Every finding on record at John J Kane Regional Center-Gl

Based on review of facility documents, the Pennsylvania Nursing Practice Act, incidents submitted to the local State Agency, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for ten of 43 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).Findings include: Review of the facility Nurse Assessment Coordinator job description indicated under the Duties and Responsibilities section, Performs other duties as requested or required. Review of the facility RN (Registered Nurse) Supervisor job description indicated an RN Supervisor, Accepts nursing assignments, as staffing needs require. Performs nursing duties as assigned, in accordance with facility policies and procedures. During an interview on 7/28/26, at 12:03 p.m. Staffing Specialist Employee E2 stated that during RN Employee E1's weekday schedule, she completes her Assessment Coordinator duties, but that all administrative registered nurses are required to pick up a weekend shift and work as the House Supervisor and complete the RN Supervisor job duties during that shift, not their Monday through Friday administrative position job duties. Review of a facility submitted document dated 7/14/26, indicated, On Sunday, July 12, 2026, from approximately 1930-2300, [Registered Nurse (RN) Employee E1], was assigned to unit 3B with a census of 43 residents, at that time. This employee did not pass any medications that were scheduled on that unit for the time frame cited. *Update: [RN Employee E1] was the assigned supervisor for the 3-11 shift due to call offs she was directed that she would need to take on a resident assignment. Upon the NHA (Nursing Home Administrator) coming into work on Monday, July 13, 2026, and reviewing the weekend staffing sheets it was determined that she had not written down the staffing changes and unit 3B had no nurse assigned. The staffing coordinator began to work on figuring out where each of the nurses had worked. Camera footage showed that the daylight nurse had stayed over til 7:44 pm and that [RN Employee E1] had arrived on 3B around 7:36pm and at that time had put the med cart away and it was not taken back out the remainder of the shift. [RN Employee E1] was seen on camera at the nurses station on the unit. A review of documentation, MARS, and TARS revealed that the daylight nurse had passed all medications for the unit prior to leaving except for one eyedrop for [Resident R1] that was due from 8p-9p. However, multiple residents had missing treatment orders and no residents had documentation regarding behaviors completed. Documentation review is still ongoing. Review of an electronic communication dated 7/14/26, written by Security Employee E3, indicated, I reviewed camera footage on July 12, 2026 on 3p-11p shift and did not see [RN Employee E1] working on any Med cart on any floors. She was at the table in mid lobby from 3p-4p, then went to office on 2A-203, then wen to 3B bubble at 7:30p.m. Noticed her talking to [LPN Employee E4] working on Med cart on 3B, at 7:36 p.m. [LPN Employee E4] put med cart away in Med room and it never came out for the erst of the shift and she left the day. The Guard let [RN Employee E1] in Pyxis (medication dispensing machine room) at 9:13 p.m. then she went back up to 3B-Bubble until her shift was over. Review of a statement written by the Nursing Home Administrator on 7/14/26, indicated, At 4:42 p.m. I sent her a text message 'We put out bonuses for agency staff but you must take a cart until someone else comes in just to ensure that she was clear on the directive. I did not hear back from her the rest of the evening. Review of Medication Administration Records for Unit 3B, for 7/12/26, evening medications and treatments, revealed the following;-Resident R1 did not receive their eye drops to treat glaucoma (a group of eye conditions that can cause blindness).-Resident R2 did not receive their ointment for dry skin.-Resident R3 did not receive their ointment for dry skin.-Resident R4 did not receive their ointment for dry skin.-Resident R5 did not have their security bracelet checked for functionality.-Resident R6 did not receive their scheduled skin assessment.-Resident R7 did not receive their scheduled skin assessment.-Resident R8 did not receive their muscle rub.-Resident R9 did not receive their ointment for dry skin or their scheduled pain assessment.-Resident R10 did not receive their ordered blood sugar check. During an interview on 7/29/26, at approximately 12:00 p.m. the Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to ensure care and services were provided in accordance with professional standards for ten of 43 residents. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, facility provided documents and clinical records, and staff interviews, it was determined that the facility failed to protect residents from abuse and neglect which resulted in actual harm of a fracture of the right tibia (lower leg bone) for one of four residents (Resident R86). This deficiency is cited as past non-compliance.Findings include: Review of the facility policy, Abuse-Resident and Reasonable Suspicion of a Crime dated 6/13/26, and previously reviewed 6/30/25, indicated the facility is to treat every resident with consideration, respect and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property programs. This policy also provides direction to staff regarding procedures required to protect residents from abuse, to respond appropriately to allegations, to satisfy reporting and notifications obligations, and to conduct investigations. For purpose of this policy staff include facility employees, practitioners, consultants, contractors, volunteers, and students who provide care and services to residents in the facility. Review of the facility policy, Accident Prevention dated 6/13/26, and previously dated 6/30/25, indicated [NAME] Community Living Centers will prevent accidents and injuries to the extent possible by maintaining as much as possible, an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. To safeguard all residents and employees, the facility reserves the right to discharge any residents who willfully and/or repeatedly disregards facility rules and places his/herself and others in danger. Review of the admission record indicated Resident R86 was admitted to the facility on [DATE]. Review of Resident R86's Minimum Data Set (MDS-a periodic assessment of care needs) dated 5/28/26, indicated the diagnoses of high blood pressure, vascular dementia (decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain, depriving it of vital oxygen and nutrients), muscle weakness, and cognitive communication deficit (impairment in communication caused by disrupted brain functions like attention, memory, and executive functioning, rather than a primary speech or language disorder). Section GG0170-Mobility: (Roll left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer) is coded as 01, (01-indicating dependent), Walk 10 feet is coded 09, (09-Not applicable-not attempted and resident did not perform this activity prior to current illness, exacerbation, or injury) Functional Abilities-utilizes a wheelchair. Review of Resident R86's care plan initiated 3/20/25 (1), and updated 5/18/26 (2) indicated: -Focus (1): Resident will have all necessary assistance with ADL's-may move around the facility without supervision but may not exit the facility without supervision. -Focus (2): Bruising bilateral lower extremities, swelling lower right ext. will resolve, fracture of right tibia will not worsen. Resident R86 placed on bed rest, Hoyer for all transfers with two caregivers. Review of an incident note dated 5/18/26, at 1:40 p.m. indicated Resident R86 presented with bruising and swelling to the right lower extremity. Bruising was documented on 5/16/26 on the 3-11 shift. CCTV (closed circuit television) review for 5/15/26, 3-11 shift showed agency nurse aide (NA) pulling Resident R86 who was caught in the doorway out. When NA attempted to push her in the doorway forcefully, Resident R86's right foot got caught on the doorframe striking her right shin then her left shin, then the NA pushed her through the doorway. Review of progress notes revealed no notes from 5/15/26, and 5/16/26. Review of progress notes from 5/17/26, at 11:35 a.m. documented bruise noted to right shin, area appears dark purple/green in color. RN Supervisor notified. Resident remains monitored for changes in condition, will continue to monitor closely and notify RN Supervisor of any further changes. Review of progress notes from 5/18/26, at 12:14 p.m. documented It was reported to writer from CNA that resident refused care d/t (due to) right leg pain. Upon assessment, Right leg is noted to be bruised and swollen, painful to touch, Supervisor aware, phoned ADON (assistant director of nursing), Vitals taken. Review of progress notes from 5/18/26, at 12:40 p.m. documented Spoke at length to grandson regarding the bruising noted to both lower extremities and the swelling noted to the right leg. Unable to perform any type of ROM (range of motion) check at this time as resident yells out and swings at this nurse. Skin temperature is consistent from upper leg to lower leg including foot. Call placed to doctor; he ordered x-rays at this time. Grandson aware and in agreement with x-ray of right hip, femur and tibia/fibula. He would like to be called with results when available. Doctor also ordered new pain meds. Review of an X-Ray report from 5/18/26, at 8:52 p.m. revealed there is an acute mildly displaced spiral fracture below the level of the tibial prosthetic stem. There is evidence of total knee replacement with intact femoral and tibial components in anatomic alignment. There is no radiographic evidence of loosening or particle disease. The bony mineralization is moderately decreased. There is no joint effusion. Review of progress notes from 5/19/26, at 11:44 a.m. documented Spoke with M.D. after he spoke with grandson, grandson agreed to hospice and chose a provider for possible splinting and pain control. Bed rest for 1 week due to pathological fx (fracture). right tibia, Hoyer transfers for future transfers. Review of Workplace Investigation-Employee/Witness Statement Form dated 5/19/26, indicated that Nursing Aide (NA) Employee E1 neglected to follow facility recommended safety measures, and was terminated from her employment. Review of multiple Workplace Investigation-Employee/Witness Statement Form signed and dated from 5/18/26, through 5/19/26 revealed other employees that had seen bruising on bilateral legs after 5/15/26. Review of facility submitted information dated 5/20/26, indicated Resident R86 presented with bruising and swelling to right lower extremity on 5/18/26, at 12:40 p.m. This deficiency is cited as past non-compliance.On 5/18/2026, at 1:00 p.m. the facility initiated a plan of correction that included: -The resident involved was immediately assessed when change in condition was noted on 5/18/2026, at 12:40 p.m., appropriate medical evaluation and monitoring were conducted, portable x-ray ordered and obtained, resident did not leave the facility. -The involved agency staff member was placed on the Do Not Return list at all four [NAME] facilities. -The incident was immediately investigated by the Director of Nursing and the Nursing Home Administrator. -An in-service education program was conducted by the Staff Development Coordinator with all direct care and ancillary staff addressing the facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. Nursing-All residents were audited for any type of abuse at the time of the investigation with audit completed on 5/20/2026, at 1:00 p.m., the Director of Nursing confirmed via verbal report to the Nursing Home Administrator. -All staff were re-educated on policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS Abuse Critical Element Pathway. -Education signature sheets were reviewed with staff signatures for 119 of the facility's total 126 employees by 5/28/26. -Weekly observation audits conducted to observe compliance with wheelchair transport safety. Results on file with the Nursing Home Administrator reviewed and intact. -The Director of Nursing or designee will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any alleged violations are identified, properly investigated and reported according to facility policy and procedures. -Resident Interview and Observation Audits communicated and provided to QAPI (Quality Assurance and Performance Improvement) Committee. The facility was back in compliance on 5/28/26. During an interview on 7/7/26, at 11:10 a.m., NA Employee E2 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. During an interview on 7/7/26, at 11:10 a.m., NA Employee E3 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. NA Employee E3 also discussed that they received training on transferring residents at the same time. During an interview on 7/7/26, at 11:10 a.m., NA Employee E4 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. During an interview on 7/7/26, at 11:10 a.m., NA Employee E5 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. NA Employee E5 also discussed that they received training on transferring and wheelchairs, due to the incident. During an interview on 7/7/26, at 11:10 a.m., Licensed Practical Nurse (LPN) Employee E6 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. During an interview on 7/7/26, at 11:10 a.m., Licensed Practical Nurse (LPN) Employee E7 confirmed that training was provided regarding facility policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS abuse critical element pathway. Interviews with six of six facility staff present on 7/7/26, indicated they received education on policies and procedures regarding alleged violations, injuries of unknown origin, and the CMS Abuse Critical Element Pathway. During an interview on 7/8/26, at 8:45 a.m. the Nursing Home Administrator confirmed the facility failed to protect residents from abuse for one of four residents that resulted in actual harm of a fracture of the right tibia, which was identified by the surveyor as past non-compliance for Resident R86. 28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b) (1)(3) Management.28 Pa. Code 211.10(d) Resident Care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on staff interviews it was determined that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 of 12 months (June 2025 through July 2026). Findings include:During an interview on 7/6/26, at approximately 9:46 a.m., the Dietary Supervisor Employee E12 stated that he was the manager and was not certified.During an interview on 7/6/26, at 9:50 a.m., Registered Dietician Employee E13 stated that she works 4 days a week and is clinical only does not manage the dietary department.During an interview on 7/6/26, at approximately 9:50 a.m., the Nursing Home Administrator confirmed that the facility currently does not have a Certified Dietary Manager failed to provide documented evidence that any staff met the qualifications for the position of Food Service Director.Pa Code: 201.18(e)(6) Management.Pa Code: 211.6(c)(d) Dietary Services.

Based on observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen). Findings include:During an observation of the kitchen on 7/6/26, from 9:32 a.m., through 9:46 a.m., the following was observed:The deep freezer had food stored under pipes to fans with ice buildup attached to boxes of food items and dripping into food items underneath. A ham loaf and two other meat packages were not sealed and exposed.The dry storage area had drawers of cereals that were unsealed and could allow for rodents.A can of foam cleanser was on a food prep table with food items. Next to this was a table with multiple rotten/black bananas.The toaster area had a pan of melted butter left uncovered and allowed for potential cross contamination.A cart had a bag of buns on the bottom touching the floor.Dietary Supervisor Employee E12 entered the kitchen with no hair restraint or beard guard.During an interview on 7/6/26, at approximately 9:45 a.m., Dietary Supervisor Employee E12 confirmed that the facility failed to maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.6(b)(c)(d) Dietary services.

Based on observation and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpster to prevent the potential for rodent and insect infestation. Findings include:During an observation and interview of the facility's outdoor trash receptacle on 7/6/26, at approximately 9:46 a.m., with the Nursing Home Administrator, confirmed that there is no lid/cover for the facility dumpster, and it was overflowing with garbage and that the facility failed to properly contain and dispose of garbage in the outside trash receptacle to prevent the potential for rodent and insect infestation.28 Pa. Code 201.18(b)(3) Management.

Based on observation and staff interviews it was determined that the facility failed to provide a dignified dining experience for two of four residents (Resident R16 and R118). Findings include: Review of the facility policy Feeding Program, dated 6/13/26, with a previous review dare of 6/30/25, indicated that residents are fed in a therapeutic and dignified manner. During an observation on 7/6/26, at approximately 11:45 a.m., Resident R16 was seated at a table with two other residents, one resident was being assisted with her meal by Nurse Aide Employee E8 and the other fed herself. Resident R16 was not fed until the other resident was done at approximately 12:05 p.m. During an observation on 7/6/26, at approximately 11:45 a.m., Resident R118 had received his tray and staff continued to pass trays in dining room. Resident was at a table with another resident who fed himself. Resident R118 was not assisted with his meal until 12:05 p.m., after another resident at another table was finished being assisted by Registered Nurse Employee E9. During an interview on 7/6/26, at 12:05 p.m., Nurse Aide Employee E8 stated that there are only two staff in room and have four feeds. Confirmed that the facility failed to provide a dignified dining experience for Residents R16 and R118. 28 Pa. Code 211.10(a)(c)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a condom urinary catheter (a condom placed over the penis to drain urine) for one of four residents using catheters (Resident R197).Findings include: Review of the facility Catheters Care and Drainage dated 6/3/26, with a previous review date of 6/30/25, indicated the purpose of this procedure is to provide staff with instructions to safely and appropriately provide hygiene, monitor output and minimize the growth and transmission of pathogens for residents with urinary catheters. Nursing provides bathing/hygiene per resident care standards. Male residents' genitalia are cleansed, and foreskin is retracted and meatus is wiped rinsed pat dry and replaces foreskin. Staff are to document all care and services provided for residents.Review of the admission record indicated Resident R197 was admitted on [DATE], with diagnoses which included a stroke, contractures, cognitive communication deficit, kidney disease, chronic sacral ulcers. A condom catheter was placed on 2/6/26, to attempt to assist in healing sacral ulcer due to bladder incontinence.Review of Resident R197's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/5/26, indicated the diagnoses remained current.Review of Resident R197's current physician orders did not include identification of use of the condom catheter or care that needed provided.Review of Resident R1's current care plan indicated to check for patency, urinary output and skin for breakdown through review date.Review of an incident report dated 6/2/26, identified Resident R197 had developed a laceration of his penis measuring 7 cm when the condom catheter became dislodged.Review of the clinical documentation did not include care, checking skin, changing catheter, etc. from 3/28/26, through 5/31/26, when the condom catheter became dislodged. During an interview on 7/6/26, at 1:26 p.m., the Nursing [NAME] Administrator confirmed that documentation did not include catheter care, changing of catheter or skin assessments being completed from 3/28/26, through 5/31/26. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(c)(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.

Based on review of facility policy, clinical records, review of facility provided documents and staff interview, it was determined that the facility failed to conduct a thorough investigation to rule out the potential for abuse/neglect for one of four residents (Resident R197).Findings include:Review of the facility policy, Abuse-Resident and Reasonable Suspicion of a Crime dated 6/13/26, and previously reviewed 6/30/25, indicated [NAME] Community Living Centers are to treat every resident with consideration, respect and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property programs. This policy also provides direction to staff regarding procedures required to protect residents from abuse, to respond appropriately to allegations, to satisfy reporting and notifications obligations, and to conduct investigations. For purpose of this policy staff include facility employees, practitioners, consultants, contractors, volunteers, and students who provide care and services to residents in the facility.Review of the facility policy, Accident Prevention dated 6/13/26, and previously dated 6/30/25, indicated [NAME] Community Living Centers will prevent accidents and injuries to the extent possible by maintaining as much as possible, an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. To safeguard all residents and employees, the facility reserves the right to discharge any residents who willfully and/or repeatedly disregards facility rules and places his/herself and others in danger.Review of the facility policy Incident Report, dated 6/13/26, with a previous review date of 6/30/26, indicated [NAME] Community Living Centers will report and investigate any unusual incidents involving residents. Review of the clinical record indicated Resident R197 was admitted to the facility on [DATE], with diagnoses which included a stroke, contractures, cognitive communication deficit and non-healing pressure ulcers of buttocks and coccyx. Resident R118 had a condom catheter in place to decrease moisture to assist in prevention of worsening coccyx/buttocks wound healing. During a review of an incident dated 6/2/26, at 6:04 a.m., Resident R197 had a 7cm laceration of his penis from the condom catheter. The condom catheter was discontinued and an order for a treatment was applied. Review of the clinical record indicated that on 5/31/26 at approximately 10:10 p.m., that the Nurse Aide caring for Resident R197 had identified that his urine output was low and that the condom catheter became dislodged during the assessment. The Nurse Supervisor had the LPN reapply a new condom catheter at approximately 1:44 a.m., according to documentation. Review of the facility provided documentation of the incident did not include a full investigation or statements from staff in an attempt to identify the root cause of the laceration to rule out the potential for abuse/neglect. During an interview on 7/6/26, at approximately 1:26 p.m., the Nursing Home Administrator confirmed that the facility failed to complete a thorough investigation to rule out the potential for abuse/neglect for Resident R197. 28 Pa Code: 201.29 (a)(c) Resident Rights.28 Pa Code: 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on review of facility policy and clinical records it was determined that the facility failed to notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) and for change in physical assessment for three of 14 residents (Resident R 3, R11, R137).Findings include:The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy Emergency Care Guidelines: Hypoglycemia Protocol reviewed 6/13/26, and previously reviewed 6/30/25, indicated the facility will provide for timely initiation of emergency treatment for an acute hypoglycemic episode utilizing specific protocols approved by the Medical Director. The facility does not currently have a policy for Hyperglycemia and refers to the orders that the medical director orders for parameters. Review of the facility policy All Policy and Procedure General Guidelines reviewed 6/13/26, and previously reviewed 6/30/25, indicated staff will document all care and services provided to the resident. Documentation should: Be accurate, timely, and reflect the resident's status and condition. Include the rationale for decisions made, including risks and benefits. Include Resident's participation in decisions and tolerance to procedures. Include identification, evaluation, intervention, and attempts made to implement and revise the plan of care to address the changing needs of the resident. Include notification of Resident Representative, Practitioner, Nursing Management, and/or appropriate parties. Only to be completed on facility approved forms. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's Minimum Data Set (MDS-a periodic assessment of care needs) dated 4/9/26, included diagnoses of high blood pressure, diabetes (chronic condition where the body cannot properly process blood glucose), cerebro- vascular accident (occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), dementia (decline in cognitive abilities-such as memory, thinking, and reasoning-that is severe enough to interfere with daily life). Review of the physician's orders dated 5/3/26, indicated to inject Lantus (long acting insulin-controls blood glucose for 24 hours without peaking) 30 units at bedtime. Other insulin orders dated 3/20/26 for Novolog (fast-acting insulin tht starts to work about 1 to 2 hours after injection and keeps working for up to 22 hours) inject 6 units with meals, Novolog Sliding scale is extra insulin given depending on glucose readings. Review of the clinical record Electronic Administration Record (eMAR) revealed that the residents' CBG's were as follows:1/3/26: 707/1/26: 67 Review of Resident R3's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R137 was admitted to the facility on [DATE]. Review of Resident R137's Minimum Data Set (MDS-a periodic assessment of care needs) dated 6/19/26, included diagnoses of high blood pressure, diabetes, muscle weakness, and cognitive communication deficit (impairment in communication caused by disrupted brain functions like attention, memory, and executive functioning, rather than a primary speech or language disorder). Review of the physician's orders dated 7/12/25, indicated check blood sugars as needed for S/S of hypo or hyperglycemia, if over 350, cover per order, recheck in 4 hours, if still 350 call MD. On 2/23/26, order indicates to obtain post-prandial blood sugar. On 7/12/25, order indicates to obtain fasting blood sugar every A.M. Orders dated 2/23/26 indicate to give Novolog 25 units with breakfast and lunch, also Novolog is to be used as a sliding scale for extra coverage. Review of the clinical record eMAR revealed that the residents' CBG's were as follows:1/1/26: LOW3/26/26: 4324/3/26: 4526/27/26: 0 Review of Resident R137's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE]. Review of Resident R11's MDS dated [DATE], included diagnoses of high blood pressure, Alzheimer's disease (slowly destroys memory and thinking skills by abnormally building up plaque in the brain which then kills off nerve cells), seizure disorder (sudden abnormal electrical activity in the brain, leading to symptoms ranging from twitches to loss of consciousness), muscle weakness. Review of the clinical record revealed on 6/1/26, it was documented that nursing support staff was notified of a bruise to left eye, the doctor was also notified. No documentation as to how the resident received the bruise was made. On 6/2/26, documentation was made to continue to monitor the bruise to left brow, point of origin unknown. On 6/3/26, at 12:32 a.m. documentation states that the resident does not have a L eye bruise present. On 6/3/25, at 2:36 p.m. documentation states to continue to be monitored r/t bruise to left brow point of origin unknown. The bruise continues to be mentioned until 6/5/26, and then no further mention of the bruise occurs or if it has resolved. During an interview on 7/7/26, at 8:45 a.m. the Nursing Home Administrator confirmed the facility failed to notify the doctor of a change in condition related to blood glucose for Residents R3 and R137 and failed to document accurately for Resident R11. 28 Pa. Code 201.18 (b)(1) Management.28 Pa. Code 201.29(d) Resident Rights.28 Pa. Code 211.1(c)(d) Resident Care policies.28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

Based on resident observation and staff interview it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R239).Findings include: During an observation on 7/7/26, from 6:54 a.m., through 7:02 a.m., there was Licensed Practical Nurse (LPN) Employee E10 and the 2A clerk on the nursing unit observed. Resident room [ROOM NUMBER]-bathroom call light was illuminating (Resident R239's room). During an observation on 7/7/26, at 7:03 a.m., Resident R239 had ambulated from the bathroom to bed by herself and stated she got tired of waiting for help. When LPN Employee E10 went to assist her as there were no other staff on the unit. Review of Resident R239's plan of care identified that she required assistance of two staff for ambulation and toileting. During a review of 11p-7a staff out punches identified: one NA punched out at 6:48one NA punched out at 6:58 a.m.two others punched out with supervisor at 7amthe first NA for 7-3 shift was observed on the unit at 7:02 a.m. During an interview on 7/7/26, at approximately 7:10 a.m., Nursing Supervisor Employee E11 stated the second nurse for the 2A unit was on 2B charting and no other staff were on unit. During an interview on 7/7/26, at approximately 11:00 a.m., the Nursing Home Administrator confirmed that that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of three residents (Resident R239). Staff should remain on nursing unit until their relief is present. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development.28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.

Based on the review of professional standards of practice, facility policy, clinical record review and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of pressure ulcers that resulted in hospitalization for the treatment of wounds. This resulted in actual harm for two of three residents with facility-acquired pressure ulcers. (Resident R15 and Resident R2).Findings include: Review of the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the Pressure Ulcer Best Practice Bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to address the areas of risk. Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning, and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement, and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of the facility policy Wound Care - Pressure Ulcer / Injury Prevention, dated 1/22/26, indicated it is the facility's policy to ensure resident's receive care to prevent pressure ulcers/injuries, residents do not develop pressure ulcers unless the clinical condition demonstrates that they were avoidable, and residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Review of the clinical record indicated Resident R15 was admitted to the facility on [DATE]. Review of Resident R15's Minimum Data Set (MDS -periodic assessment of resident care needs) dated 4/7/26, included diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of Section GG: Functional Abilities indicated Resident R15 required Substantial assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to roll left and right, to move from a sitting to a lying position, to transfer between a chair and the bed, and indicated that Resident R15 was Dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity) on staff from moving from a lying position to a sitting position and moving from a sitting position to a standing position. Review of Section M: Skin Conditions, indicated Resident R15 did not have any pressure injuries at the time of the assessment. Review of Resident R15's Functional Abilities Assessment dated 4/6/26, indicated that Resident R15 required assistance to roll left and right and to move from a sitting to a lying position. The remainder of the mobility portion of the assessment was documented as, Not attempted due to medical condition or safety concerns. Review of Resident R15's Pressure Sore Risk assessment dated [DATE], indicated that Resident R15's ability to change and control body position was slightly limited. This is contradictory to the Functional Abilities Assessment also completed on 4/6/26. Review of Resident R15's admission Observation dated 4/6/26, indicated that Resident R15 had no skin alterations upon admission. Review of the plan of care dated 4/6/26, for Potential for Alteration in Skin Integrity indicated that staff should assist with weight position changes throughout the day and night. Review of a physician order dated 4/6/26, indicated that Resident R15 should have a Braden Observation weekly, for four weeks. Review of Resident R15's clinical record revealed no documentation for a Braden Observation on 4/13/26, and 4/20/26. Review of a physician order dated 4/6/26, indicated that Resident R15 should have a skin assessment completed on shower days, and for staff to chart any abnormalities in GPN (general progress notes). Document any abnormalities including skin integrity, circulation, and repositioning ability. Review of physician orders dated 4/6/26, indicated that Resident R15 required two-person assist for bed mobility, dressing, grooming, bathing, toileting, and transferring. Review of Resident R15's point of care history indicated that from 4/6/26, through 4/26/26, Resident R15 was assisted to change position eight times, by Nurse Aide Employee E1. No other documentation was present to indicate that other staff assisted in repositioning for Resident R15. Review of Resident R15's bathing record revealed that bathing was documented on 4/24/26, at 1:15 a.m. and at 10:35 p.m. Review of Resident R15's Medication Administration Record for April 2026, indicated that the ordered weekly skin assessment with shower was completed on Friday, 4/24/26, by Licensed Practical Nurse (LPN) Employee E2. Review of progress notes failed to reveal documentation that a skin alteration was identified. Review of facility staffing information revealed that LPN Employee E2 care for Resident R15 on day shift from 6:56 a.m. through 3:35 p.m., and was not present on either bathing time documented on 4/24/26. Review of a progress note dated 4/26/26, at 10:14 a.m. indicated, CNA (nurse aide) reports open area on resident's coccyx area is reddened and size of a fist, slight odor noted to wound, wound needs assessed by wound nurse for treatment orders, RN (registered nurse) to assess. Review of a Observation Detail List Report dated 4/26/26, at 11:44 a.m. indicated Coccyx breakdown, area measured at 10cm across 9 1/2 cm across, unopened area cleansed with soap and water, barrier cream applied and covered with optifoam (silicone foam) dressing. Review of a progress note dated 4/27/26, at 9:24 a.m. indicated that, MD (doctor of medicine) and EC (emergency contact) notified of area on coccyx, will update with treatment ordered by wound nurse. Review of a nurse practitioner's order dated 4/28/26, indicated, Cleanse with wound cleanser, pad dry, apply large foam dressing. Change daily. Review of wound nurse practitioner's note dated 4/29/26, at 5:29 p.m. indicated Resident R15 had new onset wounds discovered during care on 4/25/26. The assessment indicated: Wound #1 Sacral is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 4/25/26, and has received a status of Not Healed. Initial wound encounter measurements are 8 cm length x 8.7 cm width x 0.1 cm depth. There was no drainage noted. Wound bed has 91-100% eschar (thick, dry layer of dead, necrotic tissue that forms over severe skin injuries). Wound #2 Left Heel is an acute Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer acquired on 4/29/26, and has received a status of Not Healed. Initial wound encounter measurements are 5.6 cm length x 5.6 cm width with no measurable depth. There was no drainage noted. Wound bed has 91-100% epithelialization (the process of repairing surface defects in skin and tissue damage). Review of a progress note dated 5/3/26, at 4:20 a.m. indicated that Resident R15 was sent to the emergency room. Further review of Resident R15's progress notes failed to reveal any further assessments of Resident R15's condition after the wound nurse practitioner report documented on 4/29/26. Review of a progress note dated 5/4/26, at 2:51 p.m. indicated that the hospital provided information that Resident R15 was about to get surg (surgery) and wound debridement. Review of a hospital note dated 5/3/26, at 8:43 a.m. indicated, Called next of kin. [Family member] was not aware pt (patient) was at the hospital. Gave update and informed [family member] pt will be admitted to ICU (Intensive Care Unit). Review of the hospital history and physical dated 5/3/26, indicated: Over the last 3-4 days SNF (skilled nursing facility) staff noted progressive altered mental status. EMS found him hypotensive (low blood pressure) and warm to touch and transported him to the ED (emergency department). There is high concern for malnutrition and dehydration and possible inadequate care at the SNF, as described by family and suggested by clinical course. General surgery performed bedside debridement of a sacral wound Currently minimally responsive to verbal stimuli (only yes/no). [family member] confirms this is a new change from baseline 2 weeks ago. Review of a hospital note dated 5/4/26, at 3:08 p.m. indicated, Spoke with RN (registered nurse) at [facility] about patient wounds, RN stated patient was admitted to them with wounds noted in initial admission assessment. This note is contradictory to what was documented upon admission to the facility. Review of a hospital note dated 5/6/26, at 6:43 p.m. indicated that Resident R15 was treated for multiorgan dysfunction, septic shock, and soft tissue infection. Received a Sharp debridement (removal of dead tissue, slough (soft, moist, dead tissue that accumulates in a wound bed), or eschar using a scalpel or scissors) of sacral decubitus ulcer (pressure ulcer at the base of the backbone). Measurements 9cm x 9cm x 3.5 cm. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and hypertension (high blood pressure). Review of Section GG: Functional Abilities indicated Resident R2 was Dependent on staff to roll left and right, to move from a sitting to a lying position, to move from a lying position to a sitting position, moving from a sitting position to a standing position, and to transfer between a chair and the bed. Review of Section M: Skin Conditions, indicated Resident R2 had two unstageable pressure ulcers with slough and/or eschar, and further indicated that neither of the pressure ulcers were present upon admission. Review of Resident R2's admission MDS dated [DATE], Section GG: Functional Abilities indicated Resident R2 was Dependent on staff to roll left and right, to move from a sitting to a lying position, to move from a lying position to a sitting position, moving from a sitting position to a standing position, and to transfer between a chair and the bed. Review of Section M: Skin Conditions, indicated that Resident R2 did not have any pressure injuries at the time of the admission assessment. Review of Resident R2's admission Observation dated 11/12/25, indicated that Resident R2 had no skin alterations upon admission. Review of Resident R2's Braden Scale assessment dated [DATE], indicated that Resident R2 was at high risk of pressure ulcer development. Review of the plan of care dated 11/12/25, for Potential for Alteration in Skin Integrity indicated that staff should assist with weight position changes throughout the day and night. Review of a progress note dated 3/9/26, indicated that Resident R2 had no new skin issues. Review of a progress note dated 3/11/26, indicated that Resident R2 had a reopened hematoma on her right hip that measured 1.4cm x 1cm x 0.1cm and a left hip unstageable wound that measured 3 cm x 2.2 cm.Review of a progress note dated 3/11/26, at 10:27 a.m. Resident R2 was assessed on wound rounds. Recommended Manuka honey and foam dressing MWF. Review of a progress note dated 3/18/26, at 11:29 a.m. Resident R2 was assessed on wound rounds with a recommendation for Santyl (prescription wound ointment) and foam dressing MWF for left hip, Cavilon (skin protectant film) for right hip. Further review of progress notes failed to reveal an assessment of wounds completed by a medical doctor or nurse practitioner between discovery of the wound on 3/11/26, and 3/25/26. Review of a wound nurse practitioner's note dated 3/25/26, indicated facility staff requested an evaluation of Resident R2's bilateral unstageable pressure ulcers, which were acquired at the SNF (skilled nursing facility) and noticed 3/11/26 per staff. The note further stated that the WCN (wound care nurse) was unsure of the cause of the wounds. Wound measurements were: Right hip: 1.6 cm x 2.4 cm x 0.2 cm.Left hip: 1.4 cm x 2.3 cm x 2.5 cm. Review of a wound nurse practitioner's note dated 4/1/26, indicated that wound measurements were: Right hip: 1.9 cm x 1.7 cm x 0.2 cm.Left hip: 0.8 cm x 2.3 cm x 3.1 cm. Review of a wound nurse practitioner's note dated 4/8/26, indicated that wound measurements were: Right hip: 1.7 cm x 1.2 cm x 0.2 cm.Left hip: 1.2 cm x 0.8 cm x 3.0 cm. Review of a wound nurse practitioner's note dated 4/15/26, indicated that wound measurements were: Right hip: 1.7 cm x 0.9 cm x 0.4 cm.Left hip: 0.9 cm x 0.8 cm x 2.5 cm. Review of a wound nurse practitioner's note dated 4/22/26, indicated that wound measurements were: Right hip: 1.2 cm x 1.2 cm x 0.5 cm.Left hip: 0.9 cm x 1.3 cm x 2.8 cm, with a notation that the wound was deteriorating. Review of a wound nurse practitioner's note dated 4/29/26, indicated that wound measurements were: Right hip: 2.2 cm x 1.6 cm x 0.5 cm with a notation that the wound was deteriorating.Left hip: 0.7 cm x 0.8 cm x 2.5 cm, with a notation that there was undermining (tissue erosion underneath the outwardly visible wound margins), that the wound had a strong odor, and that the wound was deteriorating. Review of a progress note dated 4/29/26, ay 10:07 a.m. indicated, Resident seen by wound care team today. Resident has purulent drainage to left hip wound with odor. Wound culture collected. Review of a progress note on 5/5/26, indicated that three different bacteria were present in Resident R2's wound cultures. Review of a progress notes dated 5/5/26, indicated Resident R2 was provided with her first dose of antibiotics related to her hip wound. Review of a wound nurse practitioner's note dated 5/6/26, that wound measurements were:Right hip: 1.8 cm x 2.2 cm x 0.8 cm with a notation that the wound was deteriorating.Left hip: 1.0 cm x 1.5 cm x 2.5 cm, with a notation that there is undermining present. Review of a progress note dated 5/11/26, at 10:34 a.m. indicated Resident R2's wounds to remained reddened and foul smelling, with a moderate amount of purulent drainage (commonly known as pus). Review of a wound nurse practitioner's note dated 5/13/26, that wound measurements were:Right hip: 2.1 cm x 1.7 cm x 0.8 cm with a notation that there was undermining present and that the wound was deteriorating.Left hip: 1.0 cm x 1.3 cm x 2.5 cm, with a notation that there was undermining present, a large amount of drainage with an odor, and that the wound was deteriorating. Review of a progress note dated 5/13/26, at 1:11 p.m. indicated that Resident R2 was sent to the hospital for worsening wounds. Review of emergency room notes dated 5/13/26, indicated: Resident R2 was treated for dehydration in the setting of sepsis and was placed on broad-spectrum antibiotics. On my exam looked volume depleted with decreased skin turgor (skin's elasticity and its ability to change shape and snap back to its normal position). Patient blood pressure stabilized after receiving 1.5 L (liters) of LR (an isotonic, sterile intravenous fluid used to rapidly replace water and electrolytes in cases of dehydration, blood loss, or shock), the infection source is likely from her chronic bilateral hip wound that is concerning for either soft tissue infection or osteomyelitis (inflammation of bone or bone marrow, usually due to infection) pending further imaging and plastic evaluation. Does appear to be in pain and cries out when her hips are palpated. Review of a hospital note dated 5/15/26, indicated the infectious source would likely be bilateral hip wound, and noted purulence from the left side. Resident R2 continued on Vancomycin (a potent antibiotic used to treat serious, hard-to-treat bacterial infections) and Cefepime (broad-spectrum antibiotic used to treat moderate-to-severe bacterial infections). Review of a plastic surgery consultation note dated 5/13/26, indicated: L Hip wound: 2x2 cm wound over L hip. Wound bed with necrotic tissue. Tracks approx. 4 cm deep along lateral aspect. Could not palpate bone. Purulent drainage appreciated.R Hip wound: 2 x 2 cm wound over R hip with some necrotic tissue appreciated. No visible bone. Review of facility provided documentation on 5/16/26 indicated that on 5/4/26, the facility confirmed that the facility was in non-compliance with pressure ulcer care requirements. During an interview on 5/26/26, at 1:30 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of pressure ulcers that resulted in hospitalization for the treatment of wounds. This resulted in actual harm for two of three residents with facility-acquired pressure ulcers. 28 Pa. Code 211.10(c)(d) Resident care policies28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of facility documents, observations, and staff interview, it was determined that the facility failed to maintain an effective call system for 15 of 17 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14).Findings include: Review of the Facility Assessment last reviewed 2/9/26, indicated the facility is equipped with a nurse call system. During an observation on 5/16/26, at 10:02 a.m. of the shared restroom for Residents R1, R2, R3, and R4, revealed that the call light cord for was wrapped so tightly around the handrail it was unable to be alarmed. During an observation on 5/16/26, at 10:06 a.m. of the shared restroom for Residents R5, R6, and R7, revealed that the call light cord for was wrapped so tightly around the handrail it was unable to be alarmed. During an observation on 5/16/26, at 10:16 a.m. of the shared restroom for Residents R8, R9, R10, and R11, revealed that the call light cord for was wrapped so tightly around the handrail it was unable to be alarmed. During an observation on 5/16/26, at 10:19 a.m. of the shared restroom for Residents R12, R13, and R14 revealed that the call light cord for was wrapped so tightly around the handrail it was unable to be alarmed. During an interview on 5/26/26, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain an effective call system for 14 of 17 residents. 28 Pa Code 201.14 (a) Responsibility of licensee.28 Pa Code 201.18 (b)(1) Management.28 Pa Code 204.11 (b) Equipment for Bathrooms.

Based on review of facility policy, clinical record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to ensure a safe environment resulting in a burn for one of thirteen residents (Resident R1). Findings include: Review of facility policy Abuse-Resident and Reasonable Suspicion of a Crime dated 1/22/26, indicated every resident will be treated with consideration, respect and full recognition of his/her dignity and individuality by preventing abuse, neglect, exploitation of residents, and misappropriation of resident property program. Review of facility policy Accident Prevention dated 1/22/26, indicated the facility will prevent resident accidents and injuries to the extent possible by maintaining as much as possible, an environment free from accident hazards and by assuring residents receive adequate supervision and assistive devices to prevent accidents. To safeguard all residents and employees, the facility reserves the right to discharge any resident who willfully and/or repeatedly disregards facility rules and places his/herself and others in danger. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/22/26, indicated diagnoses of high blood pressure, seizure disorder (neurological condition characterized by recurrent unprovoked seizures caused by abnormal electrical activity in the brain), diabetes(chronic condition characterized by high blood sugar resulting from inadequate insulin production), bipolar disorder (chronic mental condition characterized by severe mood swings, alternating between extreme highs (mania) and lows (depression)), and need for assistance with meals to set-up and clean-up. Resident R1 is able to eat independently after set-up without adaptive equipment, nursing sets up the tray and records percent consumed for breakfast, lunch, dinner and snacks. Review of a change in status note dated 3/26/26, stated, Resident alerted nurse aide (NA) and nurse on 3/26/26, at 7:10 a.m., that she had accidently burned herself after spilling hot coffee received from the employee cafe on 3/25/26, from an employee that did not work in the kitchen. Burn noted to area above left breast approximately 5 centimeters (cm) x 10cm, irregular shaped and red. Superficial open area noted of 1cm x 1cm at proximal red area. Review of clinical record revealed Resident R1 alerted nursing supervisor at approximately 7:18 a.m. on 3/26/26, that she had accidently burned herself the day before, the nursing supervisor inspected the area and then contacted the medical doctor who gave verbal orders to apply triple antibiotic ointment and dressing over area until resolved, changing dressing on Monday, Wednesday and Friday. Review of a witness statement dated 3/26/26, completed by Nursing Assistant Employee E1 stated, Resident came up to me and showed me her burn on the boob (Left), she was already dressed. Review of a witness statement dated 3/26/26, completed by Director of Rehab (DOR) stated, ADON informed me that resident has a coffee burn on her chest. He asked if I got her coffee. I said yes- from the cafe with ice in it. There is no existing policy for staff to get resident food/beverages from the employee cafe, which is a dining area with food served from the main kitchen for staff. There are beverages available here for staff self-service. Review of witness statement dated 3/27/26, obtained via phone with Director of Rehab (DOR), Resident has been here about a year and a half. I've been giving her coffee out of the cafe area for about 8 months. The resident does not go in. I go in and get it for her. Yesterday I got her coffee. I always put ice in it. I double cup it. ADON came to me yesterday and said Hey resident got burned from coffee on her chest, did you get her coffee? I said Yes. The DON came to me later on in the day asking me about it. She asked did I give her coffee. I said yes, I did but I didn't see her actually drink it and then she asked me to fill out the incident report. I get her coffee for her and then I sit it on my desk, and she comes and gets it. This coffee was not monitored for a temperature to ensure safety. Facility does not know what the temperature of this coffee was; kitchen temperature logs for meals are kept for foods coming out of the kitchen at mealtimes. Review of Resident R1's interview dated 3/26/26, was asked to describe what happened, resident stated, I got burnt with coffee. When asked what occurred, Resident R1 stated, I was drinking coffee from a cup, don't remember what hand the cup was in, it did have a lid and was a throw away cup. She did remember it happed around noon on 3/25/26. When asked to describe the person who obtained the coffee, Resident R1 stated white girl with glasses, she goes in the kitchen. When asked if she works in the kitchen, Resident R1 said, No. When asked did she get the coffee from the kitchen, Resident R1 stated, Yes. When asked if there were any witnesses, Resident R1 stated she told her nurse this morning (3/26/26). When asked if the incident happened yesterday (3/25/26), she stated, Yes. When asked if she told anyone, Resident R1 replied, No, it did not hurt yesterday, it started hurting today. During interviews on 4/6/26 from approximately 12:10 through 12:40 with facility staff including nurses and nurse aides confirmed they would only provide hot beverages from the meal carts. During an interview on 4/6/26, at 1:10 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision to ensure a safe environment for one of thirteen residents resulting in actual harm of a burn (Resident R1). 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, documents, clinical record and staff interviews, it was determined that the facility failed to make certain a resident was free from the use of physical restraints without a physical restraint order for one of eight residents reviewed. (Resident R2).Findings include:Review of facility policy, Abuse-Resident and Reasonable Suspicion of a Crime reviewed 1/7/25, indicated the resident is to be treated with consideration, respect and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property program.Review of facility policy, Resident Rights and Responsibilities reviewed 1/7/25, indicated the facility is to treat each resident with dignity and respect. All activities and interactions to assist the resident in maintaining and enhancing self-esteem and self-worth by incorporating resident goals, preferences, and choices.Review of facility policy, Restraints-Physical reviewed 1/7/25, indicated the facility is to ensure residents are free from physical restraints for purposes of discipline or convenience unless they are required to treat a medical symptom AND are the least restrictive alternative for the least amount of time with ongoing evaluation of need.Review of the Resident Assessment Instrument User's Manual Effective October 2024 indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aids in detecting cognitive impairment. The BIMS score suggests the following distributions:-13-15: cognitively intact-8-12: moderately impaired-0-7: severe impairmentReview of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS-federally mandated assessment of a resident's abilities and care needs) dated 10/28/25, included diagnoses of vascular dementia (decline in thinking, memory, and behavior caused by reduced or blocked blood flow in the brain), peripheral vascular disease (circulation disorder where blood vessels outside the heart become narrowed, blocked, or weakened), anxiety disorder (group of mental health conditions characterized by persistent and excessive feelings of worry, fear, or panic that can significantly impact daily life). Review of Section C: Cognitive Patterns, Question C0500: BIMS Summary Score revealed Resident R2's score to be 0.Review of Resident R2's orders revealed no order for bed to be against wall and no restraints of any kind every ordered.Review of incident report of 11/11/25, revealed resident was found at 12 p.m. by therapy staff in bed with bed pushed against wall, over bed table over resident, two chairs, one wheelchair and one nightstand all barricaded him in the bed.Review of interview with staff member on 11/11/25, revealed that she was trying to keep resident safe. Resident had placed himself on floor multiple times that day, was combative with care, as well as verbally aggressive. Resident was not harmed and showed no signs of distress; resident remained on locked behavioral dementia unit.Review of progress notes revealed social services met with the resident on 11/11/25 for psychosocial well-being with no issues identified.During an interview with the Director of Nursing and Nursing Home Administrator on 11/25/25, at approximately 1:00 p.m. it was confirmed that the facility failed to make certain a resident was free from the use of physical restraints without a physician's order for one of eight residents reviewed.28 Pa. Code 201.18 (e)(1) Management.28 Pa. Code 201.29 (a)(c)(d) Resident Rights.28 Pa. Code 211.12 (d)(5) Nursing Services.28 Pa. Code 211.8 (d)(e)(f) Use of Restraints.

Based on review of facility policies and documents, clinical record review, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in a laceration (deep cut) for one of eight residents (Resident R1).Findings include:Review of the facility policy, Abuse-Resident and Reasonable Suspicion of a Crime reviewed 1/7/25, indicated the facility is to treat every resident with consideration, respect and full recognition of his/her dignity and individuality. This policy is part of the centers overall prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property program. Neglect is the failure of the facility, the staff, or service providers to provide goods and services to a resident that are necessary to avoid or may result in physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:-13-15: cognitively intact-8-12: moderately impaired-0-7: Severe impairmentReview of the clinical record indicated Resident R1 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS- periodic assessment of resident care needs) dated 10/26/25, included diagnoses of diabetes (high blood glucose (sugar) levels), cardiomyopathy (disease of the heart muscle which makes it hard for the heart to pump blood), congestive heart failure (chronic condition where the heart can't pump enough oxygenated blood to meet the body's needs), morbid obesity (extremely overweight). Review of Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed Resident R1's score to be 0.Review of the MDS dated [DATE], Section GG: Functional Abilities indicated Resident R1had no impairment of upper or lower extremities, is partial to moderate assistance with rolling from lying on back to left or right and return to back when lying on the bed.Review of a progress note dated 11/2/25, at 1:58 a.m. Documents sent with resident to the hospital.Review of a progress note dated 11/2/25, at 2:07 a.m. Called report to [NAME] hospital, doctor took report of wound on resident's leg was a large open wound down to the tendon. Pressure applied till bleeding stopped then pressure dressing applied. Patient sent to [NAME] hospital.Review of progress notes dated 11/2/25, at 5:46 a.m. facility spoke with nurse at [NAME] hospital ER stated an x-ray was done on the right leg. No breaks that they are numbing the area and are going to stitch up, and he should be headed back our way shortly.Review of progress notes dated 11/2/25, at 6:30 a.m. nurse called from [NAME] ER stated, they stitched him up and would be sending hm back on Keflex. Supervisor notified.Review of a progress note dated 11/2/25, at 8:02 a.m. indicated Resident R1 was being changed by CNA, started to cough and rolled out of bed receiving a laceration to the right lower leg.Resident R1's orders on 10/22/25 are for bed mobility assist of 1, on 11/3/25, resident orders changed to bed mobility assist of 2.Resident's R1 plan of care for Falls on 10/27/25, monitor resident's position in bed every two hours. On 11/3/25, plan of care updated to assist of 2 with bed mobility and Hoyer lift due to declining functional ability. Ensure fall mats are down when in bed.Review of the facility incident report dated 11/3/25, indicated, Resident rolled out of bed at 0030, 11/2/25, during care. Was being changed by CNA when he started to cough and rolled out of bed. Assessed by RN. Sustained laceration to right calf, after hitting it off incremental unit. Resident care planned for 1 assist. Resident on bariatric air mattress. Care provided. MD notified. Order to transfer to ED for evaluation. Family notified. Abuse training was conducted with all staff completing training 11/4/25 through 11/6/25.During an interview on 11/25/25, at approximately 1:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in a laceration that required sutures in one of eight residents (Resident R1).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 observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen. Findings include: Review of facility policy Use of Hair Restraints reviewed 1/7/25, indicated hair nets, baseball caps, chef hats, and/or mustache/beard restraints must be worn when any employee is in the food production and kitchen area. Hair restraints and mustache/beard guards must be worn to cover all visible hair. During an observation on 6/4/25, at 11:09 a.m. Food Service Worker Employee E4, Food Service Worker Employee E5, and Food Service Supervisor Employee E6 were observed in the kitchen without beard restraints. During an observation on 6/4/25, at 11:23 a.m. Dietary Manager Employee E7 was observed in the kitchen without a beard restraint. During an observation on 6/4/25, at 11:44 a.m. [NAME] Employee E8 was observed with a hair net on the crown of her head, not covering the front three inches of hair from forehead back. During an observation on 6/5/24, at 9:40 a.m. [NAME] Employee E8, and Dietary Aide Employee E9 were observed in the kitchen with a hair net on, not covering the front two or three inches of hair from forehead back. [NAME] Employee E8 stated, My bad, you caught me again. During an interview on 6/4/25, at 11:25 a.m. the Dietary Manager Employee E9 confirmed the kitchen staff should wear hair nets to cover all hair and/or mustache/beard restraints, if facial hair is present. 28 Pa. Code: 211.6(c)(d)(f) Dietary services.

Based on a review of scheduled activities, observations, and staff interviews, it was determined that the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one of five nursing units (Nursing Unit 3B). Findings include: Review of the activities calendars for Nursing Unit 3B (secure unit for residents with dementia) from January through June 2025 revealed each weekend had one activity on 24 of 26 Saturdays, and 23 of 25 Sundays the only activity was Social Visits. Review of the Activities calendar for June 2025 revealed the following: 6/15/25: Donuts for Dads 6/16/25: Afternoon Painting 6/17/25: Fine Art Miracles: Music and Movement 6/18/25: Morning Exercise 6/19/25: Juice Break 6/20/25: First Day of Summer Social 6/21/25: Nail Salon During an observation on 6/2/25, at 10:53 a.m. there were approximately 18 residents in the dining room. A movie was playing on the television, which one resident appeared to be watching. One staff member was seated against the wall, not interacting with the residents. During an observation on 6/3/25, between 1:30 p.m. and 1:43 p.m. Nurse Aide (NA) Employee E18 identified all the residents attending Bingo on the second floor. Review of unit census sheets confirmed all the residents that attended resided on the second floor. NA Employee E18 confirmed that residents from Nursing Unit 3B did not attend activities on the second floor. During an observation on 6/3/25, at 1:45 p.m. 20 residents were present in the dining room/lounge on the third floor. The movie [NAME] in Wonderland was playing on the television, which one resident appeared to be watching. One staff member was seated at a table, not interacting with the residents, using a tablet. During an observation on 6/4/25, at 9:53 a.m. 18 residents were present in the dining room/lounge on the third floor. Golden Girls was being played on the television. No activities were occurring. No staff members were interacting with the residents. During an observation on 6/4/25, at 10:23 a.m. no activities were occurring in the dining room/lounge. Two staff members were present, having a personal conversation between themselves. No staff members were interacting with the residents. During an observation on 6/4/25, at 10:30 a.m. one additional staff member entered the dining room/lounge and began using a computer on wheels. No staff members were interacting with the residents. During an observation on 6/4/25, at 10:35 a.m. the Wizard of Oz began playing on the television, and multiple residents were moved into position to watch it. During an observation on 6/5/25, at 9:40 a.m. 22 residents were present in the dining room/lounge on the third floor. Golden Girls was being played on the television. No activities were occurring. During an observation on 6/5/25, at 10:15 a.m. nursing staff dimmed the lights in one side of the room, and spoke of putting a movie on. During an observation on 6/5/25, at 10:20 a.m. Recreation Assistant Employee E19 began setting up for an activity in a smaller resident lounge. During an interview on 6/5/25, at 10:25 a.m. Recreation Assistant Employee E19 confirmed the week of 6/15/25, through 6/21/25, had minimal activities due to her being on vacation. When asked why the Target Toss activity scheduled on 6/4/25, did not occur, Recreation Assistant Employee E19 stated it was due to the residents being taken outside. When asked which residents went, Recreation Assistant Employee E19 provided two names. When asked, Recreation Assistant Employee E19 confirmed that only two of the 37 residents on the unit were provided an activity on the morning of 6/4/25. During an interview on 6/5/25, at 1:04 p.m. Activities Director Employee E20 confirmed that on weekends the residents were only provided one activity per day. Activities Director Employee E20 stated that she is not able to have additional staff to assist in covering vacations unless there are other staff on modified duty who are available to help. During an interview on 6/6/25, at approximately 10:30 a.m. the Nursing Home Administrator confirmed the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents on one of five nursing units. 28 Pa. Code: 201. 18(b)(3) Management. 28 Pa. Code: 207.2(a) Administrators Responsibility.

Based on review of facility assessment, personnel file reviews, and staff interviews, it was determined that the facility failed to implement, and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles. Findings include: Review of the Facility Assessment reviewed 4/9/25, indicated, All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. Included in the list of education provided to new hires, facility staff, contracted staff, and volunteers - as applicable to role in facility were; -Resident Rights -Resident Abuse and Suspicion of a Crime -Compliance, HIPAA, Code of Conduct, and Ethics -Infection Prevention and Control -Psychosocial Needs -Dementia - Positive Approach -Emergency Preparedness and Fire Safety -Accident Prevention and Risk Management -Communication and Customer Service -QAPI - Mission , Vision, Values -Person Centered Care -Trauma Informed Care -Behavioral Health -HR Policy Review of the facility policy In-Service Training dated 1/7/25, indicated the policy applies to all employees, contractual staff, and volunteers. During an interview on 6/6/25, at 9:49 a.m., the Nursing Home Administrator was asked to provide all required training records for the contracted Nursing Staff. Training records were not provided to the survey team for the Contracted Nursing Staff. During an interview on 6/6/25, at 9:49 a.m., the Nursing Home Administrator confirmed the facility failed to implement, and maintain an effective training program for individuals providing services under contractual arrangement, consistent with their expected roles. 28 Pa. Code 201.20(a)(b)(c)(d) Staff development.

Based on review of facility policy and documents, clinical record review, resident, and staff interviews, it was determined that the facility failed to make certain that necessary care and services were provided for two of ten residents (Resident R17 and R400). Findings include: Review of the facility policy All Policy and Procedure: General Guidelines reviewed 1/07/25, indicated to provide the necessary care and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being in accordance with their comprehensive person-centered plan of care that is culturally-competent and trauma informed. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R17 was admitted to the facility on [DATE], with diagnoses that included cerebral infarct (stroke), aphasia (difficulty to speak) stroke related, and hemiparesis (reduced ability to move) stroke related. Review of the Minimum Data Set (MDS - comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated 4/09/25, indicated the diagnoses remain current. Resident R17 has a BIMS of 00 and Section GG 130 personal hygiene indicates resident is dependent, caregiver does all of the effort or requires assistance of two or more for care. During an observation on 6/02/25, at 11:28 a.m. Resident R17 was observed to have long, unkempt fingernails. Review of the clinical record indicated Resident R400 was admitted to the facility on [DATE], with diagnoses that included cerebral infarct (stroke), dysarthria (slurred speech) stroke related, and heart failure. Review of the MDS dated [DATE], indicated the diagnoses remain current. Resident R400 has a BIMS of 14 and Section GG 130 personal hygiene indicates resident requires substantial/maximal assistance, caregiver provides more than half the effort for care. During an interview and observation on 6/02/25, at approximately 11:40 a.m. Resident R400 had noticeable facial hair growth on the chin and upper lip area, resembling a goatee. When asked, Resident R400 nodded yes and verbalized she would like assistance in removing her facial hair. During an interview on 6/2/25, at 12:05 p.m. Employee E10 RN confirmed the above findings. During an interview on 6/4/25, at 1:00 p.m. The Nursing Home Administrator confirmed the above findings, and that the facility failed to make certain that necessary care and services were provided for two of ten residents (Resident R17 and R400). 28 Pa. Code: 211.12(1) Nursing services. 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12 (2)(5) Nursing services.

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels for three of nine residents reviewed (Residents R8, R45, and R154), and the facility failed to appropriately respond to a resident's change in condition for one of four residents (Resident R146). Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility policy General Guidelines regarding Nursing care reviewed 1/7/25, indicated the nurse must verify all practitioners orders to ensure all required information/directions are included. Staff must monitor the resident ' s status and condition and respond to significant changes promptly. Staff must document all care and services provided to the resident. Notifies physician of changes, assessment findings and secures treatment and diagnostic direction and orders from the physician. Documents findings and notifications in the nurses notes. Review of the facility policy Notification of Change in Resident Condition and Treatment Changes reviewed 1/7/25, indicated to assess resident's condition including dialogue with the resident and evaluation of findings. Review of the User Guide for Contour Next EZ blood glucose monitoring system indicated under Test Results a Caution: HI results are greater than 600. The facility was unable to provide policies regarding care of a diabetic resident. Review of information provided by the Mayo Clinic dated 10/8/22, indicated that, A normal resting heart rate for adults ranges from 60 to 100 beats per minute. Review of information provided by the Mayo Clinic dated 5/17/22, indicated a normal blood sodium level is between 135 and 145 milliequivalents per liter (mEq/L). Review of National Institute of Health information titled, Dehydration dated June 2020, defined dehydration as a condition caused by the loss of too much fluid from the body. In the Who is more likely to develop dehydration section, the first entry was older adults. Further within the document indicated to get medical help right away if a person has a rapid heartbeat. Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and depression. Review of Resident R8' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/21/25, indicated the diagnoses remain current. Review of Resident R8 physician's order revealed the following orders: - Accucheck every morning. If blood sugar less than 60 and symptomatic or greater than 400 call MD (doctor) - Lantus (long-acting type of insulin that works slowly, over about 24 hours) 28 units in morning. - Novolog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours) two units with meals - Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 2/28/25, at 10:18 a.m. the CBG was noted to be HI. Review of the care plan dated 6/17/24, indicated the following interventions: - Administer medications per MD order. - Monitor for signs and symptoms of hyper/hypoglycemia. - Accuchecks as needed. Notify MD for hypoglycemic/hyperglycemic episodes per order. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed date. Review of a clinical record indicated Resident R45 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and seizure disorder (abnormal electrical activity in your brain that temporarily causes changes in awareness and muscle control, behavior and senses). Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R45 physician's orders revealed the following orders: - On 7/23/24 through 2/25/25, Lispro (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours) two units with meals. - On 8/5/24 through 2/25/25, Lispro per sliding scale. If blood sugar is less than 60, and resident is symptomatic or greater than 400 call MD. Four times a day before meals and at bedtime. - On 11/14/24 through 3/4/25, Lantus six units once a day in AM (morning). - On 2/25/25, Aspart (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about one hour, and keeps working for two to four hours) - On 4/18/25, Aspart per sliding scale. If blood sugar is less than 60 and resident is symptomatic or greater that 400 call MD. Review of Resident 45's eMAR revealed that the resident's CBG's were as follows: - On 1/14/25, at 7:18 p.m. the CBG was noted to be HI. - On 5/27/25, at 3:36 p.m. the CBG was noted to be 59. Review of the care plan dated 6/17/24, indicated the following interventions: - Administer medications per MD order. - Monitor for signs and symptoms of hyper/hypoglycemia. - Accuchecks as needed. Notify MD for hypoglycemic/hyperglycemic episodes per order. Review of Resident R45's eMAR and clinical progress notes indicated the resident was not assessed for hyper-/hypoglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the clinical record indicated Resident R154 was readmitted to the facility on [DATE], with diagnoses that included diabetes, depression, and dementia. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of Resident R154 physician's order revealed the following orders: - Accucheck every morning. No coverage but if blood sugar less than 60 and symptomatic or greater than 400 call MD twice a day. Review of the clinical record, and electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: - On 11/4/24, at 8:11 p.m. the CBG was noted to be HI. Review of the care plan dated 1/30/24, indicated the following interventions: - Administer medications per MD order. - Monitor for signs and symptoms of hyper/hypoglycemia. - Accuchecks as needed. Notify MD for hypoglycemic/hyperglycemic episodes per order. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed date. During an interview on 6/5/25, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E11 stated it depends on the resident ' s order for when to notify the doctor. If the blood sugar was below 70, they would provide juice or snack depending on their signs and symptoms. If the blood sugar was greater that 250, they would give the resident water, the ordered insulin, and is signs and symptoms were present, they would notify the doctor. They stated that each resident should have individualized orders for diabetic care, if necessary. During an interview on 6/5/25, at 10:05 a.m. Registered Nurse (RN) Employee E12 stated it would depend on the signs and symptoms and the resident ' s ordered parameter. They would assess the resident, check the parameters, and give the necessary intervention (snack or ordered insulin). They would report any vital out of range result and the computer charting system prompts the user to make a progress note. During an interview on 6/5/25, at 10:08 a.m. RN Employee E13 stated if the blood sugar was less that 70 or over 250, they would follow the ordered parameters to when to notify the doctor. If the blood sugar was less than 70, they would provide a snack or juice and recheck the blood sugar in 15 minutes. If the blood sugar was over 400, they would give the ordered insulin and encourage the resident to drink water. They would re-assess the resident in 30 minutes. During an interview on 6/5/25, at 10:10 a.m. LPN Employee E14 stated they would assess the resident, if the blood glucose was elevated, they would encourage water, give the ordered insulin, assess the resident, call the doctor, and monitor the resident. If the blood sugar was low, they would provide juice or a snack, tell the supervisor, and reassess the resident in 30 minutes. They would document in the progress notes. They stated that the medical record charting flags the resident for reassessment. During an interview on 6/5/25, at 10:15 a.m. RN Employee E15 stated she would assess the resident for signs and symptoms of hypo-/hyperglycemia and check the resident ' s orders. If the blood sugar was less than 70, they would provide a snack, orange juice, or peanut butter, and recheck the blood sugar within an hour. If the blood sugar was greater than 350-400 they would check the ordered parameters, and notify the doctor if needed. They would document in the progress notes, and eMAR. During an interview on 6/5/25, at 10:20 a.m. LPN Employee E16 stated they would be concerned if the resident ' s blood sugar was less than 70, or greater than 120. They would check the orders for parameters, assess the resident for signs and symptoms of hypo-/hyperglycemia. They would document on the doctor ' s board in the facility, in the progress notes, and they would document the reassessment. During an interview on 6/5/25, at 10:25 a.m. LPN Employee E17 stated they would check the resident ' s orders for the parameters. If the blood sugar was less than 70, they would check the orders and provide a snack or juice. If the blood sugar does not increase after the intervention, they would notify the doctor. If the blood sugar was over 400, the would check the ordered parameters, give the ordered insulin, recheck in five to ten minutes, and call the doctor if needed. They would document in the eMAR, and they would notify the RN supervisor on duty. During an interview on 6/5/25, at 1:00 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition, failed to document an assessment or interventions used related to blood glucose, and failed to follow physicians orders for Residents R8, R45, and R154. Review of the clinical record indicated Resident R146 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). Review of Resident R146's Potential for alteration in nutrition/dehydration care plan initiated 5/6/24, indicated for staff to Monitor fluid intake on an ongoing basis and assess for signs and symptoms of dehydration. Review of Resident R146's heart rate record indicated the highest blood pressure assessed from admission (5/6/24) to 2/22/25, indicated on 1/25/25, Resident R146's heart rate was 90 beats per minute, on 12/10/24, Resident R146's heart rate was 94 beats per minutes, and the remainder of the assessments (94) were below 90 beats per minutes. Review of Resident R146's heart rate record from 2/26/25, through 2/28/25, revealed: 2/28/25, 1:55 a.m. Pulse: 137 per minute 2/28/25, 1:49 a.m. Pulse: 150 per minute 2/27/25, 8:22 p.m. Pulse: 138 per minute 2/27/25, 1:57 p.m. Pulse: 126 per minute 2/27/25, 1:22 p.m. Pulse: 125 per minute 2/26/25, 2:34 p.m. Pulse: 100 per minute 2/26/25, 8:44 a.m. Pulse: 110 per minute Review of a progress note dated 2/17/25, at 9:42 p.m. indicated, CNA (nurse aide) informed this writer of blood in brief upon observation small pink tinged area to rear side of soiled brief along with small pink tinged area to wash cloth noted. Review of a progress note dated 2/20/25, at 1:26 p.m. indicated, [Psychiatrist] made aware of resident increase irritability, aggression, agitation. Resident is a two persons caregiver due to her aggressive behavior. Review of a progress note dated 2/20/25, at 4:01 p.m. indicated, Staff called this writer to the room to assist with getting resident into her w/c (wheelchair), stating resident physical aggression escalate as the two caregivers attempt to get resident washed & dressed, resident is two persons caregivers due to her physical aggression, verbal aggression, per staff resident was kicking CNA R (right) knee, choking one of the CNA then grabbed her chest, hitting staff in the face, grabbing CNA neck, grabbing staff breasts causing her breasts to bleed. Staff stated they gave resident time to deescalate, then proceed to get her into her w/c. Resident self-inflicted and re-open a skin tear to her R shin. Area cleanse & dress with band aid. Alert [Psychiatrist] of resident increase agitation. Review of a progress note dated 2/21/25, at 12:01 p.m. indicated, This writer in to assist staff with routine AM care, observed resident using her right hand digging her nails into CNA #1 arm, after staff asked resident to let go of the arm, she took a full swing with her left arm to CNA #2 chest, staff position resident on her side so caregivers can pulled the dirty brief's out to give resident peri care, she used her right leg to kick staff but missed, resident is very quick with her arms & hands, always reaching out to hit, punch, kick, or digging her hands to hurt staff. Resident was medicated with Olanzapine 5MG (antipsychotic medication) prior to care, meds are not effective, unable to redirect resident. [Psychiatrist] is aware of resident behaviors, will be here next week to exam resident. Review of a progress note dated 2/24/25, at 9:31 a.m. indicated, Received orders from [Psychiatrist] CBC-CMP-TSH-UA C&S (blood laboratory tests and a urinalysis with culture and sensitivity testing). Resident is incontinent. Straight cath (one time catheterization) if unable to obtain urine via clean catch. Acetaminophen (Tylenol) 650 MG PO BID DX: pain (by mouth, twice daily for pain). Review of a progress note dated 2/24/25, at 11:15 a.m. indicated, N/O (new order) received start Olanzapine 7. 5MG in AM give prior to care & Olanzapine 5MG in PM. One time order for Ativan 0.5MG (anti-anxiety medication) give prior to straight cath. Review of a progress note dated 2/24/25, at 1:49 p.m. indicated, Straight Cath using sterile technique with immediate return of yellow urine. Assist of 4 staff to obtain urine specimen. Ativan somewhat effective. Review of a progress note dated 2/25/25, at 1:36 p.m. indicated, Staff reported resident with less aggression noted during AM care. Observed resident talking to herself today in the dining room then took her finger pointing to the table questionable if resident is hallucinating. Olanzapine 7. 5MG was started this AM. Will continue to monitor for adverse reaction. Review of a progress note dated 2/26/25, at 2:03 a.m. indicated that the urine sample results are still pending. Review of a progress note dated 2/26/25, at 8:45 a.m. indicated, Resident on charting for increase in Olanzapine 7. 5MG PO in AM. Observed resident with shakiness, stiffness, difficulty with speech, somnolence. Alert MD (doctor of medicine) of noticeable side effects of meds. MD will be in today. Meds held as per nursing measures. Review of a progress note dated 2/26/25, at 1:15 p.m. indicated, [Psychiatrist] in assessed resident due to increase in Olanzapine 7. 5MG in AM started yesterday 2/25. Due to adverse side effects, med was discontinued. N/O decrease Olanzapine 5MG PO BID. Meds held today due to resident having difficulty with her speech, stiffness, somnolence, unable to swallow. Resident did poorly for breakfast, but did manage to consume mostly liquid for lunch, she ate all her pudding. Will continue to monitor & hold meds if she is sedated. Review of a progress note dated 2/26/25, at 2:35 p.m. indicated, Recheck apical pulse now 100. Review of a progress note dated 2/26/25, at 9:40 a.m. indicated, Received a call from [laboratory provider] stating that the collection tube was incorrectly filled and required recollection. Obtained new urine sample using sterile technique. Review of a progress note dated 2/27/25, at 10:57 a.m. indicated the resident started a new order for Ciprofloxacin 500 mg. Review of a progress note dated 2/27/25, at 1:24 p.m. indicated, Resident accept Cipro with much cueing, combative-aggressive while attempt to administer meds. Unable to redirect. HR (heart rate) remains above 120, attempt several times to retake HR, no changes noted. Review of a progress note dated 2/27/25, at 8:29 p.m. indicated, Resident's nurse notified, and supervisor notified about HR. Already aware and Dr aware. Review of a progress note dated 2/28/25, at 1:50 a.m. indicated, peripheral pulse taken while patient was sleeping soundly, snoring, offering no resistance 150. Review of a physician's note dated 2/28/25, at 5:02 a.m. indicated, [Resident R146] is seen in follow-up. She has had delirium of late with a change of mental status. She has been very aggressive towards staff. She has underlying anxiety and she had been ordered a urine study which shows positive nitrites, leukocyte esterase, and many bacteria. She does get delirious with the urinary tract infections typically. She has a history of left humerus fracture and left ulna fracture. She flows (flails) her arms when she gets anxious or delirious from a UTI (urinary tract infection). Review of a progress note dated 2/28/25, at 8:16 a.m. indicated, Resident is being sent to [hospital] for eval. Her heart rate has been elevated with increased confusion. VSS 97.6, 114/76, 161, 95% RA, 17 RR. Resident is in NAD (no apparent distress), but MD wanted an EKG (electrocardiogram, a test that records the electrical signals in the heart, helping to check the heartbeat and diagnose various heart conditions) which was not successful yesterday due to resident being combative and removing leads. Review of a progress note dated 2/28/25, at 8:34 p.m. revealed Resident R146 was admitted to the hospital for a urinary tract infection and dehydration. Review of a progress note dated 3/3/25, at 4:18 p.m. revealed Resident R146 returned to the facility at approximately 3:00 p.m. Review of hospital documentation dated 3/3/25, indicated Resident R146 was treated for: -Urinary tract infection with hematuria (blood in the urine). Patient is a permanent resident of [the facility]. Patient was started on Cipro (ciprofloxacin) on 02/27 for UTI. Unfortunately, the facility did not send urine culture. Urine culture negative but may be skewed by antibiotics will complete treatment. Received vanco (vancomycin, an antibiotic medication) and cefepime (an antibiotic medication) in the emergency room . -Hypernatremia (elevated blood sodium). Likely due to poor intake / severe dehydration. Sodium 153 on admission. Much improved status post aggressive IV (intravenous) hydration. -A-fib (atrial fibrillation, disease of the heart characterized by irregular and often faster heartbeat). Tachycardic likely AFib with RVR (rapid ventricular response) with dehydration. Rate improving. During an interview on 6/6/25, at approximately 10:30 a.m. the Nursing Home Administrator and the Director of Nursing were made aware of concern related to the delay of care in treating Resident R146's initial sign of a urinary tract infection (blood in the brief) and subsequent hospitalization . During this interview, the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to assess, document, and notify physicians of increased and decreased CBG levels for three of nine residents reviewed. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code: 201.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.

Based on observation, review of facility policies, review of clinical records and staff and resident interviews, it was determined that the facility failed to timely provide adequate preventative treatment and services to prevent new pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development associated with use of an orthopedic brace (immobilizer), which resulted in harm in the development of two pressure ulcers for one of four residents (Resident R1) reviewed. Findings include: The facility policy entitled Pressure Ulcer Prevention dated 1/5/21, indicated that the facility will consider all residents to be at risk and therefore will provide defined prevention interventions via written protocols. The Pressure Ulcer Prevention policy also indicted that nursing staff initiates and updates Plan of Care accordingly, utilizing At Risk Care Plans individualizing the plan according to each resident ' s needs. The facility policy entitled Pressure Ulcer Prevention and Treatment Protocol dated 1/5/21, indicated that staff will manage friction, shear and pressure by evaluating contact surfaces. Review of the Minimum Data Set (MDS-periodic assessment of care needs) dated 1/13/21, indicated that Resident R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/13/21, MDS also indicated that Resident R1 had severe cognitive impairment, required total assistance of two staff for bed mobility and was at risk for pressure ulcer development but had no pressure ulcers at that time. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 1/12/21, indicated that Resident R1 was at high risk for the development of pressure ulcers. Review of Nurses Notes dated 2/13/21, at 1:00 p.m., indicated that Resident R1 complained of pain in the right knee, on observation her right knee appeared swollen. Nurses Note indicated that resident R1's physician was contacted and resident was transported to the hospital for evaluation. Review of Nurses Notes dated 2/14/21, at 4:37 a.m., indicated that Resident R1 returned to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/14/21, Nursing Notes also indicated that Resident R1 was complaining of pain when moved. Review of the Interdisciplinary Care Plan did not include evidence that Resident R1's Care Plan was updated to include the change in risk of pressure ulcer development due to the presence of the right knee immobilizer on 2/14/21. During an interview on 8/2/21, at 2:55 p.m., Wound Care Registered Nurse (RN) Employee E1 confirmed that the Plan of Care was not updated after Resident R1 was readmitted with the right knee immobilizer brace on 2/14/21, and the nursing staff did not do an updated Braden Scale Risk of Pressure Ulcer assessment until 2/26/21, when the right heel wound was discovered. In addition, no interventions were developed to address the increased pressure ulcer risk presented by the presence of the right knee immobilizer until 3/10/21. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Care Nurses Notes dated 2/26/21, at 11:29 a.m., indicated assessed right heel per unit request. There is an area of mushy, rusty, non-blanchable (no tissue color change with applied pressure) discoloration 9 x 8 (centimeter) cm oval shape. The edges are hardened to callous. The skin is intact s drainage . Right leg splint in place above knee to ankle. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/26/21, orders did not include any orders for prevention of pressure areas to the skin beneath the knee immobilizer brace. Review of the Treatment Administration Record (TAR) for the month of February 2021, did not include evidence that Resident R1 had skin assessments and repositioning every 2 hours performed prior to the development of the right heel wound on 2/26/21. Review of the Wound Care physician notes on 3/3/21, indicated that Resident R1 had a deep tissue injury (DTI- pressure-related injury to subcutaneous tissues under intact skin), right heel, 3.0 x 2.9 cm, no depth, skin intact. There is a satellite lesion c/o dry, hyperkeratinized callous. No pus or discharge, no slough (yellow decay tissue), no peri wound [CONDITION(S)] (redness). The 3/3/21, notes also indicated that Resident R1's DTI was on same extremity as the fracture. Pt (Resident R1) may not have been able to support herself and may have used the heel to push herself up, or may not have been able to hold the leg up and developed a soft tissue contusion. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Wound Care Nursing Notes dated 3/8/21, indicated that assessed wounds c (with) wound care team this morning. See wound reports. The right heel is stable. The DTI has hardened into thin eschar. The area on right Achilles (rear ankle area) heel is new, onset 3/7/21. It developed beneath the edge of her brace despite padding and other prevention that was in place with her heel wound. Review of a Wound Management Detail Report dated 3/8/21, indicated that Resident R1 had a right Achilles area unstageable (full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because it is obscured by debris, slough, or eschar) measuring 4 cm. by 5 cm. covered by 100% slough (dead tissue) and indicated wound was new onset under edge of brace. Review of the Care Plan dated 3/10/21, did not include interventions to prevent pressure areas beneath the right knee immobilizer brace until Resident R1 developed the unstageable pressure ulcer on 3/7/21. During an interview on 7/27/21, at 12:15 p.m., the Wound Care RN Employee E1 confirmed that Resident R1 had sustained a right knee fracture on 2/13/21, which necessitated placement of a right knee immobilizer brace and had then developed a DTI right heel wound on 2/26/21, and had subsequently developed an unstageable pressure ulcer to the right Achilles area on 3/7/21, which was due to pressure from the right knee immobilizer brace. RN Employee E1 confirmed that Resident R1's had not been reassessed for risk of pressure ulcer development after placement of the immobilizer brace and that there were no interventions to prevent pressure on the Achilles heel area implemented until pressure area developed on 3/7/21. The facility staff failed to assess and implement measures to prevent pressure ulcer development associated with pressure from a right knee brace resulting in harm to Resident R1. 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(d)(1)(3)(5) Nursing services.