Every finding on record at Homestead Village, Inc

Based on review of facility policy, resident records, and staff interview it was determined that the facility failed to follow transmission-based precautions and utilize enhanced barrier precautions (EBP) during wound care creating the potential for cross contamination for two out of three sampled residents (Residents R29 and R32).Findings include:Review of facility policy Transmission-Based Precautions & MDRO last revised June 2024, states Enhanced Barrier Precautions (EBP) are used for reducing transmission of multidrug-resistant organisms (MDROs) during high-contact resident care activities in residents with chronic wounds (e.g. pressure, diabetic, unhealed surgical, and venous stasis) and/or indwelling medical devices. Further review of the policy indicated that enhanced barrier precaution needs to be implemented during high contact resident care activities, such as dressing changes to wounds. Review of Resident R29's admission record indicated he/she was originally admitted on [DATE]. Review of Resident R29's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 3/20/25, indicated she had diagnoses that included Alzheimer's disease, venous insufficiency, localized edema, non-pressure chronic ulcer on the right foot. Review of Resident R29's clinical record revealed an active order for Lymphademic (issue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic syste) wound left 3rd toe: Cleanse with NSS (normal saline solution). Apply Betadine daily and as needed. Leave open to air. With a start date of February 27, 2026. Observation conducted of Resident R29's room on March 3, 2026, at 10:12 a.m. revealed personal protective equipment (PPE) hanging on the resident's dresser located next to the bed. Review of Resident R29's care plan revealed the following intervention: Enhanced Barrier Precautions due to open wound per protocol. During an interview with the Director of Nursing (DON) on March 4, 2026, wound treatment observation for Resident R29 was scheduled for March 5, 2026, at 9:00 a.m. Observation of wound treatment conducted on March 5, 2026, at 9:10 a.m. revealed licensed staff employee E3 performing wound care for Resident R29 while wearing gloves only and not wearing a protective gown. Upon completion of the wound treatment, interview with licensed staff employee E3 confirmed that Resident R29 was on Enhanced Barrier Precautions due to wounds and that appropriate PPE for wound care should have included gloves and a protective gown. Interview conducted with the Infection Preventionist, licensed employee E4, on March 5, 2026, at 10:37 a.m. confirmed that licensed employee E3 did not wear the appropriate PPE during the wound care treatment. During an interview conducted on March 5, 2026, at 1:30 p.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of observations indicating the facility failed to follow transmission-based precautions and implement Enhanced Barrier Precautions (EBP) in accordance with the resident's care plan and infection prevention protocols. This deficient practice had the potential to result in cross-contamination and place Residents R29 and R32 at risk for the transmission of infectious organisms. Review of Resident 32's clinical record revealed Resident 32 was admitted to the facility on [DATE]. Further review of Resident 32's clinical record revealed Resident 32 had a sacral pressure ulcer. Observation of wound treatment conducted on March 5, 2026, at 9:12 a.m. revealed Licensed Employee E5 performing wound care for Resident 32. Further observation of the wound treatment failed to reveal evidence that Licensed Employee E5 was wearing appropriate personal protective equipment (PPE) during the wound care treatment. Interview with Licensed Employee E4 on March 5, 2026, at 10:37 a.m. confirmed that Licensed Employee E5 was not wearing the appropriate PPE during the wound treatment and further confirmed Licensed Employee E5 failed to follow transmission-based precautions during the wound treatment. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.28 (b)(1)(e)(1) Management. 28 Pa Code: 211.10 (d) Resident care policies.

Based on clinical record review, resident interview, and staff interviews, it was determined the facility failed to ensure equipment was used in a safe manner, resulting in actual harm to one of eight residents reviewed (Resident R1). Specifically, the facility failed to ensure a Broda chair was positioned and operated safely during resident care, resulting in Resident R1 sliding out of the chair and sustaining a fracture.Findings include:Review of Resident R1's clinical record revealed the following diagnoses: Hemiplegia and Hemiparesis following non-traumatic intracerebral hemorrhage (muscle weakness or partial paralysis on one side of the body), Cerebral Infarction (stroke), Osteoarthritis (degenerative joint disease, causing pain, stiffness, and reduced mobility when protective cartilage wears down, causing bones to rub together), Type 2 Diabetes (chronic condition where the body develops insulin resistance and cannot use insulin effectively, leading to high blood sugar levels), Fibromyalgia (widespread pain and fatigue), and Macular Degeneration (loss of vision).Review of Resident R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Review of Resident R1's Comprehensive care plan dated December 18, 2025, revealed Resident R1:Required substantial assistance for upper body dressingWas dependent on staff and required a Hoyer lift for all transfersWas non-ambulatoryRequired staff assistance for all mobility while seated in a Broda chairReview of information dated January 15, 2026, submitted to the Department of Health by the facility, revealed that on the evening of January 11, 2026, Resident R1 slid out of his/her Broda chair during evening care and sustained an injury. Review of Resident R1's nursing progress note dated January 11, 2026, at 8:06 p.m. revealed Certified Nursing Assistant (CNA) Employee E3 leaned Resident R1 forward to check the placement of the Hoyer lift sling, the resident slid forward and landed on the floor on (his/her) knees. The note further documented the seat of the Broda chair was tilted forward, with the front edge lower than the back edge, and was not parallel to the ground. Resident R1 was assisted back to bed using a Hoyer lift (mechanical device designed to assist in lifting and transferring individuals with limited mobility) and two nurses. The physician and family were notified.Review of Resident R1's clinical record revealed a Registered Nurse (RN) assessment completed immediately following the incident documenting the Broda chair seat was tilted forward and not parallel to the ground, creating an unsafe positioning during resident care.Review of nursing progress notes dated January 13, 2026, revealed the resident reported pain and bruising to the right lower extremity. Additional review of nursing progress notes indicated that Resident R1 was receiving routine Tylenol and Gabapentin for pain management. Review of Resident R1's clinical record revealed diagnostic imaging (X-RAY) performed on January 13, 2026 (9:20 a.m.) confirmed Resident R1 a recent fracture of the distal (lower) shaft of the right fibula (lower leg bone).Review of facility incident report dated January 11, 2026, included a written statement from Certified Nursing Assistant (CNA) Employee E3, indicating that while providing evening care and leaning the resident forward to change (his/her) blouse, Resident R1 slid out of the Broda chair and onto (his/her) knees.Review of Resident R1's clinical record revealed Resident R1 was transported to a local hospital on January 13, 2026, for further evaluation and returned the same day at 9:15 p.m., with a plaster splint applied to the right foot/ankle.Additional review of the clinical record revealed a Physician order for Tramadol 50 mg (milligram) by mouth every eight hours as needed for pain for ten days with a start date of January 19, 2026.During an interview conducted with the Nursing Home Administrator (NHA) on February 2, 2026, at 9:27 a.m., the NHA reported that Resident R1 received a new Broda chair on January 12, 2026, and that the seat of the new chair does not tilt forward.The Nursing Home Administrator (NHA) provided a list of all residents currently using Broda chairs. Observations conducted of the Broda chairs used by Residents R2 through R8 revealed that all chairs had levers clearly labeled, indicating the top lever adjusted the back support and the bottom lever adjusted the seat tilt.During an interview conducted with Certified Nursing Assistant (CNA) Employee E4 on February 2, 2026, at 10:50 a.m., Employee E4 revealed the labels were placed on the Broda chairs following the incident involving Resident R1.During an interview conducted with Resident R1 on February 2, 2026, at 11:33 a.m., the resident stated (he/she) slid out of (his/her) Broda chair because the seat was tilted too far forward and reported experiencing significant pain as a result of the injury.During a phone interview conducted on February 2, 2026, at 11:48 a.m., non-licensed staff, Employee E3 confirmed that Resident R1 slid out of the Broda chair after Employee E3 tilted the seat too far forward. As a result of the fall, Resident R1 sustained a right ankle fracture.During an interview conducted with Occupational Therapist Employee E5 on February 2, 2026, at approximately 1:38 p.m., Employee E5 reported all nursing staff received one-on-one training on the safe operation of resident adaptive equipment, including Broda chairs.During an interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on February 2, 2026, at approximately 2:15 p.m., facility leadership confirmed the above findings.The facility failed to ensure Resident R1's Broda chair was positioned and operated in a safe manner during care, resulting in the resident sliding out of the chair and sustaining a right ankle fracture, constituting actual harm.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(e)(1) Management.28 Pa. Code 201.29(a) Resident rights.28 Pa. Code 211.10(c)(d) Resident care policies.28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for one of three residents reviewed for nutrition (Resident 20). Findings include: Review of facility policy, Weight Management/Weight Loss, revised July 12, 2022, revealed that monthly weights will be taken by qualified staff during the first 5 days of each month and documented in the electronic medical record after being verified by licensed staff. If a +/- 5 lb [pound] discrepancy exists, the resident should be reweighed immediately with nurse verifying weight. If unable to verify immediately reweight will be obtained on the following day. Additionally, if a weight loss/gain of 5 or more pounds is noted, dietitian is to be notified in a timely manner for follow up and recommendations. Review of Resident 20's clinical record revealed recorded weights of 121.4 pounds on January 4, 2025; 121.4 pounds on January 5, 2025; 108.4 pounds on February 5, 2025, with a reweight on February 6, 2025, of 107.6 pounds. (loss of 13.8pounds or11.37% in one month) Further review of Resident 20's clinical record revealed a dietary note dated February 10, 2025, indicating the resident's weight. Further review of the same dietary note failed to reveal recommendations to address the weight loss. Interview with Employee E3 on February 21, 2025 at 11:30 a.m. confirmed that further dietary interventions should have been implemented to address Resident 20's weight loss. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review, it was determined the facility failed to ensure monitoring for effectiveness and side effect monitoring for psychotropic medications was completed for one of five residents reviewed (Resident 6). Findings include: Review of Resident 6's clinical record revealed Resident 6 had been receiving Trazodone (anti-depressant medication) for insomnia since March 2024. Further review of Resident 6's clinical record failed to reveal evidence of monitoring for side effects and/or effectiveness of Trazodone since the medication was initiated in March 2024. Interview with the Director of Nursing on February 21, 2025, at 10:00 a.m. confirmed that no monitoring for side effects or effectiveness was documented since March 2024 to present when Resident 6 was receiving Trazodone. 28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services Previously cited 3/1/2024

Based upon observation and clinical record review, it was determined the facility failed to adequately investigate a missing extended-release opioid medication patch and failed to provide lock free doors to resident bathrooms for one of 18 residents reviewed (Resident 35) and three of three nursing units. Findings include: Review of Resident 35's physician orders revealed an order for Buprenorphine 5 mcg/hr [micrograms per hour] apply one patch transdermally every day shift every 7 days. Apply 1 patch topically every 7 days; remove old before applying new. Review of Resident 35's February 2024 Medication Administration Record (MAR) revealed a Butrans patch was applied on February 8, 2024, and another patch was due to be applied on February 15, 2024. Review of Resident 35's clinical progress notes dated February 13, 2024, revealed Staff unable to locate Butrans [Buprenorphine - Schedule III opioid pain medication] patch. Caregivers reported patch was on back in am, when nurse went to confirm placement of patch, patch was missing. Full body check completed and room searched, but unable to locate patch. [physician] updated and gave order to wait on next schedule day to apply new patch. Interview with the Director of Nursing on March 1, 2024, at 11:00 a.m. failed to reveal evidence that any further investigation was conducted to locate the missing Butrans opioid patch. The facility failed to conduct a thorough investigation to determine the location or cause of the missing Butrans opioid patch. Review of Resident 35's clinical progress notes dated October 4, 2023, revealed Resident is often locking herself in the bathroom and is not safe. Work order placed into Worxhub for maintenance to replace with doorknob so that resident is not able to lock for safety concerns. Observation of Resident 35's bathroom door and all bathroom doors on all three nursing units revealed bathroom doors had door locks in place. Resident 35's doorknob was not replaced with a non-locking doorknob. Interview with nursing personnel on the [NAME] nursing unit on February 29, 2024, at 11:00 a.m. revealed nursing personnel identified a key ring with an item to unlock the bathroom doors. Upon attempting to unlock the door, the item on the key ring failed to unlock the door. Interview with the Director of Nursing on February 29, 2024, at 11:30 a.m. revealed a second item on the key ring that opened the locked bathroom doors and also revealed all key rings have an item to unlock the doors and extra keys are located the Director of Nursing's office. Nursing personnel were unaware of the correct item to use to unlock the bathroom doors on the nursing units. The above information was conveyed to the Nursing Home Administrator on March 1, 2024, at 11:00 a.m. 28 Pa. Code 201.18(a)(b)(1) Management

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of four residents reviewed for nutrition (Residents 12, 36, and 45). Findings include: Review of facility policy, Weight Management/Weight Loss, revised July 12, 2022, revealed that monthly weights will be taken by qualified staff during the first 5 days of each month and documented in the electronic medical record after being verified by licensed staff. If a +/- 3 lb [pound] discrepancy exists, the resident should be reweighed immediately with nurse verifying weight. If unable to verify immediately reweight will be obtained on the following day. Additionally, if a weight loss/gain of 3 or more pounds is noted, dietitian is to be notified in a timely manner for follow up and recommendations. Review of Resident 12's clinical record revealed an admission weight of 147.0 pounds on August 28, 2023. Resident's weight was recorded as 135.8 pounds on January 4, 2024 and 129.4 pounds on February 1, 2024, with a reweight on February 2, 2024 of 127.4 pounds (loss of 8.4 pounds or 6.2% in one month). Further review of the clinical record revealed that a nutrition/dietary progress note on February 26, 2024, (24 days after the reweight was obtained) indicated that the resident triggered on the monthly weight report for significant weight loss. No further recommendations were initiated. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. revealed that potentially would expect some intervention to be put into place due to significant weight loss over one month and progressive weight loss since admission. Review of Resident 36's clinical record revealed a weight of 99.0 pounds on January 1, 2024, and a weight of 83.8 pounds on February 1, 2024 (loss of 15.2 pounds or 15.4% in one month). Further review revealed that a reweight was not obtained. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. confirmed that a reweight should have been completed. Review of Resident 45's clinical record revealed a weight of 204.8 pounds on January 2, 2024, and 188.4 pounds on February 1, 2024( loss of 16.4 pounds or 8.00% in one month). Further review revealed that a reweight was not obtained. Review of nutrition assessment of February 4, 2024, noted significant weight loss. Interview with Employee E3 on March 1, 2024, at 11:15 a.m. confirmed that a reweight should have been obtained so an accurate assessment could be completed. Employee E3 indicated that a reweight should be obtained for a 5 pound change for a resident over 100 pounds and a 3 pound change for a resident under 100 pounds. A reweight should have been completed within 24 hours. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon clinical record review and interview, it was determined the facility failed to accurately complete a discharge Minimum Data Set Assessment upon discharge for one of three records reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed Resident 51 was admitted to the facility on [DATE], and was discharged to home on January 19, 2024. Review of Resident 51's discharge Minimum Data Set (MDS - periodic assessment of resident needs) dated January 19, 2024, revealed Resident 51 was discharged to an acute care facility. Interview with the Director of Nursing on March 1, 2024, at 10:00 a.m. confirmed Resident 51's discharge MDS was inaccurate and should have reflected Resident 51 was discharged to home. 28 Pa. Code 211.5(f) Clinical Records

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to timely identify a pressure ulcer for one of six residents reviewed (Resident 43). Findings include: Review of facility policy, Altered skin integrity: Assessment, prevention, and treatment, last revised February 2023 revealed that the Braden Scale for Predicting Pressure Ulcer Risk should be completed quarterly. The policy also revealed that weekly skin checks will be completed in the resident's record. Review of Resident 43's clinical record revealed Resident 43 was admitted to the facility on [DATE] Review of Resident 43's clinical record revealed the resident had a diagnosis of spinal stenosis (a condition where spinal column narrows and compresses the spinal cord), Low back pain, Radiculopathy (pinched nerve due to increased pressure causing numbness, weakness, and pain), (lumbar region), Spondylosis of lumbar region (degeneration of the vertebra of lumbar region), Other Intervertebral Disc Degeneration of lumbar region (occur when cushioning in spine weakens causing weakness and numbness in back, neck, and legs) and Osteoporosis (weakening of the bones). Review of Resident 43's clinical record revealed Resident 43's Braden Scale Assessment (tool used to evaluate a resident's risk of developing pressure ulcers) dated January 19, 2024 indicated Resident 43 was At Risk of developing pressure ulcer/wound. Review of Resident 43's Minimum Data Set (MDS - periodic assessment of resident care needs) dated January 25, 2024, revealed the resident experiences pain daily and prevents the resident from sleeping and participating in therapy. The MDS assessment further revealed the resident was at risk for skin breakdown. The MDS assessment also indicated that the resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of Resident 43's clinical record including weekly Skin assessment dated [DATE], and January 31, 2024, revealed the resident's skin was intact at the time of the assessment. Review of Resident 43's clinical record revealed a progress note dated February 2, 2024 (17:23) indicating, Message left at Pain management office due to resident's reports of increased pain in LE (lower extremity) and numbness/tingling in right leg and left leg, more in right per resident following spinal injection. Injection site on low back bruised, no warmth, no redness, no drainage. Awaiting call back. [Provider] CRNP (Certified Registered Nurse Practitioner) updated on call to pain management. Review of Resident 43's clinical record including nursing note dated February 4, 2024, which revealed, [Resident] has reported increased low back pain since [his/her] spinal steroid injection (anti-inflammatory medicine) on January 29, 2024. Nursing contacted office for recommendations February 2, 2024: Cannot assess effectiveness of epidural as it is too early. Two weeks out date is February 12, 2024. Previous shift reported to oncoming nurse that an open area was observed this a.m. to sacrum [triangular bone at the base of the spine] measuring 4.2 cm (centimeters) x 1.5 cm with 100% slough [yellow, tan, gray, green or brown] to wound bed. Staff reports resident slept in recliner past x 2 nights per resident request as it helps with the discomfort. Review of Resident 43's clinical record revealed a nursing progress note dated February 14, 2024, indicating the unstageable pressure ulcer has been classified as a stage 3 pressure ulcer (full thickness skin loss exposing subcutaneous tissue). Further review of the same progress note revealed Resident 43 experiencing pain during wound treatment. Review of Resident 43's initial wound consult dated February 20, 2024, revealed the wound was reclassified to Stage 3 pressure ulcer with new measurements of 4.0 x 1.5 x 0.2 cm by the wound doctor on February 20, 2024. Review of Resident 43's care plans revealed a care plan for skin integrity was initiated and developed on February 4, 2024, with interventions of Encourage resident to nap in bed to offload sacral area; Do incontinence care to prevent skin breakdown; House stock barrier cream to be applied to prevent skin breakdown; and Keep skin clean and dry. Resident 43 was discharged home on February 29, 2024, and therefore unavailable for an interview or observation of wound conducted. The facility's failure to notify the physician of Resident 43's increased pain, resulted in a delay in identifying an unstageable pressure ulcer to the resident's sacrum. This facility deficient practice was discussed with the Nursing Home Administrator and Director of Nursing on March 1, 2024, at 11:50. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a rationale for not making a change in the medication was documented by the physician for a medication regime review (MRR) for one of five residents reviewed (Resident 12). Findings include: Review of Resident 12's clinical record revealed that a MRR was completed on November 14, 2023. The MRR included a recommendation to consider a gradual dose reduction of Quetiapine (antipsychotic medication) due to questionable need with stable behaviors. The physician responded no change with no rationale documented. Interview with the Nursing Home Administrator on March 1, 2024, at 12:11 a.m. confirmed the physician did not provide a rationale. 483.45 Pharmacy Services 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observation, facility policy and procedure and clinical documentation reviews it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy and procedure titled Resident Directed Medication Administration, revised February 19, 2018, revealed [CONDITION(S)] medications and Proton Pump Inhibitors [PPIs] are to be administered upon arising, while resident is preparing for the day. Other AM medications are given at least one-half hour after [CONDITION(S)] and PPIs are given. Review of Resident 9's clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 9's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Medication Administration observation on April 13, 2022 at 10:10 a.m. revealed Resident 9 received all of her medications in the dining room during the breakfast meal at 10:10 a.m. including the [MEDICATION(S)] and Omeprazole. Interview with the Director of Nursing on April 14, 2022 at 10:00 a.m. revealed that Resident 9 should have received the [MEDICATION(S)] and Omeprazole 30 minutes prior to receiving the other medications and 30 minutes prior to the meal. The facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based upon review of Facility Assessment and clinical documentation, the facility failed to obtain a contract or agreement for [CONDITION(S)] services for residents requiring [CONDITION(S)] treatment. Findings include: Review of the Facility-wide Self-assessment dated [DATE], provided by the facility, revealed one resident required [CONDITION(S)] services. Further review of the Facility-wide Self-Assessment revealed that the facility had an agreement with a [CONDITION(S)] facility. A copy of the agreement/contract was requested from the facility. Interview with the Nursing home Administrator on April 14, 2022, at 10:48 a.m. revealed that the facility did not have an agreement and/or contract with a [CONDITION(S)] facility. 28 Pa. Code 201.18(b)(1)(3) Management

Based on observation, interview with staff and resident, review of the facility's policy and procedure, clinical records, and facility documentation, it was determined that the facility failed to ensure that one of 12 residents reviewed (Resident #17) was free from neglect when the temperature of the resident's tea was not checked before serving. The neglect resulted in actual harm when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of the facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Property, with a revision date of March 2017, revealed neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of Resident #17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #17's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated February 12, 2021, revealed that the resident had a BIMS (Brief Interview for Mental Status-A screen used to assist with identifying a resident's current cognition) of 15 which indicated that the resident as cognitively intact. The MDS also revealed that the resident required supervision with one person to assist with eating. A review of the nursing progress notes dated April 10, 2021, at 3:33 p.m. revealed that the nurse was notified that the resident had spilled a cup of hot tea on her/his left leg. Redness was noted to the resident's left inner thigh measuring 8.0 x 19.0 cm. Border appeared raised and welted (a red bump, ridge, or swelling of unbroken skin). The resident denied pain but stated that the area feels funny. The physician was notified, and a new order was received for [MEDICATION(S)] 1% cream three times a day (a topical antibiotic used to treat or prevent infections on areas of burned skin). An interview with the Licensed Nurse Employee E7 on April 21, 2021, at 10:36 a.m. revealed that on April 10, 2021, at around lunchtime, Resident #17 was heard yelling. Employee E7 stated that she/he was by the medication cart and did not check the resident because the staff (unable to recall specifically who) informed her/him that the resident spilled her/his drink and was ok. Employee E7 stated that Nurse Aide (NA) Employee E8 brought the resident to another table still wearing the same pants and the resident finish eating lunch. After lunch, the resident was brought to the resident's room to lay down. Employee E7 stated that she/he noted redness on the resident's left thigh. When asked what happened, Employee E8 informed Employee E7 that the resident spilled hot tea on her/his lap during lunch. Employee E7 stated that she immediately called the nursing supervisor, assessed the area, and notified the physician and the responsible party. A treatment order of [MEDICATION(S)] was obtained and applied to the resident's burn. Employee E7 stated that on Tuesday after the incident (April 13, 2021), Employee E8 informed her/him that the hot tea was served in a blue mug with a lid on and was microwaved before serving it to Resident #17 on April 10, 2021. A phone interview with Employee E8 on April 21, 2021, at 2:50 p.m. revealed that Resident #17 was able to eat independently and usually asks for a hot tea. Employee E8 stated that at lunchtime, she/he prepared the resident's tea by taking hot water from the carafe. Employee E8 stated that she/he placed a spoon in the cup of tea, and drip some of the water on her/hand, and felt that the tea was not warm so she/he microwaved the tea for five seconds then served it to Resident #17 with a lid on. Employee E8 stated that she/he was aware that the temperature of the beverage should have been checked but she/he confirmed that she/he forgot to check the temperature of the microwaved hot tea before serving it to Resident R#17. Employee E8 stated that the hot beverage temperature should not be more than 165 F. Employee E8 suddenly heard the resident yelling, I got burned. Employee E8 stated that the resident's hot tea was spilled on the table, floor, and some of her/his lap (left). The lid was on the table and the cup was on the floor, Employee E8 stated that the resident always removes the lid of the cup. Employee E8 asked one of the co-workers to get cold water while checking if the resident was ok, Resident #17 informed Employee E8 that she/he was ok. Employee E8 dripped a small amount of the cold water to the spilled (hot tea) spot on the resident's left thigh. Employee E8 stated that she/he tried to check the area but was unable to see it, Resident #17 informed Employee E8 that she/he was ok. Employee E8 stated that the resident resumed eating after being transferred to another table. Employee E8 stated that she/he did not inform the nurse because she/he was not around. After half an hour, the nurse asked Employee E8 to bring Resident #17 back to bed to lay down. Employee E8 stated that a pink spot was noted on the resident's left thigh when the pants were removed, and the nurse (Employee E7) was made aware that the resident had spilled hot tea on her/his lap during lunchtime. An interview with Resident #17 was conducted on April 21, 2021, at 11:00 a.m. The resident confirmed that she/he spilled the hot tea on her/his lap but unable to recall when. The resident stated that she/he might have removed the lid of the cup. The resident did not answer other questions of the surveyor. An interview with the Nursing Home Administrator on April 21, 2021, at 2:08 p.m. confirmed that Employee E8 did not check Resident #17's hot tea after placing it in the microwave and serving it to the resident. The facility failed to ensure that Resident #17 was free from neglect when Employee E8 failed to check the temperature of the tea after reheating in the microwave resulting in actual harm when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 6/7/19 28 Pa. Code 201.18(b)(1) Management Previously cited 6/7/19 28 Pa. Code 201.18(e)(1) Management Previously cited 6/7/19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/7/19

Based on observation, interview with staff and resident, review of the facility's policy and procedure, clinical records, and facility documentation review, it was determined that the facility failed to implement interventions to prevent resident incident/accident for one of 12 residents reviewed (Resident #17). The incident resulted in actual harm when the resident sustained a redness (a burn) and required antibiotic treatment for an infection of the burn to the resident's left upper thigh. Findings include: A review of the facility's policy titled, Cooking: TCS (Temperature Control for Safety), which was undated, revealed that the team members must monitor the temperature of the food during preparation and cooking to ensure that the food reaches its required minimum internal temperature. Hot beverages should be between 160-F to 180-F. A review of Resident #17's diagnoses list revealed Cerebral Infarction (stroke), [CONDITION(S)] (caused by problems in the supply of blood to the brain, leading to worsening cognitive decline that occurs step by step), and dysphagia (difficulty in swallowing). A review of Resident #17's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated February 12, 2021, revealed that the resident was cognitively intact and required supervision with one person to assist with eating. A review of the nursing progress notes dated April 10, 2021, at 3:33 p.m. revealed that the nurse was notified that the resident had spilled a cup of hot tea on her/his left leg. Redness was noted to the resident's left inner thigh measuring 8.0 x 19.0 cm. Border appeared raised and welted (a red bump, ridge, or swelling of unbroken skin). The resident denied pain but stated that the area feels funny. The physician was notified, and a new order was received for [MEDICATION(S)] 1% cream three times a day (a topical antibiotic used to treat or prevent infections on areas of burned skin). A review of the facility's documentation, incident report dated April 10, 2021, at 1:00 p.m. revealed that the staff reported that Resident #17 spilled hot tea on herself at lunchtime. The resident stated, I spilled my hot tea. The resident denied pain in the area but stated, it feels funny. The resident also stated, I'm unsure if I took my lid off my cup today. The lid was not on the cup when staff retrieved the cup from her lap. Caregivers reported the resident has a history of taking lids off her cups. The resident had a reddened area (burn-like) on the upper inner left thigh (8.0 x 19.0 cm). RN (Registered Nurse) assessed the area and followed throughout the day to see if redness disappeared/worsened. The physician and POA (Power of Attorney) were notified, [MEDICATION(S)] was ordered to the area. An interview with the Licensed Nurse Employee E7 on April 21, 2021, at 10:36 a.m. revealed that she/he was the nurse during the incident on April 10, 2021. Employee E7 stated that during lunchtime (unable to recall the exact time) while he/she was standing in front of the medication cart, Resident #17 was heard yelling. Employee E7 stated that she did not check the resident because she was informed by the staff (unable to recall specifically who) that the resident spilled her/his drink and was ok. Employee E7 stated that Nurse Aide (NA) Employee E8 brought the resident to another table still wearing the same pants and finish eating lunch. After lunch, the resident was brought to the resident's room to lay down. Employee E7 stated that she/he noted redness on the resident's left thigh. When asked what happened, Employee E8 informed Employee E7 that the resident spilled hot tea on her/his lap during lunch. Employee E7 stated that she immediately called the nursing supervisor, assessed the area, and notified the physician and the responsible party. A treatment order of [MEDICATION(S)] was obtained and applied to the resident's burn. Employee E7 stated that on Tuesday after the incident (April 13, 2021), Employee E8 informed her/him that the hot tea was served in a blue mug with a lid on and was microwaved before serving it to Resident #17 on April 10, 2021. A phone interview with Employee E8 on April 21, 2021, at 2:50 p.m. revealed that Resident #17 eats by herself/himself and usually asks for a hot tea. Employee E8 stated that at lunchtime, she/he prepared the resident's tea by taking hot water from the carafe. Employee E8 stated that she/he placed a spoon in the cup of tea, and drip some of the water on her/hand, and felt that the tea was not warm so she/he microwaved the tea for five seconds then served it to Resident #17 with a lid on. Employee E8 stated that she/he was aware that the temperature of the beverage should have been checked but she/he confirmed that she/he forgot to check the temperature of the microwaved hot tea before serving it to Resident R#17. Employee E8 stated that the hot beverage temperature should not be more than 165 F. Employee E8 suddenly heard the resident yelling, I got burned. Employee E8 saw that the resident's hot tea was spilled on the table, floor, and some of her/his lap (left). The lid was on the table and the cup was on the floor, Employee E8 stated that the resident always removes the lid of the cup. Employee E8 asked one of the co-workers to get cold water while checking if the resident was ok, Resident #17 informed Employee E8 that she/he was ok. Employee E8 dripped a small amount of the cold water to the spilled (hot tea) spot on the resident's left thigh. Employee E8 stated that she/he tried to check the area but was unable to see it, Resident #17 informed Employee E8 that she/he was ok. Employee E8 transferred the resident to another table and the resident resumed eating lunch. Employee E8 stated that she/he did not inform the nurse because she/he was not around. After half an hour, the nurse asked Employee E8 to bring Resident #17 back to bed to lay down. Employee E8 stated that a pink spot was noted on the resident's left thigh when the pants were removed, and the nurse (Employee E7) was made aware that the resident had spilled hot tea on her/his lap during lunchtime. An interview with Resident #17 was conducted on April 21, 2021, at 11:00 a.m. The resident stated that she/he spilled the hot tea on her/his lap, unable to recall when. The resident stated that she/he might have removed the lid of the cup. The resident did not answer other questions of the surveyor. An interview was conducted on April 21, 2021, with the following staff: Employee E9 at 12:00 p.m., Employee E10 at 12:07 p.m., Employee E11 at 12:14 p.m., Employee E12 at 1:15 p.m., and Employee E12 at 1:20 p.m. The employees mentioned were able to enumerate procedures on reheating food and beverages on the microwave. They all stated that hot beverages temperature should be checked with a thermometer which was kept on each unit's kitchen drawer after placing hot beverages in the microwave. All employees interviewed stated that hot beverages should not be more than 165 F. A review of the nursing progress notes dated April 12, 2021, at 3:28 a.m. revealed the resident's left thigh was reddened and blistered, [MEDICATION(S)] cream was applied per order. A review of the nursing progress notes dated April 13, 2021, at 1:24 p.m. revealed that the resident's left thigh was red with several blistered areas that have opened, treatment applied as ordered and tolerated without complaints. Fluids are encouraged while awake. A review of the progress notes dated April 14, 2021, at 2:36 p.m. revealed an order for a wound consult evaluation and treatment for the left thigh skin alteration was obtained, the POA was updated. A review of the nursing progress notes dated April 15, 2021, at 2:30 p.m. revealed that wound assessment from the wound doctor revealed left thigh burn with a measurement of 16.0 x 8.0 cm with moderate serous (a clear or slightly yellow fluid) drainage. Recommendation for treatment: [MEDICATION(S)], daily cover with non-adherent pad, and secure with ace wraps. A review of the nursing progress notes dated April 15, 2021, at 6:55 p.m. revealed that a new order from the Nurse Practitioner (NP) was received to start Resident #17 on [MEDICATION(S)] (antibiotic) 500 mg two times a day for the infected burn. A review of the nursing progress notes dated April 19, 2021, at 7:15 p.m. revealed that the left thigh has 40 % yellow slough (a separation of the dead tissue from the living tissue, yellow, tan, gray, green, or brown), remaining area was pink without warmth, swelling, or drainage. The resident denied pain. An observation was conducted on April 20, 2021, at 10:00 a.m. During the observation, the resident's left thigh wound had a 40% light yellow slough, and 60% pink with moderate serous drainage was observed from the non-adherent pad. The resident denied any pain. A review of the nursing progress notes dated April 20, 2021, at 2:15 p.m. revealed that the wound doctor assessed the resident's left thigh burn, an area measuring 13.0 x 9.0 cm, with 100 % dermis, light serous drainage. Continue with treatment as prescribed. An interview with the Nursing Home Administrator on April 21, 2021, at 2:08 p.m. confirmed that Employee E8 did not check Resident #17's hot tea after placing it in the microwave and serving it to the resident. The facility failed to implement interventions to prevent accidents/incidents resulting in actual harm when Resident #17 sustained an 8.0 x 19.0 burn on her/his left thigh and requiring an antibiotic treatment due to failure to check the resident's hot tea temperature after placing it in a microwave. 483.25(d)(2) Free of Accident Hazards/supervision/devices Previously cited 6/7/19 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 6/7/19 28 Pa. Code 201.18(b)(1) Management Previously cited 6/7/19 28 Pa. Code 201.18(e)(1) Management Previously cited 6/7/19 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/7/19

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's current status in the area of tube feeding for one of 15 residents reviewed (Resident R19). Findings include: Review of Resident R19's Quarterly Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated February 14, 2021, revealed under section K0210- Swallowing/Nutrition resident was coded as having a feeding tube. Observation on April 23, 2021 at 12:45 p.m. revealed Resident R19 did not have a feeding tube. During an interview on April 23, 2021 at 12:50 p.m. Licensed Employee E3 confirmed that Resident R19 did not have a feeding tube at any point while a resident at the facility. During an interview on April 23, 2021, at 2:15 p.m. the Nursing Home Administrator confirmed that Resident R19's MDS was coded incorrectly regarding the use of a feeding tube. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on observations, clinical record review, and staff interviews it was determined that the facility failed to review, revise and implement care plans and interventions related to falls for two of 16 residents reviewed (Residents R1 and Resident R192). Findings include: Review of facility policy entitled Fall prevention protocol revised in July 2019 stated staff will monitor and document the individual's response to interventions to reduce falls or the consequences of falling. Further review of the policy revealed fall prevention for all residents included placing items of need within reach and for residents who are determined to be high risk will be kept in a highly visible area as able. Review of Resident R1's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed a Morse Fall Assessment (an assessment to determine a resident's likelihood of falling) on October 5, 2020 indicating the resident to be a high fall risk. Review of Resident R1's clinical record revealed a nursing progress note dated November 1, 2020, that identified resident sitting on carpet in hallway after an unwitnessed fall. Further review of clinical documentation for Resident R1 lacked evidence of an assessment of the current fall interventions in place or that a review and revision of the care plan was completed. Review of Resident R1's clinical record revealed a progress note dated December 6, 2020, identifying that the resident had an unwitnessed fall in his/her room. Further review of clinical documentation for Resident R1 lacked evidence of an assessment of the current fall intervention in place or that a review and revision of the care plan was completed. Review of Resident R1's clinical record revealed a progress note dated December 18, 2020, that identified the resident was laying on the floor in the hallway. Further review of Resident R1's clinical documentation revealed a social work progress note on December 22, 2020, indicating that social services employee contacted family to change resident room (Room R13) closer to other residents and in a high traffic area when a room becomes available. Review of facility documentation titled Quality Management review dated April 2, 2021, identified an intervention for Resident R1 was for staff to chart in back hallway for increased supervision. Observation on April 19, 2021 at 10:45 a.m. revealed Resident R1 remained in room R13. Additional observations on April 19, 2021, April 20, 2021, April 21, 2021, and April 22, 2021, failed to reveal any staff members in the back hallway near room R13 to provided increased supervision. During an interview on April 20, 2021, Resident R1 stated I just wish they could figure something out to help me so I do not fall so much. Interview with Nursing Home Administrator on April 22, 2021, at 1:20 p.m. confirmed the above information. Review of Resident R192's clinical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident R1's clinical documentation revealed resident was non-verbal (unable to speak) without Passy Muir valve (when place on the hub of a [CONDITION(S)] tube, redirecting airflow through the vocal cords). Review of a nursing progress note on January 8, 2021, revealed resident on trial of Passy Muir valve, resident may keep on 20 minutes to speak with wife and eat lunch. Review of Resident R192's Quarterly Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated March 5, 2021, indicated resident is an extensive assist for locomotion (movement from one place to another), transfers and bed mobility. Further review of Resident R192's MDS revealed a BIMS (Brief interview for Mental Status)score of 14 indicating resident is cognitively intact. Review of Resident R192's clinical documentation revealed a Morse fall assessment on December 3, 2020, indicating resident is a high fall risk. Review of Resident R192's clinical documentation dated December 7, 2020, at 1:21 p.m. revealed resident was observed on the floor in his/her room after a fall. Resident gestured he/she was looking for his/her phone. Further review of clinical documentation revealed an intervention added to the care plan on December 7, 2020, to keep resident in common area when awake if agreeable. Review of Resident R192 clinical record dated December 21, 2020, at 6:45 p.m. revealed resident was laying on floor in his/her room after resident attempted to transfer him/herself from their wheelchair. Further review of clinical documentation for Resident R192 lacked an assessment of the current fall intervention in place or that a review and revision of the care plan was completed. Review of Resident R192 clinical record revealed resident with progress note dated December 31, 2020, at 5:00 p.m. stated resident was observed in his/her room, on his/her back in front of his/her bathroom door. Further review of clinical documentation for Resident R192 lacked an assessment of the current fall intervention in place or that a review and revision of the care plan was completed. Review of Resident R192 clinical record revealed a progress note dated January 28, 2021, at 7:25 p.m. that identified resident was observed by staff on floor in his/her room with a laceration on right forehead. Further review of clinical documentation revealed resident was sent via ambulance to hospital. Resident returned to the facility with 23 sutures. Further review of clinical documentation for Resident R192 revealed an intervention of check placement of TV remote control is in resident reach when in room added to the care plan on January 29, 2021. Review of facility documentation falls investigation report completed on January 29, 2021, revealed four witness statements obtained from staff. Witness one stated he/she last observed resident in dining room. Witness statement two revealed resident last seen in room being suctioned by a nurse. Witness statement three revealed he/she last observed resident in his/her room receiving [CONDITION(S)] care. Witness statement four stated the door partially closed, staff member heard resident wheezing, knock and went in, observed resident on floor. Interview with non-verbal Resident R192 on April 22, 2021, at 9:45 a.m. revealed that resident responded with a thumbs up when asked if he/she prefers sitting in common area. Thumbs down when asked if he/she ever prefers to be in his room, thumbs down when asked if he/she ever requests to stay in his room During an interview on April 22, 2021, at 9:15 a.m. Licensed Employee E3 stated that they have never seen resident (R192) not want to come out of their room, he/she likes being out and his/her family member loves that he/she is around people. During an interview on April 22, 2021, at 10:30 a.m. Licensed Employee E4 stated that maybe once (R192) wanted to stay in his/her room when he/she wasn't feeling well and stayed in bed. During an interview on April 22, 2021, at 2:00 p.m. the Nursing Home Administrator confirmed the above findings. 28 Pa. Code 211.10 (c)(d) Resident Care Plan 28 Pa. Code 211.11 (b)(d) Resident Care Plan 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa. Code 211.5(f) Clinical records

Based on clinical record review and staff interview, it was determined that the facility failed to notify the State Ombudsman's office of residents transferred to acute care facilities for three of three residents reviewed (Resident #43, Resident #48, and Resident #52). Findings include: Review of Resident #43's clinical record revealed Resident #43 was transferred to the hospital in (MONTH) 2019 with [DIAGNOSES REDACTED]. Further review of Resident #43's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident #43's transfer to the hospital. Review of Resident #48's progress note dated (MONTH) 20, (YEAR), indicated that the physician ordered the resident to be sent to the emergency room for evaluation. Review of progress note of (MONTH) 1, 2019, indicated verbal telephone order received to send resident to the hospital for an elevated white blood cell count. Further review of Resident #48's record revealed no evidence that the State Ombudsman's office was notified of the transfers to the hospital. Review of incident report under nursing description notes dated (MONTH) 10, 2019, indicated that Resident #52 was found lying supine on dining room, right leg of Resident #52 was extended with lateroflexion (bending to one side) of the knee and patellar (knee cap) swelling. Further review of Resident #52's progress notes revealed facility notified physician on (MONTH) 10, 2019 regarding Resident #52's fall incident and right leg condition and gave verbal telephone order to send resident to emergency room for evaluation of right knee pain. Further review of Resident #52's clinical records revealed no documented evidence that the State Ombudsman was notified of the transfer to the hospital. Interview with the Nursing Home Administrator on (MONTH) 7, 2019, at 9:18 a.m. confirmed that the State Ombudsman's office had not been notified of transfers. 28 Pa. Code: 201.18(b)(1)(2) Management

Based on clinical record review and staff interview, it was determined that the facility failed to provide a bed-hold notice to the resident or responsible party upon transfer to the hospital for three of three residents reviewed (Resident #43, Resident #48, and Resident #52). Findings include: Review of facility policy Bed Hold & Transfer/Discharge Notice, revised (MONTH) (YEAR), indicated that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer or as soon as practicable. Review of Resident #43's clinical record revealed Resident #43 was transferred to the hospital in (MONTH) 2019 with [DIAGNOSES REDACTED]. Further review of Resident #43's clinical record failed to reveal evidence that Resident #43 or their responsible party were given notification regarding the bed-hold policy before the transfer to the hospital. Review of Resident #48's progress notes of (MONTH) 20, (YEAR), and (MONTH) 1, 2019, revealed that the resident was admitted to the hospital for pneumonia on both occasions. There was no documented evidence that notification regarding the bed-hold policy was provided to Resident #48 or their responsible party before the transfer to the hospital on any of the above dates. Review of Resident #52's progress notes dated (MONTH) 10, 2019 revealed Resident #52 was transferred to the emergency room due to right knee pain following a fall and was admitted to the hospital with [REDACTED]. Review of Resident #52's clinical records revealed no documented evidence that bed-hold policy notification was provided to Resident #52 or their responsible party before the transfer to the hospital on any of the above date. Interview with the Nursing Home Administrator on (MONTH) 7, 2019, at 9:18 a.m. confirmed that information regarding the bed hold was not provided to residents transferred to the hospital. Pa. Code: 211.5(f) Clinical records Previously cited 5/18/18

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent accidents for one of 14 residents reviewed (Resident #28). Findings include: Review of Resident #28's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) of (MONTH) 18, 2019, indicated that the resident was cognitively intact. Observation on (MONTH) 4, 2019, at 3:25 p.m. revealed Resident #28 sitting on a recliner in resident's room. A blue and white pill capsule was noted to be on the footrest of the recliner. Resident #28 was not aware that the pill capsule was there. This information was presented to the Director of Nursing on (MONTH) 7, 2019, at 9:50 a.m. 483.25(d)(2) Free of Accident Hazards/supervision/devices Previously cited 4/9/19 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 4/9/19 28 Pa. Code 201.18(b)(1) Management Previously cited 4/9/19 28 Pa. Code 201.18(e)(1) Management previously cited 4/9/19, 05/18/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 4/9/19, 05/18/18

Based on staff interview and clinical records review, it was determined that the facility failed to obtaine a behavioral consultation for a resident experiencing behaviors with a [DIAGNOSES REDACTED].#54). Findings include: Clinical records review of Resident #54's [DIAGNOSES REDACTED]. Review of Resident #54's physician order [REDACTED].#54 was order [MEDICATION NAME] (an antipsychotic medication) 75 milligrams (mg) two times a day and the antidepressant medication [MEDICATION NAME] 20 mg at night. Review of Resident #54's Minimum Data Set (MDS-periodic assessment of resident needs) dated (MONTH) 2, 2019, revealed a BIMS (Brief interview for mental status) of four out of 15 which placed Resident #54 with severe cognitive impairment. Further review of Resident #54's MDS on Behavior Section E, revealed physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others were coded as 1 (behavior of this type occurred 1-3 days). Behavioral symptoms under Rejection of care revealed that behavior of this type occurred one to three days. Behavioral symptoms under Wandering revealed that behavior of this type occurred four to six days, but less than daily. Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #54's clinical records revealed no documented evidence that the consult with behavioral services was followed by the facility. Interview with the Director of Nursing on (MONTH) 7, 2019, at approximately 10:00 a.m., confirmed that physician's orders [REDACTED].#54 was not followed. 28 Pa. Code 201.18(b)(1) Management Previously cited 5/18/18 28 Pa. Code 211.5(f) Clinical records Previously cited 5/18/18 28 Pa. Code 211.12(c) Nursing services Previously cited 5/18/18 28 Pa. 211.12(d)(1)(3)(5) Nursing services Previously cited 5/18/18

Based on clinical record review, it was determined that the facility failed to ensure resident's physician timely addressed the consultant pharmacist medication review and failed to ensure that the physician provided clinical rationales for declining the consultant pharmacist's recommendations for one of five residents reviewed (Resident #34). Findings include: Review of Resident #34's physician's orders [REDACTED]. Review of Resident #34's Consultant Pharmacist's Medication Regimen Review dated (MONTH) 12, (YEAR) revealed a recommendation to decrease Resident #34's Aspirin dose to 81 mg or 162 mg daily and to consider a gradual dose reduction (GDR) of Quetiapine. Review of Resident #34's physician's response regarding the Quetiapine GDR revealed Resident #34's physician declined the GDR on (MONTH) 7, 2019 two months after the recommendation. Further review of Resident #34's physician response regarding the Aspirin dosage reduction revealed that on (MONTH) 7, 2019 Resident #34's physician stated no change. Further review of Resident #34's clinical record failed to reveal a clinical rationale for the continued use of Aspirin 325 mg daily. Review of Resident #34's Consultant Pharmacist's Medication Regimen Review dated (MONTH) 17, 2019 revealed that the consultant pharmacist recommended re-evaluating the use of Donepezil. Review of Resident #34's physician's response dated (MONTH) 22, 2019 revealed no changes at this time. Further review of Resident #34's clinical record failed to reveal a clinical rationale for the continued of Donepezil. Interview with the Nursing Home Administrator and Director of Nursing on (MONTH) 7, 2019 at approximately 12:30 p.m. confirmed that the resident's physician failed to timely address the Consultant Pharmacist's Medication Regimen Review and failed to provide clinical rationales for declining the consultant pharmacist's recommendations. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c) Nursing Services Previously cited 4/9/19 28 Pa. Code 211.12(d)(3) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 4/9/19

Based on clinical record review and review of documentation provided to the State Agency by the facility, it was determined that the facility failed to ensure a resident was transferred appropriately into bed resulting in actual harm to Resident R1, sustaining a right leg laceration and requiring antibiotic therapy for one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's Annual Minimum Data Set assessment (MDS - periodic assessment of resident needs) dated (MONTH) 23, (YEAR), revealed Resident R1 required the extensive assistance of two staff members for bed mobility and transfers. Review of Resident R1's plan of care (undated) revealed Resident R1 had an activities of daily living self-care performance deficit related to muscle weakness, tremors, chronic pain and [MEDICAL CONDITION] with interventions which included extensive assistance with bed mobility, is able to assist with reapportioning herself when in bed and the use of a stand-up lift and two person assist for transfers. Review of documentation provided to the State Agency by the facility dated (MONTH) 21, 2019, revealed that on (MONTH) 19, 2019, caregiver assisted (resident) to bed by herself and (resident's) right leg twisted, causing pain and a skin tear. The caregiver had removed the enabler bar to place resident up further in (resident's) bed. This exposed a bracket which caused the skin tear over an old bruised area. Resident has fragile skin tissue with [MEDICAL CONDITION] and receives aspirin daily, making (resident) prone to bruising. The nurse immediately observed resident's right lateral lower extremity where bruise had previously existed and noted a 4.5 centimeter (cm) x 5 cm skin tear . skin edges intact and able to be approximated although small (approximately 0.5 cm) tear into flap noted at posterior area . area with continued small amount bleeding and drainage of serous (blood-tinged) fluid due to [MEDICAL CONDITION] (swelling) in leg .Resident requires assistance of two with transfers due to muscle weakness, unsteadiness, difficulty walking, tremor [MEDICAL CONDITION](stroke). Further review of this documentation noted STAT (immediate) x-ray ordered due to resident's increased complaint of discomfort. X-ray of right knee and hip negative for fracture. Ultrasound ordered and performed on (MONTH) 21, 2019, at 2:45 p.m. due to knee swelling negative for [MEDICAL CONDITION] ([MEDICAL CONDITION] (clot). Review of the facilty investigations including a written statement from the nursing assistant who assisted Resident R1 into bed on (MONTH) 19, 2019, confirmed that at 7:30 p.m. after transfering the resident she had bumped her leg against the bedrail. Review of Resident R1's nursing progress note dated (MONTH) 19, 2019, at 8:35 p.m. revealed called to resident's room by caregiver who stated that resident had cut leg on the bed. Observed resident with skin tear on right lateral lower extremity where bruise had previously existed. Caregiver stated that (caregiver) removed the right enabler bar while assisting resident into bed so that resident could be positioned higher up in bed and resident bumped leg against metal bar where enabler attaches. Further review of this progress note revealed measured as 4.5 cm x 5 cm skin tear. Resident requires assistance with transfers due to muscle weakness, unsteadiness, difficulty walking, tremor and [MEDICAL CONDITION]. Review of Resident R1's nursing progress note dated (MONTH) 20, 2019, at 4:33 p.m. revealed Resident with reports of pain to RLE (right lower extremity) at area of skin tear off and on throughout day. Further review of this nursing progress note revealed swelling noted at right upper lateral and right lower medial parts of knee. New order for stat X-ray of right knee for new onset of pain and [MEDICAL CONDITION]. Review of Resident R1's nursing progress note dated (MONTH) 21, 2019, at 11:49 a.m. revealed Resident continues to voice pain RLE. Resident does not want to move right leg secondary to pain. Shortening and external rotation noted in RLE while resident is laying in bed. New order for stat X-ray 2 views of right hip to r/o (rule out) fracture (broken bone). Stat ultrasound of RLE to r/o [MEDICAL CONDITION]. Review of Resident R1's physician's communication note dated (MONTH) 27, 2019, at 11:04 a.m. revealed skin tear right leg; purulent drainage; yellow, light brown, foul smelling. Periwound red, warm. Right leg with +2 [MEDICAL CONDITION] from ankle to mid shin. Review of Resident R1's physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of Resident R1's physician's progress note dated (MONTH) 30, 2019, revealed Resident seen today for follow up evaluation and treatment of [REDACTED]. After evaluation and discussion with the nursing staff, the follow orthopedic recommendations will be written into order; cleanse with NSS (normal saline solution), pat dry, apply Xeroform to wound and cover with 4 x 4 s (gauze dressing), apply ace bandage daily and then discontinue treatment once healed, continue the currently ordered antibiotics and a referral to (hospital) wound care was ordered. Review of Resident R1's wound care consultant note dated (MONTH) 7, 2019, revealed Resident R1's right lower extremity wound measured 3.0 cm x 1.2 cm. Further review of the wound care consultant note revealed Resident R1 had necrotic tissue removed from the right lower extremity skin tear site. Review of Resident R1's wound care consultant note dated (MONTH) 22, 2019, revealed Resident R1's right lower extremity wound measured 1.0 cm x 0.3 cm. Review of Resident R1's wound care consultant note dated (MONTH) 1, 2019, revealed Resident R1's right lower extremity wound had healed. Interview with the Nursing Home Administrator and the Director of Nursing on (MONTH) 9, 2019, at approximately 2:00 p.m. confirmed the above information. The facility failed to properly transfer Resident R1 into bed with a stand-up lift and to provide proper staff assistance of two staff for bed mobility, which resulted in Resident R1 sustaining a right leg laceration and requiring antibiotic therapy. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management previously cited 05/18/18 28 Pa. Code 211.12(c) Nursing services Previously cited 06/19/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 05/18/18, 06/19/17