Every finding on record at Hillcrest Rehabilitation & Healthcare Center

Based on observations and staff interviews, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility, and failed to properly monitor refrigerator temperatures for two of two nursing units (East and Northwest) which created the potential for food borne illness.Findings include: During an observation with Food Services Director (FSD) Employee E12 in the Main Kitchen on 4/13/26, at 10:20 a.m. revealed that the cold air condenser unit, (2) fan covers, and the area immediately surrounding in the main walk-in cooler had a build-up of dust, grime, and dark colored debris. During an interview on 4/13/26, at 10:21 a.m. the FSD Employee E12 confirmed that the facility failed to properly maintain kitchen equipment in a sanitary condition in the Main kitchen walk-in cooler. During an observation on 4/16/26, at 9:10 a.m. with FSD Employee E12 revealed the East Nursing Unit refrigerator was found with an incomplete temperature log for April 2026. During an observation on 4/16/26, at 9:14 a.m. with FSD Employee E12 revealed the Northwest Nursing Unit refrigerator was found without a temperature log for April 2026. During an interview on 4/16/26, at 9:15 a.m. FSD Employee E12 confirmed that the facility failed to properly monitor refrigerator temperatures for two of two nursing units (East and Northwest) which created the potential for food borne illness. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(b)(1) Management.

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic (substances that act on the brain to alter cognition, perception, and mood) medications without adequate indications for use for three of six residents (Resident R2, R19, and R90). Findings include: Review of facility policy Antipsychotic Medication Use, dated 1/15/26, indicated: Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a residents behavior, mood, function, medical condition specific symptoms and risks to the residents and others. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The duration of the PRN order will be indicated in the order. Review of Resident R2 admission record indicated he was admitted on [DATE]. Review of Resident R2 admission record indicated diagnosis of anxiety disorder (group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and altered mental status (is a change in mental in mental function. It stems from certain illnesses, disorders and injuries affecting your brain). Review of Resident R2's clinical record MAR for April 2026 (medication administration record - record used to document medications given to a resident) indicated: Vistaril (is used to control anxiety and tension caused by nervous and emotional conditions) oral capsule 25 mg (hydroxzyine pamoate) give 1 capsule by mouth every 6 hours as needed for anxiety/agitation start date 4/1/26: review of the MAR indicated medication was given: 4/4/26: 2106 (9:06 p.m.). 4/9/26: 1458 (2:58 p.m.) 4/10/26: 1456 (2:56 p.m.) 4/12/26: twice at 900 and 2209 ( 9:00 a.m. and 10:09 p.m.) 4/15/26: 1653 (4:53 p.m.) And Zyprexa oral tablet (olanzapine) (is an antipsychotic that can treat schizophrenia and bipolar disorder. It balances the levels of dopamine and serotonin in your brain) give 2.5mg by mouth every 6 hours as needed for agitation: review of the MAR indicated medication was given: 4/13/26: 1318 ( 1:18 p.m.) 4/14/26: 1013 (10:13 a.m.) 4/15/26: 1653 ( 4:53 p.m.) Review of the MAR and clinical progress notes failed to include what non-pharmacological interventions were provided prior to giving the prn medications. During an interview on 4/16/26, at 2:42 p.m. DON (Director of Nursing) confirmed that the facility failed to provide non-pharmacological interventions were provided prior to giving the prn medications. Review of Resident R19's admission record indicated she was admitted [DATE]. Review of Resident R19's Minimum Data Set (MDS- periodic assessment of care needs) dated 3/15/26, indicated diagnoses of pneumonia (infection that inflames the air sacs in one or both lungs), dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and anxiety disorder. Review of Section N: Medications revealed Resident R19 received antianxiety medications in the seven days prior to the assessment. Review of Resident R19's physician order dated 3/19/26, indicated Ativan (is used to treat anxiety disorder, insomnia, and other conditions. It works by enhancing the activity of certain neurotransmitters in the brain, leading to relaxation and reduced anxiety) oral tablet 0.5 mg (milligram) give 1 tablet by mouth every six hours as needed for anxiety. Review of Resident R19's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R19s Ativan. Review of Resident R19's clinical record MAR for April 2026 (medication administration record - record used to document medications given to a resident) indicated: Ativan oral tablet 0.5 mg (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety start date: 3/19/26. Review of the April 2026 MAR indicated medication was given: 4/1/26: three times a day at 845, 1510, and 1949 (8:45 a.m., 3:10 p.m., and 7:49 p.m.) 4/2/26: two times a day at 1322, 1933 (1:22 p.m. and 7:33 p.m.) 4/3/26: three times a day at 908, 1515, and 2128 (9:08 a.m., 3:15 p.m. and 9:28 p.m.) 4/4/26: once a day at 1013 (10:13 a.m.) 4/5/26: once a day at 2200 (10:00 p.m.) 4/6/26: two times a day at 0815 and 1615 (8:15 a.m. and 4:15 p.m.) 4/7/26: two times a day at 0940 and 1918 (9:40 a.m. and 7:18 p.m.) 4/8/26: three times a day at 638, 1328, 2000 (6:38 a.m., 1:28 p.m. and 8:00 p.m.) 4/9/26: two times a day at 908 and 2055 (9:08 a.m. and 8:55 p.m.) 4/10/26: two times a day at 1332 and 1940 (1:32 p.m. and 7:40 p.m.) 4/11/26: once a day at 1344 (1:44 p.m.) 4/12/26: three times a day at 836, 1441, and 2049 (8:36 a.m., 2:41 p.m. and 8:49 p.m.) 4/13/26: two times a day at 753 and 1910 (7:53 a.m. and 7:10 p.m.) 4/14/26: three times a day at 545, 1216, and 1847 (5:45 a.m., 12:16 p.m. and 6:47 p.m.) 4/15/26: three times a day at 807, 1410,and 2015 (8:07 a.m., 2:10 p.m. and 8:15 p.m.) 4/16/26: once a day at 708 (7:08 a.m.) Review of the MAR and clinical progress notes failed to include what non-pharmacological interventions were provided prior to giving the prn medications. During an interview on 4/15/26, at 1:48 p.m., the DON confirmed that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic medications without adequate indications for use for Resident R19. Review of Resident R60's admission record indicated she was admitted [DATE]. Review of Resident R60's MDS assessment dated [DATE], indicated diagnoses of lung cancer, respiratory failure, and high blood pressure. Review of Section N: Medications revealed Resident R60 received antianxiety medications in the seven days prior to the assessment. Review of Resident R60's physician order dated 3/11/26, indicated Ativan oral tablet 1.0 mg (Lorazepam) give 1 tablet by mouth every four hours as needed for agitation/restlessness. Review of Resident R60's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R60's Ativan. Review of Resident R60's clinical record MAR for April 2026 (medication administration record - record used to document medications given to a resident) indicated: Ativan oral tablet 1.0 mg (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety start date: 3/11/26. Review of the April 2026 MAR indicated medication was given: 4/1/26: two times a day at 903 and 2021 (9:03 a.m. and 8:21 p.m.) 4/2/26: two times a day at 1225 and 2050 (12:25 p.m. and 8:50 p.m.) 4/5/26: once a day at 804 (8:04 a.m.) 4/6/26: once a day at 2035 (8:35 p.m.) Review of the MAR and clinical progress notes failed to include what non-pharmacological interventions were provided prior to giving the prn medications. During an interview on 4/16/26, at 10:46 a.m., the DON confirmed that the facility failed to make certain resident medication regimens were free from potentially unnecessary psychotropic medications without adequate indications for use for Resident R60. 28 Pa Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 211.5(f) Medical records. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on a review of the facility policy, clinical record reviews and staff interviews, it was determined that the facility failed to assess the nutritional status as required, failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for four of six residents (Resident R5, R30, R40, and R50), and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of six resident (Resident R40 and R50) records reviewed. Findings include: Review of the facility policy Nutritional assessment dated [DATE], previously dated 2/20/25, indicated that as part of the comprehensive assessment, a nutrition assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. As part of the comprehensive, the nutritional assessment will be a systemic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Once current condition and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications, Such interventions will be developed within the context of the resident's prognosis and personal preferences. Review of facility policy Weight Assessment and Interventions dated 1/15/26, previously dated 2/20/25, indicated that multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in the resident's electronic medical record. Any weight change of 5% or more since the last weight assessment will be addressed by the Dietitian. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/26, indicated diagnoses of high blood pressure, anxiety, and history of falling. Review of Resident R5's weight record failed to reveal any documented weights for June 2025 or July 2025. During an interview on 4/17/26, at 10:25 a.m. the Director of Nursing (DON) confirmed that the facility failed to properly monitor weight and status by failing to obtain and document weights for Resident R5. Review of Resident R30's admission record indicated she was admitted to the facility 5/11/25. Review of Resident R30's MDS assessment dated [DATE], included diagnoses of heart failure, adult failure to thrive, and paroxysmal atrial fibrillation (irregular heart rhythm). Section K0300 was coded a 2, which indicated that Resident R30 had a weight loss of 5% or more in the last month or weight loss of 10% or greater in the last six months. Review of Resident R30's Nutrition Evaluation dated 4/2/26, indicated that current weight from 3/5/26, was 125# (pounds), weight loss noted in 3 months, and significant weight loss 11.5% x 180 days (6 months). Documentation failed to indicate specific dates and weights referenced in evaluation. Review of Weight Summary for Resident R30 indicated the following weights: 3/5/26 - 125# 2/13/25 - 126# 2/4/25 - 124.8# 9/2/25 - 141.2# Documentation failed to include weights for October 2025, November 2025, December 2025, and January 2025, indicating inaccurate documentation of weight loss in 3 months due to weight not being obtained in December 2025, as noted in 4/2/26 Nutrition Evaluation. During an interview of 4/17/26, at 11:15 a.m., the DON confirmed that the facility failed to properly obtain weights for Resident R30 therefor documentation of nutritional status was inaccurate. Review of Resident R30's MDS assessment dated [DATE], Section K0200B Weight (in pounds) revealed a - (dash - standard no information code), however rationale for use of standard no information code was not documented. Further review of clinical record failed to reveal documentation of Resident R30's nutritional status relevant to MDS assessment dated [DATE]. During an interview on 4/17/26, at 12:18 p.m., Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E3 confirmed that a - was coded on Resident R30's MDS dated [DATE], Section K0200B and further confirmed that the clinical record failed to contain a clinical nutritional assessment explaining rationale for MDS documentation or current nutritional status. Review of Resident R40's admission record indicated she was admitted to the facility 10/28/25. Review of Resident R40's MDS assessment dated [DATE], included diagnoses of rhabdomyolysis (condition characterized by the rapid breakdown of skeletal muscles), morbid obesity, and respiratory failure. Review of Section Z - Assessment Administration revealed that LPNAC Employee E3 completed Section K on 1/15/26. Review of the clinical record for Resident R40 failed to reveal clinical nutrition documentation completed by a Registered Dietitian for MDS assessment dated [DATE]. Review of Weight Summary on for Resident R40 indicated the following weights: 3/5/26 - 238# 2/13/26 - 241.6# -- entry was errored out by the DON 12/2/25 - 336# 12/1/25 - 336# 11/10/25 - 336.3# 10/29/25 - 337# Documentation failed to include weights for the week of 11/2/25, week of 11/16/25, monthly weight for January 2026, and monthly weight for February 2026. As of review on 4/17/26, Resident R40's monthly weight had not been obtained. Review of clinical nutrition note dated 2/19/26, by Registered Dietitian Employee E13 revealed weight obtained 2/13 is a suspected entry error. Recommendation: obtain reweight. Review of clinical nutrition note dated 3/12/26, by RD Employee E13 revealed weight 3/5 likely an entry error. Recommendation: obtain reweight. RD will continue to monitor, and follow-up as needed. During an interview of 4/17/26, at 11:15 a.m., the DON confirmed that the facility failed to properly obtain reweights as requested and monthly weights for Resident R40. Review of Nutrition Evaluation dated 4/14/26, by RD Employee E13, identified current body weight as 238# on 3/5/26, stating weight noted to be stable at present time. Further review of Nutritional Evaluation failed to identify, provide rationale, or recommend interventions for significant weight loss of 98# from 12/2/25, weight, until current weight per evaluation of 238#. Review of Resident R40's current plan of care, updated 2/3/26, failed to indicate any nutritional concerns related to significant weight loss or interventions to prevent significant weight loss. During interview on 4/17/26, at 12:23 p.m., LPNAC Employee E3 confirmed that Resident R30's clinical record failed to provide clinical nutrition documentation by the RD for MDS assessment dated [DATE], and failed to have significant weight loss addressed accurately by the RD; LPNAC Employee E3 also confirmed that Resident R30's care plan failed to address current nutritional status identifying significant weight loss of 98# with goals and interventions. Review of Resident R50's admission record indicated he was admitted to the facility 4/24/24. Review of Resident R50's MDS assessment dated [DATE], included diagnoses of heart failure, dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and high blood pressure. Section K0300 was coded a 2, which indicated that Resident R50 had a weight loss of 5% or more in the last month or weight loss of 10% or greater in the last six months. Review of Section Z - Assessment Administration revealed that LPNAC Employee E3 completed Section K on 3/8/26, 1/1/26, and 12/26/25 MDS assessments. Review of physician order dated 1/1/26, indicated 2.0 (calorie) nutritional supplement two times a day for nutrition support/increased nutrient needs/weight maintenance; 120 mls (milliliters) 2x/day with AM/PM med passes. Review of Nutrition Evaluation dated 3/10/26, by RD Employee E13 indicated current weight of Resident R50 to be 144# on 2/4/26; further noted that no weight obtained x 30 days, and significant weight loss 8.8% x 90 days. Nutrition Evaluation failed to identify date and weight of referenced significant loss. Review of Weight Summary for Resident R50 indicated the following weights: 4/13/26 - 153.4# 3/15/26 - 158.2# (significant weight gain of 9.9% x 30 days) 2/4/26 - 144# (significant weight loss of 8.8% x 90 days) 12/6/25 - 148# 12/5/25 - 148.2# 12/4/25 - 149.8# 11/11/25 - 157.8# 10/3/25 - 157.3# 9/28/25 - 155.8# 9/1/25 - 157.8# 5/3/25 - 155.4# Documentation failed to include a weight for January 2026. During an interview of 4/17/26, at 11:15 a.m., the DON confirmed that the facility failed to properly obtain a monthly weight for Resident R50 for January 2026. Review of clinical nutrition note dated 2/6/26, by RD Employee E13 identified significant weight loss of 8.8% by Resident R50 x 90 days; review of clinical nutrition note dated 3/24/26, identified significant weight gain of 9.9% x 30 days, reweight pending. Both clinical nutrition notes failed to identify date and weight of referenced significant weight change. Review of clinical nutrition documentation failed to reveal nutrition notes or evaluations from 9/23/25, until 2/6/26, indicating that Resident R50's MDS's dated 12/26/25, and 1/14/26, failed to have a RD assess his nutritional status. Review of Resident R50 current plan of care, updated 4/9/26, failed to identify significant weight changes as a nutrition focus, and failed to include current 2.0 nutritional supplement as an intervention. During an interview on 4/17/26, at 12:28 p.m., LPNAC Employee E3 confirmed that RD Employee E13 failed to provide referenced dates for time frames of significant weight change documentation, failed to maintain accurate care plan, and failed to assess Resident R50's nutritional status from 9/23/25, through 2/6/26. During an interview on 4/17/26, at 2:45 p.m., the Nursing Home Administrator and DON confirmed that the facility failed to assess the nutritional status as required, failed to properly monitor weight and nutrition status by failing to obtain weights or act upon weight changes for four of six residents (Resident R5, R30, R40, and R50), and failed to update an individualized care plan to address the resident's specific nutritional concerns for two of six resident (Resident R40 and R50) records reviewed. 28 Pa. Code: 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for five of six residents (Residents R1, R4, R47, R54, and R61).Findings include: Review of the facility policy Administering Medications through a Small Volume (handheld) Nebulizer last reviewed 1/15/26, indicated the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. When treatment is completed rinse and disinfect the nebulizer equipment. When equipment is completely dry, store it in a plastic bag with the resident's name and date on it. Review of the facility policy CPAP (continuous positive airway pressure)/BiPAP (bilevel positive pressure) Support last reviewed 1/15/26, indicated to improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. To promote resident comfort and safety. Review of facility policy Oxygen Administration dated 1/15/26, indicated staff are to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/6/26, indicated diagnoses of high blood pressure, respiratory failure (a condition where the lungs cannot get enough oxygen into the blood), and obstructive sleep apnea (OSA - disorder that causes breathing to repeatedly stop and start during sleep). Review of a physician order dated 12/6/25, indicated BiPAP settings 15/8 bleed in 3 liters of oxygen every night shift for OSA. During an observation on 4/13/26, at 10:24 a.m. Resident R1's BiPAP machine was observed on the resident's bedside table, the mask was laying on the table, not stored in a bag while not in use. During an interview on 4/13/26, at 10:37 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R1's BiPAP mask was not stored in a plastic bag while not in use and that the facility failed to provide appropriate respiratory care. Review of the clinical record revealed Resident R4 was originally admitted to the facility 10/30/23, recently readmitted [DATE]. Review of Resident R4's MDS dated [DATE], indicated diagnoses of urinary tract infection, respiratory failure, and diabetes mellitus (chronic condition that occurs when the body cannot properly use blood sugar (glucose), leading to high blood sugar levels). Review of a physician order dated 3/23/26, indicated Oxygen at: 4 liters per minute via nasal cannula (medical device that delivers supplemental oxygen directly into the nostrils) as needed for SOB (shortness of breath). Review of Resident R4's current plan of care updated 2/12/26, indicated oxygen per physician orders. During an observation on 4/13/25, at 11:20 a.m., Resident R4's nasal cannula was found lying on the floor next to his bed, between the wall and his concentrator, not stored in a bag while not in use. During an interview on 4/13/26, at 11:24 a.m., Registered Nurse (RN) Employee E14 confirmed that Resident R4's nasal cannula was lying on the floor, between the wall and his concentrator, not stored in a bag while not in use. Review of Resident R47's clinical record indicated an admission date of 6/15/24. Review of R47's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Review of Resident R47's physician orders dated 4/5/26, indicated Ipratropium-Albuterol 0.5-2.5 milligram (MG)/3 milliliter (ML) Solution administer one ampule via nebulizer every four hours as needed for wheezing. During an observation completed on 4/13/26, at 10:58 a.m. indicated a handheld nebulizer sitting on top of Resident 47's nightstand, not stored in a bag as required. During an interview completed on 4/13/26, at 11:01 a.m. LPN Employee E9 confirmed the nebulizer was on the nightstand not stored in as bag as required and stated, it should be. Review of Resident R54's clinical record indicated an admission date of 3/30/22. Review of Resident R54's MDS dated [DATE], indicated the diagnoses of COPD, diabetes (high sugar in the blood) and heart failure (the heart doesn't pump the way it should). Review of Resident R54's physician orders dated 3/4/26, indicated Noninvasive ventilation BiPap on every night shift keep oxygen saturation 90% and above every night shift for COPD During an observation completed on 4/13/26, at 10:44 a.m. indicated a BiPap mask on the nightstand, not stored in a bag as required. During an interview completed on 4/13/26, at 11:02 a.m. LPN Employee E9 confirmed the BiPap mask was not stored in a bag as required and confirmed that the facility failed to provide appropriate respiratory care. Review of the clinical record revealed Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and anxiety. During an observation on 4/13/26, at 10:08 a.m. Resident R61 was observed receiving two liters of oxygen via nasal cannula. Review of Resident R61's clinical record failed to reveal a physician order for oxygen therapy. Review of Resident R61's comprehensive care plan failed to reveal goals and interventions related to the resident's oxygen therapy. During an interview on 4/15/26, at 12:56 p.m. LPN Employee E1 confirmed Resident R61 did not have a physician order for oxygen therapy and stated, Usually residents have an order for oxygen. During an interview on 4/16/26, at 1:59 p.m. Licensed Practical Nurse Assessment Coordinator Employee E3 confirmed Resident R61 did not have a physician order for oxygen or a care plan developed for oxygen therapy and that the facility failed to provide appropriate respiratory care. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly store medications in two of three medication carts (North Hall Medication Cart and [NAME] Hall Medication Cart) and one of two medication storage rooms (East Medication Room) and failed to properly secure a medication cart while not in use for one of three medication carts (East Hall Medication Cart). Findings include: Review of the facility policy Administering Medications last reviewed 1/15/26, indicated when opening a multi-dose container, the date opened is recorded on the container. During administration of medications, the medication cart is kept closed and locked. Review of the facility policy Storage of Medications last reviewed 1/15/26, indicated medications and biologicals are stored safely, securely, and properly, Medication storage areas are kept clean, well-lit and free of clutter and extreme temperatures. Outdated, contaminated, or deteriorated medications and those that are cracked, soiled, or without secure closures are immediately removed from sock and disposed of. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During an observation completed on 4/14/26, at 10:40 a.m. the [NAME] Hall Medication Cart contained: 1 bottle of Lactulose opened and failed to be labeled with a date as required During an interview completed on 4/14/26, at 10:46 a.m. Licensed Practical Nurse (LPN) Employee E9 confirmed the bottle of Lactulose was opened and failed to be labeled with a date as required and that the facility failed to properly store medications. During an observation completed on 4/14/26, 10:46 a.m. the North Hall medication Cart contained the following: - 1 opened bottle of normal saline solution opened and labeled 4/11/26. - 1 tube mupirocin cream opened and not labeled with a date as required. - 1 bottle plain packing strip opened and not labeled with a date as required. - 1 tube manuka honey opened and not labeled with a date as required. - 1 albuterol inhaler opened and not labeled with a date as required. - 2 deep spray nasal saline opened and not labeled with a date as required. - 1 bottle of tums opened and not labeled with a date as required. - 1 small package of ritz bit crackers. During an interview completed on 4/14/26, at 11:04 a.m. LPN Employee E10 confirmed the above observations and stated, the normal saline should be good for 24 hours after opening and the crackers are given to residents during the medication pass and that the facility failed to properly store medications. During an observation completed on 4/14/26, at 11:09 a.m. the East Medication Room contained the following: 1 bottle tube green pain relief gel opened and not labeled with a date as required. 1 clear glass vase in the top cupboard next to refrigerator. 1 ceramic snowman sitting on top on top of refrigerator. 1 hat decorated for Christmas. 1 Christmas stocking. A radio 2 black coffee cups The medication room refrigerator contained: 1 vial Tubersol opened and not labeled with a date as required. 1 bottle of liquid gabapentin opened and not labeled with a date as required. During an interview completed 4/14/26, at 11:17 a.m. LPN Employee E1 confirmed the above observations and that the facility failed to properly store medications. During an observation on 4/15/26, at 8:16 a.m. the East Hall Medication Cart was at the nurse's station unlocked and unattended. During an interview on 4/15/26, at 8:18 a.m. LPN Employee E1 confirmed the above observation and that the facility failed to properly secure a medication cart while not in use. 28 Pa. Code: 201(a) Responsibility of licensee. 28 Pa. Code: 211.9(a)(1) Pharmacy services. 28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a diagnosis for hospice services for one of four residents (Resident R60) and failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for three of four residents (Residents R9, R60, and R61). Finding include: Review of facility policy Hospice Program dated 1/15/26, indicated in general, it is the responsibility of the facility to meet the resident's personal and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. This includes communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including diagnosis. Review of the clinical record revealed Resident R9 was admitted to the facility on [DATE]. Review of Resident R9 MDS (minimum data set - a periodic assessment of resident needs) dated 2/24/26, indicated diagnosis of non-traumatic brain dysfunction (neurological consequences of an inquired brain injury of traumatic or non-traumatic origin) and Alzheimer's disease (brain condition that slowly damages your memory, thinking, learning and organizing skills). Review of Section O, Question O0110K1 indicated the resident received hospice care while in the facility. Review of Resident R9 physician orders indicated diagnosis of senile degeneration of brain. Review of Resident R9 comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 4/16/26, at 2:42 p.m. the Director of Nursing (DON) confirmed that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for Resident R9. Review of the clinical record revealed Resident R60 was admitted to the facility on [DATE]. Review of Resident R60's MDS dated [DATE], indicated diagnoses of lung cancer, respiratory failure, and high blood pressure. Review of Section O, Question O0110K1 indicated the resident received hospice care while in the facility. Review of a physician order dated 2/4/26, indicated to admit to hospice. Physician order failed to include diagnosis for providing hospice services Review of Resident R60's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include diagnosis for providing services, contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 4/16/26, at 2:15 p.m. Licensed Practice Nurse Assessment Coordinator (LPNAC) Employee E3 confirmed that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for Resident R60. Review of the clinical record revealed Resident R61 was admitted to the facility on [DATE]. Review of Resident R61's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and anxiety. Review of Section O, Question O0110K1 indicated the resident received hospice care while in the facility. Review of a physician order dated 1/28/26, indicated to admit resident to hospice services with a diagnosis of heart failure. Review of Resident R61's current comprehensive care plan failed to indicate a plan of care by the facility that displayed the coordination of hospice services by failing to include contact information for the hospice agency and how to access the hospice's 24 hour on-call system. During an interview on 4/16/26, at 2:35 p.m. LPNAC Employee E3 confirmed that the facility failed to ensure the coordination of hospice services with facility services to meet the needs of each resident for end-of-life care for Resident R61. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(3)(5) Nursing services.

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that a COVID-19 vaccination was offered to five of five residents (Residents R6, R8, R34, R37, and R65).Findings include: Review of facility policy SARS-CoV-2 Management dated 1/15/26, indicated the facility will encourage everyone to remain up to date with all recommended COVID-19 vaccine doses. Review of the Centers for Disease Control (CDC) document Staying Up to Date with COVID-19 Vaccines dated 11/19/25, indicated the CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2025-2026 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Review of the clinical record revealed Resident R6 was admitted to the facility on [DATE]. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/31/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and anxiety. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R6's clinical record indicated the resident was last offered and refused a COVID-19 vaccination on 11/6/23. Review of Resident R6's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined since 11/6/23. Review of the clinical record revealed Resident R8 was admitted to the facility on [DATE]. Review of Resident R8's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms). Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R8's clinical record indicated the resident was last offered and refused a COVID-19 vaccination on 11/16/23. Review of Resident R8's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined since 11/16/23. Review of the clinical record revealed Resident R34 was admitted to the facility on [DATE]. Review of Resident R34's MDS dated [DATE], indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R34's clinical record indicated the resident last received a COVID-19 vaccination on 8/13/22. Review of Resident R34's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined since 8/13/22. Review of the clinical record indicated Resident R37 was admitted to the facility on [DATE]. Review of Resident R37's MDS dated [DATE], indicated diagnoses of high blood pressure, hyperlipidemia, and shortness of breath. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R37's clinical record indicated the resident was last offered and refused a COVID-19 vaccination on 11/6/23. Review of Resident R37's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined since 11/6/23. Review of the clinical record indicated Resident R65 was admitted to the facility on [DATE]. Review of Resident R65's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and depression. Question O0350 was coded no for Resident's COVID-19 vaccination is up to date. Review of Resident R65's clinical record indicated the resident last received a COVID-19 vaccination on 11/16/23. Review of Resident R65's clinical record failed to include documentation that the COVID-19 vaccination was offered and administered or declined since 11/16/23. During an interview on 4/15/26, at 2:40 p.m. Infection Preventionist Employee E2 confirmed that the facility failed to make certain that a COVID-19 vaccination was offered to five of five residents (Residents R6, R8, R34, R37, and R65). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.5(f) Medical records.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Effective Communication for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Effective Communication from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Effective Communication for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Resident Rights for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Resident Rights from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Resident Rights from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Resident Rights from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Resident Rights from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Resident Rights from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Resident Rights for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Abuse, Neglect, and Exploitation from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Abuse, Neglect, and Exploitation for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on QAPI from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on QAPI from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on QAPI from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on QAPI from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on QAPI from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on QAPI for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Infection Control for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Infection Control from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Infection Control from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Infection Control from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Infection Control from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Infection Control from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Infection Control for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Compliance and Ethics for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Compliance and Ethics from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Compliance and Ethics for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8) and failed to ensure that three of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E4, NA Employee E5, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Annual in-services are no less than 12 hours per employment year. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention from 1/1/25 through 12/31/25. Review of facility nurse aide training records did not include credible documentation that NA Employee E4 received 12 hours of in-service training from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention from 1/1/25 through 12/31/25. Review of facility nurse aide training records did not include credible documentation that NA Employee E5 received 12 hours of in-service training from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Dementia Management and Resident Abuse Prevention from 1/1/25 through 12/31/25. Review of facility nurse aide training records did not include credible documentation that NA Employee E8 received 12 hours of in-service training from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Dementia Management and Resident Abuse Prevention for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8) and failed to ensure that three of three sampled Nurse Aides received a minimum of 12 hours of in-service education per year (NA Employee E4, NA Employee E5, and NA Employee E8) 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, facility in-service documentation, personnel files, and staff interviews, it was determined that the facility failed to provide training on Behavioral Health for five of five staff members (Nurse Aide (NA) Employee E4, NA Employee E5, Registered Nurse (RN) Employee E6, Licensed Practical Nurse (LPN) Employee E7, and NA Employee E8).Findings include: Review of facility policy In-Service Training Program, Nurse Aide dated 1/15/26, indicated all nurse aide personnel participate in regularly scheduled in-service training classes. Insofar as practical, notice of in-service training classes, their time, place, date, etc., are posted on the employee bulletin board at least seven (7) days prior to the scheduled class. All training classes attended by the employee are entered on the respective employee's Record of In-Service by the department supervisor or other person(s) as designated by the supervisor. Review of NA Employee E4's personnel file indicated a date of hire on 3/20/24. Review of NA Employee E4's personnel file did not include credible annual in-service training on Behavioral Health from 1/1/25 through 12/31/25. Review of NA Employee E5's personnel file indicated a date of hire on 10/22/19. Review of NA Employee E5's personnel file did not include credible annual in-service training on Behavioral Health from 1/1/25 through 12/31/25. Review of RN Employee E6's personnel file indicated a date of hire on 5/30/19. Review of RN Employee E6's personnel file did not include credible annual in-service training on Behavioral Health from 1/1/25 through 12/31/25. Review of LPN Employee E7's personnel file indicated a date of hire on 10/19/15. Review of LPN Employee E7's personnel file did not include credible annual in-service training on Behavioral Health from 1/1/25 through 12/31/25. Review of NA Employee E8's personnel file indicated a date of hire on 3/9/81. Review of NA Employee E8's personnel file did not include credible annual in-service training on Behavioral Health from 1/1/25 through 12/31/25. During an interview on 4/16/26, at 2:15 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on Behavioral Health for five of five staff members (NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.20(a)(d) Staff development.

Based on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to provide medications as ordered by the physician and ensure the physician was appropriately notified of missed medication doses for one of three residents reviewed (Resident R21).Findings include: Review of the facility Medication Ordering and Receiving Pharmacy last reviewed 1/15/26, indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medications are met by using the facility's approved emergency supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances and products for infusion in limited quantities in sealed containers or automatic dispensing system (ADS). The ordered medication is obtained either from the emergency box or ADS, from the provider pharmacy or a back up pharmacy that is determined by the provider pharmacy. Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE], with the diagnosis of aftercare following joint repair surgery of left knee, hypertension (high blood pressure) and breast cancer. Review of Resident R21's nursing admission/readmission evaluation indicated admission to the facility on 4/2/26, at 4:54 p.m. Review of Resident R21's physician orders indicated:Cefadroxil Oral Capsule (used to treat bacterial infections by preventing bacteria from forming - preventing infection) 500 milligrams (MG) Give 1 capsule by mouth two times a day for status post-surgery related to aftercare following joint replacement surgery for seven days start date 4/2/26, at 9:00 p.m.Celecoxib Oral Capsule (anti-inflammatory) 200 MG Give 1 capsule by mouth two times a day for status post-surgery for 30 Days start date 4/2/26, at 9:00 p.m.Hydrochlorothiazide Oral Tablet (treats high blood pressure) 25 MG Give 1 tablet by mouth at bedtime for hypertension start date 4/2/26, at 9:00 p.m.Lysine Oral Tablet (wound healing) 500 MG give 1 tablet by mouth one time a day for nutrient deficiency start date 4/3/26 at 8:00 a.m. Review of Resident R21's April 2026, Medication Administration Record (MAR) revealed the following: Cefadroxil oral capsule scheduled 4/2/26, at 9:00 p.m. coded as 9 = other/see nursing notes Celecoxib oral capsule scheduled 4/2/26, at 9:00 p.m. coded as 9 = other/see nursing notes Hydrochlorothiazide oral tablet scheduled 4/2/26, at 9:00 pm coded as 9 = other/see nursing notes Lysine oral tablet scheduled for 4/3/26, at 8:00 a.m. and 4/5/26, at 8:00 a.m. coded as 9 = other/see nursing notes Review of Resident R21's order administration note dated 4/2/26, 4/3/26, and 4/5/26, indicated unavailable, awaiting from pharmacy. The nursing notes failed to ensure the physician was appropriately notified of the missed medication doses for Resident R21. During an interview completed on 4/16/26, at 12:10 p.m. upon reviewing Resident R21's MARS's, Licensed Practical Nurse (LPN) Employee E7 stated sometimes we will pull what we can from the emergency medication box and confirmed that the facility failed to provide medications as ordered by the physician and ensure the physician was appropriately notified of missed medication doses for one of three residents reviewed (Resident R21). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on a review of the Resident Assessment Instrument (RAI) User's Manual, clinical record review, and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of five residents (Residents R5).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 2025, indicated the following instructions:O0110K1, Hospice care: code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of Resident R5's MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and history of falling. Section O0110K1 (Hospice care) was coded yes, indicating that the resident received hospice care during the 14-day assessment period. Review of Resident R5's clinical record failed to reveal documentation that the resident was admitted to hospice services during the MDS dated [DATE], 14-day assessment period. During an interview on 4/16/26, at 2:35 p.m. Licensed Practical Nurse Assessment Coordinator Employee E3 confirmed Resident R5 was incorrectly coded as receiving hospice services on the MDS dated [DATE], and that the facility failed to ensure Resident R5's MDS assessment accurately reflected the resident's status. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 211.5(f) Medical records.

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of three residents (Residents R47).Findings include: Review of facility policy Care Plans, Comprehensive Person-Centered last reviewed 1/15/26, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident R47's clinical record indicated an admission date of 6/15/24. Review of R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/10/26, indicated the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Review of Resident R47's physician order dated 12/24/25, indicated Azithromycin Oral Tablet 250 milligram. Give 1 tablet by mouth one time a day every Monday, Wednesday and Friday for Prophylaxis (preventative medical measure). Review of Resident R47's current care plan failed to include a focus, goal, or interventions for the Azithromycin oral tablets. During an interview completed on 4/15/26, at 1:20 p.m. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) Employee E2 confirmed the care plan failed to include a focus, goal or intervention for the Azithromycin tablets and that the facility failed to ensure that a resident's care plan was updated and revised to reflect the resident's specific care needs for one of three residents (Residents R47). 28 Pa. Code 201.24(e)(1)(5) Admissions Policy28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of clinical records and staff interviews, it was determined that the facility failed to obtain physician orders for management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for one of two residents (Resident R64) and failed to procure complete physician's orders for one of two residents (Resident R47).Findings include: Review of the facility policy Nursing Care of the Resident with Diabetes Mellitus last reviewed 1/15/26, indicated the purpose of this guideline is to help the resident control his/her diabetes with diet, exercise and insulin as ordered, Prevent recurrent hyperglycemia (blood sugar above target levels) and hypoglycemia (blood sugar below target levels). Review of the facility policy Antibiotic Stewardship last reviewed 1/15/26, indicated antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including but not inclusive to the following elements:Drug nameDrug doseFrequency of administrationDuration of treatmentIndications for use. Review of the clinical record indicated Resident R64 was admitted to the facility on [DATE]. Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/2/26, indicated diagnoses of high blood pressure, diabetes (high sugar in the blood) and heart failure (heart doesn't pump the way it should). Review of Resident R64's physician orders dated 12/24/25, indicated Basaglar (long acting) insulin 20 units subcutaneously one time a day related to type two diabetes. Review of Resident R64's physician orders dated 3/19/26, indicated blood glucose monitoring in the morning for diabetes. The physician order failed to contain parameters for when to contact the physician regarding hypoglycemia or hyperglycemia. During an interview completed on 4/16/25, at 2:10 p.m. Licensed Practical Nurse (LPN) Employee E7 confirmed that the physician order failed to contain parameters for when to contact the physician and stated, I'm not sure why it doesn't have any and confirmed that the facility failed to obtain physician orders for management of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for one of two residents (Resident R64). Review of Resident R47's clinical record indicated an admission date of 6/15/24. Review of R47's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/10/26, indicated the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- restricts breathing), and hyperlipidemia (high fats in the blood). Review of Resident R47's physician order dated 12/24/25, indicated Azithromycin Oral Tablet 250 milligram. Give 1 tablet by mouth one time a day every Monday, Wednesday and Friday for Prophylaxis (preventative medical measure). The order failed to include a diagnosis for the medication. During an interview completed on 4/15/26, at 1:20 p.m. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) Employee E2 confirmed the orders failed to include a diagnosis and that the facility failed to procure complete physician's orders for one of two residents (Resident R47). 28 Pa. Code 211.10(a)(c) Resident policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of five residents (Residents R3 and R7).Findings include: Review of facility policy Proper use of Bed Rails dated 1/15/26, indicated the resident assessment must assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail. Review of the clinical record revealed Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/25/26, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fats in the blood), and muscle weakness. Review of Resident R3's comprehensive care plan revealed the resident has an ADL (activities of daily living) self-care deficit related to weakness/deconditioning, right below the knee amputation. Interventions include bilateral (both sides) enabler bars to assist with mobility. Review of Resident R3's clinical record revealed the last Enabler/Assist Rail/Device Evaluation - V2 assessment was completed 4/11/25. During an observation on 4/13/26, at 10:05 a.m. bilateral enabler bars were observed on top of Resident R3's bed. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of Resident R7's MDS dated [DATE], indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and Cerebrovascular Accident (CVA - a stroke, blood flow to the brain is interrupted). Review of a physician order dated 10/20/25, indicated left enabler bar to assist in mobility and positioning. Review of Resident R7's comprehensive care plan revealed the resident has an ADL self-care deficit related to CVA with left sided paralysis. Interventions include left enabler/helpers rail. Review of Resident R7's clinical record revealed the last Enabler/Assist Rail/Device Evaluation - V2 assessment was completed 4/11/25.During an observation on 4/13/26, at 10:14 a.m. an enabler bar was observed on the left top of Resident R7's bed.During an interview on 4/17/26, at 10:25 a.m. the Assistant Director of Nursing (ADON) Employee E2 stated, Enabler bar assessments should be done quarterly. During an interview on 4/17/26, at 10:25 a.m. ADON Employee E2 confirmed that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of five residents (Residents R3 and R7). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide goods and services resulting in neglect that resulted in the actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy, Identifying Types of Abuse dated 2/20/25, indicated that residents have the right to be free of neglect. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of Libre Texts Medicine procedure 12.8.5: Procedure- Turning and Positioning the Patient in Bed, indicated to position yourself on the side of the bed that the patient will be turned to. Review of admission record indicated Resident R1 was admitted to the facility 10/31/18, with most recent re-admission on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/4/25, indicated the diagnoses of hypertension (the force of the blood against the artery walls is too high), heart failure (heart doesn't pump blood as well as it should), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section G0110 indicated extensive assist of two for bed mobility. Review of Resident R1's physician order on 5/18/25, indicated fall mats at bedside. Review of Resident R1's care plan on 5/18/25, indicated to minimize risk for injury related to falls, place fall mats bilaterally (both sides). Review of facility provided document dated 5/18/25, indicated while Resident R1 was being changed by Nurse Aide (NA) Employee E1, resident fell from the bed and landed on the left hip on the floor. Care plan was not followed as fall mats were not at the bedside as ordered. Bed was approximately two and a half feet up in the air due to care being provided. The fall resulted in a left hip fracture. Review of Resident R1's X-ray results dated 5/18/25, indicated angulated (a type of displaced fracture where the bone fragments are tilted or angled to each other) left hip fracture. Review of Registered Nurse (RN) Employee E2's witness statement dated 5/18/25, indicated NA Employee E1 called nurse into Resident R1's room and indicated resident was on the floor. NA Employee E1 stated that while changing Resident R1, resident rolled out of bed and resident complained of pain to the left hip. Foot rotated outward. Physician notified and ordered resident to go to the emergency department. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 instructed not to leave resident's side. Review of RN Employee E3's witness statement dated 5/18/25, indicated NA Employee E1 said as NA was providing care, NA turned around to grab the brief and Resident R1 rolled out of bed on the right side and onto her left hip. Upon entering the room Resident R1 was in a ball with her head near the dresser lying on her left hip. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 was instructed not to leave resident's side. Review of NA Employee E1's witness statement unsigned, and undated, indicated when NA arrived to Resident R1's room, resident was shifted sideways and sheets askew as Resident R1 is often sideways. Working on resident's left side (the word right was crossed out in error) first, NA repositioned resident straight and started to re-tuck the draw sheet, got over towards resident's right where resident was a bit higher. NA turned to grab the brief behind them to place on resident and resident moved her hips, shifting resident's knees over the bed enough to cause resident to flip in the air and land on opposite side of left hip. The bed was up over two and a half feet. NA led the turn with the left and couldn't stop resident as NA was trying to get brief. Interview on 6/5/25, at 1:49 p.m. NA Employee E4 indicated You roll a resident towards you in bed. Interview on 6/5/25, at 1:52 p.m. Licensed Practical Nurse (LPN) Employee E5 who was working as a NA, indicated We always roll a resident towards us, so they don't roll off the bed. Interview on 6/5/25, at 1:56 p.m. NA Employee E6 indicated Always roll towards you. Interview on 6/5/25, at 2:15 p.m. NA Employee E7 indicated If I'm by myself, I roll towards me. Interview on 6/5/25, at 2:20 p.m. the Director of Nursing indicated I came in and had NA Employee E1 re-enact what had happened to Resident R1. NA Employee E1 is six feet two inches, and there is no way the event occurred as stated by NA, because NA would have been standing where Resident R1 was found on the floor on the left hip. Further interview on 6/5/25, at 2:20 p.m. the Director of Nursing confirmed that NA Employee E1 was neglectful in following the care plan for floor mats and assist of two staff was not followed. Interview on 6/5/25, at 2:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide goods and services resulting in neglect that resulted in the actual harm of an angulated left hip fracture for one of five residents (Resident R1). 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services.

Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 2/20/25, indicated all accidents occurring on our premises must be investigated and reported to the administrator. Review of facility policy Activities of Daily Living dated 2/20/25, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). Review of admission record indicated Resident R1 was admitted to the facility 10/31/18, with most recent re-admission on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/4/25, indicated the diagnoses of hypertension (the force of the blood against the artery walls is too high), heart failure (heart doesn't pump blood as well as it should), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section G0110 indicated extensive assist of two for bed mobility. Review of Resident R1's physician order on 5/18/25, indicated fall mats at bedside and failed to have an order for bed mobility assistance required. Review of Resident R1's care plan on 5/18/25, indicated to minimize risk for injury related to falls, place fall mats bilaterally (both sides). The care plan failed to indicate extensive assistance for bed mobility. Review of facility provided document dated 5/18/25, indicated while Resident R1 was being changed by Nurse Aide (NA) Employee E1, resident fell from the bed and landed on her left hip on the floor. Care plan was not followed as fall mats were not at the bedside as ordered. Bed was approximately two and a half feet up in the air due to care being provided. The fall resulted in a left hip fracture. Review of Registered Nurse (RN) Employee E2's witness statement dated 5/18/25, indicated NA Employee E1 called nurse into Resident R1's room and indicated resident was on the floor. NA Employee E1 stated that while changing Resident R1, resident rolled out of bed and resident complained of pain to the left hip. Foot rotated outward. Physician notified and ordered resident to go to the emergency department. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 instructed not to leave resident's side. Review of RN Employee E3's witness statement dated 5/18/25, indicated NA Employee E1 said as NA was providing care, NA turned around to grab the brief and Resident R1 rolled out of bed on the right side and onto her left hip. Upon entering the room Resident R1 was in a ball with her head near the dresser lying on her left hip. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 was instructed not to leave resident's side. Review of NA Employee E1's witness statement unsigned, and undated, indicated when NA arrived to Resident R1's room, resident was shifted sideways and sheets askew as Resident R1 is often sideways. Working on resident's left side (the word right was crossed out in error) first, NA repositioned resident straight and started to re-tuck the draw sheet, got over towards resident's right where resident was a bit higher. NA turned to grab the brief behind them to place on resident and resident moved her hips, shifting resident's knees over the bed enough to cause resident to flip in the air and land on opposite side of left hip. The bed was up over two and a half feet. NA led the turn with the left and couldn't stop resident as NA was trying to get brief. Interview on 6/5/25, at 2:20 p.m. the Director of Nursing indicated I came in and had NA Employee E1 re-enact what had happened to Resident R1. NA Employee E1 is six feet two inches, and there is no way the event occurred as stated by NA, because NA would have been standing where Resident R1 was found on the floor on the left hip. Further interview on 6/5/25, at 2:20 p.m. the Director of Nursing confirmed that NA Employee E1 failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a left hip fracture for one of five residents (Resident R1). 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services.

Based on review of policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to follow its abuse policy regarding the immediate suspension of an involved staff member from their duty pending a full investigation, putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical safety. Findings include:A review of the personnel file for Registered Nurse 6 revealed that she was hired as the facility's Assistant Director of Nursing (ADON) on [DATE], and worked in that position until she quit on February 28, 2022.The facility's policy regarding abuse, dated [DATE], indicated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown sources would be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. The Nursing Home Administrator would suspend immediately any employee who had been accused of resident abuse, pending the outcome of the investigation.The facility's investigation of the ADON, dated [DATE], revealed that on [DATE], at 11:00 a.m. Certified Occupational Therapy Assistant 1 retrieved wash cloths and was entering Resident 1's room. At this time, the ADON requested that Resident 1 be left alone. Certified Occupational Therapy Assistant 1 voiced that she just wanted to wash her face and reposition her, as she was lying supine, drool was on her face, and she only had one sock on. The ADON insisted again that Resident 1 was not to be touched and that she was just repositioned and her justification for the request was that Resident 1 was in pain and she did not have ordered pain medication to administer before repositioning. Certified Occupational Therapy Assistant 1 continued to wash Resident 1's face, raise the head of her bed, reposition her shoulders and hips, and remove the one sock remaining on her, and elevated her heels on a pillow. During the process, Certified Occupational Therapy Assistant 1 noted that the ADON was having a conversation with the nurse aides in the hallway complaining that Certified Occupational Therapy Assistant 1 did not listen to her requests.On [DATE], at 1:00 p.m. the verbal order was received for Roxanol and it was administered to Resident 1 as ordered. Resident 1's time of death was 1:19 p.m. Shortly before 1:19 p.m. Registered Nurse Assessment Coordinator (RNAC) 2 talked with Certified Occupational Therapy Assistant 1 and discussed her interaction with the ADON. At this time RNAC 2 went to the Director of Nursing's office and asked what happened to Resident 1 and specifically asked, Did the ADON order morphine on Resident 1?.At approximatley 2:00 p.m. RNAC 2 returned to her office and was visibly angry and stated, Resident 1 is dead!. The Director of Rehabilitation entered the room and began rehashing the interaction that Certified Occupational Therapy Assistant 1 had with the ADON earlier in the day and at this time the intercom button was inadvertently turned on.At this time the facility was now listening to the conversation that was being held in the RNAC's office between the two RNAC's (RNAC 3 and RNAC 4) and the facility's Registered Dietician. The ADON, as well as two other nurses on the floor, submitted statements that report during the conversation that was being broadcast, the two nurses were referred to as bitches as well as multiple other profanities when referring to the nurses and aides in general, as well as specifically stating that the ADON was killing people. They reported hearing shouldn't they be able to see the pattern? and maybe the ADON thinks she is an Angel of Mercy.At approximately 3:00 p.m. the Nursing Home Administrator received a call from the Director of Nursing regarding the incident where a private conversation was inadvertently broadcast over the phone intercom system where a group of department managers were having a discussion about the ADON. During the overhead call, it was overheard that individuals stated the ADON was an Angel of Mercy and was killing people. At 3:30 p.m. the ADON was walking out because of the embarrassment of the event. The Director of Nursing was able to calm her down and get a statement in regards to the timeline of Resident 1.On [DATE], at 11:30 a.m. the Nursing Home Administrator and Director of Nursing interviewed RNAC 2 and she felt that a formal investigation should be initiated based on a funny feeling she was having and has been having for quite some time that something was fishy. When asked if she understood that she was alleging the ADON was murdering our patients and the seriousness of that allegation, she said that she understood and something was just fishy. At 12:30 p.m. on [DATE], the ADON was suspended.An employee statement from RNAC 2 regarding the ADON, dated [DATE], revealed that she felt there was something fishy and it was not sitting right in her gut, and that there should be an internal investigation. RNAC 2 stated that something just did not sit right in her gut and it seemed fishy that people died under the ADON's care.A punch detail, dated [DATE], revealed that the ADON punched in on [DATE]. There was no documented evidence that the ADON was immediately removed from duty following RNAC 2's allegation.Interview with Clinical Consultant 5 on [DATE], at 8:30 am. revealed that he was the Nursing Home Administrator when the conversation inadvertently got played over the loud speaker when the phone button for page was accidentally pressed and the entire facility heard that they believed the ADON was killing residents. He confirmed that the ADON worked a full day on [DATE], and worked a half a day on [DATE].On [DATE], at 12:45 p.m. the Clinical Consultant was given the Immediate Jeopardy template and informed that the health and safety of all residents was placed in Immediate Jeopardy as past non-compliance due to the failure to immediately suspend the ADON after hearing allegations from other staff members that the employee was an Angel of Mercy and was killing people.The Immediate Jeopardy was lifted on [DATE], at 6:55 p.m. when it was confirmed that the corrective action plans developed on [DATE], were completed by [DATE], and that the ADON was suspended on [DATE].Following the incident on [DATE], the facility's corrective actions included:An audit was completed on all current residents to identify any abuse or neglect.Staff who heard the conversation over the loud speaker were were interviewed.The ADON was suspended on [DATE], at 12:30 p.m.The reportable event was reported to the Department of Health on [DATE].Lookback audits on residents that ceased to breath in the facility over the last 30 days was completed on [DATE].Education was provided to nursing staff on investigating abuse, reporting any allegation of abuse within time frames as required by state and federal requirements and being mandatory reporters. Education on abuse, neglect, and reporting was completed on [DATE]. Any perpetrator was to be immediately suspended when accused of abuse, pending the outcome of the investigation.The facility continues to educate on abuse/neglect upon hire, annually, and as necessary.28 Pa. Code 201.14(c) Responsibility of licensee.28 Pa. Code 201.18(e)(1) Management.28 Pa. Code 211.12(d)(5) Nursing services.

Based on resident interviews, review of clinical records, review of facility policies and facility provided documentation, and interviews with staff, it was determined that the facility failed to protect residents from staff initiated sexual abuse. This failure resulted in actual psychosocial harm to three residents for three of four residents reviewed (Resident R1, R2, and R3). Findings include: A review of facility Abuse Policy, dated 1/11/21, updated 9/8/21, indicated that residents have the right to be free from abuse. The policy further defined sexual abuse as non-consensual sexual harassment, sexual coercion, contact or sexual assault, and includes sexual contact of any type with a resident. A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment A review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE]. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 7/14/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 15, cognitively intact. A review of documentation submitted by the facility on 10/3/21, at 8:00 p.m. revealed that on 10/3/21, at 2:00 p.m. Resident R1 told her daughter (Resident Family RF5) that one of the male nurses made her feel uncomfortable. During a staff interview on 10/3/21, conducted by the Director of Nursing, Resident R1 stated that on the night of 9/30/21-10/1/21, RN Employee E1 had come in to assist her with toileting and was inappropriate during care. A review of facility provided investigation documentation revealed the following description provided in a signed statement by Resident R1, dated 10/3/21: on Thursday night September 30, 2021 that RN Employee E1 assisted her with using the bed pan. After assisting her with the bed pan, Resident R1 reported that RN Employee E1 tickled her, fondled her breasts, and then bent over and kissed her on the lips. A review of a psychological visit documentation on 10/4/21, Resident R1 endorsed a sleep difficulty and feeling frustrated. Visit notes indicated Resident R1 stated I'm confused, unnerved. He would tickle us after care He kissed me on the lips and touched my nipple. Provider comments indicated that Resident R1 is concerned what he (RN Employee E1) is doing to others. New orders were provided to increase Resident R1's [MEDICATION(S)] (an antidepressant medication medication used to treat depression, anxiety, and inability to sleep) from 50mg to 100 mg at bed time. A review of a progress note dated 10/4/21, at 2:04 p.m. indicated the [MEDICATION(S)] increase was due to anxiety. A review of a progress note dated 10/4/21, at 3:54 p.m. indicated Resident R1 stated she is a little shaken by the events that occurred over the weekend. A review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE]. A review of Resident R2's MDS dated [DATE], indicated that the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of documentation submitted by the facility on 10/3/21, revealed that on 10/3/21, Resident R2 told her roommate's daughter (RF5) that one of the male nurses made her feel uncomfortable. During a staff interview on 10/3/21, conducted by the Director of Nursing, Resident R2 stated that on the night of 9/30/21-10/1/21, RN Employee E1 had come in to assist her with toileting and was inappropriate during care. A review of facility provided investigation documentation revealed the following description provided in a signed statement by Resident R2, dated 10/3/21: RN Employee E1 came into my room sometime last week at night to change my brief, he put cream up my vagina and made me feel uncomfortable. When he was done helping me, he tickled me and then fondled my breast. I told him to stop, and he kissed me on the mouth. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a psychological visit on 10/4/21, Resident R2 endorsed a depressed mood, helplessness, and nervousness and Resident R2 was observed to be tearful. Visit notes indicated Resident R2 stated I was too scared to tell anybody it happened. He was touching me, tried to kiss me; I'm not sleeping well He felt me up and He tickled me. Provider comments indicated that Resident R2 is voicing depression and anxiety regarding the alleged inappropriate behaviors. New orders were placed to start [MEDICATION(S)] 50 mg at bedtime, and to increase Resident R2's [MEDICATION(S)] (an antidepressant and antianxiety medication medication used to treat depression and anxiety) from 30 mg to 60 mg every morning. A review of a progress note dated 10/4/21, at 1:38 p.m. indicated that the increased [MEDICATION(S)] and new order of [MEDICATION(S)] were due to anxiety and inability to sleep. A review of progress note dated 10/5/21, at 4:05 p.m. and 10/6/21, at 4:07 p.m. indicated that Resident R2 is upset still. A review of facility investigation documentation indicated: On 10/3/21: -RN Employee E1 was suspended pending investigation. -Resident R1 and R2's family and resident representatives notified. -Resident R1 and R2's physicians notified. -Notification to local police. -Area Agency on Aging notified. -Reports submitted to the Pennsylvania Department of Health. -Education begun by facility to all staff on abuse and mandated reporting. On 10/4/21: -Interview conducted with RN Employee E1. -Other staff members interviewed. -Pennsylvania State Board of Nursing notified. -Resident R1 and R2 assessed by clinical psychologist. A review of the facility investigation documentation dated 10/5/21, indicated that RN Employee E1 admitted that he did complete the acts upon which he was accused to detectives. to the local police detective. A review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE]. A review of the MDS dated [DATE], indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R3's score to be 15, cognitively intact. During an interview on 10/7/21, at 12:30 p.m. Resident R3 stated that RN Employee E1 had made her feel uncomfortable during her admission. Resident R3 stated that RN Employee E1 and Nurse Aide Employee E2 had admitted her on 9/2/21. Resident R3 stated that during the admission assessment, she had all of her clothes removed with no attempt at providing modesty. Resident R3 stated that RN Employee E1 told her she had a nice bum. Resident R3 further stated to the surveyor, that it was all I could do to tell you. A review of documentation submitted by the facility on 10/7/21, Resident R3 confirmed these concerns with the Nursing Home Administrator (NHA), and that the instance brought up remembrances of having been raped earlier in life. A review of a progress note dated 10/8/21, at 1:21 a.m. indicated that Resident R3 was in bed by 7:00 p.m., asked resident if she was feeling okay because she is never in bed that soon. Resident stated, It was a very rough day today. During an interview with on 10/7/21, at 11:00 p.m. Licensed Practical Nurse (LPN) Employee E2 was called away to assist Resident R3, who was complaining of difficulty breathing. When the interview resumed at 11:08 p.m., LPN Employee E2 stated that Resident R3 was having an anxiety attack, and stated that was not normal for Resident R3. A review of facility provided investigation documentation 10/8/21, revealed the following findings: Resident R3's experience upon admission, combined with a recent substantiated allegation of sexual abuse that occurred in the facility and was on the television via the local media made Resident R3 relive a traumatic experience. It was unknown at the time of admission about her history and the alleged perpetrator and witness, NA Employee E2 did not adequately explain the process while performing the act. Mental abuse was substantiated as RN Employee E1 did say, nice bum while performing the admission assessment. During an interview on 10/8/21, at 2:20 p.m. the Nursing Home Administrator confirmed that the facility failed to protect residents from staff initiated sexual abuse resulting in psychosocial harm for residents R1, R2, and R3. 28 Pa. Code 201.18(e)(1) Management Previously cited: 4/16/21, 9/1/21 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 211.12(a)(c) Nursing services

Based on facility policy, clinical records and staff interviews, the facility failed to notify physicians of elevated Capillary Blood Glucose (CBG) levels, failed to assess residents for [CONDITION(S)] (high blood glucose) and failed to educate staff on facility policies related to [CONDITION(S)] for six of 12 Residents (Residents R1, R2, R4, R7, R8, and R9), resulting in immediate jeopardy and harm which resulted in a resident being found unresponsive and not breathing, Cardiopulmonary Resuscitation (CPR) being initiated by staff, resident being transported to the emergency department by emergency medical services and death occurring to one of six residents (Resident R1). Findings include: The Centers for Disease Control defines diabetes as: Diabetes is a chronic (long-[MEDICATION(S)]) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin (injectable medication used to lower blood sugar). Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body. Review of the facility policy Nursing care of the resident with diabetes mellitus dated [DATE], indicates that for Glucose Monitoring 1. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. 5(b) Normal refernce ranges are defined as ,d+[DATE] mg/dl before meals and <180 mg/dL after meals. Review of the facility policy Guidelines for notifying Physicians of Clinical Problems dated [DATE], indicates that the guidelines are intended to help ensure medical care problems are communicated to the medical staff, efficient and effective manner and that all significant changes in resident/ patient status are assessed and documented in the medical record including symptoms a. Sudden in onset OR a marked change AND are Unrelieved by measures which have already been prescribed and/or attempted. Additionally, the facility policy appendix B Guidelines for Reporting Abnormal Test Results to Physicians includes: glucose: >300 in diabetic with signs/symptoms and >430 or high on glucose monitor in anyone. Review of the facility policy Change in a Resident's Condition or Status, dated [DATE], states our facility shall promptly notify the resident, his/her attending physician, and representative of changes in the residents medical/mental condition and or status .including significant change of condition is a major decline or improvement in the residents status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical intervention (it is not self-limiting). Resident R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician orders dated [DATE], indicated that the resident's CBG (Capillary Blood Glucose- a measurement of blood glucose using a fingerstick and device) be taken before meals and at bedtime for 56 administrations (2 weeks). Resident R1 was receiving [MEDICATION(S)] (an oral medication used to reduce glucose levels) 500 mg before meals three times daily. Additionally, Resident R1 was receiving [MEDICATION(S)] (insulin) administrations every morning 30 units and 35 units at bedtime. The orders had no maximum parameters (high limit in which the physician should be contacted) for CBG ordered, to guide nursing staff in providing further care to the resident. Review of Resident R1's Medication Administration Record (MAR) dated [DATE], revealed that the resident's CBG were as follows: 11:16 a.m. CBG 178 11:16 a.m. CBG 401 6:09 p.m. CBG 432 8:06 p.m. CBG 186 Review of Resident R1's clinical progress notes dated [DATE], indicated no documentation of a resident assessment was completed until [DATE], at 12:22 a.m., no documentation of CBG discrepancy was noted for 11:16 a.m., and no documentation that the physician was notified of elevated CBGs. Review of Resident R1's MAR dated [DATE], revealed that the resident's CBG were as follows: 11:21 a.m. CBG 399 11:25 a.m. CBG 335 6:18 p.m. CBG 270 9:37 p.m. CBG 138 Review of Resident R1's clinical progress notes dated [DATE], revealed no documentation that the resident was assessed for symptoms of [CONDITION(S)] and the physician was notified of elevated CBGs. Review of Resident R1's MAR dated [DATE], revealed that the resident's CBG were as follows: 10:23 a.m. CBG 140. 10:23 a.m. CBG 119. 2:39 p.m. CBG 400. Review of Resident R1's clinical progress notes dated [DATE], at 4:38 p.m., revealed a nursing note stating, blood sugar taken 4 times and is 500. Dr. ordered an additional 7 units of his [MEDICATION(S)] (insulin) x1 dose now. Had already received his regularly scheduled dinner dose. Review of Resident R1's MAR dated [DATE], at 5:20 p.m., documentation indicates CBG was 500. No other documentation was noted to indicate an assessment was completed and the physician was not notified of the elevated CBG. Review of Resident R1's vital signs log dated [DATE], 8:56 p.m., CBG was 452. No other documentation was noted to indicate an assessment was completed and that the physician was notified of the elevated CBG. Review of Resident R1's vital signs log dated [DATE], at 12:52 a.m., revealed a blood pressure (BP),d+[DATE], pulse 70, respirations 18. No other documentation of an assessment of Resident R1was completed. No additional CBG readings were taken. Review of Resident R1's clinical record dated [DATE], at 5:33 a.m., states: CNA reported resident unresponsive and not breathing @ 04:35. Resident without pulse or respirations. Code Blue called @ 04:35. CPR initiated and continues until EMS arrived at 04:55 when they relieved the staff. CPR continued including 3 rounds of [MEDICATION(S)] (a drug used to stimulate the heart during [CONDITION(S)]). Heart beat reestablished and resident transported to ER at 05:25. Review of the Emergency Department hospital records dated [DATE], indicated Resident R1 arrived at the emergency department and was unresponsive with a blood glucose on arrival at 6:21 a.m., of 1,347 and was diagnosed with Diabetic Ketoacidosis. During a telephone interview on [DATE], at 10:59 a.m. Physician E2 stated that he usually does place upper limits on CBG's for expecting notifications, that he would reasonably expect a call for a resident with a CBG >300, and thought it was a nursing measure if no parameters were listed. He did not recall the resident as Resident R1 was only in the facility a few days and was not seen by him in person. During an interview on [DATE], at 1:51 p.m., LPN Employee E4 had no recollection of events for [DATE], after contacting the physician at 4:38 p.m. During the interview, while the resident had no upper parameter limits for CBG's, LPN Employee E4 stated that Resident R1's physician would usually expect a call regarding a CBG greater than 450. LPN Employee E4 confirmed she was unaware of the facility's policy for CBGs. Resident R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R2's physician orders dated [DATE]- [DATE], indicated resident sliding scale (insulin given according to CBG testing results) insulin as follows: CBG ,d+[DATE] 12 units of insulin and call MD (Medical Doctor). Review of Resident R2's clinical record dated [DATE], at 4:21 p. m., indicates resident's CBG was 463, no assessment was completed, and that the physician was not notified of the elevated CBG. Review of the physician orders dated [DATE]- [DATE], indicated Resident R2's orders changed as follows: CBG ,d+[DATE]= 20 units of insulin and call MD. Review of Resident R2's MAR revealed that the resident's CBGs were as follows: [DATE] at 4:55 p.m. CBG was 417. [DATE] at 8:45 a.m. CBG was 496. [DATE] at 11:34 a.m. CBG was 409. [DATE] at 5:14 p.m. CBG was 422. Review of Resident R2's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)], and the physician was not notified. Review of Resident R2's physician orders dated [DATE], indicated that orders changed as follows ,d+[DATE]= 28 units and to call MD. Review of Resident R2's MAR revealed that the resident's CBG were as follows: [DATE], 3:00 p.m. CBG was 110. [DATE], 3:36 p.m. CBG was 455. [DATE], 10:53 a.m. CBG was 402. [DATE], 4:53 p.m. CBG was 488. [DATE], 8:03 a.m. CBG was 446. [DATE], 7:41 a.m. CBG was 579. Review of Resident R2's MAR and clinical progress notes indicated for the listed dates the physician was not notified of the high blood sugar or the increase from 110 to 455 in 36 minutes During an interview on [DATE], at 2:40 p.m. with LPN Employee E5, indicated that she would have contacted the physician, but may have been too busy to document it at the time. She admitted she was unaware of the facility policy for CBGs. During an interview on [DATE], at 12:05 p.m. with ADON Employee E6, she stated the reason she did not call the physician for the high CBG was that the resident was care planned for diabetic noncompliance. Resident R4 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident R4's physician orders dated [DATE]-[DATE], indicated orders for CBG ,d+[DATE] to be given 15 units of insulin and to notify the MD. Review of Resident R4's MAR revealed that the resident's CBGs were as follows: [DATE], 4:07 p.m. CBG was 400. [DATE], 3:30 p.m. CBG was 396. [DATE], 4:37 p.m. CBG was 400. [DATE], 8:11 a.m. CBG was 377. [DATE], 5:22 p.m. CBG was 399. [DATE], 3:44 p.m. CBG was 352. [DATE], 10:33 a.m. CBG was 357. [DATE], 11:12 a.m. CBG was 362. Review of Resident R4's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)] and the physician was not notified. During an interview on [DATE], at 12:16 p.m., LPN Employee E7 stated that she usually notifies doctors but may not have documented it. She was unaware of the facility policies for CBGs. During an interview on [DATE], at 11:50 a.m., RN Employee E10 stated she would call doctor if CBG was 325 and if the resident was symptomatic and it would be a judgement call for resident blood glucose for an asymptomatic resident. She was not aware of the facility policy. During an interview on [DATE], at 12:00 p.m., RN Employee E9 stated he would call for anything (CBG of) below 60 and greater than 400. He was not aware of the facility policy. During an interview on [DATE], at 12:05 p.m., RN Employee E11 stated it depended on the resident, but if the resident was symptomatic, she would call at about (CBG of ) 350 but would call the doctor at 400 no matter what. She was not aware of the facility policy. On [DATE], the facility provided a copy of in servicing being provided to staff completed on [DATE], stating: The physician/practitioner will order the frequency of glucose monitoring. If resident is receiving Diabetic medication and physician/practitioner has not ordered glucose monitoring, you must verify that physician does not think it is necessary testing and document the clarification. The physician practitioner may alter the frequency of glucose monitoring dependent on the readings and resident symptoms. The physician/practitioner will provide parameters for administering insulin and for when notification is required. The nurse must notify the physician/practitioner according to the orders in the medical record related to elevated or low blood sugars. The nurse needs to complete and document an assessment of residents with blood glucose reading that are above or below physicians ordered parameters. Additionally, the facility placed in a schedule for audits of residents with diabetes to ensure orders were in place, that the DON/designee would reeducate licensed nurses on when to notify physician of changes in blood glucose levels, audits of physician notifications, to be completed five times a week for one week, then three times a week for three weeks.' Licensed staff present at work signed the acknowledgement and unavailable staff were notified by Telephone. Ongoing clinical record reviews from [DATE]- [DATE], revealed the following additional concerns: Review of Resident R5's clinical record revealed Resident R5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician orders dated [DATE]- [DATE], indicated CBG ' s were to be completed twice daily. No parameters for physician notification were listed on the order. Review of Resident R5's MAR revealed the following elevated CBG readings: [DATE], 8:32 p.m. CBG was 417. [DATE], 7:41 p.m. CBG was 403. Review of Resident R5's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)] and the physician was not notified. Review of Resident R7's clinical record revealed that resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders dated [DATE]-[DATE], indicated that CBGs were to be completed four times daily with physician notification for CBGs of greater than 400mg/dl. Review of Resident R7's MAR revealed that the resident's CBGs were as follows: [DATE], 11:00 a.m. CBG was 434. [DATE], 11:00 a.m. CBG was 411. [DATE], 11:00 a.m. CBG was 424. [DATE], 11:00 a.m. CBG was 424. [DATE], 4:00 p.m. CBG was 409. [DATE], 11:00 a.m. CBG was 464. [DATE], 11:00 a.m. CBG was 403. [DATE], 7:00 a.m. CBG was 441. Review of Resident R5's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)] and physician was not notified. Review of Resident R8's clinical record revealed Resident R8 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R8's physician orders dated [DATE], state sliding scale parameters of CBG 451 give 51units of insulin and call MD. [DATE], 8:00 p.m. CBG was 457. [DATE], 5:00 p.m. CBG was 482. [DATE], 8:00 p.m. CBG was 461. Review of Resident R8's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)] and the physician was not notified. Review of Resident R9's clinical record revealed Resident R9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders dated [DATE], indicated sliding scale insulin CBG 341 + to be given 6 units and notify MD. Review of Resident R9's MAR revealed that the resident's CBGs were as follows: [DATE], 4:00 p.m. CBG was 395. [DATE], 9:00 p.m. CBG was 467. [DATE], 7:00 a.m. CBG was 379. [DATE], 9:00 p.m. CBG was 439. [DATE], 9:00 p.m. CBG was 342. [DATE], 9:00 p.m. CBG was 423. Review of Resident R9's MAR and clinical progress notes indicated for the above listed dates the resident was not assessed for symptoms of [CONDITION(S)] and the physician was not notified. The NHA was made aware that Immediate Jeopardy due to the failure of the facility to monitor, evaluate and/or revise the resident's response to interventions which caused a negative outcome, or placed the residents at risk by failing to assess and document signs or symptoms of [CONDITION(S)], notify physicians of acute condition changes, follow physician orders, and educating staff on facility policies: related to [CONDITION(S)] for the residents in the facility on [DATE], at 3:07 p.m., and a corrective action plan was requested; and the IJ template was provided at that time. On [DATE], at 8:26 p.m. an acceptable Corrective Action Plan was approved which included the following interventions: Corrective Action Taken: [NAME] Health Care and Rehabilitation respectfully submit this allegation of compliance to lift the allegation of immediate jeopardy identified on [DATE]. 1. Residents identified to be affected by the alleged official practice. R1 was discharged from the facility. Unable to retroactively correct our one baseline care plan documentation of assessment, documentation of physician notification. R2 Unable to retroactively complete assessment of symptoms [CONDITION(S)] on dates identified. Director of nursing reviewed the blood glucose is [DATE], with the attending physician. RN assessment completed [DATE], no ill effects noted. R4 Unable to retroactively complete assessment of symptoms of [CONDITION(S)] on dates identified. Director of nursing reviewed the blood glucose is [DATE], with the attending physician. RN assessment completed [DATE], no ill effects noted. 2. Residents with potential to be affected by the alleged deficient practice. 72 hours look back of residents with orders for blood glucose check to ensure MD orders/parameters were followed and MD notification if warranted, completed [DATE]. Care plan audit completed of current residents with diabetes mellitus to ensure care plan in place with appropriate interventions, completed [DATE]. Audit completed of residents on diabetic medication; audit entailed if residents identified or ordered blood glucose check and parameters. Review of residents identified with MD, completed [DATE]. Audit for blood glucose check to ensure MD orders parameters were followed and MD notification if warranted will be completed every shift x two days, then five times per week for two weeks, and then monthly for three months. All audits will be reviewed as part of the monthly QAPI process. Audits for care plans for residents with diabetes mellitus to ensure care plan in place with appropriate interventions will be completed every shift X two days, then five times a week for two weeks, and then monthly for three months. All audits will be reviewed as part of the monthly QAPI process. Audits completed of residents on diabetic medications, which entails if residents identified or ordered blood glucose check and parameters will be completed every shift X two days, then five times a week for two weeks, and then monthly for three months. All audits will be reviewed as part of the monthly QAPI process. Audits completed of resident assessment if CBG is outside of physician order parameters will be completed every shift x two days, then five times a week for two weeks, and then monthly for three months. All audits will be reviewed as part of the monthly QAPI process. 3. Systemic measures The Director of nursing/designee-initiated education on [DATE], with licensed staff and MD's on blood glucose parameters which includes MD notification, assessment of a resident with [CONDITION(S)]/[CONDITION(S)], completion of care plan related to diabetes mellitus. Staff that were educated both in person and verbally over the phone, were given the following direction of information/policies: Nursing care of residence with DM, guidelines for notifying physician of clinical problems, change in a residence condition or status, acute condition changes, charting and documentation, and care plans. Including but not limited to: Following patient's physician orders as it pertains to their specific parameters. If no parameters review with the attending physician. Assessing of patients when CBG is outside the physician order parameters. Documentation of physician contact and assessing of patients will be completed in the nurse progress notes section of the electronic health record. Patient care plans will be updated appropriately per individual patient needs. Beginning [DATE], no staff will be allowed to work without this education deleted prior to the start of their shift. Any newly hired licensed staff members or newly scheduled license agency staff will be educated and oriented to the facilities guidelines as it pertains to the monitoring diabetic patients. As of [DATE], 100% of all regular staff and regular staff not scheduled have been educated. During observations, interviews, and document review the facility in serviced all staff and provided education offsite by telephone. Observations of training in house for staff members as they entered for work along with question-and-answer sessions was ongoing and review of signature sheets verified the training sessions. The Immediate Jeopardy was removed on [DATE], at 2:55 p.m. when the action plan implementation was verified. During an interview on [DATE], at 4:42 p.m., the Director of Nursing confirmed the facility failed to assess Residents R5, R7, R8, and R9 for symptoms of [CONDITION(S)] and notify the physicians as ordered. Refer to F835 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29(d) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident Care Policies Previously cited [DATE], [DATE] 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing Services Previously Cited [DATE], [DATE]

Based on observation, review of the Pennsylvania Professional Nursing Practice Act, facility policy and clinical documentation and staff interview, it was determined that the facility failed to make certain that a resident was protected from neglect by failing to provide care and services in the event of an emergency resulting in death for one of five residents reviewed (Resident CR1). Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General Functions and 21.13. Resuscitation and Respiration indicates that the Registered Nurse (RN) carries out nursing care actions which promote, maintain and restore the well being of individuals, and external cardiac resuscitation and artificial respiration shall be performed by a nurse on an individual when respiration, or pulse, or both cease unexpectedly. The facility policy entitled, Code (performance of emergency procedures in the event of cardiopulmonary arrest) Status Orders and Response, dated [DATE], indicated that when the resident has elected to receive CPR (cardiopulmonary resuscitation - manual life support for a resident without heart beat or breathing), staff should initiate CPR and continue until: Emergency Medical Services (EMS) arrives, relieved by another staff member who continues CPR, the physician orders [REDACTED]. The facility policy entitled, Code Status Orders and Response with use of AED (automated external defibrillator - portable life saving device to diagnose and deliver electric shock for treatment of [REDACTED]. The clinical face sheet indicated that Resident CR1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated [DATE], and signed by the resident, indicated that Resident CR1 elected to receive CPR and full treatment if no pulse and/or respirations were present. Review of the physician's orders [REDACTED]. During an observation on [DATE], at 9:30 a.m. an AED was noted to be hanging on the wall by the first floor nurses' station. Review of the information dated [DATE], submitted by the facility indicated that on [DATE], at 10:30 p.m. Resident CR1 was found to be unresponsive by the staff. The Registered Nurse (RN) Supervisor, Employee E1, assessed the resident who was without pulse or respirations and she called the physician's answering service. She next called RN Employee E2 for assistance and initiated CPR on Resident CR1 at 10:30 p.m. The report indicated the CPR on Resident CR1 was discontinued by Employee E1 and Employee E2 at 10:45 p.m. Review of a witness statement written on [DATE] at 1:22 p.m. by Employee E1 indicated that CPR was discontinued after seven to 10 minutes and that she determined that Resident CR1 had expired. During an interview on [DATE], at 11:40 a.m. the Director of Nursing (DON) confirmed that Employee E1 and Employee E2 failed to call 911 for EMS at any time and failed to use the AED for Resident CR1. In addition, Employee E1 and Employee E2 did not receive an order from the physician to discontinue CPR on Resident CR1. The DON confirmed the actions of Employee E1 and Employee E2 constituted neglect in failing to provide appropriate emergency services to Resident CR1. The facility failed to make certain that a resident was protected from neglect by failing to provide care and services in the event of an emergency that occured when the resident's heart stopped, resulting in the death of the resident. 42 CFR 483.12(a)(1) Prohibit Mistreatment/Neglect/Misappropriation. Previously cited [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.29(c) Resident rights. Previously cited [DATE]. 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE].

Based on observation, review of the Pennsylvania Professional Nursing Practice Act, facility policy and clinical documentation and staff interview, it was determined that the facility staff failed to follow professional standards in performing and obtaining life sustaining emergency services resulting in death for one of five residents reviewed (Resident CR1). Findings include: The Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General Functions and 21.13. Resuscitation and Respiration indicates that the Registered Nurse (RN) carries out nursing care actions which promote, maintain and restore the well being of individuals, and external cardiac resuscitation and artificial respiration shall be performed by a nurse on an individual when respiration, or pulse, or both cease unexpectedly. The facility policy entitled, Code (performance of emergency procedures in the event of cardiopulmonary arrest) Status Orders and Response dated [DATE], indicated that when the resident has elected to receive CPR (cardiopulmonary resuscitation - manual life support for a resident without heart beat or breathing), staff should initiate CPR and continue until: Emergency Medical Services (EMS) arrives, relieved by another staff member who continues CPR, the physician orders [REDACTED]. The facility policy entitled, Code Status Orders and Response with use of AED (automated external defibrillator - portable life saving device to diagnose and deliver electric shock for treatment of [REDACTED]. Review of a facility attachment to the clinical job description signed by Registered Nurse, Employee E2, on [DATE], indicated that, I acknowledge my responsibilities as a nurse and employee to provide care under an advance directive (resident's election of life-sustaining treatment in the event of a change of condition) for the resident when they are unable to direct their care. Review of a facility Registered Nurse job description signed by RN Supervisor Employee E1 on [DATE], indicated that the RN is responsible to handle emergency situations in prompt, precise and professional manner, performs CPR as required and demonstrates the ability to be calm and professional during emergency situations. The clinical face sheet indicated that Resident CR1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated [DATE], and signed by the resident, indicated that Resident CR1 elected to receive CPR if no pulse and/or respirations were present. Review of the physician's orders [REDACTED]. An observation on [DATE], at 9:30 a.m. revealed that an AED was noted to be hanging on the wall by the first floor nurses station. Review of information dated [DATE], submitted by the facility indicated that on [DATE], at 10:30 p.m. Resident CR1 was found to be unresponsive by staff. The Registered Nurse Supervisor, Employee E1, assessed the resident who was without pulse or respirations and she called the physician's answering service. She next called RN Employee E2 for assistance and initiated CPR on Resident CR1 at 10:30 p.m. The report indicated the CPR on Resident CR1 was discontinued by Employees E1 and E2 at 10:45 p.m. Review of a witness statement written by Employee E1 on [DATE], at 1:22 p.m. indicated that CPR was discontinued after seven to 10 minutes and that she determined that Resident CR1 had expired. During an interview on [DATE], at 11:40 a.m. the Director of Nursing (DON) confirmed that Employee E1 and Employee E2 failed to follow professional standards of practice to continue to perform CPR after initiated, use the AED emergency resuscitation equipment and call for EMS for Resident CR1 after a change in condition. The facility staff failed to follow professional standards in performing and obtaining life sustaining emergency services resulting in the death of a resident. 42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards. Previously cited [DATE]. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 201.18(b)(1) Management. Previously cited [DATE], [DATE]. 28 Pa. Code 201.20(a) Staff development. 28 Pa. Code 201.29(c) Resident rights. Previously cited [DATE]. 28 Pa. Code 211.10(d) Resident care policies. Previously cited [DATE], [DATE], [DATE]. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited [DATE], [DATE], [DATE], [DATE], [DATE].

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to provide the necessary care to prevent physical harm for one of 9 residents reviewed (Resident R1). Findings include: The facility policy, Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. The facility policy, Physician Notification, reviewed 1/29/16, indicated that the staff were to notify the physician of a change in the resident condition. The, [DIAGNOSES REDACTED]. the knee leg amputation, [MEDICAL CONDITION] (hardening of the arteries) and anxiety. The urologist (a physician specializing in conditions of the urinary tract) consult dated 2/9/16, indicated that Resident R1 had chronic [MEDICAL CONDITION] (the inability to empty the bladder) and required the use of a Foley catheter (indwelling catheter - tube placed in the urinary tract to drain urine from the bladder). physician's orders [REDACTED]. to secure the placement of the catheter) and that the Foley catheter was to be changed if necessary. The care plan dated 9/8/16, indicated that Resident R1 received anticoagulants (a medication used to prevent blood clots) and the staff were to monitor for abnormal bleeding and to notify the physician if it occurred. The care plan dated 9/9/15, indicated that Resident R1 had a urinary catheter and any changes in bladder status were to be reported to the physician. Nursing progress notes dated 9/23/16, at 10:30 p.m. indicated that when Licensed Practical Nurse (LPN), Employee E1, attempted to change Resident R1's Foley catheter he/she, went into change (Resident R1's) Foley (catheter), inserted the Foley (catheter), went to inflate the balloon, (Resident R1) started to yell out that it hurts, so I stop to give (Resident R1) a break. I started to push the syringe slowly and (Resident R1) started to yell out again in pain so I stop again, (Resident R1) said push it fast so I did and (he/she) yelled out in pain and said stop it, it's hurting and then said if you don't stop I'm going to 'f*****g' punch you. I told (Resident R1) I don't disrespect you and I will not tolerate you disrespecting me, so I stop what I was doing and went and got the RN (Registered Nurse) supervisor, the RN supervisor tried to push the syringe (Resident R1) said in a calm voice that hurts, so the RN supervisor told (Resident R1) she/he would give (Resident R1) a break and would be back to put (Resident R1's) Foley catheter back in later, the RN supervisor told (Resident R1) to drink plenty of fluids, about 4:30 a.m. RN supervisor went back to reinsert the Foley (catheter), no further complaint of pain, blood tinged urine will continue to monitor. Nursing progress notes dated 9/24/16, at 4:30 a.m. indicated that RN Supervisor, Employee E2, inserted an 18 French 10 cc Foley catheter without any difficulty. The balloon was inflated and the resident was encouraged to drink fluids. Nursing progress notes dated 9/24/16, at 11:00 a.m. indicated that the RN was notified by the LPN at 9:00 a.m. that Resident R1 was having hematuria (blood in the urine) and complained of pain. The Foley catheter was draining blood and urine, approximately 150 cc in drainage bag. The note indicated that the resident then requested the North Unit LPN to remove the Foley catheter since he feels comfortable with her, at 10:40 a.m At this time, the Foley catheter appeared to be draining blood. The note indicated that the Foley catheter was removed at 10:50 a.m. The resident continued to have a large amount of bright red blood from the urethra (an opening from the bladder to the outside of the body). Review of the clinical record did not indicate that the staff notified the physician of Resident R1's complaint of severe pain with the Foley catheter insertion or the noted hematuria. Review of the record did not include documentation that the staff monitored Resident R1's condition, the function of the Foley catheter or the urinary output after it was reinserted at 4:30 a.m. until the RN was notified of the hematuria at 9:00 a.m. A written statement dated 9/24/16, at 7:30 p.m. indicated that between the hours of 11:00 p.m. and 1:00 a.m. RN Supervisor, Employee E2, heard a resident screaming very loudly, Stop, you are hurting me. The note indicated that LPN, Employee E1, approached the Supervisor and stated, Did you hear (Resident R1) yelling? I just wanted to come and tell you what was going on and that I am not going to put up with (Resident R1) swearing at me and verbally abusing me. The note indicated that Employee E1 then informed the Supervisor that the resident started to scream during LPN, Employee E2's, attempt to insert a new Foley catheter. The note indicated that when RN Supervisor, Employee E2, asked Resident R1 what was wrong the resident, was very anxious and pointed at LPN, Employee E1, and stated he/she, is really hurting me trying to put catheter in and when I told (LPN Employee E1) to stop (he/she) wouldn't listen and kept putting it in. (Resident R1) said then (LPN Employee E1) started to put the water in the balloon and I kept screaming until (LPN Employee E1) finally stopped after I told (him/her) stop it, it's hurting and then said if you don't stop I'm going to [***] ing punch you. The statement indicated that RN Supervisor, Employee E2, attempted to inflate the Foley catheter balloon and Resident R1 said, it is hurting. The statement indicated that the Foley catheter did not drain any urine from the time it was inserted by LPN, Employee E1, until RN Supervisor, Employee E2, entered the room. The statement indicated that RN Supervisor, Employee E2, asked if Resident R1 would like the Foley catheter removed and that RN Supervisor, Employee E2, removed Foley catheter slowly and observed a long light red clot at end (tip) of (Foley) catheter and instructed the resident to increase fluid intake. The statement indicated that RN Supervisor, Employee E2, reinserted Resident R1's Foley catheter around 4:30 a.m. and there was no urine return at that time. The written statement of Nurse Aide (NA), Employee E3, dated 9/24/16, indicted that at approximately 6:15 a.m. he /she got report from LPN, Employee E1, that Resident R1 would probably have blood in the Foley catheter bag. The statement indicated that upon answering the call light, Resident R1 complained of a lot of pain and NA, Employee E3, noticed 300 cc of red fluid and yellow urine in the Foley catheter tube and reported this to the oncoming nurse. The written statement dated 9/24/16, indicated that: at 9:15 a.m. RN, Employee E4, was notified by the LPN that Resident R1 had hematuria (blood in urine) and complained of pain related to the Foley catheter change on the previous shift. The Foley catheter bag had 150 cc of red fluid and a clot in the tube. The tubing was repositioned to clear and monitor what was draining. At 10:15 a.m. the resident requested the North Unit LPN and demanded that the Foley catheter be removed. At 10:50 a.m. the Foley catheter was removed. A large amount of bright red blood followed the removal of the Foley catheter. A nurse progress note indicated that Resident R1 was sent to the emergency roiagnom on [DATE], at 11:00a.m. The written statement dated 9/24/16, indicated that when LPN, Employee E5, approached Resident R1 about changing the Foley catheter as requested by RN supervisor, Employee E4, the resident, asked me not to change the (Foley) catheter but demand to just remove the Foley cath due to resident having severe 'penis' pain. Noted small amount deep gross hematuria in Foley (catheter) tubing. Upon removing the Foley (catheter) without difficulty (no resistance or increased pain per resident), moderate large amount gross deep bleeding with few dark clots expelled from penis immediately. The statement indicated that the Foley catheter bag was noted with approximately 300 cc of hematuria. Review of the hospital emergency department record indicated that Resident R1 stated that they did attempt to change the Foley catheter at the nursing home and that the resident, feels like the nurse inserted the Foley catheter and inflated the balloon, he feels like it was not in the bladder as (Resident R1) had sudden onset of pain. When this is done they deflated the balloon and removed the Foley catheter. At around 5:30 a.m. they attempted to place another Foley catheter; however, they noticed that there were significant amounts of blood and the patient was continuing to have significant amount of pain from the penis. (Resident R1) states he has been urinating intermittently whenever he feels like he needs to go, but that he has continued to be oozing blood. The emergency department record indicated that Resident R1 was diagnosed with [REDACTED]. Review of the hospital record from a secondary hospital indicated that Resident R1 ceased to breathe on 9/25/16. A review of the Certificate of Death indicated the cause of death as Urethral Laceration Foley Catheter Replacement. During an interview on 10/11/16, at 11:40 a.m. RN, Employee E6, confirmed that the facility failed to provide the necessary care when the physician was not notified of Resident R1's pain and bleeding from the attempted Foley catheter insertion. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/23/16, 4/10/15 28 Pa. Code 201.18(b)(1) Management Previously cited 5/23/16 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/18/16, 4/10/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/17/16, 6/9/16, 3/18/16, 4/10/15

Based on review of facility documents, policies and clinical records and staff interview, it was determined that the facility failed to make certain that professional standards of practice were met when care was provided to one of 9 residents reviewed (Resident R1). Findings include: The Title 49 Professional and Vocational Standards of the Commonwealth of Pennsylvania Code Chapter 21 Section 21.11(a)(4) General functions indicated that the registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals and carries out nursing care actions which promote, maintain and restore the well-being of individuals. The Title 49 Professional and Vocational Standards of the Commonwealth of Pennsylvania Code Chapter 21 Section 21.145(a) Functions of the LPN indicated that the LPN (Licensed Practical Nurse) is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The undated facility, Procedure Guidelines - Catheterization of the Urinary Bladder indicated that the catheter (flexible draining tube) was to be inserted into the urethra (opening from bladder to outside of body) until urine flows. The facility policy, Physician Notification, reviewed 1/29/16, indicated the staff were to notify the physician of a change in the resident's condition. The, [DIAGNOSES REDACTED]. the arteries) and anxiety. The urologist (a physician who specializes in conditions of the urinary tract) consult dated 2/9/16, indicated that Resident R1 had chronic [MEDICAL CONDITION] (the inability to empty the bladder) and required the use of an indwelling Foley catheter (indwelling catheter - tube placed in the urinary tract to drain urine from the bladder). Physician orders [REDACTED]. that the catheter was to be changed if necessary. The care plan dated 9/8/16, indicated that Resident R1 received anticoagulants (a medication used to prevent blood clots) and the staff were to monitor for abnormal bleeding and to notify the physician if it occurred. The care plan dated 9/9/15, indicated that Resident R1 had a urinary catheter and any changes in bladder status were to be reported to the physician. Nursing progress notes dated 9/23/16, at 10:30 p.m. indicated that when Licensed Practical Nurse (LPN), Employee E1, attempted to change Resident R1's catheter he/she, went into change (Resident R1's) Foley (catheter), inserted the Foley (catheter) went to inflate the balloon (Resident R1) started to yell out that it hurts, so I stop to give (Resident R1) a break. I started to push the syringe slowly and (Resident R1) started to yell out again in pain so I stop again, (Resident R1) said push it fast so I did and (he/she) yelled out in pain and said I will 'f*****g' punch you, I told (Resident R1) I don't disrespect you and I will not tolerate you disrespecting me, so I stop what I was doing and went and got the RN (Registered Nurse) supervisor, the RN supervisor tried to push the syringe (Resident R1) said in a calm voice that hurts, so the RN supervisor told (Resident R1) she/he would give (Resident R1) a break and would be back to put (Resident R1's) Foley (catheter) back in later, the RN supervisor told (Resident R1) to drink plenty of fluids, about 4:30 a.m. RN supervisor went back to reinsert the Foley (catheter), no further complaint of pain, blood tinged urine will continue to monitor. Review of the 9/23/16, 10:30 p.m. note did not indicate that LPN, Employee E1, observed urine flow when the Foley catheter was inserted by him/her at that time. Nursing progress notes with a designated time of 4:30 a.m. indicated that RN Supervisor, Employee E2, inserted an 18 French 10 cc Foley catheter without any difficulty. The balloon was inflated and the resident was encouraged to drink fluids. A written statement dated 9/24/16, at 7:30 p.m. indicated that between the hours of 11:00 p.m. and 1:00 a.m. RN Supervisor, Employee E2, heard a resident screaming very loudly Stop, you are hurting me. The note indicated that LPN Employee E1 approached the supervisor and stated Did you hear (Resident R1) yelling? I just wanted to come and tell you what was going on and that I am not going to put up with (Resident R1) swearing at me and verbally abusing me. The note indicated that Employee E1 then informed the Supervisor that the resident started to scream during LPN Employee E2's attempt to insert a new Foley catheter. The note indicated that when RN supervisor Employee E2 asked Resident R1 what was wrong the resident was very anxious and pointed at LPN Employee E1 and stated he/she is really hurting me trying to put (Foley) catheter in and when I told (LPN Employee E1) to stop (he/she) wouldn't listen and kept putting it in. (Resident R1) said then (LPN Employee E1) started to put the water in the balloon and I kept screaming until (LPN Employee E1) finally stopped after I told (him/her) stop it, it's hurting and then said if you don't stop I'm going to 'f*****g' punch you. The statement indicated that RN supervisor Employee E2 attempted to inflate the (Foley) catheter balloon and Resident R1 said it is hurting. The statement indicated that the (Foley) catheter did not drain any urine from the time it was inserted by LPN Employee E1 until RN supervisor Employee E2 entered the room. The statement indicated that RN supervisor Employee E2 asked if Resident R1 would like the Foley catheter removed and that RN supervisor Employee E2, removed Foley catheter slowly and observed a long light red clot at end (tip) of (Foley) catheter and instructed the resident to increase fluid intake. The statement indicated that RN supervisor Employee E2 reinserted Resident R1's Foley catheter around 4:30 a.m. and there was no urine return at that time. Review of the clinical record did not indicate that the physician was notified of Resident R1's screaming with pain and lack of urine flow with the Foley catheter insertion, blood tinged urine or observation of clot at end of Foley catheter when it was removed. Nursing progress notes dated 9/24/16, at 11:00 a.m. indicated that the RN was notified by the LPN at 9:00 a.m. that Resident R1 was having hematuria (blood in urine) and complained of pain. The Foley catheter was draining blood and urine, approximately 150 cc in the drainage bag. The note indicated that the resident then requested the North Unit LPN, Employee E5, to remove the Foley catheter since he feels comfortable with her, at 10:40 a.m. At this time the Foley catheter appeared to be draining blood. The note indicated that the Foley catheter was removed at 10:50 a.m. Resident R1 continued to have a large amount of bright red blood from the urethra (an opening from the bladder to the outside of the body). A nurse progress note indicated that Resident R1 was sent to the emergency roiagnom on [DATE], at 11:00a.m. Review of the hospital emergency department record indicated that Resident R1 stated that they did attempt to change the Foley catheter at the nursing home and that the resident, feels like the nurse inserted the Foley catheter and inflated the balloon, he feels like it was not in the bladder as (Resident R1) had sudden onset of pain. When this is done they deflated the balloon and remove the Foley catheter. At around 5:30 (a.m.) they attempted to place another Foley (catheter); however, they noticed that there were significant amounts of blood and the patient was continuing to have significant amount of pain from the penis. (Resident R1) states he has been urinating intermittently whenever he feels like he needs to go, but that he has continued to be oozing blood. The emergency department record indicated that Resident R1 was diagnosed with [REDACTED]. A review of the hospital record from the secondary hospital indicated that Resident R1 ceased to breathe on 9/25/16. Review of the Certificate of Death indicated cause of death was Urethral Laceration Foley Catheter Replacement. Review of facility incident documentation regarding Resident R1 included signed statements dated 9/26/16, that indicated LPN, Employee E1, used an 18 Fr/10 cc Foley catheter and RN Supervisor, Employee E2, used a 16 Fr/10 cc Foley catheter, which has a larger diameter that the 18 Fr Foley catheter. During an interview on 10/13/16, at 1:45 p.m. the Director of Nursing (DON) acknowledged that the staff did not use the correct size of Foley catheter and that there was not an indication that urine flow was observed as required when a Foley catheter is inserted. The DON stated that there was no reason to expect pain with the Foley catheter insertion when Resident R1 had tolerated the procedure well in past, and confirmed that the physician was not made aware that Resident R1 screamed with pain when the Foley catheter insertion was attempted on 9/23/16. The DON confirmed that the staff would be expected to follow the physician's orders [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 5/23/16, 4/10/15 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/18/16, 4/10/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 8/17/16, 6/9/16, 3/18/16, 4/10/15

Based on facility policy, reports and clinical record review and staff interview, it was determined that the facility failed to follow the physician's orders and failed to implement the plan of care resulting in harm for one of 9 residents reviewed (Resident R1). Findings include: The undated facility policy, Procedure Guidelines - Catheterization of the Urinary Bladder, indicated that the catheter (indwelling catheter - tube placed in the urinary tract to drain urine from the bladder) was to be inserted into the urethra (an opening from the bladder to the outside of the body) until urine flows. The facility policy, Physician Notification, reviewed 1/29/16, indicated that the staff were to notify the physician of a change in the resident condition. The, [DIAGNOSES REDACTED]. the arteries) and anxiety. A urologist (a physician who specializes in conditions of the urinary tract) consult dated 2/9/16, indicated that Resident R1 had chronic [MEDICAL CONDITION] (the inability to empty the bladder) and required the use of an indwelling urinary catheter. Physician's orders for 9/2016, indicated that Resident R1's catheter was to be 18 Fr (French) with 5cc (cubic centimeters) Foley (designated the size of the catheter and the amount of liquid to be inserted in the balloon to secure the placement of the catheter) and that the catheter was to be changed if necessary. The care plan dated 9/8/16, indicated that Resident R1 received anticoagulants (a medication used to prevent blood clots) and that staff were to monitor for abnormal bleeding and to notify the physician if it occurred. The care plan dated 9/9/15, indicated that Resident R1 had a urinary catheter and any changes in bladder status were to be reported to the physician. Nursing progress notes dated 9/23/16, at 10:30 p.m. indicated that when Licensed Practical Nurse (LPN), Employee E1, attempted to change Resident R1's catheter he/she went into change (Resident R1's) Foley, inserted the Foley when to inflate the balloon (Resident R1) started to yell out that it hurts, so I stop to give (Resident R1) a break. I started to push the syringe slowly and (Resident R1) started to yell out again in pain so I stop again, (Resident R1) said push it fast so I did and (he/she) yelled out in pain and said stop it, it's hurting and then said if you don't stop I'm going to 'f*****g' punch you. I told (Resident R1) I don't disrespect you and I will not tolerate you disrespecting me, so I stop what I was doing and went and got the RN (Registered Nurse) supervisor, the RN supervisor tried to push the syringe (Resident R1) said in a calm voice that hurts, so the RN supervisor told (Resident R1) she/he would give (Resident R1) a break and would be back to put (Resident R1's) Foley back in later, the RN supervisor told (Resident R1) to drink plenty of fluids, about 4:30 a.m. RN supervisor went back to reinsert the Foley, no further complaint of pain, blood tinged urine will continue to monitor. Review of the 9/23/16, 10:30 p.m. note did not indicate that LPN, Employee E1, observed urine flow when the catheter was inserted. Nursing progress notes with a designated time of 4:30 a.m. indicated that the RN Supervisor, Employee E2, inserted an 18 French 10 cc Foley catheter without any difficulty. The balloon was inflated and the resident was encouraged to drink fluids. Written statement dated 9/24/16, at 7:30 p.m. indicated that between the hours of 11:00 p.m. and 1:00 a.m. RN supervisor Employee E2 heard a resident screaming very loudly Stop, you are hurting me. The note indicated that LPN Employee E1 approached the supervisor and stated Did you hear (Resident R1) yelling? I just wanted to come and tell you what was going on and that I am not going to put up with (Resident R1) swearing at me and verbally abusing me. The note indicated that Employee E1 then informed the supervisor that the resident started to scream during LPN Employee E2's attempt to insert a new catheter. The note indicated that when RN supervisor Employee E2 asked Resident R1 what was wrong the resident was very anxious and pointed at LPN Employee E1 and stated he/she is really hurting me trying to put catheter in and when I told (LPN Employee E1) to stop (he/she) wouldn't listen and kept putting it in. (Resident R1) said then (LPN Employee E1) started to put the water in the balloon and I kept screaming until (LPN Employee E1) finally stopped after I told (him/her) that I was going to 'f*****g' punch (him/her). The statement indicated that RN supervisor Employee E2 attempted to inflate the catheter balloon and Resident R1 said it is hurting. The statement indicated that the catheter did not drain any urine from the time it was inserted by LPN Employee E1 until RN supervisor Employee E2 entered the room. The statement indicated that RN supervisor Employee E2 asked if Resident R1 would like catheter removed and that RN supervisor Employee E2 removed Foley catheter slowly and observed a long light red clot at end (tip) of catheter and instructed the resident to increase fluid intake. The statement indicated that RN supervisor Employee E2 reinserted Resident R1's Foley around 4:30 a.m. and there was no urine return at that time. Review of the clinical record did not indicate that the physician was notified of Resident R1's pain and lack of urine flow with catheter insertion, blood tinged urine or observation of clot at end of catheter when removed. Nursing progress notes dated 9/24/16, at 11:00 a.m. indicated that the RN was notified by the LPN at 9:00 a.m. that Resident R1 was having hematuria (blood in urine) and complained of pain. Catheter was draining blood and urine, approximately 150 cc in drainage bag. The note indicated resident then requested North Unit LPN, Employee E5, to remove the catheter since he feels comfortable with her, at 10:40. At this time the catheter appeared to be draining blood. The note indicated the catheter was removed at 10:50 a.m. Resident R1 continued to have a large amount of bright red blood from the urethra (an opening from the bladder to the outside of the body). A nurse progress note indicated that Resident R1 was sent to the emergency roiagnom on [DATE], at 11:00a.m. Review of hospital emergency department record indicated that Resident R1 stated that they did attempt to change catheter at nursing home and resident feels like the nurse inserted the Foley catheter and inflated the balloon, he feels like it was not in the bladder as (Resident R1) had sudden onset of pain. When this is done they deflated the balloon and remove the catheter. At around 5:30 they attempted to place another Foley; however, they noticed that there were significant amounts of blood and the patient was continuing to have significant amount of pain from the penis. (Resident R1) states he has been urinating intermittently whenever he feels like he needs to go, but that he has continued to be oozing blood. The emergency department record indicated that Resident R1 was diagnosed with [REDACTED]. Review of hospital record from secondary hospital indicated Resident R1 ceased to breathe 9/25/16. Review of Certificate of Death indicated cause of death: Urethral Laceration Foley Catheter Replacement. Review of facility incident documentation regarding Resident R1 included signed statements dated 9/26/16, that indicated LPN Employee E1 used an 18 Fr/10 cc Foley and RN supervisor Employee E2 used a 16 Fr/10 cc Foley. During an interview on 10/13/16, at 1:45 P.M. the Director of Nursing (DON) acknowledged that the staff did not use the correct size of catheter and there was not an indication that urine flow was observed as required when catheter was inserted. The DON acknowledged that the physician was not notified of Resident R1's complaint of severe pain and bleeding with catheter insertion and confirmed that the facility failed to follow physician orders and Resident R1's plan of care. 483.25 Provide Care/services for Highest Well Being Previously cited 6/9/16, 3/18/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 3/18/16, 4/10/15 28 Pa. Code 211.12(d) (1)(5)Nursing services Previously cited 8/17/16, 6/9/16, 3/18/16, 4/10/15

Based on facility policy, clinical record, hospital record review, and staff interviews, it was determined that the facility failed to properly assess and monitor a resident's fluid intake, and provide sufficient fluids to prevent dehydration for one of five residents (Resident R1). Findings include: Review of the facility policy entitled, "Hydration" reviewed July 26, 2010, indicated: Identify causes and/or risk factors for dehydration which may include dementia in which a resident forgets to drink; monitor for physical signs of dehydration; monitor and evaluate labs pertinent to hydration status; and provide a minimum of 1500 cubic centimeters (cc's) of fluid per day with meals. The clinical record indicated that Resident R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the May 4, 2010, Nutrition Risk Data Collection and Assessment indicated that Resident R1, "scored high risk secondary to medications, [DIAGNOSES REDACTED]. Resident R1's May 10, 2010, Nutritional Risk Plan of Care, indicated that staff was to assist with meals as needed, monitor for signs of dehydration, encourage fluids, and monitor labs. The August 4, 2010, Nutrition Progress Note, indicated that Resident R1's average fluid intake was 1,055 cc's of fluids with meals plus ad lib (as desired) fluid between meals. Review of the September 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's Intake/Output (I/O) by Day Chart indicated that for the seven day period from September 18, 2010 through September 24, 2010, Resident R1's average total fluid intake was 282.9 cc's. The September 22, 2010, Dietary Progress Note indicated that Resident R1's appetite had "greatly declined - average intake 9% (down from 74% per 8/4/10 note)." The note did not document the amount of fluid intake. During an interview on October 1, 2010, at 11:00 a.m., the Dietician, Employee E3, confirmed that Resident R1's average daily fluid intake was 282.9 cc's from September 18, 2010 through September 24, 2010. Employee E3 indicated at that time that the intake records were not reviewed daily and acknowledged that the decrease in Resident R1's fluid intake was not identified and no interventions were initiated. Resident R1's clinical record did not contain nurses' notes for the period of September 1, 2010 until September 23, 2010. Resident R1's un-timed September 23, 2010, progress notes completed by nursing indicated that the physician would be notified regarding the lethargy and decreased appetite due to psychoactive medications, and to obtain laboratory studies. The note did not include documentation of Resident R1's physical assessment or fluid intake status. During an interview on October 1, 2010, at 12:15 p.m., Registered Nurse, Employee E4, indicated that nursing staff wrote the September 23, 2010, progress notes based on a morning report but did not see or assess Resident R1. Resident R1's September 24, 2010, progress notes indicated that the physician was notified at 10:00 a.m., of critical lab values: BUN (Blood Urea Nitrogen) 111 (normal level is between 9 to 20); Sodium 167 (normal is between 134 to 142); and Chloride 130 (normal level is between 98 to 107). The progress notes indicated that at 12:30 p.m., on September 23, 2010, the resident had a decrease in blood oxygen level, increasing congestion, temperature elevation, and was transferred to the hospital on September 24, 2010, at 1:00 p.m. The hospital history and physical examination [REDACTED]. The hospital Discharge Summary dated September 27, 2010, indicated that Resident R1 ceased to breathe on September 25, 2010. During an interview on October 1, 2010, at 2:15 p.m., Registered Nurse, Employee E2, confirmed that the facility failed to assess or implement interventions for Resident R1 to prevent dehydration. 28 Pa. Code 211.10(c) Resident care policies. Previously cited 5/29/09. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 3/19/10, 5/29/09. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 3/19/10, 5/29/09. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 5/29/09.