but lacked evidence that the immobilizer was a potential risk factor. A Wound Evaluation Flow Sheet dated 1/30/15, revealed that on admission Resident CR21 had an area over the right posterior (back), lower leg, measuring 8 centimeters (cm) in length, by 2.1 cm in width, with the depth measurement field listed as blank. Further wound documentation indicated that the wound was, scabbed over, the surrounding tissue described as, dry, ecchymotic (discoloration from bleeding underneath the skin) and the wound margins documented as, surgical? Weekly wound descriptions of the area remained unchanged, with measurements documented as follows: 2/06/15 - 6.8 cm in length, by 1.9 cm in width, with the depth measurement field blank; 2/13/15 - 4 cm in length, by 0.4 cm in width, with the depth measurement field blank; and 2/20/15 - 5 cm in length, by 1 cm in width, with the depth measurement field blank. During an interview on 9/03/15 at 10:00 a.m., Licensed Practical Nurse (LPN), Employee E2, stated that the initial evaluation of Resident CR21's right lower posterior leg, looked like a surgical area to me. LPN Employee E2 further stated that Resident CR21's leg immobilizer/brace, never really fit right . it was too long . she was little and it was probably too big. A Consultation/Clinic Referral sheet dated 2/20/15, revealed that Resident CR21 was sent for an orthopedic consult in follow up to the [MEDICAL CONDITION] tibia. The Orthopedic Physician Assistant, Employee E1, documented a, soft tissue defect from immobilizer to the right posterior calf with a request that the wound team evaluate the area and to, please fit for range of motion brace (a device to provide support and permit joint movement) locked in extension (without bend). A 2/20/15 nurses' note, written at 6:21 p.m., indicated, got a call from resident's orthopedic appointment stating that there was an open area to the right lower extremity. Waited upon residents return . took immobilizer off and an open area to posterior right lower leg was opened due to the immobilizer putting pressure and not fitting properly. The note indicated that the wound was 3 cm in length, 2 cm in width, with a wound bed 100% covered by necrotic (dead) tissue, dark tan in color. The note lacked an indication of a wound category/stage (assessment of depth and severity). The Wound Evaluation Flow Sheet, completed on the same date and time, indicated the wound to the right posterior lower leg was 5 cm in length, 1 cm in width and with the depth measurement field blank. The assessment lacked a wound category/stage. On 2/23/15, three days following identification of the open area, a wound evaluation was completed by the Assistant Director of Nursing and documented on the Wound Evaluation Flow Sheet, and assessed the wound as a Stage III pressure ulcer (full thickness tissue loss). Resident CR21's care plan related to Altered Skin Integrity, last updated on 2/10/15, lacked documentation related to the Stage III pressure ulcer to the right posterior lower leg, an associated goal for healing, or interventions related to its care. During an interview on 9/04/15, at 10:45 a.m., Orthopedic Physician Assistant, Employee E1, stated that pressure from the immobilizer resulted in skin breakdown to Resident CR21's right posterior lower leg; that no one from the facility had contacted the office with complaints that the immobilizer/brace was ill-fitting; and that no surgical intervention had been completed on Resident CR21's right lower leg placing the area at risk for breakdown. During an interview on 9/04/15 at 11:00 a.m., the Director of Nursing and the Assistant Director of Nursing confirmed that there was no order for Resident CR21's leg immobilizer/brace or its associated care, that the care plan was never updated to reflect the development of a Stage III pressure ulcer and its care, and that the clinical record lacked evidence of interventions to reduce the risk for skin breakdown associated with the brace's use resulting in harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/31/2014 28 Pa. Code 211.10(d) Resident care policies. Previously cited 10/31/2014 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Previously cited 07/24/2015, 10/31/2014