Every finding on record at Haida Nursing and Rehab

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 14 residents reviewed (Resident 9). Findings include: The facility's policy regarding assistive devices and equipment dated October 15, 2025, revealed that the facility maintains and supervises the use of assistive devices and equipment for residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated May 21, 2026, revealed that the resident was severely cognitively impaired, dependent on staff for daily care needs and used a wheelchair as a mobility device. The resident had diagnoses that included dementia and Alzheimer's disease, and was care planned for generalized weakness and communication and cognitive loss related to dementia. There was no care plan or documented evidence that the resident had the ability to hold her feet up while being transported though the facility. Observations on July 21, 2026, at 11:12 a.m. revealed that the resident was transported in her wheelchair by the beautician down the hallway from the dining room to the beautician's room without the use of leg rests. Observations of the resident's room and the large black bag on the back of her wheelchair did not reveal any footrests. An interview with the beautician on July 21, 2026, at 11:40 a.m. indicated that this was the first time she did the resident's hair and that she did not know if she used footrests or not. In addition, she indicated that she has seen the resident propel herself in the facility. An interview with the Nursing Home Administrator on July 21, 2026, at 4:37 p.m. confirmed that leg rests should have been in place prior to transporting Resident 9 from the dining room to the beauty shop. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for two of 10 residents reviewed (Residents 1 and 10). Findings include: A review of a facility policy regarding answering the call light, dated October 15, 2025, indicated that when a resident is in bed or confined to a chair, be sure that the call light is within reach of the resident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1, dated March 6, 2026, indicated that the resident had cognitive impairment, was clearly able to make herself understood and could clearly understand others, required substantial assistance from staff for toilet transfers and was dependent on staff for toileting hygiene, and was incontinent of bowel and bladder. A care plan for the resident, dated July 23, 2025, included an intervention to keep the call bell within reach. Observation of Resident 1 on June 9, 2026, at 10:19 a.m. revealed that the resident was sitting in her wheelchair with leg rests on and a chair alarm in place. She was yelling, stating she needed to go to the bathroom. Her call bell was out of reach and located behind her clipped to the top of her bed. She continued to moan stating she has to 'poop'. Interview Nurse Aide 1 on June 9, 2026, at 10:25 a.m. indicated that Resident 1 is able to use the toiletwith assistance and generally only uses it when she needed to have a bowel movement. She indicated that the resident was generally confused and does not usually use the call bell. She indicated that she did not believe she was care planned for inability to use her call bell and indicated that all residents should have their call bells in reach. She confirmed that the resident's call bell was not in reach. A quarterly MDS assessment for Resident 10, dated March 16, 2026, indicated that the resident had cognitive impairment, was clearly able to make herself understood and could usually understand others, was independent for most care needs, was continent of bowel and bladder and had a diagnosis of dementia. A care plan for the resident, dated September 10, 2025, included an intervention to keep the call bell within reach. Observation of Resident 10 on June 9, 2026, at 12:24 p.m. revealed that the resident was banging her empty tissue box against her overbed table calling for staff. Interview with the resident at that time indicated that she needed more tissues. This writer asked the resident if she could ring her call bell for assistance and she indicated she could not because she does not have one. The call bell was observed on the floor bedside her bed. Interview Nurse Aide 2 on June 9, 2026, at 12:28 p.m. indicated that she did place Resident 10's call bell over the top of her bed earlier and it must have slipped off of the bed. She stated that the call bells usually have a clip on them and hers did not. Interview with the Director of Nursing on June 9, 2026, at 12:33 p.m. confirmed that Resident 1's and Resident 10's call bells should have been in reach. She indicated that staff should be alerting management when they do not have clips on the call bells so they can get them. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow/clarify physician's diet orders prior to a test, for one of 10 residents reviewed (Resident 3 ).Findings include: The facility's policy regarding treatment orders, dated October 15, 2025, revealed that treatments will be consistent with principles of safe and effective order writing. In addition, nursing staff will review the overall situation for a resident for whom one or more meals are to be held to ensure that all related issues are addressed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 21, 2026, revealed that the resident was cognitively intact, always understood and always understands and has diagnoses that include quadriplegia and cancer of the lymph nodes, face and neck. Physician's orders for Resident 3, dated May 11, 2026, included the following order to start Sunday at 1:00 p.m. prior to her PET scan. The order was to have a diet of no caffeine, sugar, syrup, gum or candy. A grievance form from the family dated May 11, 2026, indicated that Resident 3 was unable to have her PET scan done as scheduled because she was not given the appropriate diet in preparation for her scan. A clinical note for Resident 3, dated May 11, 2026, at 2:17 p.m. indicated that UPMC Imaging was unable to complete the scan due to the diet not being followed according to pretesting orders. Interview with Resident 3, on June 9, 2026, at 10:38 a.m. revealed that she was unable to have her PET scan last month because she had a hot dog the night before. The imaging staff told her that the hot dog was a red meat which had salt and sugar in it. Interview with the Dietary Manager on June 9, 2026, at 1:41 p.m. confirmed that Resident 3 did not get the appropriate diet because the order and information she received was confusing. She went on to say that the diet prep should have been clarified and there was a break in communication among staff. A review of four change of diet slips given to the manager revealed that one slip contradicted the other. Interview with the Dietician on June 9, 2026, at 1:41 p.m. indicated that the diet prep for the scan was not what they usually see, and that she was going to call UPMC Imaging to clarify the prep to avoid any concerns going forward. Interview with the Nursing Home Administrator on June 9, 2026, at 2:00 p.m. confirmed that Resident 3 was given the wrong diet prior to her PET scan which caused the resident to be returned to the facility and the scan to be rescheduled. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter for one of 37 residents reviewed (Residents 20).Findings include:The facility's policy regarding urinary catheters (a tube inserted and held in the bladder to drain urine), dated October 15, 2025, indicated that the purpose of the policy was to ensure safe handling of the urinary catheter in order to reduce the risk of urinary tract infections. A quarterly Minimum Data Set (MDS) assessment for Resident 20, dated October 21, 2025, revealed that the resident was cognitively impaired, had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine) and had diagnoses that included obstructive and reflux uropathy (blockage of urine and a condition where urine flows backward from the bladder up the ureters).Physician's orders for Resident 20, dated September 23, 2025, included an order for the resident to have an indwelling urinary catheter due to having obstructive uropathy.Observations on December 1, 2025, at 10:31 a.m. revealed that Resident 20 was in a low bed, and her catheter drainage bag was lying on the floor on the right side of the bed.Observations on December 1, 2025, at 2:05 p.m. revealed that Resident 20 was in her wheelchair self-propelling down the hall and her catheter tubing was sliding across the floor. Interview with Nurse Aide 2, on December 1, 2025, at 10:51 a.m. confirmed that Resident 20's catheter drainage bag should not have been touching the floor. Interview with Licensed Practical Nurse 3, on December 1, 2025, at 2:06 p.m. confirmed that Resident 20's catheter tubing should not be sliding across the floor, and that they used to have clips to help keep the tubing off the floor.Interview with the Director of Nursing on December 1, 2025, at 2:10 p.m. confirmed that Resident 20's catheter drainage bag should not have been touching the floor, and that the catheter tubing should not have been sliding across the floor as the resident self- propelled herself down the hall. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies, clinical records, and shower schedules, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for two of 37 residents reviewed (Residents 36 and 66).Findings include: The facility's policy for resident showers, dated October 15, 2025, indicated that it was the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated November 11, 2025, indicated that the resident was cognitively impaired, required assistance from staff for personal hygiene care including showers, and had a diagnosis of dementia. A review of the shower records for Resident 36, dated October 2025 and November 2025, revealed that resident was to receive a shower on Wednesdays and Sundays during the evening shift. However, staff documented not applicable for providing showers on October 3, 6, 13, 17, 20, 24, 27, 31 and November 3, 7, 10, 14, 17, 21, 24, 28. There was no documented evidence that the resident was offered or refused a shower on these days or any days in between. A quarterly MDS assessment for Resident 66, dated October 30, 2025, indicated that the resident was cognitively impaired, required assistance from staff for personal hygiene care including showers, and had a diagnosis of dementia. A review of the shower records for Resident 66, dated October 2025 and November 2025, revealed that the resident was to receive a shower on Wednesdays and Saturdays during the day shift. However, staff documented not applicable for providing showers on October 3, 10, 14, 21, 24, 28, 31 and November 4, 7, 11, 14, 18, 25. There was no documented evidence that the resident was offered or refused a shower on these days or any other days in between. Interview with the Director of Nursing on December 3, 2025, at 3:05 p.m. confirmed there was no documented evidence that Residents 36 and 66 were provided with showers or baths on the above-mentioned dates and times. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 37 residents reviewed (Resident 4, 12, 68). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that Section N0415K1 (Anticonvulsant-medications medication used to prevent or treat seizures) was to be coded (1) was taking, if the resident received an anticonvulsant medication during the seven day look back period.A quarterly MDS assessment for Resident 4 dated October 2, 2025, revealed that Section N0415K Anticonvulsant was coded that the resident received anticonvulsants during the lookback period. However, a review of the MAR for Resident 4 for September and October 2025 revealed that the resident did not receive an anticonvulsant during the look back period.An interview with the Nursing Home Administrator on December 3, 2025, at 9:48 a.m. confirmed that Resident 4's MDS assessment was coded inaccurately, and the resident did not receive anticonvulsants during the seven-day lookback period.Physician's orders for Resident 12, dated April 2, 2025, included an order for the resident to receive 750 milligrams (mg) of Keppra (an anticonvulsant) two times a day for seizures. A quarterly MDS assessment for Resident 12, dated October 30, 2025, revealed that Section N0415K1 was not coded (1) indicating that the resident did not receive an anticonvulsant during the seven-day look-back period. However, a review of the MAR for Resident 12 for October 2025 revealed that the resident received Keppra two times a day every day in October. Interview with the Director of Nursing on December 3, 2025, at 3:15 p.m. confirmed that Resident 12's MDS dated [DATE], was not coded correctly for anticonvulsant medication use. The Long-Term Care Facility RAI User's Manual, dated October 2025, indicated that Section N0415F Antibiotic was to be coded (1) was taking, if the resident received an antibiotic medication during the seven day look back period.Physician's orders for Resident 68 dated October 28, 2025, included an order for the resident to receive 500 mg of Levofloxacin (antibiotic) intravenously (inserted through the vein) once a day.A quarterly MDS assessment for Resident 68 dated November 1, 2025, revealed that Section N0415F1 Antibiotic was not coded (1), indicating that the resident did not receive an antibiotic during the lookback period. However, a review of the MAR for Resident 68 for October 2025, revealed that the resident received an antibiotic intravenously on October 28-31, 2025, during the look back period.An interview with the Nursing Home Administrator on December 3, 2025, at 9:48 a.m. confirmed that Resident 68's MDS assessment was coded inaccurately and that the resident received an antibiotic during the seven-day lookback period.28 Pa. Code 211.5(f) Clinical records.

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that pressure relieving devices were in place as ordered by the physician for one of 37 residents reviewed (Resident 5).Findings include:A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 5, dated November 21, 2025, revealed that the resident was cognitively impaired, required assistance from staff for daily care needs, was at risk for developing pressure ulcers, and had diagnoses that included diabetes and heart failure. Physician's orders for Resident 5, dated September 17, 2025, included orders for the resident to wear Prevalon boots (a type of heel protector used in medical settings to prevent pressure injuries) on both feet for heel protection. A care plan for Resident 5, dated September 18, 2025, indicated that the resident was at risk for altered skin integrity and Prevalon boots were to be worn on both feet at all times when in bed. Observations of Resident 5 on December 3, 2025, at 10:24 a.m. revealed the resident was resting in bed without Prevalon boots on. A pillow was noted under her legs; however, her right heel, and left heel and outer ankle were resting directly on the bed. Interview with Licensed Practical Nurse 1 on December 3, 2025, at 10:24 a.m. confirmed that Resident 5 should have had Prevalon boots on while she in bed.Interview with the Director of Nursing on December 3, 2025, at 10:57 a.m. confirmed that Resident 5 should have had Prevalon boots on while in bed as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of Pennsylvania's Nursing Practice Act, facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of 37 residents reviewed (Resident 8).Findings include:The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's medication administration policy, dated October 15, 2025, revealed that medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. They will ensure the six rights of medication administration were followed: right resident, right drug, right dosage, right route, right time, and right documentation. A quarterly minimum data set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 8, dated October 1, 2025, revealed that the resident was cognitively impaired, required assistance from staff for personal care needs, had a gastrostomy (feeding tube) and had diagnoses that included a stroke. Physician's orders for Resident 8, dated July 10, 2025, included an order for the resident to be NPO (nothing by mouth) and included orders for the resident to receive 10 milligrams (mg) of Baclofen (muscle relaxant) 1 tablet by mouth one time a day, 325 mg of Ferrous sulfate (medication used for low iron) 1 tablet by mouth one time a day, 300 mg of gabapentin (medication used nerve pain) 1 capsule by mouth one time a day, and 400 mg of milk of magnesia (medication used for constipation) by mouth as needed. A review of Resident 8's December 2025 Medication Administration Record revealed that staff signed off the medications listed above as given by mouth. There was no documented evidence in the clinical record to indicate that the orders for Resident 8's medications were clarified and written to be given via peg tube due to the resident's NPO status. Interview with the Director of Nursing on December 3, 2025, at 3:22 p.m. confirmed that Resident 8's medications were not clarified and that they should have been written to be administered through the feeding tube. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 37 residents reviewed (Resident 9) who were receiving hospice services. Findings include: A hospice contract, dated July 31, 2025, indicated that all hospice assessments, plans of care, progress notes and services provided will be maintained in the medical record and integrated with the facility plan of care. Nursing staff would ensure there was a current physician's order, physician progress notes regarding hospice care, and hospice documentation that was current and available on the medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated October 18, 2025, indicated that the resident was cognitively impaired, dependent on staff for daily care needs, had diagnoses that included a cancerous tumor of the pelvic bones, and was receiving hospice (program of care and support for individuals with a terminal illness) services. Physician's orders for Resident 9, dated April 3, 2025, included an order for the resident to receive hospice services. A care plan for Resident 9, revised May 8, 2025, indicated that the resident was receiving Hospice for end-of-life care. As of December 3, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide charting (last communication was October 2, 2025). Interview with the Director of Nursing on December 3, 2025, at 11:06 a.m. confirmed that Resident 9's hospice nurse aide charting was not up to date in the resident's clinical record and/or in the hospice provider's clinical record and should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 37 residents reviewed (Resident 1 ). Findings include: The facility's policy for care plans, dated October 15, 2025, indicated that the resident and his or her representative were encouraged to participate in the development and implementation of the resident's person-centered care plan. A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 27, 2025, revealed that the resident was severely cognitively impaired, required extensive assistance from staff with daily care tasks, and had diagnoses that included chronic kidney disease, anemia and acute respiratory failure. Physician's orders for Resident 1, dated October 22, 2025, included orders for the resident to receive oxygen at 4 liters per minute, due to an onset of shortness of breath, and physician's orders, dated November 14, 2025, indicated the resident was to begin hospice services due to a loss of appetite and general decline of health. There was no documented evidence that care plans were developed to address Resident 1's individual care and treatment needs related to the use of oxygen and hospice care. Interview with the Registered Nurse Assessment Coordinator (RNAC- responsible for developing care plans) and Nursing Home Administrator on December 3, 2025, at 10:12 a.m. and 11:15 a.m. respectively, confirmed that care plans to address Resident 1's need for oxygen and hospice services were not developed, and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for six of 37 residents reviewed (Residents 2, 16, 24, 52, 70, 71). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.An admission MDS assessment for Resident 2 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 3, 2025, which was 21 days after admission.An admission MDS assessment for Resident 16 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 3, 2025, which was 15 days after admission.An admission MDS assessment for Resident 24 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on November 10, 2025, which was 15 days after admission.An admission MDS assessment for Resident 52 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on September 24, 2025, which was 15 days after admission.An admission MDS assessment for Resident 70 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 8, 2025, which was 17 days after admission.An admission MDS assessment for Resident 71 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on November 10, 2025, which was 27 days after admission.Interview with the Nursing Home Administrator on December 2, 2025, at 3:48 p.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.

Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 5 residents reviewed (Residents 1 and 5). Findings Include: The facility policy related to the use of psychotropic medications, dated April 23, 2025, indicated that residents will only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 30, 2025, revealed that the resident was severely cognitively impaired, was sometime understood, could sometimes understand, received antipsychotic and antianxiety medications, and had diagnoses that included dementia and anxiety. A skilled nursing facility psychiatric visit, dated March 25, 2025, indicated that Resident 1 was seen for ongoing agitation, was up yelling, and was difficult to redirect at night. Nonpharmacological interventions were to be used for this resident. Physician's orders for Resident 1, dated May 19, 2025 and June 11, 2025, revealed that the resident was to receive 0.25 milligrams (mg) of Alprazolam (a psychotropic medication) every eight hours as needed for anxiety. Review of Resident 1's Medication Administration Record (MAR) for May and June 2025, revealed that the resident received 0.25 mg of Alprazolam on May 19 at 2:41 p.m., on May 20 a.m at 10:17 a.m., on May 21 at 2:50 a.m., on June 11 at 1:50 p.m, on June 17 at 12:20 a.m., and on June 19 at 11:30 p.m. A review of Resident 1's clinical record revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Alprazolam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 2:54 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Alprazolam to Resident 1 on the above-mentioned dates/times. An admission MDS assessment for Resident 5, dated May 13, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic, antianxiety, and antidepressant medications (psychotropic medications) and had diagnoses that included dementia, depression, and anxiety. Physician's orders for Resident 5, dated May 9, 2025, revealed that the resident was to receive 0.5 milligrams (mg) of Lorazepam (a psychotropic medication) every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated May 24, 2025, included an order for the resident to receive 0.5 mg of Lorazepam three times daily as needed for anxiety. Physician's orders for Resident 5, dated May 27, 2025, June 8, 2025, and June 24, 2025, included orders for the resident to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Physician's orders for Resident 5, dated July 10, 2025, July 24, 2025, July 30, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours, may use three times daily, as needed for anxiety. Physician's orders for Resident 5, dated August 8, 2025, and August 25, 2025, revealed that the resident was to receive 0.5 mg of Lorazepam every eight hours as needed for anxiety. Review of Resident 5's Medication Administration Record (MAR) for May, 2025 through August, 2025, revealed that the resident received 0.5 mg of Lorazepam on May 10 at 1:20 p.m.; May 14 at 11:20 p.m.; May 18 at 10:01 a.m.; May 23 at 5:58 p.m.; May 27 at 7:15 p.m.; May 28 at 8:15 a.m.; May 31 at 3:38 p.m.; June 2 at 8:33 a.m.; June 3 at 8:11 a.m.; June 6 at 3:56 p.m.; June 10 at 3:43 p.m.; June 14 at 4:10 p.m.; July 10 at 5:48 p.m.; July 29 at 12:05 p.m.; August 14 at 2:15 p.m.; August 21 at 12:14 p.m.; and August 25 at 2:22 p.m. Review of Resident 5's clinical record, revealed no documented evidence that non-pharmacological interventions were attempted prior to administering the as needed Lorazepam on the above-mentioned dated and times. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m. confirmed that there was no documented evidence that non-pharmacological interventions were attempted prior to administering as needed Lorazepam to Resident 5 on the above-mentioned dates/times. 28 Pa. Code 211.2(d)(3) Medical director 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 5 residents reviewed (Resident 1 and 5).Findings Include: The facility's policy related to the use of psychotropic medications, dated April 23, 2025, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 30, 2025, revealed that the resident was severely cognitively impaired, received antipsychotic and antianxiety medications, and had diagnoses that included dementia and anxiety. A skilled nursing facility psychiatric visit dated March 25, 2025, indicated that Resident 1 was seen for ongoing agitation, was up yelling and was difficult to redirect at night. Start five milligrams (mg) of Buspar (medication to treat anxiety) three times a day. Patient consents for the use of current medications to be obtained with social services. Physician's orders for Resident 1, dated March 27 2025, revealed that the resident was to receive five mg of buspirone three times a day for dementia with agitation. There was no documented evidence in the resident's clinical record to indicate that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the dose of Buspar. Interview with the Director of Nursing on September 4, 2025, at 2:54 p.m., confirmed that there was no documented evidence in the Resident' 1s clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Buspar medication. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 13, 2025, revealed that she was cognitively impaired, required assistance with care needs, received antipsychotic, antianxiety, and antidepressant medications (psychotropic medications) and had diagnoses that included dementia, depression, and anxiety. A physician's note for Resident 5, dated May 14, 2025, at 8:48 p.m. revealed that the resident experienced a sudden behavioral escalation. Psychiatry was consulted and increased her Seroquel (antipsychotic medication used to treat mental health disorders) dose to 250 milligrams (mg). Physician's orders for Resident 5, dated May 15, 2025, included an order for the resident to receive 250 mg of Seroquel in the evening related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. A nursing note for Resident 5, dated May 27, 2025, at 2:11 p.m. revealed that Certified Physician's Assistant (CRNP- registered nurse with advanced education and training who can diagnose, treat and prescribe medication) with psychiatric services was called and updated with the resident's increased agitation and a medication change was ordered to add 50 mg of Seroquel twice daily in addition to the 250 mg of Seroquel daily in the evening. Physician's orders for Resident 5, dated May 27, 2025, included an order for the resident to receive two 25 mg tablets of Seroquel to equal 50 mg twice daily related to dementia with agitation. There was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Seroquel. Interview with the Director of Nursing on September 4, 2025, at 3:25 p.m., confirmed that a nursing note, dated May 15, 2025, at 1:30 p.m. and a nursing note, dated May 27, 2025, at 2:13 p.m. indicated that Resident 5's representative was notified of the dosage changes to Seroquel; however, there was no documented evidence in the resident's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased doses of Seroquel.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2). Findings Include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation in the medical record will be objective, complete, and accurate. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1, dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. She stated that she was in the emergency room . Her skin was warm and dry, cheeks ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. A statement completed by Registered Nurse 1, dated January 9, 2025, revealed that on January 6, 2025, at approximately 8:00 a.m. she entered Resident 2's room due to Resident Family Member 3 stating she felt that the resident was having a stroke. The resident was lying in bed with no visible signs of distress. The resident was awake, alert, her smile was symmetrical, her tongue was mid-line, her hand grasps and pedal pulses equal and strong. Her vital signs were stable. She then spoke with Resident Family Member 2 when he called in, informed him of the assessment, and that if there was something they can treat there, they would do so. A statement completed by the Director of Nursing, dated January 9, 2025, revealed that approximately 8:30 a.m. on January 6, 2025, she was notified that the family was questioning if Resident 2 should be transferred to the hospital. She walked back to the resident's room to visualize her status. At that time, she was alert and oriented and talking and did not appear to be in any distress. The Director of Nursing conferred with Registered Nurse 1, who stated that she assessed the resident, and she also did not see that the resident was in any distress. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. There was no documented evidence that the assessments of Resident 2 by Registered Nurse 1 and the Director of Nursing, or the physician's orders to send the resident to the hospital were in the resident's clinical record. Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. revealed that they spoke with Registered Nurse 1 regarding the morning of January 6, 2025, as well as had her write a statement after a family member voiced a grievance. Registered Nurse 1's statement indicated that she was assessing for a stroke and she was asked why that part of the assessment was not documented in the medical record. Registered Nurse 1 told them that she forgot to go back into the electronic medical record to update her note. She also confirmed that the physician's order for Resident 2 to be sent out to the hospital was not in the resident's clinical record and that Registered Nurse 1's assessments from her statement were not in the clinical record. Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. she indicated that she went back throughout her shift to re-evaluate the resident on January 6, 2025. She confirmed that she did not put the physician's orders for her to be transferred out to the hospital or her re-evaluation assessments throughout her shift in the electronic medical record for Resident 2, as well as go back in to update her note from January 6, 2025, with her assessment finding as stated in her statement from January 9, 2025. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative/interested family member was notified timely about the need to alter treatment/changes in physician's orders for one of seven residents reviewed (Resident 7). Findings include: The facility's policy regarding charting and documentation, dated July 25, 2024, indicated that documentation of procedures and treatments will include care-specific details, including notification of family, physician, or other staff, if indicated. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 2, 2024, revealed that the resident was understood, understands with a Brief Interview for Mental Status score (BIMs - intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium) of 10, indicating that the resident was moderately impaired, and had a diagnosis which included Parkinson's disease and dementia. A care plan for the resident, dated August 27, 2021, revealed that the resident has an Advanced Directive (a written statement of a person's wishes regarding medical treatment) and staff were to keep the family informed of changes in condition. The resident's clinical record revealed that Resident Family Member 1 was the resident's power of attorney (a person legally authorized to make decisions for someone else), emergency contact, and was an interested family member. Physician's orders for Resident 7, dated December 17, 2024, included an order for the resident to receive one 20 milligram (mg) tablet of Paxil (an antidepressant) one time a day for psychosis (a set of symptoms that affect a person's ability to distinguish reality from what is not real). Physician's orders for Resident 7, dated January 2, 2025, included an order for the resident to receive one 25 mg capsule of Anafranil (an antidepressant medication that treats obsessive-compulsive disorder) at bedtime for obsessive-compulsive disorder. There was no documented evidence that Resident 7 instructed the facility not to contact Resident Family Member 1, and no documented evidence that Resident Family Member 1 was notified about the physician's orders on December 17, 2024, and January 2, 2025. Interview with the Director of Nursing on January 15, 2025, at 2:25 p.m. confirmed that Resident Family Member 1 was not notified about the above changes in Resident 7's treatment. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of seven residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 20, 2024, revealed that the resident was understood, could understand others, and had a Crohn's disease (a chronic inflammatory bowel disease that causes inflammation in the digestive tract), diabetes (a chronic disease that occurs when the body can not produce or use insulin properly, resulting in high blood sugar levels), and hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body). The resident's clinical record revealed that Resident Family Member 2 (son) and Resident Family Member 3 (daughter-in-law) were the resident's emergency contacts and were interested family members. A nursing note for Resident 2, completed by Registered Nurse 1 and dated January 6, 2025, at 8:00 a.m., revealed that Resident Family Member 3 was at the nurses' station stating, I want her sent out. Upon assessment, the resident was awake, alert, and oriented to self. Resident 2 stated that she was in the emergency room . Her skin was warm and dry, her cheeks were ruddy. She was afebrile (no increased temperature), and her vital signs were stable. Physician 2 was made aware, and no new orders were received. There was no documented evidence in the clinical record to indicate that Resident 2 was sent to the hospital per Resident Family Member 3's (daughter-in-law) request. Interview with Physician 2 on January 14, 2025, at 1:42 p.m. revealed that when he received a text regarding Resident 2, he gave an order to send the resident out to the hospital at that time. He then received a text that said the resident was not going out to the hospital. He indicated that he was not aware of what changed as to why they did not send her out to the hospital at that time. Interview with the Regional Director of Clinical Services 5 on January 14, 2025, at 2:05 p.m. confirmed that the resident was not sent out to the hospital on January 6, 2025. Interview with Registered Nurse 1 on January 14, 2025, at 2:30 p.m. revealed that Resident Family Member 3 came to her and told her that she thought that the resident was having a stroke. She indicated that she went back to assess the resident and saw that the resident was not in any distress. She indicated that she did not see anything that would indicate a stroke. She indicated that before she was able to get the order in to send the resident out to the hospital the Director of Nursing came out and said that she was going to go back and assess the resident. When she came back, she said they are not sending the resident out. She indicated that she did not put the order in the electronic medical record because the Director of Nursing said that they were not sending her out, so why put the order in. She indicated that she contacted the resident's son that she had all the paperwork and that she was going to send his mother out to the hospital. Interview with the Director of Nursing on January 14, 2025, at 3:03 p.m. revealed that someone came to her office and indicated that Resident 2 was being sent out to the hospital. They said that the family went to Registered Nurse 1 and told her that the resident was a little off. So, she went back to see the resident. She indicated that she sat on the bed and spoke with the resident, and the resident did not look to be in any distress. She then told Registered Nurse 1 to go and do her assessment and then to notify the physician and the resident's family. She indicated that she went back to her office and had very little involvement after that. Interview with Licensed Practical Nurse 3 on January 14, 2025, at 3:15 p.m. revealed that he worked over from the night shift that night and he was waiting to do count with Registered Nurse 1 when someone came up to Registered Nurse 1 indicating that Resident 2 did seem like herself. Registered Nurse 1 asked me to go with her because she was relatively new to the facility and does not know all the residents. The resident thought she was in the emergency room . So, they returned to the nurses' station and Registered Nurse 4, who was the night shift supervisor, was still there, so she began helping Registered Nurse 1 with the transfer paperwork for the resident. He indicated that when he was leaving around 8:00 a.m. he was under the impression that they were sending the resident to the hospital. Interview with Registered Nurse 4 on January 14, 2025, at 3:28 p.m. revealed that she gave report to Registered Nurse 1 when she came in for the daylight shift. Then someone came up to Registered Nurse 1 and indicated that Resident 2 was incoherent and wanted her sent out to the hospital and that that person was going to call someone. Registered Nurse 1 then went back to assess the resident and when she came back, she was trying to get papers around to send her out to the hospital, so Registered Nurse 4 helped her. The Director of Nursing was there, and she went back to see the resident. When the Director of Nursing returned, she indicated that she thought the resident did not need to be sent out. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident, the responsible party, and long-term care ombudsman in writing regarding the reason for hospitalization for seven of 35 residents reviewed (Residents 1, 19, 22, 27, 29, 53, 64). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 19, dated September 24, 2024, at 1:07 a.m., revealed that the resident was admitted to the hospital with urinary tract infection and possible pneumonia. There was no documented evidence that a written notice of Resident 19's transfer to the hospital was provided to the resident's emergency contact or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that a written notice of Resident 27's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 29, dated June 1, 2024 at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the resident's responsible party or the long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). There was no documented evidence that a written notice of Resident 53's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. A nursing note for Resident 64, dated July 21, 2024, at 9:58 a.m., revealed that the resident was transferred to the emergency room for evaluation after a change in mental condition. There was no documented evidence that a written notice of Resident 64's transfer to the hospital was provided to the resident's responsible party or long-term care ombudsman regarding the reason for transfer. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a written notice to Residents 1, 19, 22, 27, 29, 53, 64; the resident's emergency contacts/responsible parties; or the long-term care ombudsman when the residents were transferred to the hospital. 28 Pa. Code 201.25 Discharge Policy. 28 Pa. Code 201.29(f)(g) Resident Rights.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of a transfer for five of 35 residents reviewed (Residents 1, 22, 27, 29, 53). Findings include: A nursing note for Resident 1, dated September 27, 2024, at 12:52 a.m. revealed that the resident was admitted to the hospital with congestive heart failure (a medical condition where the heart is unable to pump enough blood to meet the body's needs). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 1. A nursing note for Resident 22, dated September 27, 2024, at 1:21 a.m., revealed that the resident was admitted to the hospital with hypoosmolarity hyperglycemic state (high blood sugar). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 22. A nursing note for Resident 27, dated September 22, 2024, at 5:54 p.m., revealed that the resident was lethargic and disoriented when talking, the physician was notified, and the resident was transferred to the hospital for evaluation. The resident was admitted to the hospital with pneumonia. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 27. A nursing note for Resident 29, dated June 1, 2024, at 6:43 a.m., revealed that the resident was admitted to the hospital with sepsis. There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 29. A nursing note for Resident 53, dated June 3, 2024, at 8:33 p.m., revealed that the resident was admitted to the hospital with aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, liquid, and/or vomit). There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 53. Interview with the Director of Nursing on November 6, 2024, at 9:23 a.m. confirmed that the facility did not provide a bed-hold notice to Residents 1, 22, 27, 29, 53 or to the resident's responsible parties when the residents were transferred to the hospital. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(3) Management.

Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of 35 residents reviewed (Residents 24, 45). Findings include: Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 28 residents reviewed (Resident 24). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated July 5, 2024, indicated that the resident was cognitively impaired, was dependent on staff assistance for daily care needs, had a diagnosis of depression. Physician's orders for Resident 24, dated October 22, 2024, included orders for the resident to receive 0.5 mg of 2mg/ml Lorazepam (a medication to treat anxiety) every four hours as needed. Review of Resident 24's Medication Administration Record (MAR) for October 2024 revealed that the resident received 0.5 mg of lorazepam on October 25, 2024, at 1:56 a.m. and 4:29 a.m. Review of Resident 24's controlled drug accountability sheet for a 30.0 ml bottle of lorazepam (2mg/ml) revealed that the total amount remaining on October 25, 2024, at 4:29 a.m. was documented as 25.0 ml; however, observations of the bottle on November 6, 2024, at 1:42 p.m. revealed that there was 29.0 ml remaining in the bottle. Interview with Director of Nursing on November 7, 2024, at 8:43 a.m. confirmed that the amount remaining in the bottle was documented incorrectly. A quarterly MDS assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 45, dated October 11, 2024, revealed that the resident was cognitively intact. Resident 45's Kardex, undated, revealed that he preferred a shower. Resident 45's shower log, dated September and October 2024, revealed that there were 18 opportunities for a shower; however, only one shower was documented. An interview with Resident 45 on November 4, 2024, at 11:08 a.m. revealed that he receives his showers twice per week. Interview with the Director of Nursing on November 6, 2024, at 10:21 a.m. revealed that Resident 45's shower record was not in their charting system correctly; therefore, the staff could not accurately chart the resident's showers. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one of one licensed practical nurse reviewed (Licensed Practical Nurse 1). Findings include: The facility's abuse policy, dated August 27, 2024, indicated that the facility will not employ individuals that had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of personnel file for Licensed Practical Nurse 1 revealed that she was hired on September 3, 2024, and the Pennsylvania Professional Licensure check was not verified until November 4, 2024, two months after she was hired. Interview with Director of Human Resources on November 5, 2024, at 11:05 a.m. confirmed that the license check for Licensed Practical Nurse 1 was not done timely. She stated that she accidently ran the check on her graduate license and not her permanent license as she should. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders and a diagnosis of diabetes resulting in hospitalization for one of five residents reviewed (Resident 2). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect, complete, and review ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 1, 2024, indicated that the resident was admitted from a hospital, was cognitively impaired, and dependent on staff for care. A nurse's note for Resident 2, dated October 3, 2024, at 10:00 a.m., revealed that the resident's blood glucose level was 923 mg/dL, and the resident was transferred to the local hospital and admitted with hyperglycemia (high blood sugar) and altered mental status. Admission paperwork for Resident 2 (including discharge paperwork from the hospital and a history from the resident's primary care provider) revealed a diagnosis of diabetes mellitus, with physician's orders, dated April 30, 2024, for 6 units of Tresiba FlexTouch U-100 insulin 100 unit/ml (a medication for treatment of diabetes), and orders dated March 5, 2024, to test the resident's blood sugar twice daily. There was no documented evidence in the clinical record to indicate that Resident 2's diagnosis of diabetes or the orders for insulin and blood sugar checks were identified and clarified with the physician. Interview with Licensed Practical Nurse 1 on October 10, 2024, at 10:40 a.m. revealed that Resident 2 did not have a diagnosis of diabetes and confirmed that the resident had not received insulin or blood sugar checks since her admission to the facility. Interview with the Registered Dietician on October 10, 2024, at 11:17 a.m. revealed that on admission the resident's diet was a controlled carbohydrate diet (normally prescribed for diabetics); however, it was changed due to the resident not having a diagnosis of diabetes. The registered dietician stated that she reviewed the hospital discharge paperwork but not the paperwork from Resident 2's Primary Care Provider. Interview with the Medical Director on October 10, 2024, at 11:47 p.m. confirmed that the facility missed Resident 2's medical diagnosis of diabetes and the treatment for it. Interview with the Registered Nurse Assessment Coordinator (RNAC) on October 10, 2024, at 11:36 a.m. revealed that on admission from a hospital, she sends a request to the resident's Primary Care Provider for information. When the paperwork is faxed back to the facility, it is to be reviewed by the registered nurses and given to the RNAC to scan into the electronic medical record. She confirmed that the diagnosis for diabetes and orders for insulin should have been identified but were missed. Interview with Registered Nurse 4 on October 10, 2024, at 12:44 p.m. revealed that when there is paperwork on the fax machine the registered nurse will review the paperwork and input necessary information into the resident's medical chart. She confirmed that Resident 2's diagnosis of diabetes and the orders for insulin should have been identified and clarified with the physician but were missed. Interview with Director of Nursing confirmed that Resident 2's diagnosis of diabetes and orders for insulin and blood sugar checks should have been identified and clarified with the physician but were missed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies, clinical records and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of four residents reviewed (Resident 2) was free from abuse perpetrated by another resident (Resident 3) resulting in a fractured nose. Findings include: The facility's abuse policy, dated June 6, 2023, indicated that residents have the right to be free form abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental,sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2023, indicated that the resident was cognitively impaired, could rarely understand or be understood, required extensive assistance of two staff for daily care needs, and had diagnoses that included dementia, psychotic disturbance (loss of contact with reality), and osteoarthritis (degenerative joint disease). The resident's current care plan for a self-care deficit indicated that she was totally dependent on staff for all care needs and required frequent checks by staff. She also had a bolstered mattress on her bed for safety. A nursing note for Resident 2, dated July 27, 2023, at 9:50 a.m. revealed that the registered nurse (RN) was called to the resident's room because she was on the floor. When she entered the room Resident 2 was lying on her left side beside the bed facing the wall. The area was clear and the floor was dry. Per the licensed practical nurse (LPN), Resident 3 had been lying in Resident 2's bed when she entered but had been moved to her own bed before the RN arrived. A blanket over Resident 2's bed and pillow was missing from bed and not on floor. The bedside table was on other side of bed. The bed was in the lowest position to the floor and bolstered. The resident did not have socks on. The alarm was on and functioning. The top of Resident 2's head was against the night stand. Per two nurse aides assigned to the hall, Resident 2 was last seen at approximately 9:30 a.m. while doing bed checks, and she was being changed. Resident 3 was sleeping in her own bed during the previously stated bed check. The LPN stated that she was getting Resident 2's treatments ready outside of the resident's room when she heard the alarm sounding, which prompted the LPN to enter room where she found the above description and called the nurse aides for help. The RN witnessed the treatment cart right outside of the room. Per the LPN, the last time both resident's were seen was at approximately 7:30 a.m. when medications were given and both residents were on their own sides of the room. Resident 2's nose was bleeding from both nares and had a 3 cm x 3 cm hematoma to the top of the nose. Resident 3 was immediately removed from the scene to a common area where no other residents were located, with a one-on-one by a nurse aide. Resident 2 is an unreliable historian per baseline and could not state what happened. When Resident 3 was asked what happened she stated, Well, how do you think she got on the floor? Resident 2 was total dependence with bed mobility per baseline. The nose bleeding had subsided while Resident 2 was being assessed for injuries. Red areas were noted to the resident's knees and hip and were blanchable. There was no bruising at this time to those areas and no complaints or signs or symptoms of pain with range of motion. Resident 2 has contractures in the lower extremities. Neurological checks were within normal limits per baseline. Respirations were even and unlabored, and there were no signs or symptoms of shortness of breath or chest pain. Vital signs were stable. Resident 2 was on Eliquis and aspirin. The physician was notified of the above. New orders were received to send the resident to the emergency room for evaluation. 9-1-1 was activated at approximately 10:05 a.m., arrived on scene at approximately 10:11 a.m., and left the facility with Resident 2 at 10:15 a.m. A quarterly MDS assessment for Resident 3, dated June 28, 2023, indicated that the resident was cognitively impaired, could sometimes understand and is understood, requires extensive supervision to limited assistance of one staff for daily care needs. Resident 3 had diagnoses that included dementia with agitation. A care plan for Resident 3, dated June 23, 2023, identified exit-seeking behaviors and agitation related to not being able to leave the facility. Resident 3's behaviors were monitored every shift and a review of the medication administration record revealed that verbal redirection was usually attempted when the resident exhibited abusive behaviors. A nursing note for Resident 3, dated July 14, 2023, revealed that the resident became combative with staff during a shower that morning. The nurse aide reported that the resident had punched her in the stomach when she was washing the resident. There was no documented evidence that new interventions were attempted to address Resident 3's behaviors. A nursing note for Resident 3, dated July 14, 2023, revealed that the resident became combative with staff. The resident was found in her room sitting on her roommate's bed with the other resident in the bed. The resident quickly was redirected away and monitoring continued. There was no documented evidence that new interventions were attempted to address Resident 3's behaviors. A nursing note for Resident 3, dated July 18, 2023, revealed that a nurse aide entered the resident's room to find her pulling on her roommates ears and face, telling her to get up. The nurse aide stopped this by informing her that it is inappropriate to do that to other people. There were no further issues with her touching her roommate during that shift. There was no documented evidence that new interventions were attempted to address Resident 3's behaviors. A nursing note for Resident 3, dated July 24, 2023, revealed that at 8:30 a.m. she was administered Ativan for increased anxiety and aggression towards staff. At 8:30 a.m. after being reminded to use her walker for ambulation, she grabbed a staff person by the inside upper arm and pinched her. She then proceeded to kick other staff in the stomach after sitting on the bed and continued swinging at staff. Redirection was ineffective. The resident denied pain, hunger, thirst and need for restroom. There was no documented evidence that new interventions were attempted to address Resident 3's behaviors. A nursing note, dated July 27, 2023, at 9:50 a.m. revealed that the RN was called to a resident's room by nurse aides. The LPN had heard an alarm sounding while getting treatments ready for Resident 2, which prompted her to enter the room. When she entered, Resident 3 was lying in Resident 2' s bed and Resident 2 was lying on the floor with a nose bleed and hematoma above the nose. Resident 3 was removed immediately to a common area for a one-on-one with a nurse aide where no other resident's were around and she could be redirected if needed. The resident has a diagnosis of dementia and cannot be easily redirected. Resident 3 was assessed with no injuries and vital signs were stable. She received a dose of Ativan with the morning medication pass. The last time the resident was seen was at approximately 9:30 a.m. by two nurse aides while performing care on her roommate, at which time Resident 3 was lying in her own bed. She was also seen at approximately 7:30 a.m. during medication pass by the LPN when she was also lying in her own bed. When asked what had happened she replied, Well, how do you think she got on the floor? She could not state any further details. The physician was notified and a new order was received to send her to the hospital for Geropsych. The resident's son was notified of this at approximately 10:32 a.m. and 9-1-1 was activated at approximately 10:20 a.m. An officer arrived at 10:45 a.m. and had to leave the scene for another call at 10:55 a.m. Emergency medical services (EMS) was not dispatched yet as they were waiting for a 302 per police. 9-1-1 was called again at approximately 11:00 a.m. as the officer had to leave. A nurse aide is going along to fill out a petition for the 302. EMS arrived at approximately 11:20 a.m. and left facility at approximately 11:35 a.m. The resident's son was notified. A nursing note for Resident 3, dated July 27, 2023, revealed that Resident 3 was admitted to the hospital's psychiatric unit on a 302 for at least a five-day stay. It will be determined if a longer psychiatric stay is required after five days. An interview with Director of Nursing and Nursing Home Administrator on August 3, 2023, at 3:15 p.m. revealed that they had Resident 3 transferred out of the facility to prevent further harm to Resident 2 and other residents. They also confirmed that monitoring Resident 3's behaviors and administering medications as ordered did not prevent Resident 3 from physically abusing Resident 2 resulting in a fractured nose. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible, and failed to develop and implement new interventions for fall/injury prevention for two of 27 residents reviewed (Residents 27, 28) who had a history of falls, which resulted in a fracture. Findings include: The facility's policy for managing falls and fall risk, dated February 4, 2022, indicated that the fall risk factors that may contribute to a fall include footwear that is unsafe or absent and obstacles in the foot path. A fall without injury is still a fall. Unless there is evidence, when a resident is found on the floor, a fall is considered to have occurred. If a fall occurs despite intitial interventions, staff will try various interventions based on the assessment of the nature of the fall. A Quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 28, dated February 10, 2022, indicated that she was confused; required extensive assistance of one for bed mobility, hygiene, and toilet use; and required limited assistance of one for transfers and ambulation in the room. A fall risk evaluation for Resident 28, dated October 30, 2021, indicated that she was at high risk for falls. A nursing note for Resident 28, dated February 19, 2022, indicated that she had an unwitnessed fall. The staff heard the resident yelling and she was found lying on her buttocks on the right side of the bed. The resident was not able to state what she was trying to do. The resident was sleeping in bed prior to incident. The facility's investigation, dated February 19, 2022, indicated that the resident was last seen minutes before she was found and she was sleeping in bed. The investigation indicated that the family revealed that she had a history of lying on the floor to sleep. There was no documented evidence that the resident had a history of placing herself on the floor to sleep at the facility. There was no documented evidence of any new interventions attempted to ensure resident safety when she was in bed. Interview with the Director of Nursing on January 18, 2023 at 4:08 p.m. confirmed that there was no new intervention initiated after this incident. A nursing note for Resident 28, dated February 27, 2022, indicated that the nurse aide reported that the resident rolled out of bed. The resident was observed lying on the floor on the right side of the bed on her right side with her right arm behind her back. It was noted that the resident had a gross amount of bleeding/clotting to bilateral nares. There was a large pool of blood under resident's head/face that was resting on the floor. The CT scan report for Resident 28, dated February 27, 2022, indicated that she had a mildly displaced fracture of bilateral nasal bone and an acute minimally displaced nasal septum fracture. The plan of care for Resident 28, dated February 28, 2022, indicated that she was to have bilateral falls mats on the floor next to her bed when in bed and to remove them from the floor when she is out of bed. A nursing note for Resident 28, dated July 10, 2022, indicated that she was found on the floor beside her bed. She had some bruising on her right upper outer eye area. The facility's investigation, dated July 10, 2022, indicated that at the time of the fall the fall mat was not in place. Interview with the Director of Nursing on January 18, 2023, at 12:22 p.m. and January 19, 2023, at 12:15 p.m. indicated that at the time of the incident the staff were not required to document if fall mats were in place on their task record (care charting). She was not aware that the investigation indicated that the fall mat was not in place at the time of the fall per the nurse investigation and it was care planned to be in place when in bed. An annual MDS for Resident 28, dated October 4, 2022, indicated that she was confused with short and long-term memory problems and only required supervision for ambulation. The plan of care for Resident 28, dated December 24, 2018, indicated that she had a habit of wandering and pacing due to her dementia. A nursing note for Resident 28, dated October 18, 2022, indicated that the nurse at the nurse's station heard commotion and then the resident yelling. The resident was found lying in the A-wing hallway at the end of the hall. The resident appeared to have tripped over the Hoyer (mechanical lift device) in the hallway that was being used by CNA staff. She had a hematoma the size of a golf ball to her right forehead and an abrasion to her left elbow. The resident was assisted to her bed on C-wing. The facility's investigation dated October 18, 2022, indicated that the resident was walking down another hallway as she does at times. The staff had placed a lift in the hallway to get a resident into bed. Her predisposing factors indicated that she was a wanderer and that she runs into objects and things. The plan of care for Resident 28, dated October 19, 2022, indicated that staff were to redirect the resident from going down other hallways. A nursing note for Resident 28, dated December 11, 2022, indicated that the nurse aide visualized the resident walking down D-hall and she tripped on a bed frame and went down on her right side. Observations of Resident 28, on January 18, 2023, at 3:18 p.m. revealed that she was walking in hallway C (location of her room). In the hallway there was a device for taking vital signs plugged in and charging and a black treatment cart that was unattended. At 3:26 p.m. the resident walked to the end of the hallway D, past a device for taking vital signs that was plugged in and charging in the hallway. At 3:28 p.m she walked from hallway C around the nursing station and proceeded to enter hallway A. A staff member spoke to the resident then proceeded to the nursing station without any redirection as per her plan of care. The resident walked partially down hallway A then turned around. On the left side of hallway A there were four residents in variuos type of wheelchairs and a medication cart with a nurse preparing medications. On the right side of hallway A was a mechanical lift, a linen cart, a treatment cart, an over-bed table and a blue garbage can on wheels. Interview with Registered Nurse 4 on January 18, 2023, at 3:36 p.m. revealed that Resident 28 walks all of the hallways and that the vital sign equipment is plugged in to the wall outlets in the hallways for use when needed. Interview with the Director of Nursing on January 18, 2023, at 4:08 p.m. confirmed that Resident 28 should be redirected to her room area on hallway C and that equipment should not be stored in the hallway. The facility's policy for managing falls and fall risks dated February 4, 2022, indicated that staff were to implement a resident-centered fall prevention plan to reduce the risk factors of falls for each resident at risk or with a history of falls. An admission MDS for Resident 27, dated December 6, 2022, indicated that she was confused; required extensive assistance of two for bed mobility; was non-ambulatory; required extensive assistance of one for dressing, eating, and personal hygiene; and had a history of falls since admission to the facility. The plan of care for Resident 27, dated December 1, 2022, indicated that she was identified to be at risk for falls and that she was to have bilateral fall mats in use. Nursing notes for Resident 27, dated November 30, 2022, and December 2, 13, 2022, indicated that she had a history of falls due to rolling and/or sliding out of bed. Observations of Resident 27 while in bed on January 17, 2023, at 10:33 a.m. revealed that she was in a bariatric bed with a fall mat on the floor on the right side of bed; however, there was no fall mat on the left. On the left side was a bedside stand and an oxygen concentrator (device that delivers oxygen). Additional observations on January 17, 2023, at 11:55 a.m. revealed that there was no fall mat on the left side of the bed. Interviews with Nurse Aide 1 and Nurse Aide 2 on January 17, 2023, at 11:58 a.m. indicated that they were not sure if she was to have just one fall mat on the right side of her bed or one on each side of the bed. Interview with Registered Nurse 3 on January 17, 2023, at 11:59 a.m. indicated that the left side fall mat was under the bed and not in proper placement and that it should have been alongside of Resident 27's bed. Interview with the Director of Nursing on January 18, 2023, at 9:14 a.m. confirmed that the fall mats were to be on both sides of the bed and should have been in proper placement when Resident 27 was in bed. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident was free from physical restraints for one of six residents reviewed (Resident 2). Findings include: The facility's policy on restraints, dated January 3, 2022, indicated that restraints shall only be used for the safety and well-being of the resident only after other alternatives have been tried unsuccessfully. Furthermore, restraints shall only be used to treat the resident's medical symptoms, and never for discipline, staff convenience, or for the prevention of falls. A physical restraint was defined as any manual method, physical, or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts movement or restricts normal access to one's body. The facility's policy regarding abuse, dated January 3, 2022, indicated that residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting harm, pain or metal anguish. A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 4, 2022, revealed that the resident was severely cognitively impaired; required extensive assistance with bed mobility, locomotion on the unit, dressing, eating, toilet use, and personal hygiene; did not use a physical restraint; and had diagnoses that included non-traumatic brain dysfunction and dementia with behavioral disturbance. A care plan for Resident 2, revised on August 21, 2021, indicated that the resident had cognitive loss and interventions included having staff provide redirection to safe areas and activity programs. An incident report for Resident 2, dated July 10, 2022, and information reported by the facility, revealed that on July 10, 2022, Resident 2 was yelling to Registered Nurse 1, who found the resident restrained in a Broda chair (specialized chair) with a sheet across her torso and tied to the back of the chair. Nurse Aide 2, who was assigned to that hall, was immedicately suspended and removed from the building. An additional incident report for Resident 2, dated July 11, 2022, indicated that a bruise was found on her left hip. The investigation revealed that a staff member who was working on July 10, 2022, had a restraint tied across the resident's waist/hip area, most likely causing the bruise. Observations on July 20, 2022, at 1:50 p.m. revealed that Resident 2 was propelling herself down the hall in a Broda chair (special chair) and talking to herself. She was not interviewable. A quarterly MDS assessment for Resident 4, dated July 1, 2022, revealed that he was cognitively intact, could understand, and be understood, had clear speech, was independent with all care areas, but needed supervision with eating after set up. A witness statement by Resident 4, dated July 12, 2022, indicated that he witnessed Resident 2 sitting in her chair with a sheet tying her down. He felt disgusted and he wanted to leave the facility, as the incident should not have happened. Resident 4 revealed that if there were marks found on Resident 2's wrists, it was because she tried to break free by putting her hands in the sheet and pulling them. Interview with Resident 4 on July 20, 2022, at 10:59 a.m., revealed that he remembered the incident with Resident 2, and was disgusted by it. He does not know staff names to identify them, and he was unsure what to do at the time. Resident 4 revealed that he came out of the bathroom and saw Resident 2 tied down to her chair with a sheet. At one point, Resident 2 was able to remove the sheet, but a staff member came back and tightened the sheet and did something behind the chair. Resident 4 said it was horrible, because Resident 2 was screaming and wiggling trying to get loose. Interview on July 20, 2022, at 2:48 p.m. with Registered Nurse 5 (the nurse who initially interviewed Resident 4) revealed that Resident 4 had been very upset and bothered by the incident with Resident 2 being tied down. A witness statement by Nurse Aide 2, dated July 14, 2022, indicated that she was working alone on July 10, 2022, from 6:00 p.m. to 10:00 p.m. The nurses were giving report at the nurses' station, there were four call lights on, another resident was yelling, and she had to pick up meal trays from another hall. Resident 2 would not sit down, so Nurse Aide 2 took a sheet and loosely tied it in one knot at the back of the chair so that Resident 2 could pull it off. Nurse Aide 2 indicated there was no staff to ask for help and that she could have brought Resident 2 to the nurses' station. Nurse Aide 2 acknowledged that tying the sheet around Resident 2 was abuse. Interview with Nurse Aide 4, on July 20, 2022, at 11:34 a.m., revealed that she had worked with Nurse Aide 2 on July 10, 2022, and they split the assigned halls, leaving each of them about 12 residents. Nurse Aide 4 indicated that she picked up all of the meal trays she could because Nurse Aide 2 would be the only aide on both halls (B and D) when she left at approximately 6:15 p.m. Resident 2 was getting up and down a little bit on second shift. Nurse Aide 4 revealed that the registered nurse who was working would usually help out as long as she was not busy. Interview with Registered Nurse 1 on July 20, 2022, at 11:45 a.m. confirmed that she worked as the supervisor on July 10, 2022, and that at approximately 6:30 p.m., heard someone yelling her name for help on B hall. She found Resident 2 in a broda chair with a rolled sheet tied around and double knotted behind her. She took Resident 2 to the nurse's station, removed the sheet, and assessed her for injuries. Registered Nurse 1 left the facility and traveled home before calling the Director of Nursing to report the suspected abuse because she lives close to the facility and wanted privacy. Registered Nurse 1 indicated that Resident 2 could have been redirected by having her at the nurses's station coloring, folding towels, or following staff around the unit because she was able to self propel in her broda chair. Registered Nurse 1 revealed that she had used these interventions with Resident 2 prior to dinner. Interview with Registered Nurse 3 on July 20, 2022, at 3:39 p.m. revealed that she was the charge nurse on July 10, 2022, and her shift started at 7:00 p.m. She was not aware of the suspected abuse involving Resident 2 and Nurse Aide 2 until the Director of Nursing called the building and had her approach Nurse Aide 2 (who had remained on B/D Hall) and escort her out of the building. A facility training certificate for Nurse Aide 2, dated February 4, 2021, revealed that she had successfully completed training on preventing, recognizing, and reporting abuse. A facility training certificate for Nurse Aide 2, dated March 1 2021, revealed that she had successfully completed training for Dementia Care: CMS Hand in Hand Module 1: Understanding the World of Dementia: The Person and Disease. Interviews with the Director of Nursing on July 20, 2022, at 8:25 a.m., 11:45 a.m. and 5:15 p.m. revealed that there were no residents with orders for a restraint, at 11:45 a.m. she confirmed that Resident 2 had been restrained in a broda chair by using a sheet, that the abuse was not reported to her immediately and should have been, and that Nurse Aide 2 had continued to work on the B and D Hall from 6:30 p.m. until approximately 7:46 p.m. on July 10, 2022, and was later terminated for her actions. The survey team applied the reasonable person concept in determining the psychosocial outcome(s) for this deficiency. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 211.8(a) Use of restraints. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain physician-ordered laboratory tests for two of four residents reviewed (Residents 2, 3), resulting in abnormal bleeding and hospitalization for one resident (Resident 3). Findings include: The facility's policy regarding anticoagulant therapy (blood thinning medications), dated December 2019, indicated that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For residents who were ordered [MEDICATION(S)] (an anticoagulant), a prothrombin time and international normalized ratio (PT/INR - blood tests that monitor the effectiveness of the blood thinning medication) flow sheet was to be initiated, and laboratory testing was to be scheduled and completed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 30, 2020, revealed that the resident was understood and could understand others, required extensive assistance for daily care tasks, and she received an anticoagulant (medication that thins the blood) every day during the assessment period (seven days). The resident's care plan regarding the use of blood thinning medication, dated June 24, 2020, revealed that she was at risk for adverse effects such as bruising and bleeding. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The results of the INR for Resident 3, dated June 24, 2020, were 2.9 (normal range is 1-3). The Certified Registered Nurse Practitioner (CRNP - an advanced practice registered nurse who can diagnose and treat medical conditions) was made aware on June 24, 2020, and gave an order to recheck Resident 3's PT/INR in three days. There was no documented evidence that a repeat PT/INR was completed for Resident 3 on June 27, 2020, as ordered by the CRNP. The resident's Medication Administration Records (MAR's) for June and July 2020 revealed that staff continued to administer 2.0 mg of [MEDICATION(S)] daily from June 23 through July 12, 2020, and there was no documented evidence of any laboratory monitoring of PT/INR's. A nursing note for Resident 3, dated July 8, 2020, at 7:36 p.m. revealed that the resident was complaining of not feeling well and was not able to give any details. She did not know what the date was, and when asked where she was, the resident said, I don't know how to pronounce it. An assessment did not reveal any findings that were abnormal for the resident. The nurse explained that she did not note anything, but if she still did not feel well in the morning, to notify staff and the physician could see her during rounds. A nursing note for Resident 3, dated July 9, 2020, at 1:38 p.m. revealed that the CRNP assessed the resident for shortness of breath and fatigue and gave a new order for [MEDICATION(S)] (medication used to open the airways). A nursing note for Resident 3, dated July 10, 2020, at 2:39 p.m. revealed that the resident was listless and said that she ached everywhere. Laboratory tests were obtained (not a PT/INR) and the resident's white blood count was elevated, and she reported that it burned when she urinated. The physician was notified and gave orders for an intravenous (IV - administered directly in a vein) antibiotic, a chest x-ray and urine test. A procalcitonin (PCT - a blood test used to detect levels of bacteria in the blood) was added. A nursing note for Resident 3, dated July 10, 2020, at 2:43 p.m. revealed that a [MEDICATION(S)] lock (intravenous access site) was started in the right hand. No bruising was noted and the resident's chest x-ray was negative. A nursing note for Resident 3, dated July 11, 2020, at 6:20 p.m. revealed that the resident had shortness of breath on exertion and oxygen was in use at 3 liters per minute via mask. The resident had an active infection and was on antibiotics. A nursing note for Resident 3, dated July 12, 2020, at 4:04 a.m. revealed no adverse reactions due to antibiotic drug therapy for an elevated white blood cell count. The resident was restless, sitting at the side of her bed, and was unable to fall asleep. She stated that she was picking at her nose, resulting in a nose bleed of a moderate amount of bright red blood. A nursing note for Resident 3, dated July 12, 2020, at 11:00 a.m. revealed that the resident had a small oozing nose bleed off and on that morning that was easily stopped with cold compresses. She preferred to sit upright with her head drooping down. She was redirected several times to reposition and encouraged to lie back and have her bed at a 45-degree angle. The note indicated that the nurse would update the physician and check INR; the resident was on [MEDICATION(S)] and was at high risk for bleeding. A nursing note for Resident 3, dated July 12, 2020, at 11:00 a.m. revealed that multiple attempts were made to get a coagucheck (PT/INR). The machine was reading error # 6. New strips were tried, the machine was troubleshot, and the nurse received the same error. A nursing note for Resident 3, dated July 12, 2020, at 7:01 p.m. revealed that the resident was being cleaned up when a nurse aide noticed purplish bruising on her arm around 4:00 p.m. The Assistant Director of Nursing assessed the resident, who was on [MEDICATION(S)] and has had multiple bruises already. A wound evaluation sheet, dated July 12, 2020, revealed that the bruising on her arm measured 11.0 x 13.0 centimeters (cm) and was black and purplish in color. A nursing note for Resident 3, dated July 12, 2020, at 7:10 p.m. revealed that the resident's nose bleed started back up again. Staff were performing care and the resident was noted to have tarry stools (usually a sign of bleeding in the upper part of the gastrointestinal tract). The physician was notified and gave an order to send the resident to the hospital emergency room . She was cleaned up and new packing was placed into the left nose. A nursing note for Resident 3, dated July 12, 2020, at 10:40 p.m. revealed that the local hospital emergency room informed the nurse that the resident was being transferred to a regional medical center with rapid [CONDITION(S)]. An interview with the Nursing Home Administrator on July 16, 2020, at 4:36 p.m. confirmed that a PT/INR was not obtained and completed for Resident 3 since June 24, 2020, and staff administered 2.0 mg of [MEDICATION(S)] every day. The hospital informed the Nursing Home Administrator that Resident 3's INR was greater than 9 (normal is 1-3). A quarterly MDS assessment for Resident 2 , dated May 29, 2020, revealed that the resident was unable to speak or be understood, could not understand others, required extensive assistance for daily care tasks, she received an anticoagulant every day during the assessment period (seven days) and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that an INR level was obtained until June 21, 2020 (six days later). Interview with the Nursing Home Administrator on July 16, 2020, at 4:45 p.m. confirmed that an INR was not drawn on June 18, 2020, as ordered by the physician for Resident 2. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of the Pennsylvania Professional Nursing Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to provide ongoing pain evaluation and management, resulting in harm for one of 18 residents reviewed (Residents R4), failed to ensure that there were individualized physician's orders [REDACTED]. Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the Registered Nurse was to collect complete and ongoing data to determine nursing care needs, was responsible for assessing human responses and plans, implementing nursing care, and analyzing/comparing data with the norm in determining care needs, and was to carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's policy regarding changes in condition dated, January 1, 2016, indicated that the process for identification of a change of condition included gathering objective data and documenting assessment findings and the resident's response. The facility's policy regarding pain assessment and management, dated January 11, 2016, indicated that staff were to promptly assess the resident's pain levels and to provide relief of the symptoms whenever feasible, and that documentation would be reflected on the Medication Administration Record [REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R4, dated November 2, 2015, revealed that the resident was able to make himself understood and could usually understand others. physician's orders [REDACTED]. [REDACTED]. A nursing note completed by a Registered Nurse for Resident R4, dated January 30, 2016, at 3:54 a.m., revealed that the resident fell from his bed and was found on the floor beside his bed at 3:30 a.m. At that time, the resident denied any pain and had a red scratch to his left hip that was 5.5 centimeters (cm) x 0.2 centimeters (cm). There was no evidence that the registered nurse assessed the resident's condition, including if there was any shortening and rotation, numbness or tingling, and if pulses were present or absent to the left leg. A nursing note completed by a registered nurse for Resident R4, dated January 30, 2016, at 6:43 a.m., revealed that during a.m. care the resident began to complain of pain in his left hip. The physician was notified, and an X-ray of the left hip was ordered; however, there was no documented evidence that the resident's complaint of new onset pain was assessed by a Registered Nurse or that the resident was treated for [REDACTED]. A nursing note completed by a Licensed Practical Nurse for Resident R4, dated January 30, 2016, at 8:01 a.m., revealed that the resident was yelling, Help me, and that the resident had pain in his left hip due to the fall. The note indicated that there was an increase in anxiety, that they were still waiting for the X-ray, and that [MEDICATION NAME] 0.5 mg was given at that time. There was no documented evidence that the resident's pain was assessed by a registered nurse or that the resident was treated for [REDACTED]. A nursing note completed by a Licensed Practical Nurse for Resident R4, dated January 30, 2016, at 8:41 a.m., revealed that the resident was yelling, Help, I am in pain; I think I will die, and that the registered nurse was notified. The note indicated that the resident fell and had complaints of left hip pain and that the resident was given 5-325 mg of [MEDICATION NAME] at this time, one hour and 58 minutes after initially complaining of pain. There was still no evidence that the resident's complaints of pain were assessed by a registered nurse. Nursing notes for Resident R4, dated January 30, 2016, revealed that the resident was transported to the hospital for severe left hip pain, decreased oxygen level and shortness of breath, and was admitted to the hospital with [REDACTED]. Interview with the Director of Nursing on April 6, 2016, at 2:42 p.m., confirmed that Resident R4's pain was not assessed, that his pain control regimen was not evaluated in a timely manner, and that the resident did not receive timely or effective treatment for [REDACTED]. The facility's policy regarding specimen collection, dated January 11, 2016, indicated that the staff were to check the physician's orders [REDACTED]. A document regarding standard orders, which was signed by the Medical Director and dated January 15, 2006, indicated that all orders for urine culture and sensitivity (UA C&S - urine tests that determine the presence of a urinary tract infection and which antibiotics will work best to treat it) were to be obtained by straight catheterization (straight cath - the temporary insertion of a thin tube into the bladder to drain urine), and if the staff were unable to obtain a urine specimen, they were to call the Medical Director. A quarterly MDS assessment for Resident R2, dated February 2, 2016, revealed that the resident was sometimes understood and could sometimes understand, and that she was usually incontinent of bladder. physician's orders [REDACTED]. There was no documented evidence that a physician's orders [REDACTED]. A comprehensive MDS assessment for Resident R3, dated January 1, 2016, indicated that the resident was frequently incontinent of urine. The resident's care plan, dated March 28, 2016, indicated that the resident had a history of [REDACTED]. Laboratory reports, dated January 31 and March 24, 2016, indicated that the urine specimens were obtained via catheterization. However, there was no documented evidence that a physician's orders [REDACTED]. A quarterly MDS assessment for Resident R4, dated November 2, 2015, revealed that the resident was able to make himself understood and could usually understand others, and that he was occasionally incontinent of bladder. physician's orders [REDACTED]. Nursing notes, dated November 11 and December 4, 2015, and January 6, and February 26, and March 23, 2016, indicated that the resident was straight cathed to obtain urine specimens. However, there was no documented evidence that a physician's orders [REDACTED]. physician's orders [REDACTED]. Laboratory reports, dated January 14 and February 27, 2016, indicated that the urine specimens were collected by a straight cath procedure. There was no documented evidence that a physician's orders [REDACTED]. A comprehensive MDS assessment for Resident R10, dated March 14, 2016, and a care plan, dated March 27, 2016, indicated that the resident had a history of [REDACTED]. physician's orders [REDACTED]. Laboratory reports, dated February 22 and March 25, 2016, indicated that the urine specimens were obtained via catheterization. There was no documented evidence that a physician's orders [REDACTED]. Interviews with Registered Nurse 2 and the Director of Nursing on April 6, 2016, at 1:08 p.m. and 2:38 p.m., respectively, confirmed that the physician's orders [REDACTED]. An order review report for Resident R6, dated February 21, 2016, revealed that the resident had a history of [REDACTED]. physician's orders [REDACTED]. a Fleets enema was to be given in the a.m. of the fifth day without a bowel movement, and the physician was to be notified if there were no results. Resident R6's bowel movement records and MAR's for February and March 2016 indicated that the resident did not have a bowel movement on February 23 and 24, and had only a small bowel movement on February 25, 2016; therefore, she was administered Milk of Magnesia on February 25, 2016, which was ineffective. A suppository was administered on February 26, 2016, which was also ineffective, and Milk of Magnesia was administered again on February 27, 2016, instead of a Fleets enema as ordered by the physician. The resident also had no bowel movements on February 29 and March 1, 2, and 3, 2016, and Milk of Magnesia was administered on March 3, 2016, which was ineffective. The records indicated that she then had no bowel movements on March 4, and 5, 2016, and no part of the bowel medication protocol was administered until March 6, 2016, at 10:00 a.m., when a Fleets enema was given. Interview with the Director of Nursing on March 7, 2016, at 2:00 p.m., confirmed that physician's orders [REDACTED]. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 3/1/16, 3/12/15. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/1/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 3/1/16, 4/3/15, 3/12/15.