Every finding on record at Guy and Mary Felt Manor, Inc

Based on observation and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: Observation of the facility's main kitchen on Monday, June 1, 2026, at 10:45 AM, revealed the following: A package of fig snack bars in the kitchen production area with no date to indicate a receive or used by date. A plastic container labelled [NAME] cheese in the freezer with no date received, opened, or when it expires. A plastic bag in the freezer containing a product that resembled frozen grilled chicken. The bag was not labeled to indicate the contents and the date on the product noted in marker was not legible. A tray of multiple frozen dessert resembling sherbert on a shelf in the freezer was not labeled to identify the product and there were no dates to indicate when it was placed there or when it needed to be used by. The walk-in cooler contained a bottle of lemon juice labeled with two dates September 11, 2025, and September 20, 2025, a gallon jug of pickles labeled April 30, 2026, and a gallon jug of salad dressing dated May 26, 2026. Employee 7, Certified Dietary Manager, indicated the dates referenced either the opened date or the received date but could not confirm which nor indicate when the product expired or needed to be used by. A large dented can of sliced carrots was observed on a shelf in the production area among other cans to be served. A zipper style plastic bag on a shelf in the production area contained faded labeling [NAME], April 9, 2026. Employee 7 indicated she was not sure if that date was when the item was placed in the bag or when it needed to be used by and could not clearly indicate when the product expired. A large bag of graham cracker crumbs on a shelf in the production area contained a manufacturer's stamped date of October 9, 2025. The bag also contained a date written in marker of April 25, 2026. Employee 7 indicated she was not sure if that date was when the item was opened or needed to be used by and could not clearly indicate when the product expired. An opened can of thickening powder in the production area was observed with a plastic scoop down inside the product. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on June 3, 2026, at 10:15 AM. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regime concerns (Residents 2 and 4).Findings include: The facility policy entitled, Psychotropic Medication Use, last reviewed January 29, 2026, revealed that the purpose of the policy included to provide consistent monitoring of usage of medications to ensure each resident is receiving the medication that he/she needs without being overmedicated. Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals. The facility will monitor psychotropic medications for proper dose, duration, evidence of adequate monitoring for efficacy and adverse consequences and to prevent, identify, and respond to adverse consequences. As needed (PRN) orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. When selecting medications and non-pharmacological approaches, members of the interdisciplinary team and the resident and resident representative, if applicable, will participate in the care process to identify, assess, advocate for, monitor, and communicate the resident's needs and changes of condition. The indication for any psychotropic medication will be thoroughly documented in the clinical record to include behavioral symptoms being treated. Identified target behaviors will be monitored each shift along with individualized interventions. The care plan will also include the type of psychotropic medications to be monitored for side effects daily. The, Basic Guidelines for Behavior and Side Effect Monitoring, noted that a medication specific behavior and side effect monitoring system is used for each psychotropic category of medication ordered. At least one individualized behavior will be clearly linked with each antipsychotic, antianxiety, sedative hypnotic, or other psychotropic medication. These targeted behaviors are linked within the behavior monitoring system in such a way that all (staff, physicians, medical consultants, family members, regulatory, etc.) can clearly see the specific targeted behavior(s) treated with each medication prescribed. At least daily monitoring of the specific target behaviors and side effects is documented within this system. The absence of behaviors and side effects is indicated with a zero in the appropriate row. Do not leave these spaces blank as this fails to indicate that monitoring occurred. Additionally, monitoring by exception only is not the best practice since it can lead to underreporting and a lack of trust in the monitoring system. All side effects seen with medications are to be recorded in the monitoring system. Clinical record review for Resident 4 revealed her medication regime included the use of the following psychotropic medications per the following schedule: Buspirone, (Buspar) an antianxiety medication, 15 mg (milligrams) at 8:30 AM, 10 mg at 2:30 PM, and 15 mg at 9:30 PM. Cymbalta, an antidepressant medication, 60 mg at 8:30 AM and 8:30 PM. Elavil, an antidepressant medication, 10 mg three times a day. The plan of care developed by the facility to address Resident 4's utilization of the psychotropic medications Cymbalta, Elavil, and Buspar for the management of depression, anxiety, and sleep disturbance listed interventions that included: Document mood, sleep, care participation, and response to interventions per facility protocol Monitor/document side effects and effectiveness (antidepressant side effects such as dry mouth, dry eyes, constipation, urinary retention, suicidal ideations) Monitor effectiveness of medications on mood, anxiety, pain, participating in care, and hygiene routines and sleep Observe and report adverse effects The plan of care developed by the facility to address Resident 4's symptoms of depression and decreased engagement related to chronic conditions, diagnoses of anxiety, depression and insomnia, and use of psychotropic medications listed interventions that included monitoring sleep patterns. Review of Resident 4's clinical record did not include evidence that the facility monitored Resident 4's individualized targeted behavior symptoms (e.g. sleep pattern) or potential side effects related to her use of psychotropic medications. Interview with the Nursing Home Administrator and the Director of Nursing on June 3, 2026, at 10:21 AM confirmed the above findings for Resident 4. Clinical record review revealed the facility admitted Resident 2 on April 21, 2026. Review of Resident 2's physician orders revealed an order for Hydroxyzine (an antihistamine medication used to treat anxiety) 25 mg, one tablet every 12 hours as needed for relentlessness and agitation-initiated April 27, 2026. Review of a consultant pharmacy recommendation dated May 4, 2026, noted Resident 2 is currently ordered Hydroxyzine 25 mg every 12 hours as needed and according to CMS regulations there is a 14-day limitation on all as needed antipsychotic orders. The pharmacist noted the Hydroxyzine order may not be extended beyond the 14-day limit, but a new order may be written if the practitioner directly examines and assesses the resident and documents clinical rational for the new order. The pharmacist requested Resident 2's physician reassess the appropriateness of the above therapy and to document the need for continuation every 14 days. A certified nurse practitioner addressed the May 4, 2026, pharmacy recommendation on May 14, 2026, noting Resident 2's medication will be reassessed by telePsych and be based on the recommendations. Further clinical record review revealed that Resident 2's order for Hydroxyzine did not have a 14 day stop date and there was no physician's progress note that provided a rationale for the medication extending past 14 days. Interview with the Director of Nursing on June 2, 2026, at 2:12 PM confirmed the above noted findings related to Resident 2's Hydroxyzine. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on a review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to laundry processing (Residents 4, 7, 22, and 26) and the accessibility of hand hygiene materials in the laundry department. The facility also failed to implement measures to ensure an effective Water Management Program for the prevention and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease, a serious type of pneumonia).Findings include: Interview with Employee 4 (nurse aide) on June 3, 2026, at 9:13 AM revealed that laundry staff collect residents' soiled personal laundry on a schedule set by the laundry department. Residents' soiled personal laundry is stored in a hamper in their closet until laundry staff collect it. Observation of Resident 22's room on June 3, 2026, at 9:14 AM with Employee 4 revealed that Resident 22's closet contained too many of her personal possessions to accommodate a clothing hamper. Employee 4 indicated that a vented hamper along the wall in the middle of the room contained Resident 22's soiled laundry. The bag lining the vented hamper was not tied. Observation of Resident 4's closet on June 3, 2026, at 9:14 AM with Employee 4 revealed a vented clothing hamper lined with a black bag that was not tied. When Employee 4 raised the vented lid, Resident 4's soiled laundry was visible. Observation of Resident 26's closet on June 3, 2026, at 9:17 AM with Employee 4 revealed a vented clothing hamper lined with a black bag that was not tied. The lid to the clothing hamper was also vented. Observation of Resident 7's closet on June 3, 2026, at 9:17 AM with Employee 4 revealed a vented clothing hamper lined with a black bag that was not tied. The lid to the clothing hamper was also vented. The above observations of residents' clothing hampers revealed that the open bags (not tied off) in vented laundry hampers would not prevent potential odors or aerosolization of soiled laundry while stored. Interview with Employee 6 (housekeeping/laundry supervisor) on June 3, 2026, at 11:05 AM confirmed that she was aware that residents' soiled laundry is stored in the vented hampers until collected by laundry staff. Observation of the facility's laundry department on June 3, 2026, at 11:05 AM with Employee 6 revealed that the room that contained the washer used to process resident personal laundry did not have a sink or handwashing materials (soap and paper towels) to perform hand hygiene. Interview with Employee 6 on the date and time of the observation indicated that she would don a gown and gloves to transfer residents' soiled laundry from bags to the washer and remove her gown and gloves before leaving the room. Employee 6 stated that she would use alcohol-based hand sanitizer or go to the first available handwashing sink that was in another room approximately 50 feet away. Employee 6 confirmed that she was aware that if she was processing the laundry for a resident with a diagnosis of C. diff (Clostridium difficile, bacterial infection known to cause diarrhea), alcohol-based hand sanitizers would not be effective to destroy C. diff spores; therefore, not an effective method for appropriate hand hygiene. Observation of the housekeeping storage room next to the laundry room on June 3, 2026, at 11:11 AM with Employee 6 revealed that there was a faucet equipped with a hose sprayer for filling buckets. Hand soap was present near the faucet: however, the paper towels that would be used to dry hands were not contained in a closed dispenser. The roll of paper towels was held by the rod of an open shelving unit near the faucet. The storage of the paper towels would not prevent splashes or other environmental substances from contaminating the paper towels. The surveyor reviewed the above concerns related to available handwashing materials during an interview with Employee 5 (maintenance director) on June 3, 2026, at 11:20 AM. The surveyor reviewed the above concerns related to laundry processing and available handwashing materials during an interview with the Nursing Home Administrator on June 3, 2026, at 11:21 AM. Review of the facility's current Water Management Program revealed that established controls to reduce the risk of Legionella and other communicable diseases included to maintain the water heater at an appropriate temperature above 140 degrees Fahrenheit to kill the Legionella bacteria. The program did not include a way that the facility would monitor the temperature of the water heater; or what intervention would be implemented if the established control goal was not met. Interview with Employee 5 on June 2, 2026, at 2:55 PM confirmed that he has not monitored the facility water heater to ensure that the water temperature is above 140 degrees Fahrenheit. The interview also confirmed that the large scroll diagram of the building was not used to assess where Legionella and other opportunistic waterborne pathogens can grow and spread (e.g. dead legs or areas of potential water stagnation and/or other devices in the building that can spread water droplets containing Legionella (e.g. hot tubs, decorative fountains, water storage tanks). The surveyor reviewed the concerns regarding the facility's water management program during an interview with the Nursing Home Administrator on June 3, 2026, at 9:55 AM. 483.80 Infection ControlPreviously cited deficiency 6/18/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(3) Nursing services

Based on clinical record review and resident and staff interview it was determined that the facility failed to implement treatment and assistive devices to maintain vision abilities for one of one resident reviewed for vision concerns (Resident 6).Findings include: Interview with Resident 6 on June 1, 2026, at 12:36 PM revealed that she has a pair of glasses that she has had for a long time and they no longer work for her. She stated that she would like to see an eye doctor. Clinical record review revealed the facility admitted Resident 6 on November 5, 2024, with an order for an optometry consult and care as needed. During a meeting with the Nursing Home Administrator and Director of Nursing on June 2, 2026, at 11:05 AM the surveyor requested any evidence of the facility offering Resident 6 professional ophthalmology services since admission to the facility in November 2024. Social service documentation dated June 3, 2026, at 11:52 AM revealed social services reviewed vision needs and preferences with Resident 6. Resident 6 reported a desire to be seen for her vision needs. Resident 6 stated she was followed by two eye centers but has not been seen in years. Interview with Employee 10 (social services) on June 3, 2026, at 11:56 AM confirmed the facility had no further documentation to support the facility offered ongoing vision assessments to maintain her vision abilities. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure that an assessment accurately reflected a resident's status for one of 12 residents reviewed (Resident 9).Findings include: Clinical record review for Resident 9 revealed social services documentation dated January 20, 2026, at 10:56 AM that admission paperwork was completed; and that Resident 9 wore dentures. Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 20, 2026, assessed that Resident 9 was not edentulous (that she had natural teeth). Task documentation (electronic information recorded by nurse aide staff regarding care needs) dated May 2026, indicated that Resident 9's oral hygiene was, Oral Hygiene full upper and lower dentures. Interview with Employee 4 (nurse aide) on June 3, 2026, at 9:38 AM confirmed that Resident 9 did not have natural teeth. Interview with the Director of Nursing, Nursing Home Administrator, and Employee 3 (registered nurse assessment coordinator) on June 3, 2026, at 10:21 AM confirmed that the coding regarding Resident 9's dental assessment on the January 20, 2026, MDS was incorrect. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on observation, clinical record review, review of select facility policies and procedures, and resident, family, and staff interview, it was determined that the facility failed to provide a dependent resident with activities of daily living assistance for two of two residents reviewed (Residents 6 and 9). Findings include: The policy entitled Podiatry Care, last reviewed without changes January 29, 2026, revealed to ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must provide foot care and treatment in accordance with professional standards of practice, including to prevent complications from the resident's medical condition and if necessary assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. It is the policy of the facility that podiatry procedures for routine foot care and diabetic foot care. Routine foot care may include corns, calluses, and trimming of nails and is limited to every two months. During an interview with Resident 6 on June 1, 2026, at 12:36 PM she voiced complaints that her toenails are always long and cutting in to her skin. She stated that the staff refuse to trim her toenails and she is only allowed to see a podiatrist every three months. Observation of Resident 6's toenails at this time confirmed her toenails were long, extending well past her nail bed. Clinical record review revealed the facility admitted Resident 6 on November 5, 2024, with an order for podiatry care every 60 to 90 days. Further review of Resident 6's clinical record revealed her most recent significant change MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated March 19, 2026, indicated nursing staff assessed Resident 6 as dependent on staff for personal hygiene. Review of podiatry documentation provided by the facility revealed Resident 6 was seen by a podiatrist on March 27, 2025, May 30, 2025, December 8, 2025, and April 13, 2026. There was documentation noting Resident 6 refused podiatry care on August 28, 2025. Interview with the Director of Nursing on June 3, 2026, at 11:15 AM revealed that the nurses should be trimming Resident 6's toenails between podiatry visits. The Director of Nursing confirmed that the podiatrist only visits the facility every quarter (12 weeks). She was unable to provide further documentation that the facility provided personal hygiene assistance for Resident 6. Interview with Resident 9's daughter on June 1, 2026, at 11:19 AM revealed that her mother had dentures, but she believed due to changes in her mother's condition, they are so big, and did not fit appropriately. Clinical record review for Resident 9 revealed care management documentation dated February 4, 2026, at 2:55 PM that Resident 9's daughter inquired about her mother's weight loss and the effects of the fit of her dentures and ability to chew. The documentation indicated a discussion regarding denture adhesive and that nursing staff would be updated regarding its use. Review of Task documentation (electronic documentation completed by nurse aide staff for the completion of care needs) dated May 2026 revealed that Resident 9's oral hygiene was, Oral Hygiene full upper and lower dentures. There was no indication of the use of denture adhesive. Review of Resident 9's active Kardex (electronic list of care instructions used by nurse aide staff) revealed no intervention related to the use of denture adhesive. Interview with Employee 4 (nurse aide who reported as Resident 9's care provider) on June 3, 2026, at 9:38 AM confirmed that Resident 9 did not have any natural teeth and used dentures. Employee 4 reported that residents' families typically supply denture adhesive if used, that she had never seen it at the facility, and that she had never used it for Resident 9. Employee 4 provided a list of residents noted to have dentures, but none included special instructions related to the use of adhesive. Employee 4 confirmed that information available to her via Resident 9's care plan and Kardex did not include instructions to use denture adhesive. Employee 4 confirmed that Resident 9 is dependent on staff for oral hygiene care. The surveyor reviewed the above concerns related to Resident 9's denture care during an interview with the Nursing Home Administrator on June 3, 2026, at 9:55 AM. 28 Pa Code 211.11(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents, family members, and legal representatives and ensure resident identifiers were kept confidential in one of one area reviewed (atrium area; Residents 7 and 18).Findings include: Observation on June 3, 2026, at 10:15 AM revealed a blue binder that is kept in the common resident area referred to as the atrium of the facility. The binder contained previous survey results and should contain the results of the most recent survey (Statement of Deficiencies Form CMS-2567) of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Review of the binder revealed that results of the most recent standard survey ending June 18, 2025, were not in the binder. Further review of the contents of the binder revealed that there were full health survey letters and complaint deficiency letters (letters sent to administration after a survey) in the binder. The binder contained a deficiency letter for a survey ending June 18, 2025. The letter noted the name and associated specific resident identifiers for Residents 7 and 18 which should be kept confidential to ensure a resident's right to privacy. These findings were reviewed with the Nursing Home Administrator on June 3, 2026, at 10:20 AM. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion for two of three residents reviewed for ROM concerns (Residents 12 and 14). Findings include: Clinical record review revealed the facility admitted Resident 12 on January 6, 2025. Review of Resident 12's admission MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 13, 2025, noted staff assessed Resident 12 as having no impairment to her range of motion (ROM, movement of the body to maintain a resident's ability) of her bilateral upper and lower extremities. Review of 12's next quarterly MDS dated [DATE], noted staff assessed Resident 12 as having declined, with bilateral impairments to her upper and lower extremities. Review of Resident 12's physical therapy documentation revealed that she was discharged from therapy on April 10, 2025. There was no evidence that the facility addressed Resident 12's decline in range of motion. Interview with Employee 11 (registered nurse assessment coordinator) and Employee 12 (physical therapist assistant) on June 18, 2025, at 10:02 AM confirmed these findings for Resident 12. Clinical record review revealed the facility admitted Resident 14 on January 17, 2024. Review of Resident 14's annual MDS dated [DATE], noted staff assessed Resident 14 as having no impairment to her range of motion. Review of Resident 14's quarterly MDS assessment dated [DATE], noted staff assessed Resident 12 as having declined, with bilateral impairments to her upper and lower extremities. Review of Resident 14's physical therapy documentation revealed that she was discharged from therapy on April 10, 2025. Physical therapy discharge recommendations included a recommendation of a walk to dine program for Resident 14 with nursing. There was no evidence that the facility addressed Resident 14's decline in range of motion or implemented the recommended walk to dine program for Resident 14. Interview with Employees 11 and 12 on June 18, 2025, at 10:02 AM confirmed these findings for Resident 14. Further interview with Employee 12 on June 18, 2025, at 11:56 AM confirmed the nursing staff never implemented Resident 14's recommended walk to dine program. The above findings for Residents 12 and 14 were reviewed with the Director of Nursing and Nursing Home Administrator on June 17, 2025, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to offer pneumococcal vaccines to three of five residents reviewed for immunizations (Residents 20, 2, and 11). Findings include: The facility policy entitled, Pneumococcal Vaccines (PCV13, PCV20, and PPSV23) of Residents, last reviewed January 29, 2025, revealed that the purpose of the policy is to reduce morbidity and mortality from pneumococcal disease by vaccinating all residents who meet the criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. All residents of the facility should receive the pneumococcal vaccine (PCV13, PCV20, and/or PPSV23), unless there is a documented contraindication or right of refusal. The infection preventionist/designee will be responsible to monitor the facility's pneumococcal immunization program. Residents will have their immunization status determined at the time of admission and vaccine offered if not immunized. Each resident's immunization status will be documented in the resident's PCC (Point Click Care, electronic medical record system) immunization tab and on their consent form. Consent or declination is obtained upon admission. The facility distributes a consent/declination form annually to the resident/responsible party to update as needed as per regulatory guidelines. The infection preventionist is responsible for coordinating the administration of resident vaccines. The facility's active policy did not refer to the available pneumococcal vaccines PCV15 or PCV21. Clinical record review for Resident 20 revealed that the facility admitted her on December 27, 2021, at the age of 83. Resident 20's immunization tab indicated that she received a Pneumovax (PPSV23) immunization (on November 12, 2011) at the age of 73 before her admission to the facility. There were no other pneumococcal immunizations recorded in Resident 20's medical record. Current CDC recommendations (at https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html) note that the CDC offers PneumoRecs VaxAdvisor as a free application to quickly and easily provide patient-specific pneumococcal vaccine guidance. Per the PneumoRecs VaxAdvisor application, someone greater than [AGE] years old, who had the PPSV23 vaccine, should receive one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23. Interview with Employee 1 (licensed practical nurse/infection control prevention coordinator) on June 17, 2025, at 1:15 PM and June 18, 2025, at 9:00 AM confirmed that the facility had no additional evidence of pneumococcal immunizations for Resident 20. Clinical record review for Resident 2 revealed that the facility admitted her on June 5, 2019. Review of Resident 2's immunization tab revealed that Resident 2 received the PCV13 vaccine (before her admission to the facility) on May 20, 2016 (at [AGE] years old), and the PPSV23 vaccine (before her admission to the facility) on December 1, 2018 (at [AGE] years old). Per the PneumoRecs VaxAdvisor application, someone greater than [AGE] years old, who never received the PCV15, PCV20, or PCV21 immunizations, but received the PPSV23 and PCV13 immunizations at/after age [AGE] years old, should discuss with their clinical decision-making providers whether to administer one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose to complete their pneumococcal vaccinations. Interview with Employee 1 on June 17, 2025, at 1:15 PM and June 18, 2025, at 9:00 AM confirmed that the facility had no additional evidence of offering Resident 2 either the PCV20 or PCV21 immunizations. Clinical record review for Resident 11 revealed that the facility admitted her on May 5, 2023. Review of Resident 11's immunization tab revealed that Resident 11 received the PCV13 vaccine (before her admission to the facility) on February 26, 2016 (at [AGE] years old), and the PPSV23 vaccine (before her admission to the facility) on November 7, 2016 (at [AGE] years old). Resident 11's clinical record contained no evidence that the facility offered the PCV20 or PCV21 vaccines. Interview with Employee 1 on June 17, 2025, at 1:15 PM and June 18, 2025, at 9:00 AM confirmed that the facility had no additional evidence of offering Resident 11 either the PCV20 or PCV21 immunizations per current CDC guidance. 28 Pa. Code 211.5(f)(i)-(xi) Medical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on a review of select facility policies and procedures, Centers for Disease Control (CDC) standards, clinical record review, review of personnel payroll records, observation, and resident and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection related to COVID-19 work exclusions for two of two employees reviewed (Employees 3 and 4), COVID-19 outbreak testing for three of three episodes of facility COVID-19 outbreaks (July 29, 2024, to August 3, 2024; September 16, 2024; and February 9, 2025); transmission based precautions for one of one resident identified on transmission based precautions (Resident 22); enhanced barrier precautions for one of two residents observed for wound care (Resident 10); a process to obtain pertinent information following acute care hospital treatment for one of one resident reviewed for urinary tract infections (Resident 22); and resident personal laundry processing (Residents 11, 17, 15, 13, and 23). Findings include: Centers for Disease Control criteria for staff to return to work following COVID-19 infection (https://www.cdc.gov/covid/hcp/infection-control/guidance-risk-assesment-hcp.html?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html) revealed that health care personnel (HCP) with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least seven days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). At least 24 hours have passed since last fever without the use of fever-reducing medications. Symptoms (e.g., cough, shortness of breath) have improved. If using an antigen test (can give results in as little as 15 minutes, do not require laboratory testing for the results), HCP should have a negative test obtained on day 5 and again 48 hours later. Current CDC Infection Control Guidance for SARS-CoV-2 (COVID-19), at https://www.cdc.gov/covid/hcp/infection-control/index.html, revealed that asymptomatic residents with close contact with someone with COVID-19 infection should have a series of three viral tests for COVID-19 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one (where day of exposure is day zero), day three, and day five. Healthcare facilities should have a plan for how COVID-19 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP (health care personnel), and residents as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of COVID-19 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one (where day of exposure is day zero), day three, and day five. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every three to seven days until there are no new cases for 14 days. Review of the facility's submissions to the Department of Health Event Reporting System (ERS, online system established for facilities to comply with required notification to the Department of the facility's reportable events) revealed that Employee 3 tested positive for COVD-19 on July 29, 2024 (day zero). Interview with Employee 3 (receptionist) on June 17, 2025, at 3:32 PM confirmed that she tested positive for COVID-19 while working on July 29, 2024. Employee 3 stated that she began to have sinus symptoms (congestion), so she followed the facility protocol and performed a rapid (antigen) test at the facility that confirmed COVID-19 infection. Employee 3 stated that she stayed to work while wearing a mask until leaving early at 1:30 PM that day, stayed home while sick the next two days, but that she returned to work the following day (day three after her positive test). Employee 3 stated that she believed that if she did not show symptoms, she could work. Employee 3 stated that she felt sick again on day four, so she did not come to work at the facility; however, she did not take any additional sick days after the fourth day. Employee 3 denied COVID-19 testing on days five or seven to ensure negative findings before returning to work. Review of Employee 3's timecard confirmed that she did not have regular work hours paid on days one, two, and four after her positive COVID-19 test; however, Employee 3 worked regular hours on days three, five, six, seven, eight, and nine. Review of the facility's submissions to the Department of Health Event Reporting System revealed that Employee 4, nurse aide, tested positive for COVD-19 on July 29, 2024 (day zero). Review of Employee 4's timecard revealed that she worked regular hours on the following dates: August 3, 2024, 3:00 PM to 11:00 PM (day five) August 5, 2024, 3:00 PM to 11:00 PM (day seven) August 6, 2024, 3:00 PM to 11:00 PM (day eight) August 7, 2024, 3:00 PM to 11:00 PM (day nine) August 8, 2024, 3:00 PM to 11:00 PM (day 10) Review of the facility's submissions to the Department of Health Event Reporting System revealed that the facility continued to report positive COVID-19 cases for both residents and staff until August 3, 2024. The facility reported two new staff COVID-19 positive tests on September 16, 2024. The facility reported a new resident COVID-19 positive test on February 9, 2025. Interview with Employee 1 (licensed practical nurse/infection control prevention coordinator) on June 18, 2025, at 9:00 AM confirmed that the facility had no evidence of testing staff (Employees 3 and 4) returning to work before CDC guidelines for HCP with known COVID-19 infection. The interview with Employee 1 indicated that the facility had no evidence of COVID-19 testing of staff during the August 2024, September 2024, or February 2025 COVID-19 outbreaks via either contract tracing or the broad-based approach. Employee 1 provided COVID-19 staff testing logs dated November 4 through 25, 2024; and December 2 through 30, 2024 (although the facility reported no new COVID-19 cases during that time). The logs provided indicated that testing occurred on a weekly basis; and did not follow any schedule established by CDC guidelines (on day one, day three, and day five and continued every three to seven days until there are no new cases for 14 days). The logs also indicated that no testing was performed on those staff that were recorded as vaccines up to date (despite CDC guidelines that stipulate testing is done regardless of vaccination status). Interview with Resident 22 on June 16, 2025, at 1:46 PM revealed that she required antibiotics for a urinary tract infection with MRSA (Methicillin-resistant Staphylococcus aureus, bacteria that is resistant to many antibiotics and can cause serious infections) when first admitted to the facility. Clinical record review for Resident 22 revealed a laboratory report dated as collected November 27, 2024, that indicated that Resident 22 had a urinary tract infection with MRSA. Observation of Resident 22's room on June 16, 2025, at 1:08 PM revealed a sign to stop and see nursing staff before entering; and a sign to use contact precautions (clean hands before entering and when leaving the room, staff to don gloves and a gown before entering the room, and staff to use dedicated or disposable equipment for care). Interview with Employee 10 (nurse aide) on the date and time of the observation revealed that Resident 22 had MRSA in her urine, that she was incontinent of urine, and that she wears incontinence briefs. Observation of medication administration for Resident 22 with Employee 7 (licensed practical nurse) on June 16, 2025, at 3:36 PM revealed that Employee 7 did not don a gown before entering Resident 22's room. Employee 7's clothing contacted Resident 22's bed several times as she leaned over Resident 22 to administer eye drops to both of Resident 22's eyes; and during the procedure to obtain a blood pressure assessment. Employee 7 returned to the medication cart and placed the blood pressure cuff and stethoscope used to obtain Resident 22's blood pressure assessment directly on the top of the medication cart. Employee 7 then used a sanitizing cloth to clean the stethoscope and cuff; however, Employee 7 did not clean the top of the medication cart. Employee 7 then continued medication administrations to five other residents. Interview with Employee 7 on June 16, 2025, at 4:12 PM confirmed that the signage on Resident 22's room entry area indicated that she required contact isolation precautions, and that those precautions were required due to a MRSA infection in her urine; however, the interview confirmed that no gown was donned before entering her room to administer her medications and obtain a blood pressure assessment. The interview also confirmed that Employee 7 had to clean the blood pressure cuff and stethoscope because those items were not dedicated equipment for Resident 22, but that she potentially contaminated the top of the medication cart when the equipment was placed there before cleaning. The surveyor reviewed the above concerns regarding Resident 22's isolation precautions during an interview with the Director of Nursing and the Nursing Home Administrator on June 17, 2025, at 2:40 PM. Observation of Resident 22's room on June 18, 2025, at 10:20 AM revealed continued use of contact isolation precaution signage. Nursing documentation dated January 1, 2025, at 6:57 AM revealed that Resident 22 was not responding well, was pale, and exhibited nonsensical conversation. Staff arranged for her transport to the hospital emergency room for evaluation, and Resident 22 left the facility. Nursing documentation dated January 1, 2025, at 2:09 PM revealed that Resident 22 returned to the facility with a diagnosis of a urinary tract infection and would receive Macrobid (antibiotic) for seven days. A physician's order dated January 1, 2025, instructed staff to administer Macrobid 100 mg (milligrams) twice daily for seven days for a urinary tract infection. Review of an MAR (medication administration record, electronic documentation of the administration of medications) dated January 2025 revealed that Resident 22 received Macrobid two times a day for her urinary tract infection from January 1, 2025, at 10:30 PM to January 8, 2025, at 10:30 AM. A laboratory report dated January 3, 2025, indicated that the bacteria in Resident 22's urine (Enterobacter cloacae complex) was only intermediately susceptible to Macrobid. The laboratory report indicated that the organism was susceptible to the antibiotic Bactrim. Interview with Employee 1 on June 17, 2025, at 1:04 PM indicated that laboratory culture and sensitivity reports are received by the licensed nurses who will notify a physician if an ordered antibiotic is not effective to treat a condition. Employee 1 stated that he was unaware if or when the facility staff received the urine culture and sensitivity report completed by the acute hospital emergency room on January 1, 2025. The facility had no evidence that staff notified Resident 22's physician with the report that a different antibiotic presented a better treatment response to Resident 22's infecting organism. Review of the Centers for Medicare and Medicaid Services (CMS) memo entitled, Enhanced Barrier Precautions in Nursing Homes, dated March 20, 2024, revealed that nursing care facilities are to use enhanced barrier precautions (EBP, gown and glove use) for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility policy entitled, Isolation Precautions, last reviewed January 29, 2025, revealed Enhanced Barrier Precautions are in response to the detection of serious antibiotic resistance threats in nursing homes guided by the CDC in December 2019. EBP prevent transmission with residents known or suspected to be infected of novel or targeted MDROs. EBP are indicated for residents with indwelling medical devices and wounds who are at high risk for acquiring and being colonized with MDROs when they reside on the same unit as a resident colonized or infected with a novel or targeted MDRO. High-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include wound care (any skin opening requiring a dressing). Implementation of EBP include to ensure access to alcohol-based hand rub. Review of the facility policy entitled, Clean Dressing Change, last reviewed January 29, 2025, revealed that procedural steps include the following sequence: Perform hand hygiene Put on (don) clean gloves Remove dressing and place in trash can Remove (doff) gloves and perform hand hygiene Put on clean gloves Cleanse wound Remove gloves and perform hand hygiene Put on clean gloves Apply clean dressings as ordered Remove gloves and perform hand hygiene Review of the facility policy entitled, Hand Hygiene Policy and Procedure, last reviewed January 29, 2025, revealed that indications for the use of alcohol-based hand rub (ABHR) include for routine decontaminating hands in clinical situations such as moving from a contaminated body site to a clean body site during resident care and after removing gloves. Clinical record review for Resident 10 revealed nursing documentation dated May 27, 2025, at 10:07 PM that Resident 10 had an open area to her coccyx (tailbone). Observation of Resident 10's room on June 16, 2025, at 12:43 PM revealed Enhanced Barrier signs on her doorway and a cart outside her doorway with reusable gowns and disposable gloves. Observation of Resident 10's wound care with Employee 2 (registered nurse) on June 17, 2025, at 9:10 AM revealed that Employee 2 did not don a gown before performing the procedure (despite the signage on Resident 10's doorway). Employee 2 donned gloves, removed the soiled dressing from Resident 10's buttocks, removed his gloves, donned new gloves (without performing hand hygiene), cleansed Resident 10's wounds with gauze, and reapplied the new dressings to Resident 10's buttocks. Interview with Employee 2 after completion of the dressing change and his return to the treatment cart in the hallway confirmed that he did not take any hand sanitizer into Resident 10's room or wash his hands between doffing the soiled gloves and donning new gloves. Review of the facility policy entitled, Laundry and Infection Control, last reviewed January 29, 2025, revealed that staff handle all used laundry as potentially contaminated and utilize standard precautions (i.e., gloves, gowns). Contaminated laundry is bagged at the point of collection (i.e., location where it was used). The facility follows manufacturer's instructions for all materials involved in the laundry process (i.e., washing machines, dryers, laundry detergents, and rinse aids). Review of the facility policy entitled, Laundry Policy and Procedure, last reviewed January 29, 2025, revealed that picking up personal clothing includes remove and tie laundry bags from the basket, and the laundry bag must be sealed before exiting the resident's room. Use 33-gallon black bags and/or laundry bags to replace the existing one. Do not place dirty laundry in linen storerooms, linen closets, or any room that contains clean linens. Steps for washing residents' laundry included to use proper PPE (personal protective equipment) and to not over fill washing machines. Interview with Employee 5 (director housekeeping/laundry) on June 18, 2025, at 9:50 AM revealed that resident personal laundry is collected from their rooms once or twice a week. A laundry employee collects the resident's soiled laundry from their closet. The interview indicated that each resident is to have a vented laundry hamper in their closet that is lined with either a plastic or linen bag that staff are to keep tied as the resident hampers do not have lids. Employee 5 stated that she was unaware of any concerns regarding staff not securing the soiled laundry bags between collections. Observation of the room used to process resident personal laundry revealed no isolation gowns. Interview with Employee 5 on the date and time of the observation confirmed that laundry staff do not don an isolation gown when transferring resident's soiled laundry into the washing machines. Employee 5 confirmed that there was no measure to protect staff clothing when transferring the soiled laundry. Employee 5 was unaware of the capacity limit of each washing machine in the laundry room (e.g., limit of how many pounds of laundry may be processed at one time to ensure appropriate agitation of clothing in the water and detergent to hygienically clean the laundry). Employee 5 confirmed that laundry staff do not weigh residents personal laundry loads before processing. Observation of Resident 11's room with Employee 6 (nurse aide) on June 18, 2025, at 10:45 AM revealed that Resident 11's closet hamper used for her soiled personal laundry had no lid, was lined with an open bag, and clothing was visible from the top of the hamper. Other clothing items hung on hangers from a bar above the open clothing hamper. Observation of Resident 17's closet hamper (tall, vented, white hamper) used for her soiled personal laundry with Employee 6 on June 18, 2025, at 10:46 AM revealed the hamper had no lid, was lined with an open black plastic bag, and clothing was visible from the top of the hamper. Other clothing items hung on hangers from a bar above the open clothing hamper. Observation of Resident 15's closet vented hamper used for her soiled personal laundry with Employee 6 on June 18, 2025, at 10:46 AM revealed the hamper had no lid, was lined with an open linen bag, and clothing was visible from the top of the hamper. Other clothing items hung on hangers from a bar above the open clothing hamper. Observation of Resident 13's closet with Employee 6 on June 18, 2025, at 10:47 AM revealed that an open black bag that lined a tall, vented, white hamper was falling inside the hamper. Clothing was visible from the top of the hamper. Other clothing items hung on hangers from a bar above the open clothing hamper. Observation of Resident 23's closet with Employee 6 on June 18, 2025, at 10:47 AM revealed that there was soiled clothing hanging over the top rim of a hamper, and the bag used to line the hamper was open. Other clothing items hung on hangers from a bar above the open clothing hamper. Observation of a soiled utility room with Employee 6 on June 18, 2025, at 10:50 AM revealed a hopper used by nurse aide staff to rinse excessively soiled resident clothing. Employee 6 confirmed that the room did not have any isolation gowns used by nursing staff for this procedure. One isolation gown was observed hanging on the wall; however, Employee 6 stated that was for the linen person (laundry personnel who collect linens such as sheets and towels). The facility failed to handle, store, or launder resident personal laundry in a manner to prevent the potential spread of infection. The surveyor reviewed the concerns regarding the facility's process for containing and laundering residents' personal soiled clothing during an interview with the Nursing Home Administrator on June 18, 2025, at 11:58 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for two of three nurse aides reviewed (Employees 8 and 9). Findings include: During a meeting with the Nursing Home Administrator and Director of Nursing on June 16, 2025, at 2:30 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 8 and 9 (nurse aides). Review of Employee 8's training records revealed that she only received 9.50 hours in the last year. Review of Employee 9's training records revealed that she only received 11.00 hours in the last year. Interview with the Director of Nursing on June 18, 2025, at 9:10 AM confirmed there was no further evidence that Employees 8 and 9 received the required 12 hours of annual in-service training in the last year. 28 Pa. Code 201.19(7) Personnel policies and procedures 28 Pa. Code 201.20(a)(6)(d) Staff development

Based on observation and staff interview, it was determined that the facility failed to secure treatment biologicals during wound care for one of two residents observed (Resident 10). Findings include: Observation of wound care with Employee 2 (registered nurse) on June 17, 2025, at 9:07 AM revealed Employee 2 gathered all wound care supplies from a treatment supply cart in the hallway and entered Resident 10's room, shut the door, and began her wound care. Employee 2 failed to secure (lock) the treatment supply cart before entering Resident 10's room. Interview with Employee 2 after completion of the dressing change and return to the treatment cart confirmed that he did not lock the treatment cart while the cart was unattended in the hallway. 28 Pa. Code 211.12(d)(1) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for two of five residents reviewed for unnecessary medications (Residents 11 and 7). Findings include: Clinical record review for Resident 11 revealed a consultant pharmacist review note dated January 13, 2025, at 12:00 PM that indicated Resident 11 had physician orders to receive Vitamin D daily and oyster shell calcium daily for dietary supplements. The pharmacist reported that the supplements may be deemed unnecessary and asked the physician to consider discontinuing them. The consultant pharmacist report to the physician dated January 13, 2025, had no physician/prescriber response. Clinical record review for Resident 11 revealed a consultant pharmacist review note dated March 18, 2025, at 1:32 PM that current orders for Prozac (an antidepressant) daily in combination with Zyprexa (antipsychotic medication used to balance chemicals in the brain) daily was indicated for Treatment-Resistant Major Depressive Disorder (diagnosis used when a person with major depressive disorder does not respond adequately to at least two different antidepressant medications). The pharmacist requested that the physician update Resident 11's diagnosis to reflect the indication for use. The consultant pharmacist report to the physician dated March 18, 2025, noted the physician/prescriber response as, Orders Updated, on March 31, 2025. Resident 11's active physician orders for Resident 11's Prozac medication continued to list the indication for use diagnosis as major depressive disorder, recurrent severe without psychotic features since November 1, 2023. Resident 11's active physician orders for Resident 11's Zyprexa medication continued to list the indication for use diagnosis as major depressive disorder, recurrent unspecified since April 11, 2024. There was no indication that physician orders were updated regarding the indication for the combination use of Zyprexa and Prozac medications for Resident 11. Interview with the Director of Nursing on June 18, 2025, at 12:11 PM confirmed the above findings for Resident 11. Clinical record review for Resident 7 revealed current physician orders dated January 8, 2025, for Risperidone (an anti-psychotic) 0.25 mg (milligram) BID (twice daily) for therapeutic (dosage) related to unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The facility's consultant pharmacist completed a medication review on March 20, 2025. The pharmacist identified that Resident 7's Risperidone diagnosis was for Dementia, indicated that this was not an approved diagnosis, and requested that the physician address and provide an appropriate diagnosis for the medication. On March 31, 2025, Resident 7's physician addressed the pharmacist's recommendation and indicated that the Risperidone diagnosis was for depression. There was no documentation that the facility addressed the physician's response to the medication recommendation. The surveyor reviewed the above information during an interview with Nursing Home Administrator and the Director of Nursing on June 17, 2025, at 2:57 PM. 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of 12 residents reviewed (Residents 11 and 22). Findings include: Clinical record review for Resident 11 revealed nursing documentation dated March 20, 2025, at 3:32 AM that staff found Resident 11 on the floor beside her wheelchair. Resident 11 stated that she fell asleep in her wheelchair. Staff assessed redness on the upper left corner of Resident 11's forehead. Review of the facility's investigation of Resident 11's fall on March 20, 2025, revealed that the new intervention to prevent fall recurrence was to remind staff to attempt to get Resident 11 to lay in bed when she appears sleepy in her wheelchair. Nursing documentation dated April 19, 2025, at 9:54 PM revealed that staff heard yelling and found Resident 11 on the floor beside her wheelchair. Resident 11 stated that she fell asleep, had a dream, and fell out of her wheelchair. Review of the facility's investigation of Resident 11's fall on April 19, 2025, revealed that the new intervention to prevent fall recurrence was for staff to attempt to offer Resident 11 to lay down in bed if sleepy at 10:00 PM. Review of Resident 11's plan of care developed by the facility on May 5, 2023, to address Resident 11's risk for falls revealed a list of interventions; however, the instruction for staff to attempt to get Resident 11 to lay in bed when she appears sleepy in her wheelchair (before or at 10:00 PM) was not included in the interventions. Review of Resident 11's medication regime revealed the use of Apixaban (Eliquis, an anticoagulant to thin blood and prevent blood clots) two times a day related to a history of thrombosis (stationary blood clot) and embolism (blood clot that has traveled from its original location). An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 6, 2025, revealed that Resident 11's medications included the use of an anticoagulant. A physician's progress note dated June 11, 2025, at 7:26 AM revealed a list of diagnoses that included the presence of a pacemaker (medical device surgically implanted in the chest that helps regulate the heart's rhythm by delivering electrical impulses to the heart as needed). Appointment documentation dated June 16, 2025, at 3:29 PM revealed that the facility received instructions from Resident 11's cardiologist (physician that specializes in diseases of the heart) to schedule a pacemaker check in the office on June 24, 2025, at 9:45 AM. Review of Resident 11's plans of care revealed no entries related to her use of an anticoagulant or the presence of a cardiac pacemaker. The surveyor reviewed the above concerns regarding Resident 11's plan of care during an interview with the Director of Nursing and the Nursing Home Administrator on June 17, 2025, at 2:00 PM. Interview with Resident 22 on June 16, 2025, at 1:46 PM revealed that she required antibiotics for a urinary tract infection with MRSA (Methicillin-resistant Staphylococcus aureus, bacteria that is resistant to many antibiotics and can cause serious infections) when first admitted to the facility. Clinical record review for Resident 22 revealed an admission MDS dated [DATE], that did not indicate that Resident 22 had a urinary tract infection in the last 30 days or that she presented with a multi-drug-resistant organism (MDRO). Nursing documentation dated November 26, 2024, at 10:17 AM revealed that the certified registered nurse practitioner requested Resident 22 have a urinalysis with culture and sensitivity test. Lab results documentation dated November 28, 2024, at 1:18 PM revealed that the facility was made aware that Resident 22's urine had greater than 100,000 cfu (colony-forming units of viable bacteria) of Staphylococcus present. A laboratory report dated as collected November 27, 2024, revealed that Resident 22 had a urinary tract infection with MRSA. Nursing documentation dated November 30, 2024, at 10:36 AM revealed that Resident 22 received Doxycycline (antibiotic) for a urinary tract infection with MRSA, and she was on contact isolation (interventions implemented to prevent the spread of infection that include the use of handwashing, isolation gowns, and gloves for all resident care). Nursing documentation dated January 1, 2025, at 6:57 AM revealed that Resident 22 was not responding well, was pale, and exhibited nonsensical conversation. Staff arranged for her transport to the hospital emergency room for evaluation, and Resident 22 left the facility. Nursing documentation dated January 1, 2025, at 2:09 PM revealed that Resident 22 returned to the facility with a diagnosis of a urinary tract infection and would receive Macrobid (antibiotic) for seven days. A physician's order dated January 1, 2025, instructed staff to administer Macrobid 100 mg (milligrams) twice daily for seven days for a urinary tract infection. Observation of Resident 22's room on June 16, 2025, at 1:08 PM revealed a sign to stop and see nursing staff before entering, and a sign to use contact precautions (clean hands before entering and when leaving the room, staff to don gloves and a gown before entering the room, and staff to use dedicated or disposable equipment for care). Interview with Employee 10 (nurse aide) on the date and time of the observation revealed that Resident 22 had MRSA in her urine, that she was incontinent of urine, and that she wears incontinent briefs. Observation of a medication administration pass for Resident 22 with Employee 7 (licensed practical nurse) on June 16, 2025, at 4:12 PM confirmed that the signage on Resident 22's room entry area indicated that she required contact isolation precautions. Review of Resident 22's plans of care revealed no evidence that the facility developed a plan of care to address Resident 22's history of urinary tract infections with an MDRO or that she required the implementation of contact precaution isolation. The surveyor reviewed the above concerns regarding Resident 22's plans of care during an interview with the Director of Nursing and Employee 1 (licensed practical nurse/infection control prevention coordinator) on June 18, 2025, at 9:00 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of select policies and procedures, resident and staff interview, and clinical record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of one resident reviewed (Resident 130). Findings include: The policy entitled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last reviewed without changes on January 29, 2025, revealed that all alleged violations involving misappropriation of resident property are reported immediately to the administrator. All owners, operators, employees, managers, agents, or contractors must report to the State Agency and law enforcement entities any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility no later than 24-hours if the events did not result in serious bodily injury. During an interview with Resident 130 on June 16, 2025, at 12:21 PM the resident indicated that their spouse had given them $100.00 for use at the facility's beautician to receive a perm. They had placed the money in their purse. One week prior to this interview, the resident checked the purse and noticed $80.00 of the $100.00 was missing. Resident 130 sent the purse home with her spouse upon identification of the missing funds. Resident 130 indicated they notified the facility on June 13, 2025. Clinical record review for Resident 130 revealed that on May 30, 2025, Resident 130's spouse indicated that they would not like to set up a resident fund account and did not wish to have a key to their locked drawer. On June 13, 2025, at 2:39 PM the facility's social worker re-educated Resident 130 and their spouse regarding the facility's petty cash fund and a key lock for side table drawer. Both continued to deny needing a petty cash account or a key for the side drawer. Social services indicated to notify them should they wish to utilize either and requested the spouse to notify staff when leaving funds for the resident's use. There was no documentation of any incidents regarding missing funds or reported misappropriation of property for Resident 130 in their clinical record. During interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 16, 2025, at 3:05 PM information regarding the facility's investigation of Resident 130's allegation of missing money was requested. The DON confirmed that the facility was aware of the need to timely investigate resident concerns of misappropriation and reporting reasonable suspicions of crime to the appropriate identified authorities. On June 18, 2025, at 12:15 PM the facility provided copies of the Pennsylvania Department of Health's (PA DOH) Electronic Reporting System (ERS) dated June 18, 2025, the Pennsylvania Department of Aging and Pennsylvania Department of Human Services Mandatory Abuse Report dated June 18, 2025, and two witness statements dated June 13, 2025. Review of the PA DOH ERS on June 18, 2025, revealed that the NHA submitted an electronic report regarding Resident 130's misappropriation allegations on June 18, 2025, at 10:06 AM, almost 5 days after Resident 130 notified the facility of potential misappropriation. Further review of the facility's ERS report dated June 18, 2025, revealed that the facility acknowledged Resident 130's notification and indicated that the surveyor was notified of the concern by Resident 130 on June 16, 2025. The surveyor informed the facility of the resident's concern on June 16, 2025. Further review revealed that the required agencies were not notified of the reasonable suspicion of crime until June 18, 2025. There was no documentation provided that indicated that they reported Resident 130's allegation of misappropriation of resident funds to the Department of Heath, Department of Aging, or any law enforcement entity prior to June 18, 2025. The surveyor reviewed this information during an interview with the NHA and DON on June 16, 2025, at 3:05 PM. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.19 Personnel policies and procedures 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review, review of select policies and procedures, and staff and resident interview, it was determined that the facility failed to thoroughly investigate and notify the appropriate agencies of an identified incident of potential resident misappropriation of property (money) for one of one resident reviewed (Resident 130). Findings include: Review of the facility's active policy entitled Abuse Policy, last reviewed without changes on January 29, 2025, revealed that each resident will be free and protected from abuse, including misappropriation of resident property. Reports of misappropriation of resident property are promptly and thoroughly investigation. The administrator or designee will direct completion of an active search for missing item(s), immediately protect the resident, and coordinate delivery of appropriated medical and/or psychological care and attention. The investigation will consist of at least the following: Review of the completed complaint report Interview with the person or persons reporting the incident Interview with any witnesses Review of the resident record A search of the resident room (with resident permission) Interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident Interview with the resident's roommate, family members, and visitors Root-cause analysis of all circumstances surrounding the incident Results of the investigation will be documented and attached to the report. The resident and/or family will be notified of the completion of the investigation and whether the incident was substantiated. During an interview with Resident 130 on June 16, 2025, at 12:21 PM the resident indicated that their spouse had given them $100.00 for use at the beauticians to receive a perm. They had placed the money in their purse. One week prior to this interview, the resident checked the purse and noticed $80.00 of the $100.00 was missing. Resident 130 sent the purse home with her spouse upon identification of the missing funds. Resident 130 notified the facility on June 13, 2025. Clinical record review for Resident 130 revealed that on May 30, 2025, Resident 130's spouse indicated that they would not like to set up a resident fund account and did not wish to have a key to their locked drawer. On June 13, 2025, at 2:39 PM the facility's social worker re-educated Resident 130 and their spouse regarding the facility's petty cash fund and a key lock for the side table drawer. Both continued to deny a petty cash account or a key for the side drawer. Social services indicated to notify them should that wish to utilize either and requested the spouse notify staff when leaving funds for the resident's use. There was no documentation of any incidents regarding missing funds or reported misappropriation of any property for Resident 130. During interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 16, 2025, at 3:05 PM and June 17, 2025, at 2:50 PM, and with the Director of Nursing on June 18, 2025, at 8:49 AM information regarding the facility's investigation of Resident 130's allegation of missing money was requested. On June 18, 2025, at 12:15 PM, the facility provided copies of the Pennsylvania Department of Health's (PA DOH) Electronic Reporting System (ERS) dated June 18, 2025, the Pennsylvania Department of Aging and Pennsylvania Department of Human Services' Mandatory Abuse Report dated June 18, 2025, and two witness statements dated June 13, 2025. There was no documentation provided that indicated they initiated and/or thoroughly investigated Resident 130's allegation of misappropriation of resident funds prior to June 18, 2025. The surveyor reviewed this information during an interview the NHA on June 18, 2025, at 11:53 AM. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management

Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident wishes regarding advance directives for two of four residents reviewed for advance directive concerns (Residents 11 and 22). Findings include: Clinical record review of Resident 11's physical chart revealed a POLST (Physician Orders for Life-Sustaining Treatment, portable medical order form that records residents' treatment wishes so that emergency personnel know what treatment the resident wants in the event of a medical emergency) signed by a physician on [DATE], and signed by Resident 11 that indicated Resident 11 desired CPR (Full Code, cardiopulmonary resuscitation, chest compressions and artificial breathing assistance upon a medical emergency and/or death); however, limited other interventions such as refusing intubation (DNI, do not insert a tube into the airway to help with breathing). Review of active physician orders in Resident 11's electronic medical record instructed staff to implement Full Code treatment. Interview with Employee 1 (licensed practical nurse/infection prevention control preventionist) and Employee 2 (registered nurse) on [DATE], at 2:22 PM revealed that in the event of a medical emergency for Resident 11, both employees would refer to her electronic medical record physician's order that did not include a prohibition for intubation. Employees 1 and 2 confirmed that current physician orders for Resident 11 instructed staff to implement Full Code treatment. Employees 1 and 2 reviewed the POLST included in Resident 11's physical chart and confirmed Resident 11's wishes were to restrict intubation. Clinical record review of Resident 22's physical chart revealed social services documentation dated [DATE], at 4:31 PM that revealed that Resident 22 completed admission paperwork, and Resident 22 stated that her son is one person designated as her power-of-attorney. The documentation indicated that a POLST was completed with Resident 22 for Full Code, limited interventions. The writer indicated that the form would be forwarded to the physician for signature and filed. Social services documentation dated [DATE], at 4:17 PM revealed that Resident 22's son was present to discuss Resident 22's code status. Resident 22's son completed the POLST with Resident 22 and selected CPR with limited interventions. The writer indicated that the form would be forwarded to the physician for signature and filed in Resident 22's medical record. A POLST signed by a physician on [DATE], and signed by Resident 22's responsible party (son) indicated Resident 22 was to receive CPR; however, was not to receive intubation (DNI) as stipulated in the limited interventions. Review of active physician orders in Resident 22's electronic medical record (EMR) instructed staff to implement Full Code treatment. Interview with Employees 1 and 2 on [DATE], at 2:22 PM revealed that because Resident 22's active EMR (electronic medical record) physician orders instructed Full Code and there was no sticker on the outside of Resident 22's physical medical record, staff would determine that they were to implement Full Code CPR treatment without any restriction to intubation. The surveyor reviewed the DNI omission from Resident 11's and Resident 22's electronic physician orders during an interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 2:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on closed clinical record review and staff interview, it was determined that the facility failed to implement treatment and services for mobility for one of two residents reviewed (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed a physical therapy discharge summary dated October 1, 2024, that stipulated that her wheelchair seat was too high for her feet to touch the ground, and she was unable to self-propel. The documentation indicated that there was a representative from an outside resource that assessed the situation, and there were adjustments pending. Resident CR1's closed clinical record contained no evidence of any further adjustments to Resident CR1's wheelchair. A physical therapy discharge summary dated December 6, 2024, noted the discontinuation of treatment as the patient discharged to hospital. Resident CR1's closed clinical record did not indicate that she was discharged to the hospital in December 2024. A physician's order dated December 11, 2024, instructed physical therapy to continue treatment up to 20 visits in 30 days. Resident CR1's closed clinical record did not contain evidence that the physical therapy staff assessed or treated Resident CR1 on or after December 11, 2024. The facility transferred Resident CR1 to the hospital on January 6, 2025, and discharged Resident CR1 from the facility on January 15, 2025. Interview with Employee 1 (physical therapy assistant) on March 11, 2025, at 1:30 PM revealed that Resident CR1 had decreased mobility of her lower extremities with contractures of her knees. Resident CR1 propelled herself in her wheelchair using her feet in the hallways; however, the height of her initial wheelchair seat allowed her knees to remain in a bent position as she propelled her wheelchair. Resident CR1 received a customized wheelchair to allow the stretching of her legs, which lessened the ability of her feet to come in complete contact with the floor. The facility evaluated the chair again and determined that another frame would lower the seat of the wheelchair slightly to increase the contact her feet would have with the floor and, potentially, improve her ability to self-propel. The interview confirmed that the facility had no further evidence that Resident CR1's chair was modified to improve the contact her feet had with the floor. The interview also confirmed that the facility had no documentation that Resident CR1 received skilled physical therapy services after December 6, 2024. The surveyor reviewed the above concerns during an interview with the Nursing Home Administrator and the Director of Nursing on March 11, 2025, at 2:00 PM. 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a safe and sanitary condition in the main kitchen. Findings include: An observation of the facility's main kitchen on July 5, 2023, at 11:16 AM revealed the following: A countertop deep fryer had significant yellow grease buildup on the back of the fryer basket area where it connects to the base. The walk- in freezer contained significant ice buildup around the interior of the door. Pieces of ice were observed on the freezer floor. Ice buildup was also observed on the interior wall of the walk- in cooler that sits against the walk-in freezer. Employee 6, certified dietary manager, indicated the ice accumulation has been an ongoing problem and multiple repairs have been made including changing the seals around the door, but the ice continues to accumulate. Canned products including three cans of diced tomatoes, two cans of sweet corn, three cans of sweet potatoes, five cans of tomato paste, five cans of baked beans, and four cans of carrots were observed stored on shelving in the dry storage area. There was no evidence to indicate when the products were delivered, or when they needed used by. Three cardboard boxes of paper cups and foam food containers were observed stored directly on the floor in the dry storage area. Additional boxes of disposable cups and food containers were observed stored directly on the floor in the chemical room beside bottles of cleaning solutions. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 6, 2023, at 2:00 PM. 28 Pa. Code 211.6 (c)(f) Dietary services

Based on a review of select facility policies and procedures, clinical record review, and responsible party, resident, and staff interview, it was determined that the facility failed to provide the highest practicable care to promote pressure ulcer healing for four of four residents reviewed (Residents 2, 3, 13, and 15). Findings include: The policy entitled Pressure Ulcer Treatment Policy and Procedure, last reviewed without changes on January 18, 2023, revealed the registered nurse will measure and document wounds at least weekly on shower assessment or wound rounding day for positive or negative changes and act accordingly. An interview with Resident 2 on July 5, 2023, at 1:11 PM revealed she had a pressure ulcer on her buttock and right thigh. A review of Resident 2's clinical record revealed Wound Healing Solutions assessed Resident 2's wounds on June 6, 2023. Wound Healing Solutions assessed Resident 2's full-thickness ulceration of her coccyx as healed, with macerated (softening and breaking down of skin) tissue. The partial thickness ulceration of Resident 2's right posterior thigh was measured as 1.5 by 0.8 by 0.1 centimeters (cm). Wound healing solutions identified a new wound on Resident 2's right buttock measuring 0.8 by 0.2 by 0.2 cm, adjacent to the coccyx ulcer. The next assessment of Resident 2's wounds was on June 20, 2023 (14 days later). Resident 2's full-thickness ulceration of her coccyx was now reopened and measured 0.5 by 0.5 by 0.1 cm. Her right posterior thigh measured 2.0 by 0.7 by 0.1 cm, and her right buttock measured 0.5 by 0.3 by 0.2 cm. An interview with Resident 3 on July 5, 2023, at 12:56 PM revealed that she had a pressure sore on her left foot and right leg stump. A review of Resident 3's clinical record revealed Wound Healing Solutions assessed Resident 3's wounds on June 6, 2023. Wound Healing Solutions assessed Resident 3's partial thickness wound on her right posterior stump (medial) 1.8 by 1.8 by 0.2 cm, full thickness wound left heel 4.8 by 4.5 by 0.2 cm, and full thickness wound of left second toe 0.6 by 0.6 by 0.2 cm. The next assessment of Resident 3's wounds was on June 20, 2023 (14 days later). An interview with the responsible party for Resident 15 on July 5, 2023, at 11:20 AM revealed the resident came to the facility with skin breakdown on her buttocks, and probably cancer has spread to her brain, and she is at the end of her life. The responsible party also indicated that the resident does not like to be repositioned in bed and only wants to lie on her back. Review of a consultation by Wound Healing Solutions for Resident 15 dated June 6, 2023, revealed the resident had wounds that healed on both buttocks and had developed a new skin ulceration over the coccyx (tailbone) that measured 3.5 cm x 3 cm x 0.1 cm. The wound was described as a partial thickness wound and moisture related. The next assessment for Resident 15 was on June 20, 2023 (14 days later), which revealed the partial-thickness ulceration was now a Stage III pressure ulcer/injury (full-thickness loss of skin) that measured 1.5 cm x 1 cm x 0.1 cm. The facility failed to provide the necessary treatment and services, consistent with professional standards of practice to promote pressure ulcer healing and prevent new ulcers from developing. An interview with the Director of Nursing on July 7, 2023, at 10:54 AM confirmed these findings for Residents 2, 3, and 15. Clinical record review for Resident 13 revealed a progress note dated June 22, 2023, at 11:10 AM noting an assessment of the resident after a fall. A dark hard area was noted on the residents left heel noting skin prep was applied and the resident would be placed on the list for the wound care team. There was no evidence of any additional assessment at the time to determine the origin of the area to indicate if the area was a result of the fall, pressure, friction, or the size of the area. A skin assessment dated [DATE], for Resident 13 assessed the resident as having a reabsorbed and hard right heel blister, nothing was noted on the left heel. There were no measurements of the area or interventions initiated. Resident 13 was not seen by the wound specialist until June 28, 2023, who noted an unstageable pressure area on the resident's left heel measuring 1.33 cm in area, 1.17 cm in length and 1.49 cm in width. No areas were noted on the resident's right heel. A treatment was ordered to be completed every three days to the left heel, and the wound specialist would follow up in two weeks. A skin assessment completed on Resident 13 dated July 4, 2023, assessed the resident as having a right heel blister with no measurements noted. The skin assessment did not note any area on the left heel. There was no evidence of any weekly assessment or measurements to identify any improvement, decline, or need of treatment change for the area on the resident's left heel. An observation of Resident 13's heels upon surveyor request with Employee 7, registered nurse, on July 6, 2023, at 2:28 PM revealed the resident had a treatment dressing removed from his left heel. A dark purple area was observed on the left heel. There was no evidence of any compromised area or recently healed area on the resident's right heel as the resident was noted as having a blister on the heel on assessments completed by the nursing staff dated June 27, and July 4, 2023. Employee 7 redressed the area to the resident's left heel per physician orders. No measurements or documented assessment as to the condition of the area was noted. Employee 7 indicated the facility did not have a wound nurse and a company comes in every other week to assess areas on the residents with measurements and any needed treatment changes. In an interview with the Director of Nursing on July 6, 2023, at 2:40 PM it was confirmed the facility did not have a wound nurse or the wound specialist available to assess the resident's area weekly, and Resident 13 would not be assessed by the wound specialist again until a visit the week of July 10, 2023, after the resident's initial visit on June 28, 2023. The Director of Nursing confirmed the skin assessment documentation dated June 27, and July 4, 2023, for Resident 13 inaccurately identified the area as being on the resident's right heel and not the left heel. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing care services

Based on clinical record review, review of select facility policies, and staff interview, it was determined that the facility failed to implement interventions to deter skin breakdown for one of one residents sampled (Resident CR1). Findings include: The policy entitled "Prevention of Pressure Ulcers," last reviewed January 29, 2010, revealed that for a person in bed, their position should be changed at least every two hours, and use a special mattress that contains foam, air, gel, or water, as indicated. For a person in a chair, their position should be changed at least every two hours and staff should utilize a foam, gel, or air cushion, as indicated, to relieve pressure. Persons confined to chairs who are unable to shift their own weight may need repositioning more frequently. The policy entitled "treatment of [REDACTED]. The facility should identify signs of healing after two to four weeks of treatment, and they should notify the physician if any evidence of deterioration is noted. The diet of the resident with a pressure ulcer should contain nutrients adequate to support healing. The staff should avoid positioning the resident on a pressure ulcer. They should use a positioning device to raise a pressure ulcer off a support surface. Closed clinical record review revealed that the facility admitted Resident CR1 on January 26, 2010. Review of the form entitled "Resident-Data Collection," dated January 26, 2010 noted that Resident CR1 had a 0.5 centimeter (cm) long by 1.5 cm wide, Stage II (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) pressure sore to his right posterior thigh. Review of the Pressure Ulcer Risk assessment dated [DATE], revealed that the facility assessed Resident CR1 as a high risk for skin breakdown. The Weekly Pressure Ulcer Record (a form utilized by the facility to track resident wounds) revealed that Resident CR1's pressure ulcer on his right posterior thigh healed on February 16, 2010. The initial Minimum Data Set assessment (MDS, an assessment tool completed at specific intervals to determine care needs) dated February 6, 2010, revealed that staff assessed Resident CR1 as requiring extensive assistance of two people for bed mobility. Interview with Employee 1 (registered nurse, wound nurse) on October 19, 2010, at 11:00 AM, revealed that she thought that Resident CR1 was able to turn and reposition himself; therefore, she did not implement a schedule for staff to turn and reposition him. She was also unable to provide any documentation that the facility assessed Resident CR1 for a specialty mattress to alleviate pressure. Review of the clinical record revealed no documentation to indicate that Resident CR1 received staff assistance to turn and reposition himself, even though the facility identified him as a high risk for skin breakdown and he required extensive assistance for mobility. Resident CR1's plan of care initiated February 11, 2010, revealed that he has the potential for alterations in his skin integrity. The plan of care did not include any pressure relieving devices for Resident CR1's bed or chair. Resident CR1's care plan did not address staff assistance in repositioning him. The Weekly Pressure Ulcer Record dated March 13, 2010, indicated that staff noted Resident CR1 had two Stage II pressure ulcers, each 1 cm in diameter, on his posterior scrotum and right inner buttock. These areas remained open until June 9, 2010, when staff documented that the pressure sores on Resident CR1's posterior scrotum and right buttock healed. The Weekly Pressure Ulcer Record dated April 24, 2010, indicated that staff noted Resident CR1 had a 3 cm Stage II pressure ulcer on his coccyx. This area remained open until May 5, 2010, when staff documented that the pressure sore on Resident CR1's coccyx healed. The MDS assessment dated [DATE], revealed that staff assessed Resident CR1 as requiring limited assistance of two people for bed mobility. The MDS assessment noted that Resident CR1 did not have pressure-relieving devices for his bed or chair. Staff documented on the Weekly Pressure Ulcer Record that the facility's preventative measure was that Resident CR1 will turn and reposition himself every hour. Interview with Employee 1 on October 19, 2010, at 11:45 AM, confirmed that she was unaware that he required assistance to reposition himself. Review of Resident CR1's plan of care initiated June 22, 2010 related to Resident CR1's Stage II pressure ulcer on his coccyx again did not include any pressure relieving devices for Resident CR1's bed or chair, or for staff to assist Resident CR1 to reposition. The Weekly Pressure Ulcer Record dated June 23, 2010, indicated that staff noted Resident CR1 had another 4 cm Stage II pressure ulcer on his right posterior upper thigh. This area remained open until July 7, 2010 when staff documented that the pressure sore on Resident CR1's right posterior upper thigh healed. On June 23, 2010, staff also noted that Resident CR1 had a 7 cm long by 5 cm wide Stage II pressure ulcer to his coccyx. Staff documented on September 29, 2010, that Resident CR1 continued to have a 1.5 cm in diameter Stage II pressure ulcer on his coccyx. A Dietary Progress Note dated June 30, 2010, revealed that the certified dietary manager identified that Resident CR1's Stage II pressure sore on his coccyx re-opened. The certified dietary manager indicated that she notified the registered dietitian and recommended to increase Resident CR1's protein. Review of the clinical record revealed that the facility obtained a physician's telephone order for [MEDICATION NAME] 6 ounces twice a day for wound healing on July 28, 2010 (28 days after the facility identified Resident CR1's need for increased protein). The registered dietitian did not assess Resident CR1 until July 31, 2010. Nursing documentation dated July 23, 2010, revealed that the facility removed Resident CR1's bed from his room per his request. Documentation indicated that Resident CR1 refused to sleep in his bed and he preferred to sleep in his recliner. Review of Resident CR'1 clinical record revealed no documentation that the facility educated Resident CR1 on the risks of sleeping in his recliner chair related to the treatment of [REDACTED]. The MDS assessment dated [DATE], revealed that staff assessed Resident CR1 as totally dependent, with the assistance of one person for his bed mobility. The MDS assessment noted that Resident CR1 did not have a pressure-relieving device in place for his bed or chair. The Weekly Pressure Ulcer Record dated August 18, 2010, indicated that staff noted Resident CR1 had a 4 cm long by 3 cm wide, with 0.2 cm in depth pressure ulcer on his right gluteal fold. On August 25, 2010, staff noted that the area increased in size to a 4 cm long by 6 cm wide Stage II pressure ulcer. On September 1, 2010, staff noted that the pressure sore again increased in size to a 7 cm long by 6 cm wide Stage II. On September 8, 2010, staff noted that Resident CR1's right gluteal fold pressure ulcer was now a 6.5 cm long by 6 cm wide unstageable pressure ulcer. The Weekly Pressure Ulcer Record dated September 14, 2010, indicated that staff noted that Resident CR1's unstageable pressure ulcer again increased in size to 7 cm long by 10 cm wide, with a depth of 2 cm. On September 22, 2010, staff noted that his right gluteal fold was a Stage III (a full thickness of skin is lost, exposing the subcutaneous tissue, presents as a deep crater with or without undermining adjacent tissue) pressure ulcer measuring 7 cm long by 7 cm wide. On September 29, 2010 staff noted that Resident CR1's right gluteal fold deteriorated to a Stage IV (a full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone) pressure ulcer measuring 7 cm long by 7 cm wide, with a 6.8 cm depth. Interview with the Director of Nursing on October 19, 2010, at 1:00 PM, confirmed that staff is expected to document pressure relieving devices and turning and repositioning schedules on the Treatment Records and Nurse Assistant Care Records for each resident, as indicated. Review of Resident CR1's Treatment and Nurse Assistant Care Records from January to September 2010, revealed that Resident CR1 did not utilize any pressure relieving devices, nor did staff assist him with his repositioning. Employee 1 confirmed these findings. Resident CR1's physician progress notes [REDACTED]. Nursing documentation dated September 30, 2010, revealed that staff noted a blister on Resident CR1's medial side of his right heel. Review of the Weekly Pressure Ulcer Record dated September 30, 2010, revealed that Resident CR1 had an unstageable area on his right medial heel measuring 5 cm in diameter. Interview with Employee 1 on October 19, 2010, at 1:15 PM, revealed that the facility transported Resident CR1 to an appointment on September 29, 2010. She stated that he was on the litter for approximately one hour and 30 minutes and was unable to provide any documentation that the facility implemented interventions to deter skin breakdown. The facility failed to implement interventions to deter Resident CR1's multiple areas of skin breakdown. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2) Nursing services. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 2/19/10