Every finding on record at Harmon House Health & Rehab Center

Based on a review of clinical records and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary drugs for three of 43 residents reviewed (Residents 1, 43 and 50).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1 dated February 20, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included infection of the foot and diabetic ulcer. Physician's orders for Resident 1 dated April 25, 2026, included to administer 100 milligrams (mg) of doxycycline hyclate (an antibiotic) twice a day. Nurse's note for Resident 1 dated April 25, 2026, at 11:08 a.m. indicated that while doing wound care, it was noted the left foot wound had a foul odor. The Certified Registered Nurse Practitioner was notified, and orders were obtained to administer 100 mg of doxycycline twice a day for 10 days after a wound culture was obtained. Review of the (Medication Administration Record (MAR) for Resident 1 dated April 2026 revealed that 100 mg of doxycycline was administered to Resident 1 in the evening of April 25 through the morning of May 6 for a total of 11 days. Interview with the Director of Nursing on May 7, 2026, at 8:32 a.m. confirmed that Resident 1 was administered antibiotics for 11 days instead of 10 days per the physician's orders on the above-mentioned dates. An annual MDS assessment for Resident 2, dated April 22, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included osteoporosis with pathological fracture (a broken bone caused by an underlying disease that weakens the bone, rather than by a high-impact injury). Physician's orders for Resident 2, dated January 12, 2026, included an order for the resident to receive 20 mg of Pantoprazole (a PPI) daily. A pharmacy medication regimen review for Resident 2, dated December 8, 2025, indicated that the resident had received pantoprazole 40 mg once daily since December 27, 2024, and recommended to re-evaluate the continued need for pantoprazole and reduce the dose of pantoprazole to 20 mg daily while monitoring for recurrence of symptoms. The rationale for the recommendation indicated that long-term PPI use (e.g., greater than 8 weeks) was associated with increased risk of C. difficile infections (highly contagious bacterium that causes severe colon inflammation and watery diarrhea), bone loss and fractures. The physician accepted the recommendation on December 9, 2025, and indicated to implement the recommendation as written. A pharmacy medication regimen review for Resident 2, dated January 12, 2026, indicated that the prescriber accepted a pharmacy recommendation to reduce Pantoprazole to 20 mg daily on December 9, 2025, but the order had not yet been processed. Review of the MAR for Resident 2, dated December 2025 and January 2026, revealed that the resident had received 40 mg of Pantoprazole daily from December 9, 2025, through January 12, 2026. Interview with the Director of Nursing on May 6, 2026, at 11:16 a.m. confirmed that Resident 2 received 40 mg of pantoprazole daily from December 9, 2025, through January 12, 2026, and the order to decrease the dosage to 20 mg daily should have been processed when recommended and approved by the physician on December 9, 2025. A quarterly MDS assessment for Resident 50 dated April 2, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included heart failure. Physician's orders for Resident 50 dated January 15, 2026, included to administer 875-125 mg of amoxicillin-pot clavulanate (an antibiotic) twice a day for a urinary tract infection. Nurse's note for Resident 50 dated January 15, 2026, at 5:06 p.m. indicated that the resident's urine culture resulted showing over 100,000 Escherichia coli (type of bacteria). The Certified Registered Nurse Practitioner was notified, and orders were obtained to administer 875-125 mg of Augmentin (brand name for amoxicillin-pot clavulanate) twice a day for seven days for a urinary tract infection. Review of the MAR for Resident 50 dated January 2026 revealed that 875-125 mg of amoxicillin-pot clavulanate was administered to Resident 50 in the evening of January 15, 2026, through the morning of January 23 for a total of eight days. Interview with the Director of Nursing on May 7, 2026, at 11:18 a.m. confirmed that Resident 50 was administered antibiotics for eight days instead of seven days per the physician's orders on the above-mentioned dates. Physician's orders for Resident 50 dated April 14, 2026, included to administer 500 mg of cefuroxime axetil (an antibiotic) twice a day for a urinary tract infection. Nurse's note for Resident 50 dated April 14, 2026, at 7:17 p.m. indicated that the resident's urine culture resulted showing over 100,000 Escherichia coli. The physician was notified, and orders were obtained to administer 500 mg of Ceftin (brand name for cefuroxime axetil) twice a day for five days. Review of the MAR for Resident 50 dated April 2026 revealed that 500 mg of cefuroxime axetil was administered to Resident 50 in the evening of April 14, 2026, through the morning of April 20, 2026, for a total of six days. Interview with the Director of Nursing on May 5, 2026, at 3:00 p.m. confirmed that Resident 50 was administered antibiotics for six days instead of five days per the physician's orders on the above-mentioned dates. 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 ensure that physician's orders regarding medication administration were followed for three of 43 residents reviewed (Residents 61, 78 and 91). This deficiency was cited as past noncompliance. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) dated March 21, 2026, for Resident 61 revealed that the resident was cognitively intact, required assistance from staff for daily care needs, received insulin and had a diagnosis of diabetes. Physician's orders for Resident 61, dated October 23, 2024, included an order for the resident to receive Novolin R insulin (short-acting insulin used to control high blood sugar) subcutaneously (delivers medication into the fatty tissue layer between the skin and muscle) per sliding scale (the amount of insulin given is determined by the blood sugar level) before meals and at bedtime as follows: if blood sugar is less than 70 milligrams per deciliter (mg/dL) , call the physician; if blood sugar is 70 to 139 mg/dL, give 0 Units; if blood sugar is 140 to 180 mg/dL, give 2 Units; if blood sugar is 181 to 240 mg/dL, give 3 Units; if blood sugar is 241 to 300 mg/dL, give 4 Units; if blood sugar is 301 to 350 mg/dL, give 6 Units; if blood sugar is 351 to 400 mg/dL, give 8 Units; if blood sugar is greater than 400 mg/dL, give 10 Units; if blood sugar is greater than 400 mg/dL, call the physician. Review of Resident 61's Medication Administration Record (MAR) for February and March 2026, revealed that on February 8, 2026, the resident's blood sugar was 414 mg/dL at 4:00 p.m., and on March 17, 2026, the resident's blood sugar was 448 mg/dL at 4:00 p.m. There was no documented evidence that the physician was notified that the resident's blood sugars were greater than 400 mg/dL. Interview with Director of Nursing on May 6, 2026, at 3:23 p.m. confirmed that there was no documented evidence that the physician was notified of Resident 61's blood sugar results that were greater than 400 mg/dL on the above-mentioned dates and times. A quarterly MDS assessment for Resident 78 dated April 21, 2026, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs, and had medical diagnosis that includes heart failure and high blood pressure.Physician's orders for Resident 78 included orders for the resident to receive 2.5 milligrams of Midodrine (medication used for low blood pressure) twice a day and to hold if systolic blood pressure was greater than 130 millimeters of mercury (mm Hg).Review of Resident 78's MAR for February and March 2026, revealed that revealed that 2.5 mg of midodrine was administered to the resident on February 3 when the resident's SBP was 132; on February 9 when the resident's SBP was 145; on February 13 when the resident's SBP was 142; on February 17 when the resident's SBP was 140; on February 18 when the resident's SBP was 136; on February 21 when the resident's SBP was 159; on February 26 when the resident's SBP was 132; on February 27 when the resident's SBP was 138; on February 28 when the resident's SBP was 146; on March 1 when the resident's SBP was 131; on March 4 when the resident's SBP was 144; on March 5 when the resident's SBP was 133; on March 7 when the resident's SBP was 137; on March 9 when the resident's SBP was 138. Interview with the Director of Nursing on May 6, 2026, at 3:24 p.m. confirmed that midodrine was administered to Resident 78 when it should have been held on the above-mentioned dates and times. A quarterly MDS assessment dated [DATE], for Resident 91 revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had a diagnosis of hypertension (high blood pressure). Physician's orders for Resident 91, dated August 19, 2025, included an order for the resident to receive 100 milligrams (mg) of metoprolol tartrate daily and to hold the medication if the resident's systolic blood pressure (SBP-top number) was less than 120 millimeters of mercury (mm Hg) or heart rate was less than 65 beats per minute. Review of Resident 91's MAR for January, February and March 2026, revealed that 100 mg of metoprolol tartrate was administered to the resident on January 2 when the resident's SBP was 110; on January 3 when the resident's SBP was 110; on January 4 when the resident's SBP was 110; on January 12 when the resident's SBP was 110; on January 15 when the resident's SBP was 112; on January 16 when the resident's SBP was 112; on January 17 when the resident's SBP was 112; on January 18 when the resident's SBP was 112; on January 19 when the resident's SBP was 118; on January 22 when the resident's SBP was 118; on February 9 when the resident's SBP was 118; on February 23 when the resident's SBP was 110; on March 6 when the resident's SBP was 118; on March 8 when the resident's SBP was 106/72; and on March 19 when the resident's SBP was 115. Interview with Director of Nursing on May 7, 2026, at 11:39 a.m. confirmed that metoprolol tartrate was administered to Resident 91 when it should have been held on the above-mentioned dates and times. Following identification that medications were given outside of physician ordered parameters, the facility's corrective actions included: The residents identified as being administered medication outside of parameters were assessed for adverse effects. A baseline audit was conducted to identify residents with physician ordered parameters for medication administration and to ensure residents who were ordered medications with parameters had vital signs that were within normal limits. The licensed nursing staff were educated on following medication orders with parameters and following the six rights of medication administration. The Director of Nursing/designee will continue to complete audits three times a week for four weeks, then two times a month for two months. The findings will be reviewed with the quality assurance performance improvement committee. A review of the facility's corrective actions revealed that they were in compliance with F684 on April 23, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that care and services were provided according to accepted standards of practice for five of 43 residents reviewed (Residents 1, 6, 39, 78, and 91). 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, 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. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 1 dated February 20, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included infection of the foot and diabetic ulcer. Review of the wound care consultant's progress note for Resident 1 dated March 19, 2026, and March 26, 2026, indicated that the Resident had a wound to his left lateral foot and was to have hydrocortisone (medication used to reduce inflammation, swelling, itching, and allergic reactions) cream applied daily with dressing changes to the peri-wound (skin immediately surrounding a wound) area. Review of the Treatment Administration Record (TAR) for Resident 1 dated March 2026, revealed no documented evidence that hydrocortisone cream was applied to the peri-wound area of the resident's left lateral foot as ordered by the wound care consultant. Interview with the Director of Nursing on May 7, 2026, at 11:14 a.m. revealed that the wound care consultant's orders for hydrocortisone cream for Resident 1's peri-wound area were not completed because the provider did not give the facility's wound care nurse verbal orders for hydrocortisone, however, it is her responsibility to review wound care consultant's notes to identify changes in orders and she did not. An annual MDS assessment for Resident 39 dated March 30, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, received insulin and had diagnosis of diabetes. A pharmacy medication regimen review for Resident 39, dated April 3, 2026, indicated that the resident had a diagnosis of diabetes, but an A1C (blood test that measures average blood sugar levels) was not available in the medical record in the past six months and fingerstick monitoring (measuring blood sugar levels in real-time by testing a tiny, capillary blood sample) cannot be found in the medical record. The review revealed that the resident receives Lantus, Insulin Lispro, and Metformin (medications to treat diabetes) and recommended to monitor her A1C on the next convenient lab day and every six months if meeting treatment goals, or every three months if therapy has changed or goals are not being met. The physician addressed the recommendation and ordered to check the resident's A1C with the next lab day and every three months. Review of Resident 39's A1C, completed on April 10, 2026, revealed that the physician reviewed the laboratory results on April 13, 2026, and noted that staff were to check the resident's accu checks (fingerstick monitoring) with meals for five days. There was no documented evidence that orders were transcribed into the resident's clinical record for accu checks to be monitored as per the physician's orders noted on the laboratory results. An interview with the Director of Nursing on May 6, 2026, at 11:16 a.m. confirmed that the order to check Resident 39's accu checks were not transcribed into the resident's clinical record and were not completed as they should have been. A quarterly MDS assessment for Resident 78 dated April 21, 2026, revealed that the resident is cognitively impaired, required assistance from staff for daily care needs, and had medical diagnosis that includes heart failure and high blood pressure. Physician's orders for Resident 78 dated January 26, 2026, included orders for Resident to receive 4 units of insulin aspart subcutaneous before meals. A review of Resident 78's Medication Administration Record (MAR) for January, February, March and April 2026, revealed that 4 units of insulin aspart were held on January 27 for a 89 mg/dl; February 1 for 117 mg/dl; February 5 for a 72 mg/dl; February 7 for a 78 mg/dl; February 11 for a 76 mg/dl; February 19 for a 71 mg/dl; February 25 for a 90 mg/dl; March 4 for 85 mg/dl; March 8 for a 81 mg/dl; March 12 for a 70 mg/dl; March 16 for a 97 mg/dl; March 16 for a 97 mg/dl; March 18 for a 75 mg/dl; March 19 for a 97 mg/dl; March 20 for a 99 mg/dl; March 21 for a 90 mg/dl; March 25 for a 107 mg/dl; April 1 for a 77 mg/dl; April 8 for a 75 mg/dl; April 10 for a 85 mg/dl; April 10 for a 85 mg/dl; April 18 for a 79 mg/dl; April 20 for a 97 mg/dl; and April 20, 2026 for 107 mg/dl. Physician's orders for Resident 78 included orders for the resident to receive 15 units of Lantus insulin subcutaneous twice a day. A review of Resident 78's MAR for February, March and April 2026, revealed that 15 units of Lantus insulin was held on February 5 for a 72 mg/dl; February 9 for a 78 mg/dl; February 19 for a 71 mg/dl; March 19 for a 97 mg/dl; March 24 for a 72 mg/dl; April 6 for a 76 mg/dl; April 9 for a 72 mg/dl and on April 18, 2026 for a 79 mg/dl. Interview with the Director of Nursing on May 6, 2026, at 3:24 p.m. confirmed that the insulins aspart and Lantus were held and there were no physician orders or notifications to hold Resident 78's insulin. A quarterly MDS assessment dated [DATE], for Resident 91 revealed that the resident was cognitively intact, required assistance from staff for daily care needs, received antidepressant medications and had a diagnosis of depression and anxiety. Physician's orders for Resident 91, dated February 19, 2026, included orders for the resident to receive 50 milligrams (mg) of Zoloft (an antidepressant medication) daily. Physician's orders for the resident, dated February 19, 2026, included orders for the resident to receive 25 mg of Zoloft daily with instructions to give with the 50 mg tablet to equal 75 mg daily. A psychiatric note for Resident 91, dated April 9, 2026, at 9:38 a.m. revealed that the resident stated she was still having symptoms of anxiety and recommended increasing her Zoloft from 75 mg daily to 100 mg daily. A physician's note for Resident 91, dated April 9, 2026, at 2:46 p.m. revealed that she reviewed the resident's psych recommendations to increase her Zoloft. The physician was agreeable to increase her Zoloft and ordered to increase her Zoloft per psych recommendations. There was no documented evidence in Resident 91's clinical record that the Zoloft was increased per the psych recommendations as agreed upon by the physician. Interview with the Director of Nursing on May 7, 2026, at 11:39 a.m. confirmed that the physician did agree with the psych recommendations to increase Resident 91's Zoloft to 100 mg daily and that there was no documented evidence the order was transcribed as recommended and as agreed upon by the physician. A quarterly MDS assessment for Resident 6, dated February 23, 2026, revealed that the resident was cognitively intact, totally dependent on staff for care, and had diagnoses that included end stage renal disease and received dialysis (a life-sustaining medical treatment that filters waste products, toxins, and excess fluids from the blood when the kidneys have failed). Physician's orders for Resident 6, dated November 26, 2025 included an order for his Eliquis (blood thinner) to be held for a medical procedure on November 28, 2026. According to hospital discharge papers, dated November 29, 2026, readmission orders included an order for the resident to receive 2.5 milligrams (mg) Eliquis twice a day. The orders were signed off by a Registered Nurse, however, the Eliquis was not put in the resident's medication orders. Hospital discharge orders for Resident 6, dated January 14, 2026 revealed that the resident was ordered 2.5 mg Eliquis twice a day and that the registered nurse signed the orders. However, the Eliquis was not put in the resident's medication orders. A review of Resident 6's MAR, dated November and December 2025, as well as January, February, March, April and May 2026, the resident did not receive the Eliquis as ordered. An interview with the Director of Nursing on May 7, 2026 3:53 p.m. revealed that he phoned the resident's physician on this date and the physician stated that she did not want to order the Eliquis at that time. However, he stated that the orders for the Eliquis should have been clarified with the physician at that time. 28 Pa. Code 211.12(d)(1)(3)(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 non pharmacological interventions were attempted prior to the administration of a psychotropic medication for one of 43 residents reviewed (Resident 89).Findings include: The facility's policy regarding use of psychotropic medications, dated August 14, 2025, indicated that . A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 89, dated March 13, 2026, revealed that the resident was cognitively impaired, was taking an anti-anxiety medication, and had a diagnosis of anxiety. Physician's orders for Resident 89, dated November 26, 2025 included orders for the resident to be administered 0.5 milligram (mg) lorazepam as needed for anxiety. A review of the medication administration records (MAR) for Resident 89, dated March, April, and May 2026, revealed the resident was administered 0.5 mg of lorazepam on March 6, 9, 10, 11, 14, 18, April 1, 2, 6, 7, 9, 11, 20, 25, 26, 29, 30, May 4 and 5. There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of lorazepam. Interview with the Director of Nursing on May 6, 2026 at 11:21 a.m. confirmed that there were no non-pharmacological interventions attempted prior to the administration of lorazepam for the dates listed above, and there should have been. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 43 residents reviewed (Resident 50). Findings include: A facility policy for Comprehensive Care Planning, dated August 14, 2025, included that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet resident's medical, nursing, mental and psychosocial needs identified in comprehensive assessment. These plans will be focused on resident choices and abilities with the intent of maintaining and improving resident functional abilities and quality of life. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or change in condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 50 dated April 2, 2026, indicated that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnosis that included heart failure. Care plan for Resident 50 dated May 16, 2025, indicated that the resident was at risk for falls and that his hearing aids were to be within reach at his bedside. Review of the inventory checklist for Resident 50 dated May 15, 2025, indicated that the resident had one hearing aid and batteries present upon admission and a second hearing aid was present after admission. Interview with Resident 50 on May 4, 2026, at 11:11 a.m. revealed that he had difficulty hearing and did not have hearing aides in. Nurse aid in the room was able to locate his hearing aids in a bag on top of his dresser and assisted the resident to place them correctly in his ears. The resident reported he prefers to have his hearing aids in. Interview with Resident 50 on May 6, 2026, at 9:24 a.m. revealed he had difficulty hearing and that he did not have his hearing aids because they were charging. There was no documented evidence that a care plan was developed to address Resident 50's care and treatment needs related to the use of hearing aids for adequate communication. An interview with the Director of Nursing on May 6, 2026, at 3:29 p.m. confirmed there was no care plan developed to address Resident 50's care and treatment needs related to impaired hearing and the use of hearing aids. An interview with the Director of Nursing on May 7, 2026, at 11:18 a.m. revealed that the resident was seen by audiology that morning and was diagnosed with mixed hearing loss. 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 43 residents reviewed (Residents 1, 36, and 50). This deficiency was cited as past non-compliance.Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section H0100C Ostomy was to be checked (1) yes if the resident had a colostomy (An opening into the colon from the outside of the body). Section H0400 Bowel Continence was to be coded (9) not rated, resident had an ostomy or did not have a bowel movement for the entire seven days, if the resident had a colostomy during the seven-day look-back period. Physician's orders for Resident 1, dated August 13, 2024, included an order for resident's colostomy skin barrier appliance to be changed every seven days. Review of the Resident's bowel record dated February 2026, revealed that the resident was using a colostomy for bowel movements. Review of the quarterly MDS assessment for Resident 1, dated February 20, 2026, revealed that Section H0100C was checked to indicate the resident had an ostomy, however Section H0400 was coded (0) always continent, indicating that the was continent of bowel. Interview with the Director of Nursing on May 6, 2026, at 2:35 p.m. confirmed that Resident 1's MDS dated [DATE], was coded inaccurately. The Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2025, revealed that Section P0200E. Wander/elopement alarm was to be checked 2. Used daily, if the resident had a wander/elopement alarm during the seven-day look-back period. A quarterly MDS assessment for Resident 36, dated February 14, 2026, indicated that the resident is cognitively impaired, required assistance from staff for daily care needs, and had medical diagnosis that includes high blood pressure and heart failure. Physician's orders for Resident 36, dated September 9, 2025, included orders for the resident to have a wanderguard electronic bracelet for safety check functioning daily. Review of the Residents Medication Administration Record revealed that the resident had a wanderguard in place daily during the seven-day lookback period. Interview with the Nursing Home Administrator on May 5, 2026, at 2:21 p.m. confirmed that Resident 36's MDS dated [DATE], was inaccurately coded regarding alarms. The Long-Term Care Facility RAI User's Manual, dated October 2025, revealed that Section B0200 Ability to hear (with hearing aid or hearing appliances if normally used) was to be coded (0) adequate, (1) minimal difficulty. (2) moderate difficulty, or (3) highly impaired. Section B0300 Hearing Aid was to be checked (0) no or (1) yes, if a hearing aid or other appliance was used in completing Section B0200. Review of the inventory checklist for Resident 50 dated May 15, 2025, indicated that the resident had one hearing aid and batteries present upon admission and a second hearing aid was present after admission. Interview with Resident 50 on May 4, 2026, at 11:11 a.m. revealed that he had difficulty hearing and did not have hearing aids in. Nurse aid in the room was able to locate his hearing aids and assisted the resident to place them correctly in his ears. The resident reported he prefers to have his hearing aids in. A quarterly MDS assessment for Resident 50 dated April 2, 2026, revealed that Section B0200 was coded (0) adequate, indicating that the resident had adequate hearing and Section B0300 was checked (0) indicating no hearing aids were used for the assessment. Interview with the Director of Nursing on May 6, 2026, revealed that Resident 50's MDS dated [DATE], was coded inaccurately. Following identification of the inaccurate MDS coding, the facility's corrective actions included: The MDS for resident assessments completed in a seven day look back period were reviewed and corrected, if applicable including any assessments that may have been identified prior to the lookback period. A baseline audit was performed on assessment to ensure the MDS was completed and coded correctly. Education was provided to the Registered Nurse Assessment Coordinator and assessment department to ensure accurate/timely MDS coding. To prevent reoccurrence , audits are to be completed weekly for a month, then monthly for two months. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee. A review of the facility's corrective actions revealed that they were in compliance with F641 on April 24, 2026. 28 Pa. Code 211.5(f) Medical records

Based on review of established infection control guidelines and review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak for three of 12 residents reviewed (Resident's 4, 10, and 11). Findings include: CDC guidance on infection control guidelines and implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent the spread of COVID-19 indicated that early detection of signs and symptoms of COVID-19 is key to minimize transmission throughout the facility, as it enables Healthcare Personnel (HCP) to implement mitigation strategies early. As part of the facility's routine assessment of residents for signs and symptoms of illness, it is important to assess and monitor for any signs and symptoms of COVID-19 regardless of their vaccination status. Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. It is important to assess for other COVID-19 symptoms such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. A testing plan is an important component of outbreak response and management to ensure the timely identification of individuals who may be infectious with COVID-19.Regardless of vaccination status, testing recommendations include testing anyone with even mild symptoms of COVID-19 as soon as possible (fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea, or abnormal chest imaging). HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services (housekeeping), laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). Review of electronic event reports, submitted by the facility to the Department of Health, between December 25, 2025, and January 9, 2026, revealed that a total of 18 residents developed COVID-19 infection between these dates. Interview with the Nursing Home Administrator at the time of the on-site visit on January 13, 2026, revealed that they had 11 active cases of COVID-19 infection in the building and surgical masks were to be worn on the units unless entering rooms with COVID-19 positive residents at which time an N-95 mask would be used. A physician's order for Resident 4, dated September 5, 2025, indicated that the facility may test for COVID-19 as needed for COVID-19 per protocol. (If resident refused, document test offered and risks/benefits discussed).A physician's order for Resident 4, dated December 30, 2025, included orders for Isolation/Transmission-Based Precautions: Combined Droplet/Contact Precautions/Isolation related to: COVID-19.A nursing note for Resident 4, dated December 10, 2025, at 7:10 p.m. indicated that Resident 4 was running a low grade 99.4 degree Fahrenheit (F) fever earlier this AM. Resident reporting body aches, chills, shortness of breath and a dry cough. A nursing note for the resident, dated December 26, 2025, at 11:15 a.m. indicated that Resident 4 complained of a headache, fatigue, general malaise and cough. Vital signs were obtained and resident noted to have temperature of 100.4 F. The rapid covid swab positive.Interview with the Infection Preventionist (IP) and the Director of Nursing on January 13, 2026, at 3:06 p.m. indicated that typically they would test residents with COVID-19 symptoms, but that would depend on the practitioner. There was no positive COVID-19 cases in the building at the time and resident was seen by a practitioner. The Director of Nursing did confirm that Resident 4 had standing orders to test for COVID-19 as needed, and a test was not performed on December 10, 2025. A physician's order for Resident 10, dated September 5, 2025, indicated that the facility may test for COVID-19 as needed for COVID-19 per protocol. (If resident refused, document test offered and risks/benefits discussed). A physician's order for Resident 10, dated January 4, 2026, included orders for Isolation/Transmission-Based Precautions: Combined Droplet/Contact Precautions/Isolation related to: COVID-19. A nursing note for Resident 10, dated January 1, 2026, at 4:24 p.m. indicated that staff reported the resident had a cough and congestion. A nursing note for the resident, dated January 2, 2026, at 12:39 a.m. indicated that the resident was in bed and reported a cough and congestion with general malaise. A nursing note for the resident, dated January 4, 2026, at 12:00 a.m. indicated that the resident was being monitored for cold symptoms and had complaints of cough and congestion. Her skin was pale in color and she had remained in bed for the past two days due to not feeling well. A nursing note for the resident, dated January 4, 2026, at 12:15 p.m. indicated that the resident continued to not feel well. She had symptoms of cough, congestion, and malaise. The Certified Registered Nurse Practitioner (CRNP) was notified, and a new order was obtained for a rapid covid swab and the rapid covid swab resulted positive. Interview with the Infection Preventionist (IP) and the Director of Nursing on January 13, 2026, at 3:06 p.m. indicated that typically they would test residents with COVID-19 symptoms, but that would depend on the practitioner. The Director of Nursing did confirm that Resident 10 had standing orders to test for COVID-19 as needed. The Director of Nursing did not either agree or disagree that testing Resident 10 for COVID-19 was necessary, despite the facility having active cases of COVID-19 in the building at the time the resident was symptomatic. A nursing note for Resident 11, dated January 4, 2026, at 11:20 a.m. indicated that the resident reported not feeling well. On assessment, a moist productive cough was observed. She reported body aches and malaise, and expiratory wheezing was heard when assessing lung sounds. The CRNP was notified, and a new order was obtained for a rapid covid swab and the rapid covid swab resulted positive. A physician's order for Resident 11, dated January 4, 2026, included orders for Isolation/Transmission-Based Precautions: Resident receives all care and services in room while on Transmission-Based Precautions/Isolation. Observations in the North Hall for rooms 120-127 on January 13, 2026, at 12:34 p.m. revealed that Laundry Aide 1 delivered personal clothing to Resident 10 and Resident 11 in room [ROOM NUMBER] wearing only a surgical mask. This room was identified as a COVID-19 positive room with signage outside the room for droplet precautions and had an isolation station on the door containing N-95 masks, gowns, gloves and an eye shield. Interview with Laundry Aide 1 at 12:36 p.m. confirmed that he should have gowned up before he entered the room, or should have placed the clothes on the hook on the outside of the door. He stated he probably should have worn an N-95 mask when entering the room but was not sure where they were. He then stated he did see that they were available in the isolation stations on the door. Interview with the Infection Preventionist (IP), on January 13, 2026, at 3:06 p.m. confirmed that the process for all staff (any discipline) entering a COVID-19 positive room would be to donn gloves, an N-95 mask, eye protection and a gown. She confirmed that all staff are fit tested for a mask and they are to use that size of mask when entering a room with COVID-19 positive residents. The IP confirmed that Laundry Aide 1 should have donned a gown, N-95 mask, gloves and eye protection prior to entering room [ROOM NUMBER]. The Director of Nursing and NHA had confirmed that all staff had received education on COVID-19 precautions. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.----

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information and supplies in preparation for discharge for one of 12 residents reviewed (Resident 1) who were discharged to home. This deficiency was cited as past non-compliance. Findings include:The facility's discharge planning policy, August 14, 2025, indicated that when a resident's discharge was anticipated, the facility would develop and implement a discharge plan that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 21, 2025, revealed that the resident was cognitively intact, was incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had no current pressure ulcers.A wound note, dated December 4, 2025, revealed the resident developed full thickness moisture associated skin damage on the sacrum that measured 6.2 x 3.6 x 0.2 centimeters (cm). A physician's order, dated December 5, 2025, included an order for the sacrum (area located at the base of the spine) to be cleansed with soap and water, patted dry, and Medi-honey (honey based treatment used to heal wounds and prevent infection) applied to the area once a day. The Treatment Administration Record (TAR) for Resident 1 for December 2025 revealed that Medi-honey was applied to the resident's sacrum daily on December 5 and 6, 2025.A nursing note, dated December 6, 2025, at 2:13 p.m. revealed the resident was discharged to home. The medications were reviewed with the resident's family member and the discharge instructions were provided.The discharge instructions for Resident 1, dated December 6, 2025, revealed that the resident was being discharged home with home health and there was no indication that the resident was receiving wound care (wound care was marked N/A). The drug disposition (indicates which medications were sent with the resident upon discharge) form, undated, revealed that medications were sent home with the resident; however there was no documented evidence that Medi-honey was sent with the resident. Interview with the Nursing Home Administrator on January 13, 2026, at 3:31 p.m. confirmed that there was no documented evidence that Resident 1 or his family was provided Medi-honey or instructions for wound care upon discharge.Following identification that the resident was discharged home without receiving Medi-honey or wound care instructions, the facility's corrective actions included:The facility called the family after discharge to review discharge instructions/wound care orders.An audit was performed to ensure that all residents who have wounds and are anticipating a discharge within the next seven days had appropriate paperwork prepared.Education was provided to the Nursing Supervisor and licensed staff regarding accurate treatment orders and having supplies available until home health care was established.Audits were completed two days a week for two weeks, then monthly for two months to enasure all residents have received adequate and appropriate discharge instructions. Results of the audits would be reviewed by the QAPI committee for two months.A review of the facility's corrective actions revealed that they were in compliance with F627 on December 29, 2025.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending June 27, 2024, and April 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 5, 2025, identified repeated deficiencies regarding accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), issues with intravenous therapy, and following infection control practices. The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending June 27, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding a failure to ensure that intravenous therapy was completed correctly, cited during the survey ending on June 27, 2024, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy. The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending June 27, 2024, and April 22, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control practices. Refer to F641, F694, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for flushing intravenous (IV) catheters, and/or that intravenous catheters were flushed according to the facility's policy for two of 39 residents reviewed (Residents 54, 61) who had long-term intravenous catheters. Findings include: The facility's policy regarding flushing intravenous catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated August 14, 2024, revealed that specific flush orders must be obtained, documented and submitted to the pharmacy. Flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. All peripheral vascular access devices are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated May 19, 2025, revealed that the resident was cognitively intact and was dependent for daily care needs. Physician's orders for Resident 54, dated May 16, 2025, included orders to insert an IV catheter (a thin, flexible tube that is placed in a vein to administer fluids) and start Normal Saline at 80 milliliters (ml)/hour (hr). A nursing note, dated May 16, 2025, at 10:00 a.m., revealed that the nursing supervisor was called to Resident 54's room due to a change in condition. Resident 54 was lethargic, was not responsive, and vital signs were within normal limits. The Certified Registered Nurse Practioner (CRNP - a registered nurse with advanced training to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, prescribe medications and formulate treatment plans) was at the bedside and ordered an IV catheter to be inserted with Normal Saline infusing at 80 ml/hr. The IV catheter was inserted without difficulty with excellent blood return and it flushed well. Review of Resident 54's Medication Administration Records (MAR's) for May 2025 revealed no documented evidence that the IV catheter was inserted, the resident received Normal Saline at 80 ml/hr, or that the IV was flushed. Interview with the Director of Nursing on June 4, 2025, at 1:57 p.m. confirmed that there was no documented evidence that Resident 54 had an IV inserted with Normal Saline infusing at 80 ml/hr or that the IV was flushed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated May 25, 2025, revealed that the resident was cognitively intact, had IV access, and received an antibiotic. Physician's orders for Resident 61, dated May 23, 2025, included orders for staff to flush the resident's midline using 10 ml of 0.9 percent sodium chloride before and after medication administration, followed by 30 units of Heparin three times a day (6:00 a.m., 2:00 p.m., 9:00 p.m.). Physician's orders for Resident 61, dated May 29, 2025, included orders for the resident to receive 720 milligrams (mg) of Daptomycin (an antibiotic) intravenously (IV) once a day (5:00 a.m.) and 1 gram of Cefepime (an antibiotic) intravenously every 12 hours (8:00 a.m., 8:00 p.m.). A nursing note, dated May 30, 2025, at 12:28 a.m. revealed the resident was receiving Cefepime and Daptomycin for osteomyelitis (bone infection) of the left heel. Resident 61's Medication Administration Records (MAR's) for May and June 2025 revealed that the resident received IV Cefepime at 8:00 a.m. May 29 through June 4, 2025; however, there was no documented evidence that staff flushed the resident's midline catheter before and after the administration. Interview with the Director of Nursing on June 5, 2025, at 11:45 a.m. confirmed that there was no documented evidence that Resident 61's midline was flushed before and after the administration of Cefepime at 8:00 a.m. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 39 residents reviewed (Resident 76). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated August 14, 2024, indicated that EBP is intended to prevent transmission of MDRO's via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomies (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and for all those colonized or infected with a MDRO currently targeted by the CDC. High contact activities that may result in transfer of MDRO's to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 76, dated March 26, 2025, revealed that the resident was understood, could understand others, had a diagnosis which included End-Stage Renal Disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), and received dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to). A care plan for the resident, dated March 7, 2024, revealed that the resident required dialysis and had a right subclavian (located below your collarbone) dialysis catheter (a medical device used for kidney dialysis, providing access to the bloodstream for the process of cleaning waste and excess fluid from the blood). Review of Resident 76's clinical record revealed no documented evidence to indicate that the resident was on EBP's due to having the right subclavian dialysis catheter. Interview with the Infection Control Preventionist on July 31, 2024, at 10:30 a.m. confirmed that there was no documented evidence to indicate that Resident 76 was on EBP's due to having the right subclavian dialysis catheter. She indicated that the resident was on EBP's previously for a wound that the resident had, and once the wound was healed the order for EBP's was discontinued; however, the order for EBP's should not have been discontinued because the resident still needed to be on EBP's due to having the right subclavian dialysis catheter. She indicated that the Director of Nursing advised her that he was placing an order, as well as creating a care plan for EBP's for the resident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 39 residents reviewed (Resident 91). This deficiency was cited as past non-compliance. Findings include: The facility policy for medication administration, dated August 14, 2024, indicated that medications are prescribed as ordered by the physician and will be administered by certified healthcare professionals in a behavior consistent with appropriate infection control and standards of practice. A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment was independent with personal care needs, and had diagnosis that included dementia. Physician's orders for Resident 91 dated June 20, 2024, included for the resident to receive 25 milligrams (mg) of metoprolol tartrate (used to treat high blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure (SBP-top number on a blood pressure reading) was less than 120 millimeters of mercury (mm/Hg). Review of the Medication Administration Record (MAR) for Resident 91, dated January through April 2025, indicated that 25 mg of metoprolol tartrate was administered to the resident on January 14 during the a.m. med pass when the resident's SBP was 110 mm/Hg; February 8 during the p.m. med pass when the resident's SBP was 110 mm/Hg; March 1 during the a.m. med pass when the resident's SBP was 116 mm/Hg; March 6 during the a.m. med pass when the resident's SBP was 118 mm/Hg; April 10 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 15 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 17 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 20 during the p.m. med pass when the resident's SBP was 118 mm/Hg; and April 27 during the p.m. med pass when the resident's SBP was 118 mm/Hg. Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2025, at 4:40 p.m. confirmed that Resident 91 was administered metoprolol tartrate when it should have been held per physician's orders for a SBP less than 120. Following identification that medications were being administered outside of physician ordered parameters, the facility's corrective actions included: Residents who had physician-ordered parameters for medication administration were identified. Education was provided to licensed staff regarding administering medications with parameters and the six rights of medication administration. Audits were completed three times a week for four weeks to identify any medications that were administered outside of physician-ordered parameters and will continue twice monthly for two months. The findings will be reviewed with the quality assurance performance improvement committee. A review of the facility's corrective actions revealed that they were in compliance with F684 on May 30, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect the resident's specific care needs for three of 39 residents reviewed (Residents 30, 77, 91). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), and had diagnoses that included obstructive uropathy (condition where the flow of urine is blocked within the urinary tract). A care plan for Resident 30, dated January 28, 2025, indicated that the resident had urinary incontinence (the involuntary leakage of urine) and staff were to assess her pattern of urination and episodes of incontinence. A care plan, dated May 12, 2025, indicated that the resident required an indwelling urinary catheter, and that staff were to provide catheter care as ordered. A nurse's note for Resident 30, dated May 10, 2025, indicated that the resident had an indwelling catheter placed. An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:15 p.m. revealed that Resident 30's care plan was not revised to remove interventions for urinary incontinence when the resident had an indwelling catheter placed and it should have been. An admission MDS assessment for Resident 77, dated May 21, 2025, indicated that the resident was cognitively impaired, received no anti-psychotic medications, and had diagnoses that included anxiety. Physician's orders for Resident 77, dated May 27, 2025, included an order for the resident's Olanzapine (anti-psychotic medication) to be discontinued. A review of the resident's Medication Administration Record (MAR) for June 2024 revealed that Resident 77 was not receiving an anti-psychotic medication; however, the resident's current care plan indicated that the resident received an antipsychotic medication for anxiety. An interview with the Director of Nursing on June 5, 2025, at 11:38 p.m. confirmed that Resident 77's care plan was not revised to indicate that the resident's anti-psychotic medication was discontinued. A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment, was independent with personal care needs, and had diagnoses that included dementia. A care plan for Resident 91, dated June 24, 2024, indicated that the resident was receiving antipsychotic medication for depression; however, a review of the Medication Administration Record (MAR) for Resident 91, dated May and June 2025, revealed no documented evidence that the resident was receiving antipsychotic medication. An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:13 p.m. confirmed that Resident 91's care plan was not revised to indicate that the resident was not receiving antipsychotic medication and should have been. 28 Pa. Code 201.24(e)(4) Admission Policy. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a 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 six of 39 residents reviewed (Residents 18, 30, 61, 66, 77, 79). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day look-back period. Physician's orders for Resident 18, dated April 24, 2025, included an order for the resident to receive 1 gram of Cefipime (antibiotic) intravenously every eight hours for seven days for a urinary tract infection. The resident's Medication Administration Record (MAR's) for April 2025 revealed that the resident received Cefipime every eight hours from April 24 through April 29, 2025; however, a significant change MDS assessment for Resident 18, dated May 3, 2025, revealed that Section N0410F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven-day look-back period. Interview with the RNAC on June 5, 2025, at 10:33 confirmed that Section N0410F1 of Resident 18's significant change assessment of May 3, 2025, was not coded correctly. The RAI User's Manual, dated October 2024, indicated that Section O0110K1 Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be coded to indicate if the resident was receiving hospice services (a) on admission, (b) while a resident or (c) at discharge. Review of Resident 30's clinical record, including physician's orders, care plans and nurses' notes, revealed no documented evidence that the resident was receiving hospice services during the seven-day look-back period; however, a quarterly MDS assessment for Resident 30, dated May 29, 2025, revealed that Section 0O110K1 was coded (b) while a resident, indicating that the resident was receiving hospice services during the seven-day look back-period. Interview with the Registered Nurse Assesment Coordinator on June 5, 2025, at 9:13 a.m. confirmed that Resident 30's MDS, dated [DATE], was coded inaccurately. The RAI User's Manual, dated October 2024, revealed that if the resident had an unhealed pressure ulcer (skin impairment caused by pressure), then Section M0210 was to be coded (1) yes, and the number of pressure ulcers was to be coded in Section M0300A for Stage I pressure ulcers (reddened area that does not blanche), Section M0300B for Stage II pressure ulcers (superficial open area or blister), Section M0300C for Stage III pressure ulcers (full thickness skin loss), Section M0300D for Stage IV pressure ulcers (full thickness tissue loss exposing bone, tendons or muscle), Section M0300E for unstageable pressure ulcers related to a non-removable device, Section M0300F for unstageable pressure ulcers due to slough (yellow, tan, or green tissue, usually moist) or eschar (dead tissue this is black or brown in color and may appear scab like), and M0300G for unstageable pressure ulcers related to suspected deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue). A nursing note, dated May 23, 2025, at 5:08 p.m., revealed that Resident 61 was admitted to the facility and the dressing to the bottom of her left heel was removed for drainage. She had a Stage III open area that measured 4 x 3 x 0.5 centimeters (cm). The area was cleansed with normal saline solution (sterile salt water) and Hydrofera blue (antibacterial wound dressing) was applied to the area and covered with a dressing as ordered; however, an admission MDS assessment for Resident 61, dated May 25, 2025 revealed that Section M0210 was coded no (0), indicating that the resident did not have an unhealed pressure ulcer; therefore, Section M0300C (Stage III) was not coded to indicate that the resident had a Stage III pressure ulcer. Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she did not think the resident received a treatment to the left heel and that the area was coded as a diabetic ulcer after the assessment period, so it was not coded as a pressure ulcer. The RAI user's manual, dated October 2024, revealed that Section N0415A Antipsychotic (medication used for behaviors) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 66, dated May 13, 2025, included an order for the resident to receive 150 milligrams of Clozapine (an antipsychotic medication) every day at bedtime. The resident's MAR for May 2025 revealed that the resident received Clozapine daily during the assessment's seven-day look-back period; however, a quarterly MDS assessment for Resident 66, dated May 7, 2025, revealed that Section N0401A was not coded, indicating that the resident did not receive an antipsychotic medication during the seven-day look-back period. Interview with the RNAC on June 4, 2025, at 3:26 p.m. confirmed that Section N0401A of Resident 66's quarterly assessment of May 7, 2025, was not coded correctly. The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident. An admission MDS assessment for Resident 77, dated May 21, 2025, revealed that Section N0300 indicated that the resident did not receive an injection during the seven days of the assessment period; however, a review of Resident 77's Medication Administration Record (MAR) for May 2025 revealed that the resident received a PPD (purified protein derivative - skin test for Tuberculosis administered with a needle) on May 15, 2025. Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she does not code PPD injections. The RAI User's Manual, dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period. A care plan for Resident 79, dated March 11, 2025, indicated that the resident was prescribed an antiplatelet. Physician's orders for Resident 79, dated November 7, 2023, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. Review of the resident's Medication Administration Record (MAR) for April and May 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 79, dated May 7, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days. Interview with the RNAC on June 4, 2025, at 1:20 p.m. confirmed that Resident 79's MDS assessment was not coded accurately. 28 Pa. Code 211.5(f) Clinical Records.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for one of 39 residents reviewed (Resident 30). 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, 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. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), had diagnoses that included obstructive uropathy (condition where the flow of urine was blocked within the urinary tract), and had a pressure ulcer. A wound consult note for Resident 30, dated February 27, 2025, and March 6, 2025, indicated that the resident was to have her wound cleansed with wound cleanser, gently scrubbing to remove all old ointment and any loose tissue, patted dry, have Medi honey (medical-grade honey used to treat wounds) applied to the wound bed, and covered with a dry border gauze dressing (wound dressing that combines an absorbent gauze pad with a wider, adhesive border for secure placement) daily and as needed for soiling or dislodgement. A wound consult note for Resident 30, dated March 13, 2025, indicated that the resident's prior wound regimen was to be discontinued and that her wound was to be cleansed with 0.125 percent Dakin's Solution (used topically to clean and disinfect wounds and to prevent infection), the wound packed with Dakin's moistened kerlix (type of bandage roll used for wound care) to fill the void and depth, and covered with a dry ABD pad (a type of medical dressing used to absorb fluids and provide padding for wounds) twice a day and as need for soiling or dislodgement. Review of the Treatment Administration Record (TAR) for Resident 30, dated February and March 2025, indicated that from February 28 through March 20 the resident had treatments completed that included having her sacrum cleansed with wound cleanser, patted dry, Medi-honey applied, and covered with calcium alginate (highly absorbent wound dressings made from natural seaweed fibers and calcium salts) and a large border dressing daily. Interview with the Infection Control Nurse on June 5, 2025, at 3:39 p.m., in the presence of the Director of Nursing and Nursing Home Administrator, revealed that she does treatments with the wound consultant every week and receives verbal orders for treatment changes during that time. She was responsible for reviewing the wound consultant's notes each week and to identify any discrepancies between the verbal orders he provides her and the recommendations he includes in his notes. She is responsible to clarify any discrepancies. The infection control nurse confirmed that there were discrepancies that she failed to identify and clarify between the treatment orders that were being completed from February 28 through March 20, 2025, and the wound consultant's recommendations. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of manufacturer's directions and clinical records, as well as observations and 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 physician's orders for one of six residents reviewed (Resident 2). Findings include: Manufacturer's direction for use of diclofenac sodium topical gel 1 percent (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild-to-moderate pain), undated, revealed: Important: Use the dosing card that is inside the diclofenac sodium topical gel carton to correctly measure each dose. The dosing card is re-usable. Do not throw the dosing card away. For each upper body area (hand, wrist, or elbow), squeeze out 2.25 inches (two grams) and apply. For each lower body area (foot, ankle, or knee), squeeze out 4.5 inches (four grams) and apply. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was understood, and could understand others. A care plan for the resident, dated March 3, 2025, revealed that the resident was at risk for pain related to impaired mobility. Staff was to administer medications as per physician's order. Physician's orders for Resident 2, dated March 17, 2025, included an order for staff to apply four grams of diclofenac sodium topical gel 1 percent to the resident's right knee four times a day. Observations during the medication administration on April 22, 2025, at 9:25 a.m. revealed that Licensed Practical Nurse 1 entered Resident 2's room and applied gloves, and without using the diclofenac sodium topical gel dosing card she squeezed out an unmeasured amount of the diclofenac sodium topical gel onto her gloved finger, and then applied to the front of the resident's right knee. Then without using the diclofenac sodium topical gel dosing card she squeezed out another unmeasured amount of the diclofenac sodium topical gel onto her gloved finger, and then applied to the back of the resident's right knee. Interview with Licensed Practical Nurse 1 on April 22, 2025, at 9:41 a.m. confirmed that she did not use the diclofenac sodium topical gel dosing card to measure out the dose of diclofenac sodium topical gel prior to applying it to Resident 2's right knee. She indicated that a dosing card only comes with the prescription strength diclofenac sodium topical gel and not with the over-the-counter strength diclofenac sodium topical gel, which is what they receive from the facility's pharmacy. Interview with the Director of Nursing on April 22, 2025, at 1:25 p.m. confirmed that Licensed Practical Nurse 1 should have measured the diclofenac sodium topical gel prior to applying it to Resident 2's right knee to ensure the appropriate dose was received as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of six residents reviewed (Resident 5). Findings include: The facility's policy regarding comprehensive care planning, dated August 14, 2024, revealed that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated March 14, 2025, revealed that the resident was understood, could understand others, had an indwelling catheter (a flexible tube inserted into the bladder to drain urine), had diagnoses that included a wound infection, Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves), and a Stage 4 pressure ulcer (full-thickness skin and tissue loss, with exposure of muscle, tendon, or bone) of the sacral region (bottom of the spine). Physician's orders for Resident 5, dated April 5, 2024, included an order for the resident to be on Enhanced Barrier Precautions (infection control measures that involve using gowns and gloves during high-contact resident care activities, in addition to standard precautions). Observations of Resident 5's room on April 22, 2025, at 10:06 a.m. revealed that there was an Enhanced Barrier Precaution sign outside the resident's room. The sign indicated that staff were to wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use central lines (a long, thin, flexible tubes inserted into a large vein, usually in the chest or neck, and threaded up to a vein near the heart), urinary catheter, feeding tube, tracheostomy (a surgical procedure where an opening (stoma) is made in the neck and into the trachea (windpipe), wound care, and any skin opening requiring a dressing. However, as of April 22, 2025, there was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 5 regarding her Enhanced Barrier Precautions. Interview with the Director of Nursing on April 22, 2025, at 3:37 p.m. confirmed that there was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 5 regarding her Enhanced Barrier Precautions. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination, and failed to ensure that proper infection control practices were performed during care for one of six residents reviewed (Resident 5). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding transmission-based precautions and isolation, dated August 14, 2024, indicated that EBP's are intended to prevent transmission of MDRO's via contaminated hands and clothing of healthcare workers to high-risk residents. EBP are indicated for high-risk contact care activities for residents with chronic wounds and indwelling devices such as central lines, urinary catheters, and tracheostomies, and for all those colonized or infected with a MDRO currently targeted by the CDC. A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated March 14, 2025, revealed that the resident was understood, could understand others, had an indwelling catheter (a flexible tube inserted into the bladder to drain urine), had diagnoses that included a wound infection, Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves), and a Stage 4 pressure ulcer (full-thickness skin and tissue loss, with exposure of muscle, tendon, or bone) of the sacral region (bottom of the spine). Physician's orders for Resident 5, dated April 5, 2024, included an order for the resident to be on EBPs. Observations of Resident 5's room on April 22, 2025, at 10:06 a.m. revealed that there was an EBP sign outside the resident's room. The sign indicated that staff were to wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use central lines (a long, thin, flexible tubes inserted into a large vein, usually in the chest or neck, and threaded up to a vein near the heart), urinary catheter, feeding tube, tracheostomy (a surgical procedure where an opening (stoma) is made in the neck and into the trachea (windpipe), wound care, and any skin opening requiring a dressing. Nurse Aide 2 and Nurse Aide 3 entered the resident's room wearing only gloves. Nurse Aide 3 went to the resident's right side and Nurse Aide 2 went to the resident's left side. Nurse Aide 2 and Nurse Aide 3 then rolled the resident onto her left side. Nurse Aide 3 loosened the resident's brief, and the resident was incontinent of bowel. Nurse Aide 3 then removed the soiled outer dressing to the resident's wounds and then began to provide incontinent care. After she completed providing the incontinent care, she removed the packing from the resident's wounds and placed the soiled dressings in the resident's brief. Without removing her gloves and performing hand hygiene Nurse Aide 3 then obtained the mechanical lift sling and placed it under the resident. Nurse Aide 2 and Nurse Aide 3 then rolled the resident onto her back then rolled her slightly to her right where Nurse Aide 2 then pulled the lift sling under the resident. Nurse Aide 2 and Nurse Aide 3 then returned the resident to her back. Nurse Aide 2 and Nurse Aide 3 then both removed their gloves and used hand gel. Nurse Aide 2 and Nurse Aide 3 reapplied gloves. After getting the resident out of bed Nurse Aide 2 then began to remove the resident's linen from the bed. Interview with the Director of Nursing on April 22, 2025, at 1:25 p.m. confirmed that Nurse Aide 2 and Nurse Aide 3 should have been wearing gowns in addition to their gloves while providing care to Resident 5 and that Nurse Aide 3 should have removed her gloves and preformed hand hygiene after removing the resident dressings to her wounds and providing incontinent care prior to providing any additional care to the resident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for one of four residents reviewed (Resident 2) who was transferred incorrectly, resulting in a fall with a head laceration requiring staples. This deficiency was cited as past noncompliance. Findings include: The facility's abuse policy, dated September 11, 2024, indicated that the facility will not tolerate abuse, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed). A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). A nursing note for Resident 2, dated November 28, 2024, at 8:17 p.m., indicated that the resident was being transferred onto his bed by Nurse Aide 1 by a mechanical lift when the sling pad slipped from under the resident and he hit his head on the headboard resulting in a laceration to the back of his head. The physician was notified and new orders were received to transfer the resident to the emergency room . A nursing note for Resident 2, dated November 28, 2024, at 9:15 p.m., revealed that the resident returned from the emergency room with three staples to the back of his head. An incident report for Resident 2, dated December 6, at 12:05 p.m., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1. The sling pad slipped from under the resident causing him to hit his head on the headboard resulting in a laceration that required three staples. Nurse Aide 1 received the facility's abuse training on June 4, 2024. Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that Nurse Aide 1 was aware of the facility's policy for transferring a resident with two persons in a Hoyer lift and should have had a second person assist with the transfer of Resident 2. A review of the facility's plan of correction included the following: Reeducation on transporting residents in mechanical lifts and transfers completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses. Audits of residents that require mechanical lifts and assist with transfers. Audits to be completed three days a week for four weeks to ensure proper transfer status is being used. Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents. A review of the facility's corrective actions revealed that they were in compliance with F600 on December 3, 2024. Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of four residents reviewed (Resident 2), resulting in an incident that required staples for a laceration on his head. This deficiency was cited as past non-compliance. Findings include: The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed). A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for care, including transfers and bed mobility, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). The current care plan for Resident 2 indicated that he was a two-person assist for transfers. An incident report for Resident 2, dated December 6, at 12:05 pm., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1, the sling pad slipped from under the resident, and he hit his head on the headboard causing a laceration that required three staples. Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that two people should have been transferring Resident 2 while using the mechanical lift. A review of the facility's plan of correction included the following: Reeducation on transferring residents in mechanical lifts completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses. Audits of residents that require mechanical lifts and assist with transfers. Audits of transfers will be completed three days a week for four weeks to ensure proper transfer status is being used. Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents. A review of the facility's corrective actions revealed that they were in compliance with F689 on December 3, 2024. Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of clinical records, investigative reports, and staff education, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans and physican's orders for one of 32 residents reviewed (Resident 14) who required the use of a mechanical lift for transfer, resulting in fractured bones for the resident, and to use leg rests to transport one resident out of 32 residents reviewed (Resident 10). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 8, 2023, revealed that the resident was cognitively impaired, was dependent on two staff members for transfers, did not ambulate (walk), and had diagnoses that included dementia. The resident's care plan, dated July 20, 2022, revealed that she required a mechanical lift for transfers. An annual therapy screen, dated December 1, 2022, indicated that the resident unable to bear weight and required a mechanical lift for transfers. A nursing note for Resident 14, dated July 6, 2023, at 9:25 a.m. revealed that the resident complained of pain in the left shoulder. The Certified Registered Nurse Practitioner (CRNP) was notified and orders were received to x-ray the left shoulder. A CRNP note, dated July 6, 2023, revealed that the resident was seen for complaints of pain to her left shoulder that she was refusing to move. She was also seen for her right knee, which was with purple discoloration, deformity and tenderness. Upon examination the resident had tenderness to her left shoulder and swelling of the right knee with severe pain with any movement. The plan was to x-ray the right hip, femur, knee, leg and ankle regarding pain and deformity. An x-ray report, dated July 6, 2023, revealed that the resident's left shoulder had a fracture of the surgical neck (the upper arm bone (humerus) closest to the shoulder area) and greater tuberosity (bump of bone at the top of the humerus). An x-ray report, dated July 7, 2023, revealed that the resident had a proximal tibia neck fracture (upper area of the shin bone closest to the knee). The facility's investigation, dated July 6, 2023, revealed that the daylight nurse aide reported on July 6, 2023, that Resident 14 did not want to be touched in the morning because her shoulder and legs hurt. Upon investigation, it was determined that Nurse Aide 1 got Resident 14 out of bed the morning of July 5, 2023, by herself, without use of mechanical lift, via an unacceptable transfer procedure, and neglected to follow the resident's care plan. Nurse Aide 1 stated, I sat her on the edge of the bed, gave her a bear hug while she was sitting on edge of bed, and transferred her to her wheelchair. Resident 14 had reported to Nurse Aide 1 that her shoulder hurt when she came back from the podiatrist's office on July 5, 2023, but did not inform the licensed practical nurse. A written statement by Nurse Aide 1, dated July 6, 2023, confirmed that she got Resident 14 out bed the morning of July 5, 2023, by giving hear a bear hug while she was sitting on the edge of the bed and transferred her into her wheelchair. Resident 14 then went to the podiatrist and when she came back, she reported that her shoulder hurt. She was leaning on her left arm while in the wheelchair, was straightened up, and then placed into bed. The facility's agency employee orientation checklist, dated July 2 2023, revealed that Nurse Aide 1 completed training regarding safety and resident care plan locations, including transfer status. Interview with the Nursing Home Administrator on July 18, 2023, at 3:00 pm. and 3:08 p.m. confirmed that Nurse Aide 1 transferred Resident 14 by herself from her bed into the wheelchair instead of using a mechanical lift that was care planned and ordered by the physician, and they feel that is what caused Resident 14's fractures. She indicated that all staff were educated where the resident care plans were located, which included Resident 14's transfer status. The facility's policy regarding foot/leg rests, dated May 12, 2023, indicated that bilateral footrests will be utilized throughout the transport, with resident's lower extremities properly positioned. A quarterly MDS assessment for Resident 10, dated May 30, 2023, revealed that the resident was cognitively impaired, required extensive assistance of two staff for bed mobility, required one-person physical assist for locomotion on the unit, and had diagnoses that included legal blindness, osteoarthritis and peripheral vascular disease. Physican's orders, dated June 19, 2023, revealed that the resident was to use leg rests for transport. Observations on July 18, 2023, at 9:51 a.m. revealed that Nurse Aide 2 pushed Resident 10 down the hall and into the North Lounge in a wheelchair that was not equipped with a leg rests. The resident's feet were approximately two inches above the floor while being transported. Observations on July 18, 2023, at 9:54 a.m. revealed that Activity Aide 3 immediately noticed that Resident 10 did not have leg rests on the wheelchair and proceeded to take them out of the wheelchair pouch and place them on the wheelchair. Interview with Nurse Aide 2 at 9:57 a.m. and Activity Aide 3 at 9:59 a.m. confirmed that Resident 10 should not have been transferred without leg rests. Interview with the Nursing Home Administrator on July 18, 2023, at 2:53 p.m. confirmed that Resident 10 should not have been transported without leg rests. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 32 residents reviewed (Resident 14), resulting in harm to Resident 14 due to an improper transfer that resulted in fractures. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding abuse and neglect, dated May 12, 2023, indicated that each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation. No resident in the facility would be physically, verbally or sexually abused, neglected, have their property misappropriated, suffer from corporal punishment or involuntary seclusion, or be exploited by anyone. Anyone was defined as, but limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies, family members, friends, legal guardians, visitors, or any other individual. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 8, 2023, revealed that the resident was cognitively impaired, was dependent on two staff members for transfers, did not ambulate (walk), and had diagnoses that included dementia. The resident's care plan, dated July 20, 2022, revealed that she required a mechanical lift for transfers. An annual therapy screen, dated December 1, 2022, indicated that the resident unable to bear weight and required a mechanical lift for transfers. A nursing note for Resident 14, dated July 6, 2023, at 9:25 a.m. revealed that the resident complained of pain in the left shoulder. The Certified Registered Nurse Practitioner (CRNP) was notified and orders were received to x-ray the left shoulder. A CRNP note, dated July 6, 2023, revealed that the resident was seen for complaints of pain to her left shoulder that she was refusing to move. She was also seen for her right knee, which was with purple discoloration, deformity and tenderness. Upon examination the resident had tenderness to her left shoulder and swelling of the right knee with severe pain with any movement. The plan was to x-ray the right hip, femur, knee, leg and ankle regarding pain and deformity. An x-ray report, dated July 6, 2023, revealed that the resident's left shoulder had a fracture of the surgical neck (the upper arm bone (humerus) closest to the shoulder area) and greater tuberosity (bump of bone at the top of the humerus). An x-ray report, dated July 7, 2023, revealed that the resident had a proximal tibia neck fracture (upper area of the shin bone closest to the knee). The facility's investigation, dated July 6, 2023, revealed that the daylight nurse aide reported on July 6, 2023, that Resident 14 did not want to be touched in the morning because her shoulder and legs hurt. Upon investigation, it was determined that Nurse Aide 1 got Resident 14 out of bed the morning of July 5, 2023, by herself, without use of mechanical lift, via an unacceptable transfer procedure, and neglected to follow the resident's care plan. Nurse Aide 1 stated, I sat her on the edge of the bed, gave her a bear hug while she was sitting on edge of bed, and transferred her to her wheelchair. Resident 14 had reported to Nurse Aide 1 that her shoulder hurt when she came back from the podiatrist's office on July 5, 2023, but did not inform the licensed practical nurse. A written statement by Nurse Aide 1, dated July 6, 2023, confirmed that she got Resident 14 out bed the morning of July 5, 2023, by giving hear a bear hug while she was sitting on the edge of the bed and transferred her into her wheelchair. Resident 14 then went to the podiatrist and when she came back, she reported that her shoulder hurt. She was leaning on her left arm while in the wheelchair, was straightened up, and then placed into bed. The facility's agency employee orientation checklist, dated July 2 2023, revealed that Nurse Aide 1 completed training regarding safety and resident care plan locations, including transfer status. The facility's investigation, dated July 6, 2023, confirmed that there was evidence of neglect by Nurse Aide 1 due to the fact that she did not use the proper care-planned transfer technique during the morning shift. Interview with the Nursing Home Administrator on July 18, 2023, at 3:00 pm. and 3:08 p.m. confirmed that Nurse Aide 1 transferred Resident 14 by herself from her bed into the wheelchair instead of using a mechanical lift that was care planned and ordered by the physician, and they feel that is what caused Resident 14's fractures. She indicated that all staff were educated where the resident care plans were located, which included Resident 14's transfer status. Following the incident on July 5, 2023, the facility's corrective actions included: Nurse Aide 1, who was involved in the incorrect transfer of Resident 14, was suspended pending the results of the facility's investigation. On July 6, 2023, a full facility audit of the residents' transfer status was completed. Interviews were completed with residents and families to identify any other incidents of possible neglect. Education was initiated for all staff regarding abuse/neglect and ensuring that proper transfer status was being followed for all residents for the nursing staff. Review of the facility's education sign-in sheets regarding abuse/neglect indicated that education was completed for the majority of all staff, and review the residents' care plans to ensure the accuracy of the resident's transferring and ambulation status indicated that education was completed for the majority of the nursing staff. A plan was developed on July 6, 2023, for weekly observations of transfers to be conducted and audits for any abuse/neglect. The results of the audits were to be discussed during the monthly QA meeting. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(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 residents were not served foods that they were allergic to for one of four residents reviewed (Resident 2), resulting in an allergic reaction for the resident. Findings include: The facility's policy regarding documentation of allergies [REDACTED]. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated (MONTH) 5, 2019, revealed that the resident was cognitively impaired and could eat independently with supervision after set-up. The resident's care plan, dated (MONTH) 25, 2019, indicated that she required maximum verbal cueing with her meals; was on a minced, low fat diet; and that she had a strawberry allergy. An allergy list indicated that the allergy to strawberries was entered into the clinical record on (MONTH) 11, (YEAR), and was listed on the resident's Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for (MONTH) and (MONTH) 2019, and also on the dietary census list, located in a cupboard in the main dining room. A nursing note for Resident 2, dated (MONTH) 14, 2019, revealed that the unit licensed nurse reported to the nursing supervisor that the resident was given strawberry Ensure (a nutritional supplement) at dinner and that she was allergic to strawberries. At that time, she was ordered an [MEDICATION NAME] injection (given to treat life-threatening allergic reactions) as needed, [MEDICATION NAME] (an medication that can decrease allergic reactions) as needed every six hours, and to monitor the resident every hour for an allergic reaction. The nursing documentation indicated that the resident did not develop any symptoms of an allergic reaction. Resident 2's care plan, dated (MONTH) 15, 2019, indicated that she was at risk for allergy reactions and that staff were to reduce/eliminate exposure. A nursing note for Resident 2, dated (MONTH) 26, 2019, at 6:28 p.m. revealed that a nurse aide brought the resident to the nursing station from the dining room and reported that the resident was given strawberry yogurt with strawberry chunks in it. The resident was pale, had a cough, her throat began swelling, she appeared red, and she began complaining of difficulty breathing. [MEDICATION NAME] was administered subcutaneously at 6:15 p.m., an ambulance was called, and Resident 2 was sent to the emergency room . An emergency department report for Resident 2, dated (MONTH) 26, 2019, revealed that the resident was given [MEDICATION NAME] while in route to the hospital, and upon arrival to the hospital the resident had no further symptoms and her allergic reaction had resolved. Interview with the Dietary Director on (MONTH) 4, 2019, at 12:50 p.m. confirmed that at the time of the incident, Resident 2's meal ticket included that she had an allergy to strawberries; however, after serving her meal, the meal tickets are removed. The nurse aide obtained the strawberry yogurt in addition to the items provided for the meal. The nurse aide did not check the dietary census form in the dining room cupboard prior to giving the resident the strawberry yogurt. The facility failed to ensure that staff did not provide food items to Resident 2 that she was known to be allergic to, resulting in treatment and transfer to the hospital. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 10/11/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 10/11/18, 7/17/18, 4/13/18, 9/14/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/11/18, 7/17/18, 4/13/18, 9/14/17.

Based on review of manufacturer's instructions, facility policies, and training records, as well as staff interviews, it was determined that the facility failed to ensure that the manufacturer's instructions for the use of a mechanical lift were followed during a transfer, resulting in a fracture for one of 27 residents reviewed (Resident R8), and failed to notify the physician about abnormal laboratory testing results, which resulted in a delay in treatment for one of 27 residents reviewed (Resident R5). Findings include: The manufacturer's instructions for the Hoyer lift (a mechanical device that used hydraulic power to transfer a resident who cannot bear weight), undated, revealed that when lifting, the castors on the bottom of the lift device should be left free and un-braked and the lift would be able to move to the center of gravity of the lift. If the brakes were applied, the resident would swing to the center of gravity and may prove disconcerting and uncomfortable. The facility's training records for transferring residents with a mechanical lift, dated June 12 and August 28, 2015, revealed that Nurse Aides 16 and 17 attended the training, and the training did not include that staff were to lock the castors of the mechanical lift when lifting a resident. Information submitted by the facility, dated March 21, 2016, revealed that on March 19, 2016, Resident R8 was being transferred with a mechanical lift by Nurse Aides 16 and 17. The information indicated that the wheels of the lift were locked when the resident was being lifted, and when the wheels were unlocked to back the resident away from the chair, her buttocks hit the arm of the chair, causing the lift to tip and land on the resident's leg. The resident was yelling out, My leg and reached to her left leg, where it was noted that she had a skin tear and bruise. X-ray reports, dated March 21, 2016, revealed that the resident had a [MEDICAL CONDITION] ankle. Interview with the Nursing Home Administrator on August 25, 2016, at 10:55 a.m. confirmed that the manufacturer's instructions were not followed during the lifting of Resident R8 and the staff were not trained to lock the wheels of the lift. A quarterly Minimum Data Set assessment (MDS - a mandated assessment of a resident's abilities and care needs) for Resident R5, dated April 22, 2016, revealed that the resident was frequently incontinent of urine. physician's orders [REDACTED]. Interview with Unit Clerk 18 on August 25, 2016, at 11:45 a.m. confirmed that Resident R5's physician was not notified about the laboratory results until June 21, 2016. Interview with the Director of Nursing on August 25, 2016, at 1:34 p.m. revealed that the physician should have been notified sooner regarding Resident R5's laboratory results. 42 CFR 483.25 Provide Care/services for Highest Well Being. Previously cited 5/5/16, 12/8/15, 10/8/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 6/9/16, 5/5/16, 3/11/16, 12/8/15, 10/8/15, 5/5/15, 9/5/14.

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident's environment remained free of accident hazards for one of four residents reviewed (Resident CR1) who exhibited wandering behavior and who was at risk for elopement, resulting in an elopement from the facility and an accident in which the resident suffered serious injuries. Findings include: Admission information for Resident CR1 dated July 12, 2014, revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated August 12, 2015, and October 29, 2015, revealed that Resident CR1 exhibited wandering behavior (moving place to place with or without a specified course or known direction) on 1 to 3 days of the assessment period. A quarterly MDS assessment, dated January 21, 2016, revealed that the resident was confused, had [DIAGNOSES REDACTED]. The resident's daily behavior records for September 2015 through February 2016 also revealed that the resident had wandering behaviors during all six months. A nursing note, dated February 14, 2016, indicated that the resident self-propelled throughout the hallways. The instructions for an Elopement Risk Evaluation Form for Resident CR1, dated November 11, 2015, indicated that if Question #1 and either Questions #3, 4, 5 or 6 were answered yes then the resident was at high risk for elopement (leaving the facility without the knowledge of staff) and must have a care plan in place to address the risk. Question #1 on the resident's Elopement Risk Evaluation Form, which was completed by Registered Nurse 8, was answered no indicating that the resident did not ambulate independently with a wheelchair. Questions #4 and 5 were answered yes indicating that the resident had a history of [REDACTED]. The answer of no to Question #1 resulted in the Elopement Risk Evaluation Form determining that Resident CR1 was not at risk for elopement. However, review of the elopement risk evaluation form with the Director of Nursing on March 3, 2016, at 3:00 p.m., revealed that Question #1 was answered incorrectly, and if Question #1 had been answered correctly, the elopement risk evaluation would have indicated that the resident was at high risk for elopement. Interview with Registered Nurse 8 on March 10, 2016, at 9:40 a.m., revealed that she was unaware that Resident CR1 self-propelled his wheelchair, and she thought the staff had to push him around. There was no documented evidence that a care plan to address the resident's identified wandering behaviors, including the resident's risk elopement, was developed. Interview with Social Service Director 9 on March 11, 2016, at 11:45 a.m., revealed that she was responsible for completing the behavior section of Minimum Data Set assessments, including wandering behaviors, and for presenting the information to the care planning team for the development of a care plan to address behaviors. When completing Resident CR1's MDS assessment of January 21, 2016, she identified that the resident's wandering behavior had increased, but she neglected to present this information to the care planning team for the development of a care plan to address the resident's wandering. The nursing notes for Resident R1, dated March 2, 2016, revealed that on March 1, 2016, the resident was found in the adjoining personal care home at the bottom of a stairwell on the 5th floor. He fell down a flight of eight concrete steps and was found with a large amount of blood under his head, a laceration above the right eye, and a laceration to the top portion of his head. The nursing notes, dated March 2, 2016, indicated that the resident was sent to a trauma hospital and admitted with head trauma. The hospital's trauma note, dated March 2, 2016, indicated that the resident had multiple cervical spine fractures, acute unstable thoracic spine fractures, scalp lacerations, an eyebrow laceration, fractures of the frontal sinus and right nasal bones, and rib fractures, and the resident ceased to breathe on March 4, 2016. The facility's Incident Report and Investigation Report, both, dated March 1, 2016, revealed that the investigation did not include a statement from Social Service Director 9 regarding her role in completing Resident CR1's MDS assessment to determine why a care plan related to his wandering behavior and his risk for elopement was not implemented, even after an increase in the resident's wandering behaviors was identified. There was also no evidence that all of the other employees in the building at the time of the incident, or with knowledge of the resident's wandering behaviors, were interviewed or provided statements regarding how the resident travelled unsupervised from the skilled nursing center to the 5th floor in the personal care home. Interview with Nurse Aide 7 on March 9, 2016, at 3:00 p.m., revealed that she was assigned to Resident CR1 on the night of the incident, and she was not aware that she had to keep an eye on where the resident was during her shift. Interviews with Licensed Practical Nurse 1 on March 8, 2016, at 2:25 p.m., revealed that she was aware that Resident CR1 had a history of [REDACTED]. Interview with Personal Care Home Employee 2 on March 8, 2016, at 3:15 p.m., revealed that she has seen the skilled care residents unsupervised in the personal care section of the facility. Interview with Personal Care Home Employee 3 on March 8, 2016, at 3:25 p.m., revealed that the nursing home residents were known to come up the personal care elevator and that at times, Resident CR1 was seen in the elevator during the evening shift. Interview with Dietary Aide 4 on March 8, 2016, at 3:30 p.m., revealed that she has seen nursing home residents go through the personal care home entrance. Interview with Nurse Aide 5 on March 8, 2016, at 3:40 p.m., revealed that she was aware that Resident CR1 wandered freely. Interview with Nurse Aide 6 on March 8, 2016, at 3:45 p.m., revealed that she was aware that Resident CR1 wandered freely and that staff must keep an eye on him. She indicated that the resident was known to go over to the main dining room and the personal care home's 2nd and 4th floors. During observations and interviews completed with the Nursing Home Administrator (NHA) on March 8, 2016, at 8:30 a.m., the NHA revealed that Resident CR1, who resided on the Intermediate Hall travelled from his room, past the nursing station, and down the Skilled Hall to the main dining room where there were two over-sized wooden doors that swung open into the hallway and that had a latch that needed depressed in order to open the doors. The two doors had magnets that were capable of keeping the doors in an open position. The NHA indicated that the dining room doors were closed at the time Resident CR1 eloped, and that the resident must have opened the doors himself. The resident continued to travel through the main dining room to the personal care home entrance door, went through that door and another door, past the personal care nursing station, and to the elevator. The resident then got on the elevator and took it to the 5th floor. Upon exiting the elevator on the 5th floor, there was a door to the left that led to an outside terrace and a door to the right that led to a large, long furnished and unsupervised room. At the very end of this room was Stairwell #2. The door into this stairwell opened with a push bar and swung into the stairwell. Once the door was open there was an approximate eight by ten foot platform. The NHA indicated that his investigation surmised that Resident CR1 wheeled himself onto the platform area, tried to turn around and open the door from the platform, but while doing so his wheelchair wheels rolled off the platform and down the first flight of eight concrete steps. The resident was found at the end of the steps with his feet facing towards the steps and with his wheelchair on top of his legs and midsection. Interview with the Director of Nursing on March 11, 2016, at 12:50 p.m., revealed that she was aware that Social Service Director 9 failed to present information regarding Resident CR1's wandering behaviors to the care planning team, which resulted in harm to the resident. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 12/8/15, 10/8/15, 5/5/15, 9/5/14.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that each resident had an individualized plan of care to meet their safety needs related to a wandering and being a high elopement risk for one of four residents reviewed (Resident CR1). Findings include: The Quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated August 12, 2015, and October 29, 2015, revealed that Resident CR1 exhibited wandering behavior (moving place to place with or without a specified course or known direction) on 1 to 3 days of the assessment period. A quarterly MDS assessment, dated January 21, 2016, revealed that the resident was confused, had [DIAGNOSES REDACTED]. A nursing note, dated February 14, 2016, indicated that the resident propelled his wheelchair throughout the hallways. The resident's daily behavior records for September 2015 through February 2016 also revealed that the resident had wandering behaviors during all six months. The instructions for an, Elopement Risk Evaluation Form for Resident CR1, dated November 11, 2015, indicated that if Question #1 and either Questions #3, 4, 5 or 6 were answered yes then the resident was at high risk for elopement (leaving the facility without the knowledge of staff) and must have a care plan in place to address the risk. Question #1 on the resident's Elopement Risk Evaluation Form, which was completed by Registered Nurse 8, was answered no indicating that the resident did not ambulate independently with a wheelchair. Questions #4 and 5 were answered yes indicating that the resident had a history of [REDACTED]. The answer of no to Question #1 resulted in the Elopement Risk Evaluation Form determining that Resident CR1 was not at risk for elopement. However, review of the elopement risk evaluation form with the Director of Nursing on March 3, 2016, at 3:00 p.m., revealed that Question #1 was answered incorrectly, and if Question #1 had been answered correctly, the elopement risk evaluation would have indicated that the resident was at high risk for elopement. There was no documented evidence that a care plan to address the resident's identified wandering behaviors, including the resident's risk for elopement, was developed. Interview with Registered Nurse 8 on March 10, 2016, at 9:40 a.m., revealed that she was unaware that Resident CR1 self-propelled his wheelchair, and she thought staff had to push him around. Interview with Social Service Director 9 on March 11, 2016, at 11:45 a.m., revealed that she was responsible for completing the behavior section of Minimum Data Set assessments, including wandering behaviors, and for presenting the information to the care planning team for the development of a care plan to address behaviors. When completing Resident CR1's MDS assessment of January 21, 2016, she identified that the resident's wandering behavior had increased, but she neglected to present this information to the care planning team for the development of a care plan to address the resident's wandering. The nursing notes for Resident R1, dated March 2, 2016, revealed that on March 1, 2016, the resident was found in the adjoining personal care home at the bottom of a stairwell on the 5th floor. He fell down a flight of eight concrete steps and was found with a large amount of blood under his head, a laceration above the right eye, and a laceration to the top portion of his head. The nursing notes, dated March 2, 2016, indicated that the resident was sent to a trauma hospital and admitted with head trauma. The hospital's trauma note, dated March 2, 2016, indicated that the resident had multiple cervical spine fractures, acute unstable [MEDICATION NAME] spine fractures, scalp lacerations, an eyebrow laceration, fractures of the frontal sinus and right nasal bones, and rib fractures, and the resident ceased to breathe on March 4, 2016. Interview with the Director of Nursing on March 11, 2016, at 12:50 p.m., revealed that she was aware that Social Service Director 9 failed to present information regarding Resident CR1's wandering behaviors to the care planning team, which resulted in harm to the resident. 28 Pa Code 211.11(d) Resident care plan. 28 Pa Code 211.12(d)(5) Nursing services. Previously cited 12/8/15, 10/8/15, 5/5/15, 9/5/14.

Based on clinical record reviews, staff interviews and review of incident investigation documentation, it was determined that the facility failed to implement procedures to ensure that a resident's needs related to wandering behaviors and elopement risk were not neglected for one of four residents reviewed (Resident CR1), which resulted in serious injuries to the resident. Findings include: The Quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) dated August 12, 2015, and October 29, 2015, revealed that Resident CR1 exhibited wandering behavior (moving place to place with or without a specified course or known direction) on 1 to 3 days of the assessment period. A quarterly MDS assessment, dated January 21, 2016, revealed that the resident was confused, had [DIAGNOSES REDACTED]. A nursing note, dated February 14, 2016, indicated that the resident propelled his wheelchair throughout the hallways. The resident's daily behavior records for September 2015 through February 2016 also revealed that the resident had wandering behaviors during all six months. The instructions for an Elopement Risk Evaluation Form for Resident CR1, dated November 11, 2015, indicated that if Question #1 and either Questions #3, 4, 5 or 6 were answered yes then the resident was at high risk for elopement (leaving the facility without the knowledge of staff) and must have a care plan in place to address the risk. Question #1 on the resident's Elopement Risk Evaluation Form, which was completed by Registered Nurse 8, was answered no indicating that the resident did not ambulate independently with a wheelchair. Questions #4 and 5 were answered yes indicating that the resident had a history of [REDACTED]. The answer of no to Question #1 resulted in the Elopement Risk Evaluation Form determining that Resident CR1 was not at risk for elopement. However, review of the Elopement Risk Evaluation Form with the Director of Nursing on March 3, 2016, at 3:00 p.m., revealed that Question #1 was answered incorrectly, and that if Question #1 had been answered correctly, the elopement risk evaluation would have indicated that the resident was at high risk for elopement. There was no documented evidence that a care plan to address the resident's identified wandering behaviors, including the resident's risk for elopement, was developed. Interview with Registered Nurse 8 on March 10, 2016, at 9:40 a.m., revealed that she was unaware that Resident CR1 self-propelled his wheelchair, and she thought staff had to push him around. Interview with Social Service Director 9 on March 11, 2016, at 11:45 a.m., revealed that she was responsible for completing the behavior section of Minimum Data Set assessments, including wandering behaviors, and for presenting the information to the care planning team for the development of a care plan to address behaviors. When completing Resident CR1's MDS assessment of January 21, 2016, she identified that the resident's wandering behavior had increased, but she neglected to present this information to the care planning team for the development of a care plan to address the resident's wandering. The nursing notes for Resident R1, dated March 2, 2016, revealed that on March 1, 2016, the resident was found in the adjoining personal care home, at the bottom of a stairwell, on the 5th floor. He fell down a flight of eight concrete steps and was found with a large amount of blood under his head, a laceration above the right eye, and a laceration to the top portion of his head. The nursing notes, dated March 2, 2016, indicated that the resident was sent to a trauma hospital and admitted with head trauma. The hospital's trauma note, dated March 2, 2016, indicated that the resident had multiple cervical spine fractures, acute unstable [MEDICATION NAME] spine fractures, scalp lacerations, an eyebrow laceration, fractures of the frontal sinus and right nasal bones, and rib fractures, and the resident ceased to breathe on March 4, 2016. The facility's, Incident Report and Investigation Report, both dated March 1, 2016, revealed that the investigation did not include a statement from Social Service Director 9 regarding her role in completing Resident CR1's MDS assessment to determine why a care plan related to his wandering behavior and his risk for elopement was not implemented, even after an increase in the resident's wandering behaviors was identified. There was also no evidence that all of the other employees in the building at the time of the incident, or with knowledge of the resident's wandering behaviors, were interviewed or had provided statements regarding how the resident travelled unsupervised from the skilled nursing center to the 5th floor in the personal care home. Interview with the Director of Nursing on March 11, 2016, at 12:50 p.m., revealed that she was aware that Social Service Director 9 failed to present information regarding Resident CR1's wandering behaviors to the care planning team, which resulted in harm to the resident and met the definition of neglect. Interview with the Nursing Home Administrator on March 11, 2016, at 1:15 p.m., revealed that the Director of Nursing reported to him that Social Service Director 9 had knowledge of her responsibility to present information regarding Resident CR1's wandering behaviors to the care planning team and neglected to do so. 28 Pa Code 201.14(a)(e) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide pain management for one of 20 residents reviewed (Resident R12). Findings include: The facility's policy regarding pain management, dated June 24, 2015, indicated that all residents were to be monitored for pain and were to have individualized care plans for pain management. Ineffective pain relief, as evidenced by the resident's response, was to be reported to the registered nurse for further assessment and physician notification, in order to achieve the highest level of effectiveness that was possible. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R12, dated July 14, 2015, indicated that the resident was able to express her ideas and thoughts and comprehended most conversation. A current [DIAGNOSES REDACTED]. Resident R12's pain care plan, dated September 30, 2015, indicated that staff were to monitor the resident's pain, administer medications as ordered, and monitor their effectiveness, and contributing factors were to be noted and an attempt made to eliminate them. physician's orders [REDACTED]. September and October 2015 revealed that the resident requested and received [MEDICATION NAME] (narcotic pain medication) 34 times in September 2015 and 11 times from October 1 through 8, 2015; and when asked, the resident rated the pain as either a seven or eight (on a scale of one to ten). There was no documented evidence that the resident was offered or administered [MEDICATION NAME] prior to wound debridements performed on August 5 and 12, 2015; September 2 and 23, 2015; and October 7, 2015. Observations during wound care provided to Resident R12 on October 7, 2015, at 10:30 a.m. revealed that after removing the old dressings and measuring the wounds, the certified registered nurse practitioner (CRNP) sprayed the anterior shin wounds with 2 percent [MEDICATION NAME] gel spray (a topical numbing agent). She let the spray dry for 30 seconds and proceeded to scrape the areas of yellow slough (dead tissue) away with a curette (a sharp surgical instrument designed for scraping or [MEDICATION NAME] biological tissue or debris) until the wounds were bleeding. The resident moaned and sobbed softly and arched back her torso stating, Ooooooo, Oooooooo, to which the CRNP asked, Does that hurt? The resident stated, Yes, and the CRNP responded, It will be done soon, and continued to scrape the remaining anterior shin wounds and heel wound until fresh blood emerged and the resident attempted to pull back her right leg and shuddered. Interview with the CRNP immediately after the procedure revealed that in her opinion the resident experienced only temporary pain. She documented in her wound care progress note that the resident's right heel pressure ulcer had 1.92 square centimeters (sq cm) of slough (dead tissue), biofilm (a thin layer of microorganisms adhering to the surface of a structure), exudate (a fluid with a high content of protein and cellular debris that has escaped from the blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation), and subcutaneous tissue (the layer of loose connective tissue directly under the skin) excisionally debrided with a curette. The right anterior venous leg wounds had 28 sq cm of slough, biofilm, exudate, and subcutaneous tissue excisionally debrided with a curette, and the resident was unable to rate the pain but the debridement was tolerated with the use of topical 2 percent [MEDICATION NAME]. Interview with Resident R12 on October 8, 2015, at 12:59 p.m. revealed that she recalled the pain she experienced the day before during her wound care and verbalized that it was always painful when the wound was scraped and she just puts up with it. When asked about taking pain medication prior to the procedure, she indicated that it might help, and she would like to try it. 28 Pa Code 211.12 (d)(5) Nursing services. Previously cited 5/5/15, 9/5/14.