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Based on facility documentation and staff interview it was determined the facility failed to follow physician orders for bowel protocol for one of 16 residents reviewed. (Resident 15) Findings Include: Review of Resident 15's physician orders revealed an order dated August 31, 2022 for Milk of Magnesia (laxative), give 30 cc (cubic centimeter or milliliters) by mouth as needed for constipation if no BM (Bowel Movement) in 3 days: an order dated August 31, 2022 for Bisacodyl Suppository (laxative inserted rectally) 10mg (milligrams) as needed for constipation administer the next shift if no results from the Milk of Magnesia; and an order dated August 31, 2022 for Fleets Naturals Cleansing Enema (rectal cleanser), insert 1 unit rectally as needed for Constipation administer next shift if no results from Bisacodyl Suppository. Review of Resident 15's bowel continence report for May 2024 and June 2024 revealed the resident had no bowel movement from May 29th, 2024 on evening shift until the day shift of June 4, 2024, totaling 5 days. Review of Resident 15's Medication Administration Record (MAR) for the month of June 2024 revealed the resident was administered Milk of Magnesia on June 2, 2024 at 1:58 p.m., review of the Bowel continence reports revealed that was ineffective and was indicated as ineffective on the MAR. Further review of the MAR revealed there was no Suppository administered as ordered due to the ineffectiveness of the Milk of Magnesia. Further review of Resident 15's bowel continence record for June 2024 revealed the resident did not have a bowel movement from Evening shift on June 4, 2024 until day shift of June 13, 2024, a total of 9 days. Review of Resident 15's MAR for June 2024 revealed the resident received Milk of Magnesia on June 8, 2024 at 8:10 a.m. that was ineffective. There was no Suppository administered for the ineffective Milk of Magnesia on evening shift of June 8, 2024 as ordered and no other medications administered as ordered until the resident had a bowel movement on June 13, 2024. Further Review of Resident 15's MAR for June 2024 revealed the resident had a dose of Milk of Magnesia administered on June 14 2024, at 12:49 p.m. which was not indicated due to the resident having a documented bowel movement the day before. Further review of Resident 15's Bowel record revealed the resident did not have a bowel movement from evening shift on June 13 until day shift on June 23 a total of 10 days. Review of Resident 15's MAR for June 2024 revealed a dose of Milk of Magnesia as administered on June 19, 2023 at 2:17 a.m. and documented as effective but review of the bowel record revealed the resident did not have a bowel movement on the night shift on June 14. Further review of Resident 15's bowel record revealed the resident had no bowel movement from evening shift of June 24, 2024 until the end of the month. Review of Resident 15's MAR for June 2024 revealed there was a dose of Milk of Magnesia that was administered on June 28, 2024 at 12:48 p.m. that was documented as ineffective and there was no Suppository administer as ordered. Interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2024 at 10:00 a.m. confirmed that Resident 15's physician order for bowel regimen were not being followed as written. 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) Nursing Services

Based on observation, facility policy and procedure review, and staff interview it was determined the facility failed to properly label and date vials of insulin for one of three med carts reviewed. (second floor) Findings Include: Review of facility policy and procedure titled Medication Labeling and Storage, dated 2001, revealed Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Observation on September 11, 2024 at 9:20 a.m. of the medication cart on the second floor for the high number rooms revealed there were four insulin pens that were opened and being used that were undated. Interview with Nursing Employee E3 at the time of the above findings confirmed the four insulin pens were opened and being used and should have been dated with the date they were opened. 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) Nursing Services

Based on a review of clinical and hospital records and staff interviews, it was determined that the facility failed to ensure wound treatment was initiated upon admission for two of the six residents reviewed (Resident 149 and 151). Findings include: Review of Resident 149's nursing progress notes dated October 13, 2023, revealed resident was admitted to the facility from the hospital with a diagnosis of Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Review of Resident 149's admission assessment, dated October 13, 2023, revealed resident was admitted with a Deep Tissue Pressure Injury (persistent non-blanchable deep red, maroon, or purple discoloration) to the coccyx (tail bone). Further review of Resident 149's clinical record failed to reveal, a wound treatment was completed on Resident 149's coccyx DTI until October 16, 2023; three days after resident was admitted to the facility and assessed with a DTI to the coccyx. Interview conducted with the wound nurse, licensed nurse Employee E4 on October 20, 2023, at 10:00 a.m., revealed that upon the resident's admission, the resident ' s skin will be assessed by an RN (Registered Nurse). Identified skin impairment will be reported to the physician, an order will be made, and wound treatment will be initiated. Employee E4 confirmed that a wound order treatment was not placed upon resident admission and wound treatment was not done until October 16, 2023, three days after a resident was admitted and a skin impairment was identified. Review of Resident 151's hospital records, and discharge summary dated October 5, 2023, revealed resident had a stage three (Full-thickness skin loss) to the right ischium/buttock wound). Recommended wound treatment was Aquacel ag (anti-microbial dressing used in wounds that are infected or at risk for infection) to wound, covered with foam dressing daily. Review of Resident 151's clinical records and admission assessment revealed resident was admitted to the facility on [DATE], with a stage two to the right buttock, measuring 4.0 x 2.0 x 0.1 cm. Review of the physician's order dated October 14, 2023, revealed a wound treatment order was made to cleanse the right ischium/buttock with normal saline solution, pat dry, apply Aquacel ag and cover with a foam dressing. Review of the October 2023, Treatment Administration Record revealed wound treatment to Resident 151's right ischium/buttock wound was not followed until October 15, 2023, two days after resident was admitted to the facility and identified with a skin impairment. Iinterview conducted with Employee E4 on October 20, 2023, at 10:00 a.m., reported that Resident 151's wound order and treatment should have been done upon admission. Employee E4 confirmed that Resident 151's wound treatment order was not completed until October 15, 2023, two days after a resident was admitted with identified skin impairment. The facility failed to ensure Residents 149 and 151 were provided with a wound order and treatment upon admission. 28 Pa. Code 211.5(f) Clinical Records Previously cited 12/8/22 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 12/8/22

Based on a review of the facility's policy, clinical record reviews, and staff interview, it was determined that the facility failed to investigate an injury of unknown origin for one of the 12 residents reviewed (Resident 8). Findings include: Review of the facility's policy titled Abuse Prevention Program, revised in July 2021, revealed that if the cause of the injury is unknown, the person gathering facts will document the injury, the location and time it was observed, any treatment given and whether the physician, responsible party and/or the Department of Health were notified. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if can be interviewed. Review of Resident 8's diagnosis list revealed Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety Disorder, Psychotic and Mood Disturbance. Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated July 6, 2022, revealed that the resident had severe cognitive impairment. The same MDS assessment revealed the resident required extensive bed mobility, transferring, personal hygiene, and grooming. Review of Resident 8's active care plan revealed resident had physical behaviors during hands-on care and was resistant to care. Both plans of care were developed on June 3, 2020. Review of Resident 8's clinical record including document titled Change in Condition, dated October 3, 2022 (6:57 p.m.), revealed the resident was observed with a bruise to the left forearm with a measurement of 6.5 x 4.0 cm. Interview with the Director of Nursing was conducted on December 7, 2022, at 1:00 p.m. The Director of Nursing reported the resident did not have documented falls or trauma. The DON confirmed the bruise observed on Resident 8's left forearm on October 3, 2022, was not investigated. An interview with the Nursing Home Administrator (NHA) was conducted on December 8, 2022, at 10:30 a.m. The NHA confirmed that the resident did not have falls/trauma before the discovery of the left forearm bruise. The NHA confirmed that Resident 8's left forearm bruise from an unknown source should have been investigated. The facility failed to ensure Resident 8's left forearm bruise (injury of unknown origin) was investigated. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18(a)(b)(3) Management Previously cited 11/23/21 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/23/21 28 Pa. Code 211.10(a)(c)(d) Resident Care Policies Previously cited 11/23/21 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 11/23/21

Based on clinical record reviews, staff, and resident interviews, it was determined that the facility failed to ensure the physician's order was followed for one of the 12 residents reviewed (Resident 9). Findings include: Review of Resident 9's diagnosis list revealed End Stage Kidney Disease (condition when your kidneys no longer work as they should to meet your body's needs). Interview with Resident 9 conducted on December 5, 2022, at 10:00 a.m., revealed that she/he goes to Hemodialysis (process of purifying the blood /remove toxins of a person whose kidneys are not working normally) every Monday, Wednesday, and Friday. The resident reported being picked up around 10:30 a.m. and returning to the facility around 2:00 p.m. Review of Resident 9's Physician's order sheet revealed an order for a Calcium Acetate capsule given 667 mg (milligrams) by mouth with meals. The medication was ordered to be administered at 8:00 a.m., 12:00 noon, and 5:00 p.m. Review of Resident 9's November and December 2022, Medication Administration Record (MAR) revealed the Calcium Acetate medication was not administered at noon on the following dates: November 18, 23, 25, 28, 30, 2022, and on December 2, 5, and December 7, 2022. Interview with the Director of Nursing was conducted on December 8, 2022, at 10:00 a.m., and revealed that the medication was missed on the days mentioned above due the resident was out of the facility for Hemodialysis. A clinical records review failed to reveal the attending physician was notified of the missed medication doses. The above information was conveyed to the NHA on December 8, 2022, at 10:30 a.m. The facility failed to ensure Resident 9's medication order was followed. 28 Pa. Code 201.18(a)(b)(3) Management Previously cited 11/23/21 28 Pa. Code 211.5(f) Clinical Records Previously cited 11/23/21 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services Previously cited 11/23/21

Based on clinical record review, observation, and review of documentation provided by the facility, it was determined that the facility failed to ensure adequate supervision was provided to prevent accidents for one of sixteen residents reviewed (Resident R12). Findings include: Review of Resident R12's clinical record revealed diagnoses of dementia (irreversible, progressive [CONDITION(S)] disease of the brain, resulting in loss of reality contact and functioning ability) and cerebral infarction (stroke). Review Resident R12's Quarterly Minimum Data Set (an assessment tool for resident care) dated June 23, 2021 revealed that Resident R12 requires extensive assist of two people for transfers. Review of a fall investigation report revealed that on June 27, 2021, Resident (R12) was getting in bed with the help of a CNA [nursing assistant] with the walker. CNA was moving the wheelchair closer to the back of the resident and they lost balance and hit the back of the right side of the head against the table. Review of the care plan interventions revealed that the two person assist for transfers was not updated until after the fall on June 30, 2021. Interview with the Director of Nursing and Nursing Home Administrator on November 23, 2021, at approximately 1:00 p.m., confirmed that Resident R12 did not receive adequate supervision to prevent accidents. 28 Pa. Code 201.18(a)(b)(3) Management 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(a)(c)(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on observation, review of the facility's policy and procedure, clinical records review, and staff interview, it was determined that the facility failed to ensure that the physician's order was accurately reflected on the resident electronic Medication Administration Record [REDACTED]. Findings include: A review of the facility policy and procedure titled General Dose Preparation and Medication Administration with a revision date of January 1, 2013, indicated, to confirm the Medication Administration Record [REDACTED]. An observation on February 4, 2020, at 12:05 p.m., revealed a medication bag hanging on an IV (IV- a therapy that delivers fluids directly into a vein) pole in Resident #191's room. The medication bag was labeled [MEDICATION NAME] (antibiotic) 1.25 grams (12.5 milliliters) in Sodium Chloride 9%, 250 milliliters, infuse [MEDICATION NAME] 1.25 grams (250 milliliter) intravenously over 90 minutes **infuse entire contents of bag**. Review of the physician's IV order sheet dated February 3, 2020, revealed an order of [MEDICATION NAME] 1.25 grams 1.25 gram/200 milliliters, administer 250 milliliters total (1.25 grams) for 5 days. An interview with licensed nurse Employee E3, on February 4, 2020, at 12:11 p.m., revealed that the [MEDICATION NAME] medication bag observed by the surveyor was administered to Resident #191 on the morning of February 4, 2020. A review of Resident #191's Electronic Medical Record (EMR) MAR indicated [REDACTED]. Further review revealed that the MAR indicated [REDACTED]. Review of the facility documentation dated February 4, 2020, revealed that the IV [MEDICATION NAME] order was clarified with the physician. The physician ordered [MEDICATION NAME] 1.25 grams daily for Resident #191, the order was faxed to the pharmacy and the pharmacy supplied 1.25 grams of [MEDICATION NAME]. The admitting nurse did not update the previous order of [MEDICATION NAME] one gram on the computer. A review of Resident #191's MAR indicated [REDACTED]. An interview with the Director of Nursing (DON) on January 6, 2020, at 12:30 p.m., confirmed that the physician's order of [MEDICATION NAME] 1.25 grams was incorrectly transcribed to the EMR MAR. Accuracy of Assessments CFR(s): 483.20(g) 28 Pa. Code 211.5(f) Clinical records 28 Pa. code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited: 3/27/19

Based on observation, review of the facility's policy and procedure, clinical records review, and staff interview, it was determined that the facility failed to follow the physician's orders [REDACTED].#191). Findings include: A review of the facility's policy and procedure titled Administration of an Intermittent Infusion, with the last revision date of May 1, 2016, revealed that the medication bag should be completely empty, but fluid remains in the drip chamber ensuring the complete dose is delivered. Clinical records review of Resident # 191 revealed that the resident was admitted to the facility on [DATE], with list of [DIAGNOSES REDACTED]. An observation on February 4, 2020, at 12:05 p.m., revealed a medication bag that was hanging on a pole in Resident #191's room, attached to a medication pump machine with a label that revealed [MEDICATION NAME] (antibiotic) 1.25 grams (12.5 milliliters) in Sodium Chloride 9%, 250 milliliters, infuse [MEDICATION NAME] 1.25 grams (250 milliliter) intravenously ( IV- a therapy that delivers fluids directly into a vein) over 90 minutes **infuse entire contents of bag**. Additional observation revealed a 50-milliliter solution was left in the [MEDICATION NAME] bag. Review of the physician order [REDACTED]. Interview with licensed nurse Employee E3, on February 4, 2020, at 12:11 p.m., revealed that the [MEDICATION NAME] medication bag observed by the surveyor was administered to Resident #191 on the morning of February 4, 2020. During the interview, Employee E3 confirmed that the [MEDICATION NAME] bag had 50 milliliters solution left in the bag . Employee E3 further stated that the IV infusion machine had indicated that the medication infusion was already completed but upon seeing that there were solutions left in the bag, she/ he was supposed to call the supervisor, but that did not happen. Review of Resident #191's February 2020 Medication Administration Record [REDACTED] An interview with the pharmacist on February 5, 2020, at 1:35 p.m., confirmed that the entire solution in the [MEDICATION NAME] bag should have been administered to the resident. The facility failed to follow the physician's orders [REDACTED].#191. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. 211.12(d)(1)(5) Nursing services Previously cited 3/27/19

Based on review of facility policy and procedure, review of manufacturer's guidelines and observation, it was determined that the facility failed to ensure medications were appropriately labeled with expiration dates in two of two medication carts observed. (Second Floor(NAME)Low Side Medication Cart and First Floor Medication Cart). Findings include: Review of facility policy and procedure titled Medication and Treatment - General Guidelines for Medication Administration/Assistance, revised (MONTH) (YEAR) revealed the medication label, pharmacy and manufacturer directions for each individual medication prescribed. Expiration dates should be checked on medications or treatments before administration. Review of manufacturer's guidelines for Latanoprost eye drops (medication used to treat [MEDICAL CONDITION]) revealed Latanoprost must be used within 6 weeks after opening the bottle. Discard the bottle and/or unused contents after 6 weeks. Review of manufacturer's guidelines for [MEDICATION NAME] eye drops (medication used to treat [MEDICAL CONDITION]) revealed [MEDICATION NAME] should be used within 28 days after the bottle is first opened. Review of manufacturer's guidelines for Humalog insulin (medication used to treat high blood sugar levels) revealed unopened Humalog should be stored in a refrigerator and opened and unrefrigerated Humalog must be discarded 28 days after removal from refrigerator. Observation on (MONTH) 24, 2019 at approximately 11:49 a.m. of the Second Floor(NAME)Low Side Medication Cart revealed two open and undated bottles of [MEDICATION NAME] eye drops and two open and undated bottles of Latanoprost eye drops. Observation on (MONTH) 24, 2019 at approximately 12:05 p.m. of the First Floor Medication Cart revealed one open and undated bottle of Latanoprost and one unopened, undated and not refrigerated vial of Humalog Insulin. The above-information was conveyed to the Director of Nursing on (MONTH) 27, 2019 at approximately 12:30 p.m. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.9(j) Pharmacy Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/29/17, 7/7/17, 5/11/18

Based on review of facility policy and procedure and observation, it was determined that the facility failed to maintain appropriate infection prevention and control standards during medication administration on one of two nursing units. (Second Floor Nursing Unit) Findings include: Review of facility policy and procedure titled Medication and Treatment - General Guidelines for Medication Administration/Assistance, revised (MONTH) (YEAR) revealed tablets and capsules should not be poured into the associate's hand or touched during the medicine pass. Observation of medication administration on the Second Floor Nursing Unit on (MONTH) 25, 2019 at approximately 8:30 a.m. revealed Licensed Employee E3 prepare medications to be administered to Resident #32. Licensed Employee E3 returned to the medication cart after attempting to administer medications to Resident #32 who had difficulty swallowing one of the pills. Further observation revealed Licensed Employee E3 return to the medication cart, put on a pair of gloves, remove the medication cart keys from employee's pocket, unlocked and opened the medication drawer, removed a pill splitter from the drawer and placed a new pill in the pill splitter with employee's hands while wearing the same pair of gloves. Further observation revealed Licensed Employee E3 remove the pill from the pill splitter with hands wearing the same pair of gloves and place the pieces of the pill in the medication cup. Observation of medication administration on the Second Floor Nursing Unit on (MONTH) 26, 2019 at approximately 8:30 a.m. revealed Licensed Employee E4 put on a pair of gloves, opened the medication cart drawer, sorted through the medication punch packs of pills belonging to Resident #4, punched the pills from the punch pack into a gloved hand and placed the pills into the medication cup while wearing the original pair of gloves. The above-information was conveyed to the Director of Nursing on (MONTH) 27, 2019 at approximately 12:30 p.m. 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 7/7/17 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services Previously cited 3/29/17, 7/7/17, 5/11/18

Based on observations and staff interviews, it was determined that the facility failed to ensure that dignity was maintained for residents on one of two units (Glen). Findings include: Observations on (MONTH) 8, (YEAR) at approximately 4:30 p.m. revealed residents getting seated for the dinner meal on the(NAME)dining room. One table of four, at approximately 4:55 p.m. first resident at that table received their entree and began eating while three other tablemates looked on. At approximately 5:15 p.m. (20 minutes after first person served) the second resident at that same table was served a bowl of mashed potatoes. The third resident, Resident R30 at the same table was served their entree at approximately 5:27 p.m. (32 minutes after first resident was served their entree). The fourth resident at the same table got their food at 5:30 p.m. Further observation revealed that the first resident had finished their dinner by 5:20 p.m. and asked for dessert at 5:30. Observations of dinner meal service on (MONTH) 8, (YEAR), at 5:05 p.m. on the(NAME)dining room revealed three residents at a table. Resident R8 was eating and Resident R24 received the dinner meal at 5:07 p.m. Resident R14 did not receive any food until 5:20 p.m. (15 minutes after the first resident was served). Additional observations of another table on (MONTH) 8, (YEAR), at 5:19 p.m. revealed Resident R39 was being assisted by staff with the dinner meal. At 5:29 p.m. Resident R27 asked where is my food?', Resident R27 was served at 5:30 p.m. Resident R16 did not receive any food until 5:35 p.m. (16 minutes after the first resident was served at the table). Observation on (MONTH) 8, (YEAR), at 5:21 p.m. revealed four residents at a table. Resident R6 was being assisted by staff with the dinner meal. Resident R29 received food at 5:26 p.m. and Resident R37 received food at 5:27 p.m. Resident R33 received food at 5:33 p.m. (12 minutes after the first resident was served). Observation on (MONTH) 8, (YEAR) at 11:45 a.m. Resident #24 was observed ambulating with walker on the unit, wearing a pink sweater. A label with her name printed on it was placed on the outside, upside down across the bottom of her sweater, which could be seen when she ambulated throughout the unit. Resident #24 wore the sweater all day (approximately 6 hours). This information was presented to the Nursing Home Administrator and Director of Nursing on (MONTH) 9, (YEAR), at 3:00 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management Previously cited 7/7/17

Based on observation, review of facility policies, and staff interviews, it was determined that the facility failed to use proper infection control techniques during administration of medications, while providing feeding assistance and during meal service on one of two units (Glen). Findings include: Review of facility's policy Handwashing and Hand Hygiene dated (MONTH) (YEAR), states handwashing should be done in the following situations, before and after eating or handling food, before and after asisting residents with meals. Observations conducted during the dinner meal on (MONTH) 8, (YEAR) at approximately 4:55 p.m. revealed that dietary servers took dirty dishes and cups off tables, rinse them at the sink, placed them in dirty bins then proceeded to pick up dinner plates and served it to residents. This continued through the entire meal time. If dietary servers were waiting on a plate of food to be plated up, they would walk around the(NAME)dining room clearing soiled utensils, cups, and dishes from tables without washing hands in between soiled and clean dinner plates. Continued observation in the(NAME)dining room revealed non-licensed staff, Employee E5 sat between two residents assisting with feeding them. Non- licensed staff, Employee E5 assisted with spoon feeding one resident to her left, wiping the resident's mouth with a napkin, and assisting with drinking from a cup going from one resident turning to another resident and assisting with eating, drinking, and wiping their mouth without washing hands in between feeding residents. While feeding these two residents, non-licensed staff, Employee E5 got up and went to set up a third resident with their meal tray. Employee E5 was not observed washing hands between assisting all three residents during the dinner meal. Observation conducted during the medication pass with licensed staff, Employee E3 on (MONTH) 9, (YEAR) at 8:16 a.m. revealed the administration of medications to Resident R31. Licensed staff, Employee E3 was observed installing one drop of the eye drop medication [MEDICATION NAME] 0.2%-0.%5 into the resident's left eye and then installing one drop into the right eye. While administering the eye drops the licensed staff, Employee E3 touched the resident's left eye with the tip of the eye drop bottle, then touched the right eye with the tip of the eye drop bottle. Immediately after installing the one drop into the resident's right eye Resident R31 hollered ouch! The aforementioned findings were reported to the Nursing Home Administrator and Director of Nursing on (MONTH) 9, (YEAR), at 3:00 p.m. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management Previously cited 7/7/17 28 Pa Code 211.12 (d)(1)(5) Nursing services

Based on observation, it was determined that the facility failed to provide privacy and confidentiality of residents personal and medical records on one of two nursing units during the medication administration observation (Glen). Findings include: During the medication pass observation with a licensed nurse Employee E3 on (MONTH) 9, (YEAR) at 8:02 a.m. the licensed nurse left Resident #36's personal and medical information up on the computer screen located on top of the medication cart. The medication cart was positioned in the lounge area. Employee E3 proceeded to walk away from the medication cart and across the lounge area into the medication room, which was approximately 75 feet away. The viewable screen was out of site and unattended by the licensed nurse. Several residents and staff members passed by the medication cart at the time of the incident, which was displayed publicly. During the medication pass observation with a licensed nurse Employee E3 on (MONTH) 9, (YEAR) at 8:06 a.m. the licensed nurse left Resident #31 personal and medical information up on the computer screen located on top of the medication cart. The medication cart was positioned in the lounge area. Employee E3 again proceeded to walk across the lounge area to take Resident #31 vital signs, then proceed to the nurses' station, which was approximately 75 feet away. The viewable screen was out of site and unattended by the licensed nurse. Several residents and staff members passed by the medication cart at the time of the observation where Resident #31's personal and medical information was displayed publicly. The aforementioned was discussed with Nursing Home Administrator and Director of Nursing on May 9, (YEAR) at 3:00 p.m. The facility failed to protect the privacy and confidentiality of Residents #36 and #31's personal and medical information. 28 Pa. Code: 201.18 (e)(1) Management 28 Pa. Code: 201.29 (j) Resident rights 28 Pa. Code: 211.5 (f) Clinical records Previously cited 3/29/17, 7/7/17

Based on clinical record review and staff interview, it was determined that the facility failed to conduct an accurate assessment of each resident's functional capacity of one of 12 residents reviewed (Resident #24). Findings included: Review of Resident #24's current physician's orders [REDACTED]. ankle and to check the device every shift. Review of the resident's active care plan revealed the use of a wander guard to be placed on right ankle. Resident #24 was observed on On (MONTH) 11, (YEAR) at 8:27 a.m. sitting at table in dining room with a wander guard on her right ankle. Review of Resident #24's quarterly Minimum Data Set (MDS- periodic assessment of care needs) completed (MONTH) 7, (YEAR) revealed under Section E title- Behavior Has the resident wandered? The facility coded that the behavior of this type (wandering) occurred 1 to 3 days. Further review of the quarterly MDS under Section P- Restraints and Alarms under Alarm, the facility coded Not used. Interview with Registered Nurse Assessment Coordinator (RNAC), Employee E4 on (MONTH) 11, (YEAR) at 10:30 a.m. confirmed that the quarterly MDS dated (MONTH) 7, (YEAR) was inaccurately coded under Section P Restraints and Alarms, and P0200. Alarms - Wander/elopement alarm. 28 Pa. Code: 211.5 (f) Clinical record Previously cited 3/29/17, 7/7/17

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive care plan for one of seven residents reviewed (Resident R20). Findings include: Review of Resident R20's [DIAGNOSES REDACTED]. Review of Resident R20's clinical record revealed nursing note dated (MONTH) 3, (YEAR) that the resident stated that, she would rather die than live feeling the way she feels. Review of Resident R20's nursing note dated (MONTH) 4, (YEAR) revealed that the resident communicated that she wishes to die. Additional review of the resident's clinical record revealed a physician's progress noted where Resident R20 stated to the nurse practitioner give me a gun and bullets. Review of Resident R20's current care plan revealed no plan of care developed for Resident R20's [MEDICAL CONDITION]. The aforementioned findings were reported to Director of Nursing and Administrator on (MONTH) 11, (YEAR) at approximately 3:30 p.m. 28 PA Code 211.5(f) Clinical records Previously cited 3/29/17, 7/7/17 28 Pa Code 211.11(d) Resident care plan Previously cited 8/9/16 28 Pa Code 211.12(c)(d)(3) Nursing services Previously cited 8/9/16, 3/29/17, 7/7/17

Based on observations, resident, and staff interviews, it was determined that the facility failed to post the most recent survey results in a readily accessible place and post notice of the availability of the most recent survey results on two of two nursing units. (Arbor and Glen) Findings include: During the group interview conducted on (MONTH) 9, (YEAR), at 10:30 a.m. Residents R4, R7, R8, R12, R15, R23, R24, and R36 were asked by the surveyor if they were aware where the most recent survey results were located. Residents R4, R7, R8, R12, R15, R23, R24, and R36 indicated that they were unaware of the location of the survey results. Observations on (MONTH) 9, (YEAR), at approximately 11:15 a.m. revealed the survey results were in a binder located by the conference room, through a set of doors from the(NAME)nursing unit. Further observations revealed no notice posted on the nursing unit as to the location of the survey results. Interview with the Nursing Home Administrator on (MONTH) 9, (YEAR), at 3:00 p.m. confirmed that there was no posting of the location of the survey results. 28 Pa. Code 201.18(b)(3) Management

Based on review of the clinical records and staff interviews, it was determined that the facility failed to assure that assessments were accurately completed for two out of 11 residents reviewed. (Residents: C3 and B8). Findings include: Review of Resident C3's annual assessment (a periodic review of the resident's identified care needs) dated November 30, 2016 revealed that the resident was coded in Section C- Cognitive Patterns (C0100) with a (1) stating that an interview should be conducted. The brief interview for mental status was dashed (-) for all answers. An interview with the RNAC (registered nurse assessment coordinator) Employee E3, on July 6, 2017 at 10:15 a.m. revealed that the annual assessment was incorrectly coded for the brief interview for mental status. Review of Resident B8's significant change assessment dated [DATE] revealed that Section C Cognitive Patterns was coded with dashes for all answers. An interview with the RNAC on July 6, 2017 at 10:15 a.m. revealed that the annual assessment was incorrectly coded for the cognitive pattern section. 28 Pa. Code: 211.5(f) Clinical records Previously cited 08/09/2016, 3/29/2017 28 Pa. Code: 211.12(d)(1)(5) Nursing services Previously cited 08/09/2016, 3/29/2017

Based on facility policy review, clinical record review, and staff interview it was determined the facility failed to follow physician's orders regarding as needed pain medication for two of 11 residents reviewed. (Residents B10 and C10) Findings Include: Review of facility policy, titled Pain Management, last revised on July 2015, revealed if a resident is having pain the level of pain is measured using a scale of 0-10: zero (0) being the least pain, and ten (10) being the most severe pain. For PRN (as needed) pain intervention identify the level of pain and document as indicated including the effectiveness. Review of Resident B10's [DIAGNOSES REDACTED]. The resident was admitted [DATE] for rehabilitation. Review of physician's orders dated May 20, 2017 revealed an order for [REDACTED]. Review of the physician's orders for Resident B10 dated May 23, 2017 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED] On the July 2017 Medication Administration Record [REDACTED].m for pain assessed at 5. Interview with the Director of Nursing on July 7, 2017 at 1:00 p.m. confirmed that nine times since admission, the resident's pain medication was not given according to the physician's order. Review of resident C10's physician orders revealed the resident had an order for [REDACTED]. Review of Resident C10's Medication Administration Record [REDACTED] June 11, 2017- pain level 10 June 15, 2017- pain level 3 June 16, 2017- pain level 10 June 17, 2016- pain level 8 June 18, 2017- pain level 7 June 21, 2017- pain level 10 Interview with the Director of Nursing on July 6, 2017 at 1:00 p.m. confirmed that Resident C10 had received as needed pain medication outside of the pain levels that were ordered by the doctor. 28 Pa. Code 201.18(b)(1) Management Previously cited 8/9/16 28 Pa. Code 211.5(f) Clinical records Previously cited 8/9/16 28 Pa. Code 211.10(a)(c)(d) Resident care policies Previously cited 8/9/16 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Previously cited 8/9/16

Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain effective infection control techniques during the medication pass for two out of 5 residents observed. (Resident A2 and A5) Findings include: Review of the facility policy entitled Handwashing/Hand Hygiene (last revised 10/2016) revealed that the facility considers hand hygiene the primary means to prevent the spread of infection. Hand hygiene procedures help prevent the spread of infections to other associates, residents and visitors. Use an alcohol based hand rub or, alternatively soap and water before and after handling medications. The use of gloves does not replace hand washing\hand hygiene. The medication pass was observed on the nursing unit on July 6, 2017 at approximately 8:20 a.m. Throughout the medication preparation and administration to Residents A5 and A2, licensed nurse, Employee E4 prepared the medication at the cart, administered the medication to the identified residents and returned to the cart to document without performing hand hygiene. During the medication pass for these residents, the nurse touched the medication cart, computer keys as well as donning gloves to assist Resident A5 with brushing her hair and performing a blood glucose check with a glucometer. Review of the facility policy entitled Cleaning Blood Glucose Meters (last revised 10/2016) revealed that the blood glucose meters are for multi-resident use and must be disinfected before and after each resident use with provided germicidal wipes. During observation of the medication pass on July 6, 2017 at approximately 8:20 a.m., Employee E4 removed the glucose meter from the medication cart and carried it to Resident A5's room without wiping it and placed it on a bedside table. After obtaining a blood glucose reading, Employee E4 returned the glucose meter to the medication cart without wiping it with the germicidal wipes provided for cleaning use. Interview with Employee E4 on July 6. 2017 at 10:00 a.m. confimed that hand washing between residents was not completed during the medication pass and after donning gloves for blood glucose testing and assisting a resident with personal hygiene. In addition, Employee E4 failed to disinfect the blood glucose meter before and after use. 483.80 F441 Infection Control Previously cited 8/9/2016 28 Pa. Code 211.10 (c)(d) Resident care policies Previously cited 8/9/2016 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 8/9/2016, 3/29/2017

Based on facility policy review, clinical record review, and review of facility documentation, it was determined that the facility failed to ensure that one of two residents reviewed was free of neglect during a transfer which resulted in actual harm to Resident CL1 who sustained a [MEDICAL CONDITION] femur (Resident CL1). Findings include: Review of the facility policy, Abuse, Neglect, & Exploitation Policy, last revised [DATE], defined neglect as, 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. Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set assessment (MDS - periodic assessment of resident needs) completed on [DATE], under Section G - Functional Status: G0110, Activities of Daily Living Assistance, revealed that the resident required extensive assistance for transferring with two person physical assist. Section G0300, Balance During Transitions and Walking, revealed that the resident was assessed as not steady and only able to stabilize with staff assistance for moving from a seated to a standing position and from surface to surface transfers. Review of the resident's care plan developed [DATE], revealed that for transfers, the resident required assist from two people using a mechanical lift (assistive device that allows a resident to be transferred between a bed and a chair or other similar resting places, using mechanical power). Review of nursing documentation dated [DATE], at 3:30 p.m. revealed that the Director of Nursing, Employee E2, was notified that there was bruising noted on the resident's left hip area under the resident's incontinence brief. The Director of Nursing assessed the resident and noted light purple bruising in the upper posterior left hip. The resident's left knee was noted to have a significant amount of swelling. The resident presented with facial grimacing and calling out when the left leg was touched. The resident's physician was notified and an X-ray was ordered to be obtained immediately. Review of the radiology report obtained [DATE], at 7:31 p.m. revealed a [MEDICAL CONDITION] distal femoral shaft (thigh bone). Review of the information dated [DATE], submitted by the facility revealed a statement obtained from a Nursing Assistant, Employee E3, that indicated that on [DATE], at approximately 4:00 p.m. the nursing assistant transferred Resident CL1 into the resident's Geri-chair (a large padded chair with wheels, designed for those with limited mobility) by himself using a stand-pivot technique. Employee E3 further stated that during the transfer, the resident's leg was caught in the chair, causing the resident's leg to bend up towards her stomach. Review of the findings of the facility investigation revealed that it was determined that by not following Resident CL1's plan of care and by not using a mechanical lift, Employee E3 caused the resident's injury of a fractured femur. Further review of Resident CL1's closed clinical record included Resident CL1's death certificate which revealed that the resident expired on [DATE], at 4:35 p.m. and that the left femur fracture was listed as a significant condition contributing to the resident's death. The facility failed to ensure that Resident CL1 was free of neglect by transferring the resident with one person physical assist instead of using a mechanical lift, as stated in the resident's plan of care, which resulted in actual harm when the resident sustained [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code 201.18(b)(1) ManagementPreviously cited [DATE], [DATE] 28 Pa. Code 211.10(d) Resident care policiesPreviously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited [DATE], [DATE]

Based on clinical record review and review of facility documentation, it was determined that the facility failed to ensure that one of two residents reviewed was transferred using a mechanical lift and assistance of two persons, which resulted in actual harm when the resident sustained [REDACTED]. Findings include: Review of Resident CL1's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS - periodic assessment of resident needs) completed on [DATE], under Section G - Functional Status: G0110, Activities of Daily Living Assistance, revealed that the resident required extensive assistance for transferring with two person physical assist. Section G0300, Balance During Transitions and Walking, revealed the resident was assessed as not steady and only able to stabilize with staff assistance for moving from a seated to standing position and from surface to surface transfers. Review of the resident's care plan developed [DATE], revealed that for transfers, the resident required assist from two people using a mechanical lift (assistive device that allows a resident to be transferred between a bed and a chair or other similar resting places, using mechanical power). Review of the nursing documentation dated [DATE], at 3:30 p.m. revealed that the Director of Nursing, Employee E2, was notified that there was bruising noted on the resident's left hip area under the resident's incontinence brief. The Director of Nursing assessed the resident and noted light purple bruising in the upper posterior left hip. The resident's left knee was noted to have a significant amount of swelling. Further review of nursing documentation dated [DATE], at 3:30 p.m. noted that, The resident was unable to lift her leg up and any light palpitation to the left leg knee resident called out and had facial grimacing. Resident was unable to bend her left leg. Limited range of motion present. Hospice (care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) Registered Nurse in house and evaluated resident. MD (physician) was notified immediately and instructed to obtain STAT (immediate) X-rays. Review of the radiology report obtained [DATE], at 7:31 p.m. revealed that the resident sustained [REDACTED]. Review of the information dated [DATE], submitted by the facility revealed a statement obtained from a Nursing Assistant, Employee E3 that indicated that on [DATE], at approximately 4:00 p.m. the nursing assistant transferred Resident CL1 into the resident's Geri-chair (a large padded chair with wheels, designed for those with limited mobility) by himself using a stand-pivot technique. Employee E3 further stated that during the transfer, the resident's leg was caught in the chair, causing the resident's leg to bend up towards her stomach. Review of the findings of the facility investigation revealed that it was determined that Employee E3 failed to follow Resident CL1's plan of care which directed the nursing staff to transfer the resident via a mechanical lift which contributed to the resident's sustaining an injury of a fractured femur. Further review of Resident CL1's closed clinical record included Resident CL1's death certificate which revealed that the resident expired on [DATE], at 4:35 p.m. and that the left femur fracture was listed as a significant condition contributing to the resident's death. These findings were presented to the Nursing Home Administrator and the Director of Nursing on [DATE], at approximately 1:00 p.m. The facility failed to ensure that Resident CL1 was provided with a two person physical assist using a mechanical lift during transfers, which resulted in actual harm to the resident by sustaining a fracture of the left femur and contributed to the resident's death. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE] 28 Pa. Code 201.18(b)(1) ManagementPreviously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(3) ManagementPreviously cited [DATE] 28 Pa. Code 211.11(d) Resident care plan Previously cited [DATE] 28 Pa. Code 211.12(c) Nursing servicesPreviously cited [DATE] 28 Pa. Code 211.12(d)(1)(5) Nursing servicesPreviously cited [DATE], [DATE]

Based on observations, review of clinical records, facility policy, and staff and resident interviews, it was determined that the facility failed to provide the necessary care and services to prevent and/or promote the healing of pressure ulcers resulting in actual harm to one of three residents reviewed with pressure ulcers (Resident C3) and failed to provide timely, accurate and appropriate pressure ulcer assessments for one of 11 residents reviewed (Residents C6). Findings include: Review of the facility policy and procedure entitled, Wound Observation and Pressure Ulcer Staging, last revised July 2015, revealed that all licensed nurses should follow established guidelines and protocols regarding the observing, describing of tissue, evaluating, measuring of the wounds and stagging of pressure ulcers. All pressure ulcers are measured weekly by the Director of Clinical Services or licensed designee. Document of all wounds and wound measurements on the Wound Evaluation Flow Sheet. The pressure ulcer data will also be entered on the Weekly Pressure Ulcer Summary and the medical record. Interview with the facility's Director of Nursing and Assistant Director of Nursing on August 4, 2016, at 1:00 p.m. confirmed that the facility's wound care management team included: Assistant Director of Nursing, Employee E3; Registered Dietician, Employee E7; Registered Nurse Assessment Coordinator, Employee E12 and a charge nurse. Employee E3 confirmed that the facility's wound care management team did not provide for a wound specialist who was wound care certified. Employee E3 confirmed that the wound team completed wound assessment rounds weekly, on a Wednesday. Employee E3 further confirmed that if a resident was documented with a change in skin condition or a new wound, other than on a Wednesday, Employee E3 would attempt to observe the skin or wait until the next scheduled weekly wound team rounds. Employee E3 confirmed that attempts are made to observe newly identified wounds as soon as possible, or during wound assessment weekly rounds; and revealed that the facility's regional corporation did not incorporate into its policy and procedure parameters for when the wound care management team should be assessing new onset wounds. Employee E3 confirmed that when a resident was observed with changes in skin, then licensed staff were to complete a Change in Condition report. This reporting would be accessible to Employee E3 on a daily basis, and was used for coordinating weekly wound rounds. Review of Resident C3's electronic clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], identified the resident with moderate cognitive impairment. Review of the Braden Scale (a tool utilize to assess the risk of developing pressure ulcers- an area of damaged skin caused by staying in one position for a long time, that commonly forms on the bony prominence of the skin) dated July 3, 2016, revealed that the resident was identified with a score of 17 placing the resident at mild risk for developing pressure ulcers (Braden assessment scale: 15-16 mild risk; 12-14 moderate risk; less than 12 high risk; 15-18 mild risk for individuals less than [AGE] years old). Review of the skin integrity reports completed from June 19, 2016, through July 3, 2016, revealed that the resident's skin was intact (no pressure ulcer noted). Review of the weekly wound data completed by Employee E3 on July 7, 2016, revealed that on July 4, 2016, the resident was identified with a deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or sheer) on the right heel measuring 2 cm (centimeters) by 2 cm and described as 100% dark red and purple in color; non blanchable (when skin loses redness with pressure; unblanchable skin does not), boggy and circular shape. It was further noted that the heels were to be floated when in bed. Review of a second weekly wound data record also completed by Employee E3 on July 7, 2016, revealed that on July 4, 2016, the resident was identified with a deep tissue injury on the left heel measuring 2 cm by 2 cm with a depth of 0.1 cm and 100% dark red and purple with a slight open towards the top 'slit' unable to visualize the wound bed due to 95% of wound being intact and that the resident's heels were to be floated when in bed. Review of the resident's plan of care initiated on July 5, 2016, revealed that the resident's pressure ulcer will show signs of healing and remain free from infection. Review of the interventions developed in the plan of care failed to include the recommendation noted on the wound data report for the resident's heels to be elevated (floated) when in bed. An interview conducted with the Director of Nursing on August 8, 2016, at 2:00 p.m. indicated that the intervention of elevation to the resident's heels was considered by the facility as a nursing measure and was included on the nursing assistant task list. Review of Resident C8 nursing assistant task list revealed that on July 5, 2016, the elevation of the resident's heels was added to the list. During interview with the Director of Nursing at the above stated time and date, the surveyor inquired if any interventions to elevate the resident's heels had been utilized to prevent the development of the heel pressure ulcers. Employee E3 provided a resident's Kardex (information provided to nursing assistant regarding the resident which include interventions in the areas of safety, transferring, dressing, resident care, bathing, personal hygiene, mobility and monitoring). Review of the resident's Kardex revealed that under resident care, the facility staff was to ensure that the resident's heels were floated on pillows when in bed and that heel boots were on while in bed. Review of Resident C3's electronic treatment administration records for June 2016 and July 2016 and the electronic tracking system (where nursing staff input the daily activities completed for the resident) failed to reveal any evidence that the resident was provided with heel boots while in bed and that the resident heels were floated on pillows to aid in the prevention of the development of skin breakdown of the resident's heels. The facility failed to ensure that the intervention of heel boots while in bed and the intervention of floating the resident's heels on the pillows were implemented prior to the development of deep tissue injury in each of the resident's heels, and thereby contributed to the development of deep tissue injuries to both heels, which resulted in actual harm to Resident C3. Observations conducted of Resident C8 on August 8, 2016, at 10:30 a.m. revealed that the resident was wearing non-skid socks and the resident's heels were resting directly on the foot rest of the wheelchair. Observations of the resident's heels in the company of Licensed Staff, Employee E16, on August 8, 2016, at 10:45 a.m. confirmed a dark color area on the resident's right heel and the left heel with a dark colored area on the center of the heel and an area described by Employee E16 as bluish in color surrounding the dark area of the left heel. Employee E16 indicated that the resident should have heel boots on at all times. The facility failed to ensure that interventions were in place to prevent skin breakdown to the resident's heels and resulted in actual harm to Resident C3 with the development of deep tissue injury on both of the resident's heels. Review of Resident C6's annual Minimum Data Set (MDS-assessment of care needs), dated June 22, 2016, indicated that the resident was severely cognitively impaired and required staff assistance for dressing, hygiene and bathing. Review of Resident C6's physician's orders revealed a verbal order dated June 14, 2016, at 5:13 a.m. received by Licensed Staff, Employee E11, to cleanse open area (no area was documented on the physician's order) with normal saline solution (sterile salt water solution) and apply Allevyn (absorbent foam) dressing every 72 hours every evening shift, every three days for wound healing until healed. Licensed Employee E11 failed to complete a Change in Condition report documenting when this open area was first identified by the staff and failed to provide for any further comprehensive assessment of the open area of the skin as per the facility's policy. Interview with Assistant Director of Nursing, Employee E3, confirmed on August 5, 2016, at approximately 1:30 p.m. that Employee E11 received the verbal physician's treatment order for Resident C6's open area on the left buttock on June 14, 2016, at 5:13 a.m. but there was no facility documentation in the form of a Change in Condition report that was received by Employee E3. Employee E3 also confirmed that Resident C6's open area on the left buttock was first identified by the facility staff, however, there was no further documented assessment of the open area on the left buttock until June 15, 2016, at 9:30 a.m. Review of the late entry nurses' note dated June 15, 2016, at 9:30 a.m. documented that Resident C6's skin assessment was performed and a open abrasion area was noted on the inner left gluteal area, irregular shaped, but this facility documentation on June 15, 2016, at 9:30 a.m. continued to fail to provide for measurements of the irregular shaped open area. Interview with Assistant Director of Nursing, Employee E3, on August 5, 2016, at approximately 1:30 p.m. confirmed that the wound management team did not assess Resident C6's open area on the left gluteal (buttock) until June 21, 2016, eight days later after first identified. Review of Resident C6's Weekly Wound Data Collection Flow Record dated June 21, 2016, in the presence of the Assistant Director of Nursing, Employee E3, confirmed that the open area on the left buttock was first identified on June 14, 2016, and the area now measured as a 1cm x 1 cm excoriated area. There was no documented evidence that measurements of the size of the open area were obtained when the open area was first identified on June 14, 2016. The facility failed to provide a complete assessment of Resident C6's open area on the left buttock with a full description of the open area on the skin including staging and measurements at the time of identification. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 09/29/15, 08/11/14 28 Pa. Code 211.5(g) Clinical records 28 Pa Code 211.12(d)(1)(5) Nursing services Previously cited 09/29/15, 08/11/14