Every finding on record at Kadima Rehabilitation & Nursing at Lititz

Based upon observation, it was determined that the facility failed to ensure medications were appropriately labeled with open and expiration dates for two of two medication carts observed (North Hall Medication Cart and South Hall Medication Cart).Findings include:Observation of the South Hall Medication Cart on August 28, 2026, at 10:38 a.m. revealed one unopened, undated and unrefrigerated Lantus Insulin (long-acting medication to treat diabetes) Pen.Observation of the North Hall Medication Cart on August 28, 2026, at 10:43 a.m. revealed one open and undated bottle of Latanoprost (eye medication used in the treatment of glaucoma) Eye Drops; one open and undated Lantus Insulin Pen and two unopened, undated and unrefrigerated Novolog Insulin Pens.The above information was conveyed to the Director of Nursing on August 28, 2026, at 1:00 p.m.28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based upon clinical record review and facility documentation, it was determined that the facility failed to ensure Pharmacy Consultant recommendations were addressed by the facility physician for four of five residents reviewed (Resident 4, Resident 13, Resident 34, and Resident 35).Findings include: Review of Resident 4's clinical record revealed the Pharmacy Consultant reviewed Resident 4's medications and made recommendations to Resident 4's physician on January 31, 2026, March 31, 2026, April 30, 2026, June 29, 2026, and July 27, 2026. The facility was unable to provide the Pharmacy Consultant recommendations listed above and was unable to provide the facility's physician response to the Pharmacy Consultant recommendations from the above-mentioned dates. Review of Resident 13's clinical record revealed the Pharmacy Consultant reviewed Resident 13's medications and made recommendations to Resident 13's physician on September 30, 2025, March 31, 2026, and May 30, 2026, for a gradual dose reduction of Abilify (anti-depressant medication) 5 milligrams. Review of Pharmacy Consultant recommendations failed to reveal evidence that the facility physician addressed the Pharmacy Consultant recommendations. Further review of Pharmacy Consultant recommendations dated June 29, 2026, for a gradual dose reduction of Celexa (anti-depressant medication) 10 mg revealed that Resident 13's physician failed to address the recommendation of the Pharmacy Consultant. Review of Resident 34's clinical record revealed the Pharmacy Consultant reviewed Resident 34's medications and made recommendations on April 30, 2026, and May 30, 2026. The facility was unable to provide the Pharmacy Consultant recommendations dated April 30, 2026, and May 30, 2026. Further review of Resident 34's clinical record revealed the Pharmacy Consultant made recommendations on June 29, 2026, and July 27, 2026, regarding the non-use of as needed Tramadol. Review of the Pharmacy Consultant recommendations dated June 29, 2026, and July 27, 2026, failed to reveal evidence that Resident 34's physician addressed the concerns of the Pharmacy Consultant. Interview with the Nursing Home Administrator and the Director of Nursing on August 28, 2026, at 1:00 p.m. confirmed that the Pharmacy Consultant recommendations were not addressed by the facility physician. Review of Resident 35's clinical record revealed that the consultant pharmacist made a recommendation on October 31, 2025, to consider the discontinuation of hydrocodone-APAP (opiod pain reliever) prn (as needed) due to non-usage. The same recommendation was again made on July 31, 2026. The consultant pharmacist also made recommendations on January 31, 2026, and April 30, 2026, to consider the discontinuation of voltaren gel prn due to non-usage. Review of Pharmacy Consultant recommendations failed to reveal evidence that the facility physician addressed the above Pharmacy Consultant recommendations for Resident 35. 483.45 Pharmacy services 28 Pa. Code 211.9(k) Pharmacy services

Based upon observation, it was determined that the facility failed to ensure food was properly labeled with open and expiration dates and failed to discard food items that were beyond the expiration date for one of one area observed (Kitchen).Findings include:Observation of the reach in refrigerator on August 25, 2026, at 6:41 a.m. revealed one open carton of Lactaid milk with an expiration date of August 22, 2026.Observation of the walk-in refrigerator on August 26, 2026, at 6:41 a.m. revealed three cartons of Lactaid milk with an expiration date of August 22, 2026; open turkey lunch meat with no open or expiration date on the package and opened and undated ham wrapped in plastic.Interview with Employee E4 on August 27, 2026, at 1:00 p.m. confirmed that the Lactaid milk was past the expiration date and had been removed from the refrigerators and the open lunch meat had also been removed. 28 Pa. Code 211.6 Dietary Services

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to obtain and monitor weights for three of 12 residents reviewed for nutrition (Residents 7, 20, and 34). Review of facility policy and procedure titled Resident Weights revealed Weights must be obtained routinely to monitor the parameters of nutrition over time and identify residents at risk for significant weight change. Further review of facility policy and procedure revealed All monthly weights will be completed by the 7th of the month; re-weights will be obtained within 72 hours of monthly weight if a weight change greater than 3%. If the weight change is validated, the Licensed Nurse will notify the Physician and dietitian. Review of Resident 7's physician's orders included an order dated June 19, 2026, for weight every day shift every 7 days for health monitoring. Review of Resident 7's July 2026 Medication Administration Record (MAR) and weights revealed that resident's weight was obtained on July 10, 2026, at 108.0 pounds. Resident's weight was not obtained until July 27, 2026 (17 days later) and revealed weight was stable at 108.6 pounds. Resident 7's weight was obtained on August 3, 2026, at 103.8 pounds (loss of 4.8 pounds or 5.6% in one week). Further review of the record revealed no evidence that a reweight was obtained. The next weight of 104.0 pounds was recorded on August 17, 2026 (14 days later). Interview with the Director of Nursing (DON) and Employee E3 on August 28, 2026, at 1:12 P.M. confirmed that weekly weights were not completed as ordered and reweights were not obtained for Resident 7. Review of Resident 20's weights revealed a weight of 92.7 pounds on May 7, 2026, and a weight of 98.1 pounds on June 10, 2026 (an increase of 5.4 pounds or 5.9%). Further review of the clinical record revealed no evidence of a reweight. Weight was recorded on July 3, 2026, at 97.5 pounds and 92.0 pounds on August 6, 2026 (loss of 5.5 pounds or 5.1%). Further review of the clinical record revealed no evidence that a reweight was obtained. Interviewed with the DON and Employee E3 on August 28, 2026, at 1:12 P.M. confirmed that reweights were not obtained for Resident 20. Review of Resident 34's Weight Summary revealed Resident 34 weighed 145.2 pounds on May 9, 2026. Further review of Resident 34's Weight Summary revealed Resident 34 weighed 118.5 pounds on June 10, 2026, indicating a weight loss of 18.39% in one month. Further review of Resident 34's Weight Summary failed to reveal evidence that a re-weight was obtained within 72 hours to ensure accuracy of a significant weight loss. Further review of Resident 34's Weight Summary revealed the next weight obtained was on July 6, 2026, which indicated a weight of 113 pounds. Interview with the Nursing Home Administrator and Director of Nursing on August 28, 2026, at 11:00 a.m. confirmed that re-weights were not completed for Resident 34 and further that a significant weight loss could not be confirmed. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based upon review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for two of 12 residents reviewed (Residents 7 and 16) and failed to transport linens to prevent the spread of infection on one of two units (North). Findings include: Review of facility policy, Precautions Policy and Procedure, revised July 24, 2026, revealed it is the policy of this center to initiate infection control precautions when a resident has a wound and/or indwelling medical device. The policy additionally indicated that when a resident is placed on Enhanced Barrier or transmission-based precautions, appropriate notification is placed on the room entrance to alert personnel and visitors to the type of CDC precaution(s), instructions for use of PPE (personal protective equipment), and/or instructions to see a nurse before entering the room. Review of Resident 7's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated July 23, 2026, revealed that Resident 7 received nutrition through a feeding tube (medical device that delivers liquid nutrition, fluids, and medications directly into the stomach or small intestine for people who cannot eat or swallow safely). Observation of Resident 7's room on all days of the survey revealed no signage indicating enhanced barrier precautions were in place and no personal protective equipment was available in or outside Resident 7's room. Review of Resident 16's CRNP (certified registered nurse practitioner) note of June 2, 2026, revealed that orders were given to place a foley catheter (flexible medical tube inserted into the bladder to drain urine continuously into an external collection bag) for urinary retention secondary to neurogenic bladder (a condition where nervous system conditions affect bladder function). Observation of Resident 16's room on all days of the survey revealed no signage indicating enhanced barrier precautions were in place and no personal protective equipment was available in or outside Resident 16's room. Observation on August 26, 2026, at approximately 1:30 P.M. revealed an uncovered laundry cart containing towels outside of the kitchen door. Observation on August 27, 2026, at approximately 2:00 P.M. revealed an uncovered laundry cart containing towels outside of the kitchen door. Observation on August 28, at 2:30 P.M. revealed an uncovered cart containing personal clothing items on the North hallway. Interview with Employee E3 on August 28, 2026, at 3:00 P.M. revealed that residents with a feeding tube or catheter should have enhanced barrier precautions in place. Employee E3 also confirmed that all linens should be covered during transport. 483.80 Infection Control28 Pa. Code 211.10(d) Resident care policies28 Pa. Code: 211.12(d)(1)(5) Nursing services

Based upon clinical record review and staff interview, it was determined that the facility failed to ensure that a resident with a food allergy received the appropriate and dietary equivalent for one of 12 residents reviewed (Resident 34).Findings include:Review of Resident 34's clinical record revealed dietary allergies including gluten allergy, wheat bran allergy, lactose allergy, beef derived product and beef allergy.Review of dietary menus and dietary menu extensions failed to reveal evidence of a gluten free/gluten restricted dietary menu extension.Interview with Employee E4 on August 28, 2026, at 12:45 p.m. revealed that the facility had a gluten free menu extension, but it was in a drawer in the kitchen and that the menu extension wasn't usually utilized. This interview further revealed that the kitchen had some gluten free bagels for Resident 34 and that when it was time to prepare Resident 34's food tray, the kitchen staff placed items on Resident 34's tray that they knew the resident could eat and removed items that Resident 34 could not eat. This interview further revealed that the facility did not provide pre-planned alternatives to the daily menu for Resident 34 as required.Observation of Resident 34's breakfast meal ticket for August 29, 2026, revealed juice, hot cereal, cheesy egg bake, ground sausage link, toast, coffee and dairy milk.Observation of Resident 34's lunch meal ticket for August 29, 2026, revealed substitute needed for the entree; buttered noodles, vegetable blend, cherry delite cake and choice of beverage.Observation of Resident 34's dinner meal ticket for August 29, 2026, revealed ground ham and cheese quiche for the entree, hashbrowns, stewed tomatoes, iced cinnamon roll, fruit and dairy milk.Interview with Employee E4 on August 28, 2026, at 12:45 p.m. revealed when questioned about the items that included gluten that the facility would just substitute an item that contained gluten for an item that did not contain gluten. Specifically, the cake would be substituted with fruit; the resident would just receive ham and eggs and not the quiche, and the resident would not receive the iced cinnamon roll.The interview further revealed that the kitchen staff had been working at the facility for a long time and switched items out as needed. There was no system in place to ensure Resident 34 got the correct diet.The above information was conveyed to the Nursing Home Administrator and Director of Nursing on August 28, 2026, at 2:00 p.m. 28 Pa. Code 211.6(a) Dietary Services

Based on review of facility policy, clinical record review, facility documentation, and interview with staff, it was determined that the facility failed to notify the State Long-Term Care Ombudsman's office of hospital transfers for one of four residents reviewed. (Resident 2). Findings include:Review of facility policy Transfer and Discharge, reviewed November 2025, revealed that for emergency transfers to acute care the Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman.Review of Resident 2's progress note of June 22, 2026, revealed that the resident was transferred to an acute care facility. An additional note on June 22, 2026, indicated that the resident was admitted with diagnoses of hypoxic respiratory failure (low blood oxygen levels) and worsening CHF (congestive heart failure - condition in which the heart does not pump blood as efficiently as it should). Review of facility documentation failed to reveal evidence that the facility notified the State Ombudsman's Long-Term Care Office of Resident 2's transfer to an acute care facility.Interview with the Nursing Home Administrator on August 28, 2026, at 11:05 a.m. confirmed that the State Ombudsman's office was not notified of Resident 2's transfer. 28 Pa. Code 201.18(a)(b)(1)(3) Management

Based on review of clinical records and interview with staff. it was determined that the facility failed to ensure that the resident's environment was free of accidents and hazards by failing to thoroughly investigate an incident for one of 12 residents reviewed (Resident 20). Findings include: Review of Resident 20's annual MDS (Minimum Data Set - periodic assessment of resident needs) of June 5, 2026, revealed that the resident had short-term and long-term memory deficits. The resident also had severely impaired cognitive skills for daily decision making. Diagnoses included, but were not limited to, non-Alzheimer's dementia (brain condition that causes memory and thinking problems). Review of Resident 20's progress note of June 17, 2026, revealed that nurse aide made the nurse aware that resident was discovered covered in miconazole powder (topical antifungal medication). Note indicated that it appeared that the resident may have ingested the powder. The resident was assessed and displayed no signs or symptoms of acute distress. Vital signs were obtained. The physician was made aware and the resident was placed on alert charting with vital signs every three days. Further review of the clinical record revealed no evidence that the incident was investigated to determine the root cause of the accident. Interview with Employee E3 on August 28, 2026, at 10:00 a.m. confirmed that there was no evidence that the incident had been thoroughly investigated. 28 Pa. Code: 201.14 (a) Responsibility of Licensee28 Pa. Code: 201.18(b)(1) Management

Based on a review of the facility's policy, clinical records, hospital records review, and staff interview, it was determined that the facility failed to appropriately monitor and address the bowel movement of one of two residents reviewed (Resident R1).Findings include: A review of the facility's policy titled Bowel Protocol, revised on November 1, 2024, revealed that residents' bowel movements will be monitored daily by the 11-7 nursing supervisor. Residents who have not had a bowel movement for 2 days are identified and considered to be at risk for constipation. Residents will continue to be monitored by nursing for bowel movements following each step: Step one, for residents who have not had a bowel movement for 2 days: Give Prune juice 4 ounces, three doses, or two ounces of bran mixture. If prune juice was ineffective, administer Milk of Magnesia (Used as a laxative to relieve constipation) 30 ml PO in AM on day 3. Step 3: If there are no results from the MOM within 24 hours of administration, administer a Dulcolax Suppository (Provides fast relief for occasional constipation by stimulating bowel muscles, and are inserted rectally for localized action) rectally at bedtime on day 4. Step 4: If there are no results from the Dulcolax suppository after 12 hours (morning day 5, administer a Fleets enema (Involves inserting liquid into the rectum to clear the lower bowel for treating constipation) rectally. Step 5: If no results from enema, identification of pain, or absence of bowel sounds, notify RN Supervisor and physician. A review of the physician's order dated November 4, 2025, revealed the following order: Prune juice 4 ounces every 4 hours as needed for constipation. Magnesium Hydroxide Suspension gives 30 cc once daily as needed for constipation. Bisacodyl suppository 10 mg once daily as needed for constipation. Fleet enema insert 1 applicator rectally once daily as needed for constipation. A review of Resident R1's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated November 11, 2025, revealed that the resident was cognitively intact. The same MDS revealed that the resident requires supervision with toilet transfers and partial/moderate assistance with toilet hygiene. Under the bowel continence section, the resident was assessed (9), indicating that the resident had an ostomy (A surgical procedure that creates an opening in the abdominal wall to divert waste out of the body) or did not have a bowel movement for the entire seven days. Resident 1's admission assessment revealed residents did not have an ostomy. A review of the facility's documents task for bowel movements (BM) revealed that Resident 1 did not have a bowel movement for four days, from November 5, 2025, until November 8, 2025. Nursing progress notes dated November 7 and 8, 2025, failed to reveal that the facility followed its BM protocol and provide an assessment which includes abdominal examination, and checking of bowel sounds, to determine constipation. A review of the nursing progress notes dated November 9, 2025, at 10:44 p.m., revealed Resident complained of nausea and diarrhea. Vitals were checked. The same note revealed unsure of how many BM (bowel movement) residents had. Nursing progress notes dated November 9, 2025, failed to reveal residents were comprehensively assessed to determine if the reported diarrhea was fecal seepage (A liquid stool passing which can result from constipation) Further review of the facility's documents task for (BM) revealed that Resident 1 continued with no bowel movement for five days, from November 10, 2025, until November 14, 2025. Another five days with no BM from November 18, 2025, until November 22, 2025. There was no documented evidence that the facility had followed their BM protocol, assessed the resident's bowel status and followed the physician's order to administer medications as needed for constipation for the above dates. An interview was conducted with the Director of Nursing on January 23, 2026, at 10:00 a.m. The DON reported that an alert is sent by the EMR (electronic medical records) if a resident has not had a documented bowel movement in two days. The alert is communicated by the supervisor to the nursing staff to implement the facility's bowel protocol. The DON confirmed that there was no documented evidence that facility had followed its BM protocol for Resident 1. The facility failed to ensure Resident 1's bowel movement was appropriately monitored; resident was comprehensively assessed for presence of constipation and followed physician's medication order for constipation as needed. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 7/18/25, 12/17/25 28 Pa Code 211.5(f) Clinical RecordsPreviously cited 7/18/2,12/17/25

Based on review of clinical records, hospital records, and staff interviews, it was determined that the facility failed to timely and appropriately provide behavioral services for one of two residents reviewed (Resident1).Findings include: A review of Resident 1's diagnosis list includes altered mental status, urinary tract infection (UTI- A common bacterial infection occurring anywhere in urinary system, most frequently in the bladder), depression (A mood disorder causing persistent sadness, loss of interest, and function impairment), and anxiety (A disorder that involve repeated episodes of sudden feeling of intense anxiety and fear of terror that reach a peak within minutes). A review of Resident R1's admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated November 11, 2025, revealed that the resident was cognitively intact. A review of the nursing progress notes dated November 18, 2025, at 1:55 p.m., revealed that the medication nurse was informed by the therapist regarding several marks on the resident's neck. The residents denied harming themselves and were unsure how the marks on the neck happened. The resident denied feeling suicidal. The resident was placed on a suicide watch, monitored every 15 minutes, and had the removal of cords and other items that can cause harm to the resident. The facility contacted the crisis intervention team. A review of the social service notes dated November 18, 2025, at 1:53 p.m., revealed Crisis Intervention came to assess the resident and found that the resident was not in a state of crisis. The resident denied harming themselves. A review of the psychiatry (A medical doctor specializing in mental health) consults dated November 18, 2025, at 2:47 p.m., revealed the resident had a linear scratch to the neck with no concerns noted. The notes indicated that the resident denied suicidal ideation, homicidal ideation, and auditory and visual hallucination. The physician recommended starting Hydroxyzine (A medication used to treat itching, anxiety, and as a sedative) 25 mg two times daily and follow up in four to six weeks / PRN (as needed) per facility request. Nursing notes dated November 18, 2025, at 6:47 p.m., revealed that the resident's son came in to visit and asked about the safety precautions in place, which were answered by the nursing supervisor. The son disclosed that during the visit, the resident admitted to using a picture frame in the room to hurt themselves. As per the son, the resident reported feeling depressed due to health issues, loss of independence, and increased confusion. A review of the social services notes dated November 19, 2025, at 9:46 a.m., revealed that the granddaughter disclosed that the resident told the son that she/he did try to kill themselves. Crisis intervention was called back and recommended to talk to the residents regarding emergency room evaluation and treatment. The same note revealed the resident denied harming themselves and declined hospitalization. A review of the nursing progress notes dated November 19, 2025, at 3:39 p.m., revealed that suicide precautions were not removed at this time. Granddaughter reported to the social worker that the resident told the son that the resident grabbed the glass from the picture frame and used it to cut their neck. An interview with the Director of Nursing (DON) conducted on January 20, 2026, at 11:00 a.m., revealed that the resident informed the son that she/he tried to hurt themselves with the glass on the picture frame. The DON also reported that slashes were observed in the resident's reading book sleeves. The picture frame was never found in the resident's room. A review of the progress notes documentation after November 18, 2025, failed to reveal that a follow-up consult was made to the behavioral health services after the resident confirmed hurting themselves with the use of the glass in the picture frame to cut their neck, despite the psychiatrist's recommendation to follow up as needed. A review of the nursing progress notes dated November 25, 2025, at 12:41 a.m., revealed the resident was sent to the emergency room after a request to be hospitalized for abdominal pain and was returned to the facility. A review of the hospital records, After Visit Summary dated November 25, 2025, revealed Diagnoses: Fecal impactions (A condition where a large, hard mass of stool gets stuck in the colon or rectum, preventing normal bowel movement) and suicidal ideations (The thought process of having ideas about possibility of dying by suicide). The same report revealed consult to behavioral intervention team-suicide. A review of the hospital records, emergency room (ER) provider notes, dated November 25, 2025, revealed that in addition to abdominal pain, this patient admitted that she/he attempted to kill themselves two days ago. Further notes review revealed: Patient states that she is depressed about the state of her health. Apparently, she scratched her neck with glass and then attempted to wrap a cord around her neck 3 days ago. She admits she was [too chicken] to really go through with it The ER physician ordered for the patient to be seen by a behavioral health while at the ER. A review of the ER behavioral health consult dated November 25, 2025, revealed that the patient admitted that a few days ago, she/he attempted to kill themselves with a piece of glass and cords but chickened out. The recommendation includes follow up primary care physician and restart with the previous counselor. Nursing notes dated November 30, 2025, at 4:23 p.m., revealed Resident verbalized delusional statements: people were out to do population control and were drugging all food and fluids to kill people, and President [NAME] is going to come get me and bring clean water in a metal tin. Nursing progress notes dated December 9, 2025, at 12:30 a.m., revealed that the resident was pushing a chair up and down the hall at 12:30 a.m. Nursing progress notes dated December 9, 2025, at 4:41p.m., revealed noted to have some increased anxiety mixed with paranoia. Resident refused medications this morning and evening. Residents have been going in and out of room wandering most of the shifts. Nursing progress notes dated December 10, 2025, at 7:01 p.m., revealed Resident stated to therapy that her time was coming up and she was going to die. The same note revealed that the DON (Director of Nursing) spoke to the resident and reported she does not hear voices but has thoughts that tell her Jesus is coming soon and God is going to judge her and have no mercy and that the time is soon. She stated at the same time devil is trying to take her soul, but God continues to protect her, and she hopes he has mercy on her. An interview with the DON and Nursing Home Administrator conducted on January 23, 2026, at 10:00 a.m., revealed that the facility was not aware of a second attempt (wrapping a cord on the neck). The facility reported that the hospital did not communicate its findings and recommendations to the facility. The DON reported that despite a behavioral intervention being completed in the hospital, as documented on the discharge summary, the facility did not ask for the report/recommendations since the resident was sent back to the facility. There was no documented evidence that the primary physician was notified of the residents' increased anxiety, paranoia, and delusions after the transfer to the hospital on November 25, 2025. There was no documented evidence that facility had the resident followed by a behavioral health until December 16, 2025. Resident 1 would not have been seen by the behavioral health team after an admission of cutting neck with a glass on November 18, 2025, if the resident did not request to be sent to the ER for abdominal pain on November 25, 2025, reporting suicidal ideation twice which prompted ER behavioral health consult. The facility failed to ensure Resident R1 was provided with timely behavioral health services after an admission of hurting self on November 18, 2025, failed to timely follow an ER behavioral health recommendation on November 25, 2025, to start counselling after reporting two times suicidal ideation, and notifying primary physician of the resident's increasing behaviors of paranoia, delusion and anxiety. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 7/18/25, 12/17/25 28 Pa Code 211.5(f) Clinical RecordsPreviously cited 7/18/2,12/17/25

Based on a review of the facility's policies, clinical records review, and staff interviews, it was determined that the facility failed to ensure resident was free from neglect for one of the two residents reviewed. (Resident CL1).Findings include:A review of the facility's policy titled Abuse Reporting and Investigation, revealed ABUSE means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse facilitated or enabled using technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Types of abuse include Verbal Abuse, Sexual Abuse, Physical Abuse, Involuntary Seclusion, Mental Abuse, Neglect, and Misappropriation of Resident Property.A review of the facility's policy titled Medication Administration, with a revision date of November 2024, revealed that medications are administered, as prescribed, in accordance with good nursing principles and practices and only by person legally authorized to do so to comply with Federal Laws governing Medication Administration and in order to ensure the safe, accurate and timely administration of medications.Clinical records revealed Resident CL1 had a diagnosis of as follows: Chronic Lymphocytic Leukemia (Cancer of the white blood cell), Congestive Heart Failure (CHF-A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and generalized anxiety. Further review revealed the resident's medical condition continues to decline. The resident was placed on Hospice care (A compassionate, team-based care approach for terminally ill patients with a focus on comfort, dignity, and quality of life) in July 2025.Clinical records revealed Resident CL1 had a fall in the facility, which resulted in a left femur (The longest and strongest bone in your body, running from the hip to the knee) fracture on November 24, 2025. The resident was sent to the hospital for evaluation, but it was determined that the resident was not a candidate for surgery, Resident CL1 was returned to the facility on November 25, 2025.A review of Resident CL1's physician's order dated November 26, 2025, revealed an order for Morphine Sulfate (A powerful opioid analgesic used to manage moderate to severe pain) oral solution 100/5 ml. Give 0.5 ml every 2 hours for pain. An additional order was made on November 27, 2025, for lorazepam (to treat anxiety), give 1 tablet by mouth every 6 hours for terminal restlessness at 12:00 a.m., 6:00 a.m., 12 noon, and 6:00 a.m.A review of November 2025, Medication Administration Record (MAR) revealed Resident CL1 was not administered with Morphine Sulfate on November 27, 2025, at 8:00 p.m., 10:00 p.m., November 28, 2025, at 12:00 a.m., and 2:00 a.m. Additional MAR review revealed the resident was also not administered Ativan (lorazepam) on November 28, 2025, at 12:00 a.m.A review of the nursing progress notes dated November 28, 2025, at 8:16 a.m., revealed that the agency nurse, Employee E3, reported that the daughter was upset and was insisting on giving the residents' Ativan and Morphine medication. Further review of the same notes revealed Per [Employee E3's name], she/he stated she/he was uncomfortable with administering both doses together due to no signs of restlessness per assessment.A review of the facility's investigation statement from the Director of Nursing, dated November 28, 2025, revealed as follows: It was reported to me that the 3-11 nurse [nurse name] did not administer scheduled Morphine to the resident. The nurse was assigned to residents and in charge of the medication cart until 1:00 a.m. After investigating, it was discovered that the 8 pm, 10 pm, and 12 am doses were not administered.An interview with the Nursing Home Administrator conducted on December 17, 2025, at 2:00 p.m., confirmed that Resident CL1's morphine and Ativan medication orders were not followed. the NHA reported that the agency nurse was not to return to the facility.The facility failed to ensure Resident CL1 was free from neglect by intentionally not administering ordered medication to treat pain and terminal restlessness. 28 Pa. Code 201.18(e)(1) ManagementPreviously cited 7/18/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 7/18/25 28 Pa Code 211.5(f) Clinical RecordsPreviously cited 7/18/25

Based on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely provide wound treatment on an identified skin impairment on a resident's ankle for one of the two residents reviewed (Resident CL2). Findings include:A review of the facility's policy titled Skin and Wound Management Policy, revised on April 3, 2025, revealed Residents identified with skin impairments will have appropriate interventions implemented to promote healing. Wound location, characteristics, and a physician's order for treatment are documented in the medical records. The same policy revealed Residents are provided with appropriate prevention and treatment to encourage integrity and healing.Clinical record review revealed Resident CL2 was admitted to the facility from the hospital on November 12, 2025, post fall and diagnosis of Rhabdomyolysis (A serious condition where damaged muscle tissue breaks down, releasing harmful substances [Myeloglobin] into the bloodstream).Hospital records review revealed Resident CL2 also had a diagnosis of left quadricep (a large group of muscles located at the front of the thigh that are essential for movement, and balance), and right peroneal nerve compression (Occurs when the peroneal nerve, which runs by the knee, gets pinched, causing pain, numbness, and weakness leading to footdrop). The resident had an order to wear a left knee brace and right extremity AFO (Ankle Foot Orthosis- a supportive device worn on the lower leg and foot to control motion, provide stability with walking).A review of the resident's admission skin assessment dated [DATE], revealed no skin impairment observed on the bilateral feet.A review of the skin care plan developed on November 13, 2025, revealed the following interventions: turning and repositioning at least every 2 hours, pressure reduction mattress, offload heels, and monitor and report any reddened areas to the physician.A review of the nursing progress notes dated November 30, 2025, at 1:40 p.m., revealed the resident was observed with a .01 cm (centimeter) circular open area on the left ankle and redness on the right ankle. The area was cleaned, and a 4 x 4 dressing was applied.Clinical records review failed to reveal that the physician was notified of the identified skin impairments on the bilateral ankle until December 3, 2025. There were no documented treatments made on the resident's bilateral ankle from December 1, 2, and 3, 2025. A review of the wound NP's (Nurse Practitioner) consult dated December 3, 2025, revealed Deep Tissue Pressure Injury (DTPI- Persistent non-blanchable deep red, maroon or purple discoloration) to the left lateral ankle measuring 0.3 x 0.6 cm. The right ankle was identified as an unstageable pressure ulcer (Obscured full-thickness skin and tissue loss) measuring 2.2 x 0.8 cm., no drainage, with 26-50% eschar (a dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). A wound treatment to apply skin protectant wipe or spray and leave open to air was made by the wound NP. A review of the resident's Treatment Administration Record (TAR) revealed skin prep treatment to the bilateral ankle was not initiated until December 5, 2025, two days after the wound treatment order was made.An interview with the corporate nurse, Employee E2, on December 17, 2025, at 2:00 p.m., confirmed physician was not notified of the identified skin impairment on the resident's bilateral ankle on November 30, 2025. Employee E2 also confirmed treatment order made by the wound NP on December 3, 2025, was not initiated until December 5, 2025.The facility failed to ensure Resident CL2's identified wound impairment to both ankles was timely followed up and communicated with the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing servicesPreviously cited 7/18/2528 Pa Code 211.5(f) Clinical RecordsPreviously cited 7/18/25

Number of residents sampled: Number of residents cited: Based upon clinical record review, review of facility documentation, and staff interview it was determined the facility failed to ensure proper care and treatment after a fall resulting in actual harm when a resident experienced severe pain after a fall and subsequent fracture due to the facility not providing interventions or monitoring the resident's pain for one of one resident reviewed (Resident 52).Findings include:Review of Resident 52's diagnosis list revealed diagnoses including Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Peripheral Vascular Disease (PVD - poor circulation of the extremities) and osteoarthritis (degenerative joint disease).Review of Resident 52's care plan revealed Resident 52 was at risk for falls and has acute and chronic pain.Review of Resident 52's progress notes dated May 8, 2025, revealed [At] 4:30 a.m. resident screamed out from room and found lying flat on the floor rolled in blankets. Last observed resident in bed five minutes prior to the incident. On assessment [resident] was alert, no obvious bruising and swelling noted on head, all extremities were moving, no shortening or obvious deformity noted. Skin assessment, open area on the left leg below the knee seen, slight bleeding noted, cleaned, dressed. Helped in bed with three (person) assist. Neuro checks started and vitals were WNL [within normal limits]. Notified hospice, notified MD, and DON [director of nursing]. New order for x-ray of femur [long bone in upper leg] stat [immediately]. Hospice suggested to give Tylenol PRN but resident declined. Tried to notify the family but left message as to directed to voicemail.Further review of Resident 52's progress notes dated May 8, 2025, at 10:19 a.m., approximately six hours post fall, revealed notified [mobile x-ray company] to obtain a STAT (immediately or at once) x-ray today. Xray tech will be in sometime today. ASAP (As Soon As Possible).Further review of Resident 52's progress note dated May 8, 2025, at 1:09 p.m., approximately nine hours post fall, revealed entered residents room to attempt administration of PRN [as needed] Tylenol for visible pain noted, upon entering resident holding right leg grimacing, pale in color with golf size ball above the knee and swelling to left side of right knee, resident would not allow writer or aide to get close to the right leg. RN sup [supervisor] and DON [Director of Nursing] notified for further assessment.Further review of Resident 52's progress notes dated May 8, 2025, at 2:20 p.m., approximately ten hours post fall, revealed Nurse placed call to hospice to notify of visible injury to right knee/femur told they were already aware no further instructions call placed to daughter voicemail left for a call back regarding sending resident out, resident appears in distress holding right leg grimacing stating please do something PRN Tylenol given, BP [blood pressure] 70/44, HR [heart rate] 76, R [respirations] 22.Further review of Resident 52's progress notes dated May 8, 2025, at 6:30 p.m., 14 hours post fall, revealed right leg x-ray completed showing acute fracture of the distal femoral metaphysis comminuted and displaced. [Resident's] right leg is swollen and hard upon palpation above right knee. Unable to move resident due to pain. Resident on hospice and morphine needed to be signed to take out of emergency cart. Resident in pain and cannot be moved at this time. Daughter is present and would like [resident] evaluated in ER [emergency room].Review of facility documentation revealed all responsible parties, including the Director of Nursing and Nursing Home Administrator, were informed of Resident 52's ongoing severe pain with documentation or signs of intervention.Further review of facility documentation revealed facility was aware of the delay in services regarding obtaining an x-ray of Resident 52's leg, but no additional assessments, treatments or emergency services were initiated until an x-ray was completed 14 hours post fall.Further review of facility documentation revealed Despite being informed throughout the day of the resident's condition, the DON did not assess the resident nor follow up on the x-ray order.Interview with Nursing Home Administrator and Director of Nursing on July 18, 2025, at 2:30 p.m. confirmed that no appropriate action was taken regarding Resident 52's severe pain for 14 hours post fall.The facility failed to ensure appropriate and timely treatment was provided for a resident in severe pain for 14 hours, causing prolonged and unmanaged pain and actual harm to Resident 52. 28 Pa. Code 201.18(e)(1) ManagementPreviously cited 8/31/202328 Pa. Code 211.12(d)(1)(3) Nursing ServicesPreviously cited8/31/2023, 6/7/2024, 6/3/2025

Based on facility policy, clinical record review and staff interviews, it was determined that the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge for 4 of 4 (6, 7, 41, and 47) residents reviewed. The facility also failed to provide written information about the bed-hold policy to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours for 3 of 3 residents reviewed (7, 41, and 47). Additionally, the facility failed to reconcile the medications prior to discharge for one of one resident (6).Findings include:Review of facility policy Bed Hold Policy and Procedure revised November 1, 2024, revealed that upon discharge from the facility and admission to a hospital, the social service department or the Administrator's designee will contact, by telephone and in writing, the resident/agent (responsible party) to inform them that the resident was discharged to the hospital. The bedhold letter and bedhold reservation request must be mailed on the date the resident was discharged to the hospital for all residents, regardless of payer. Documentation regarding the contact by telephone and a copy of the bedhold letter and bedhold reservation request sent to the family will be kept on file in the resident's admission folder.Review of Resident 6's clinical record revealed that the resident was discharged to home on June 28, 2025. Further review of the clinical record revealed no evidence that the resident's medications were reconciled prior to discharge. Interview with the Director of Nursing on July 18, 2025, at 11:42 a.m. confirmed that there was no evidence of the medication reconciliation or that a representative of the Office of the State Long-Term Care Ombudsman was notified of the discharge.Review of Resident 7's progress note of February 20, 2025, revealed that the resident was admitted to the hospital for a scheduled surgical procedure. Review of Resident 7's progress note of May 23, 2025, revealed that the resident was admitted to the hospital with a diagnosis of UTI (urinary tract infection) and encephalopathy (disorder or disease of the brain). Review of Resident 7's progress note of June 11, 2025, revealed that the resident was admitted to the hospital with a diagnosis of encephalopathy. Interview with the Director of Nursing on July 18, 2025, at 12:41 p.m. confirmed that there was no evidence that the bed-hold policy was provided to the resident or the resident's representative when the resident was hospitalized . Additionally, there was no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the hospitalizations.Review of Resident 41's clinical record revealed Resident 41 was admitted to an acute care facility on April 18, 2025, with a diagnosis of sepsis.Further review of Resident 41's clinical record failed to reveal evidence that the resident or resident's representative were provided with a copy of the facility bed-hold policy. Additionally, there was no documented evidence that the State Ombudsman was notified of the transfer and admission to the acute care facility.Interview with the Director of Nursing on July 18, 2025, at 11:43 a.m. confirmed that there was no evidence the bed hold policy was provided to Resident 41 or Resident 41's representative and further there was no evidence that the State Ombudsman was notified of Resident 41's transfer and admission to an acute care facility.Review of Resident 47's progress note of May 30, 2025, revealed that the resident was sent to the hospital for evaluation and treatment. Interview with the Nursing Home Administrator on July 18, 2025, at 9:58 a.m. confirmed that there was no evidence that the bed-hold policy was provided to the resident's representative when the resident was hospitalized . Additionally, there was no evidence that a representative of the Office of the State Long-Term Care Ombudsman was notified of the hospitalization. 28 Pa. Code 201.14(a) Responsibility of licensee

Number of residents sampled: Number of residents cited: Based upon interview and observation, it was determined the facility failed to employ a Licensed Dietitian.Findings include:Review of clinical records failed to reveal evidence that a Licensed Dietitian was reviewing or monitoring the nutritional status of residents.Interview with the Nursing Home Administrator on July 18, 2025, at 1:30 p.m. confirmed that the Licensed Dietitian, supposedly employed by the facility, was unavailable. This interview further revealed that a Licensed Dietitian had not been reviewing the nutritional status or providing nutritional services to residents in the facility. 28 Pa. Code 201.18(e)(1) Management

Number of residents sampled: Number of residents cited: Based upon interview and review of facility documentation, it was determined that the facility failed to ensure that a staff person was certified as an Infection Preventionist.Findings include:Review of facility documentation failed to provide evidence that the facility had a qualified staff person certified as an Infection Preventionist.Interview with the Nursing Home Administrator on July 18, 2025, at 1:00 p.m. confirmed that the Director of Nursing was taking the required classes but had not completed the required classes and certification for Infection Prevention. The interview further revealed that the facility had no Infection Preventionist on staff. 28 Pa. Code 201.18(b)(2) ManagementPreviously cited 4/29/2025

Number of residents sampled: Number of residents cited: Based upon clinical record review, review of select facility policies and procedures, and facility documentation, it was determined the facility failed to implement non-pharmaceutical interventions prior to the administration of pain medication for three residents and failed to monitor side effects of pain medication and anti-depressant medication for two residents (Resident 1, Resident 4, Resident 17). Findings include: Review of facility policy “Pain Management Guideline” effective August 2017, indicated that documentation and observation of care and treatment reflects ongoing monitoring of pain levels and interventions (pharmacological and non-pharmacological). The documentation will be reflected on the eMAR (electronic medication administration record) and progress notes. Review of Resident 1’s physician’s orders included an order for Oxycodone HCl (pain medication) 5 milligrams (mg) to be administered every six hours as needed for moderate to severe pain. Review of Resident 1’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 4’s diagnosis list revealed diagnoses including left femur [long bone in upper leg] fracture and left shoulder dislocation. Review of Resident 4’s physician orders revealed an order for Hydrocodone – Acetaminophen [pain medication] 7.5-325 milligrams (mg) to be administered every 4 hours as needed for pain. Review of Resident 4’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 4’s clinical record failed to reveal evidence that non-pharmaceutical interventions were attempted prior to the administration of the as needed pain medication and failed to reveal evidence that side effects were being monitored for the use of pain medication. Review of Resident 17’s physician’s orders included an order for Percocet 5-325 mg (oxycodone with acetaminophen) every six hours as needed for moderate to severe pain. Interview with the Nursing Home Administrator and Director of Nursing on July 18, 2025, at 1:00 p.m. confirmed that no non-pharmaceutical interventions were attempted prior to the administration of pain medication and no side effects were monitored during the use of the pain medication. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 6/7/2024, 6/3/2025

Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to handle, store, and process so as to prevent the spread of infection.Findings include:Observations of the laundry area on July 18, 2025, at 11:00 a.m. revealed large trash bags on the floor containing dirty items in front of the dryer. The folding table containing clean items was located approximately four feet from the dirty items. Shelves on the walls contained various maintenance items such as tools and small hardware items. Additional observations revealed no PPE (personal protective equipment) was available for staff to use while sorting and handling contaminated items.Interview with E4 at that time revealed that PPE is used when items are from rooms that are on transmission-based precautions, but the PPE is not available in the laundry area.483.80 Infection Prevention and ControlPreviously cited 6/7/2428 Pa. Code 205.2(c)28 Pa. Code 205.26(d)

Number of residents sampled: Number of residents cited: Bases on observations and interviews with staff, it was determined that the facility failed to store food in accordance with professional standards for food service safety.Findings include:Observations on July 15, 2025, at 9:40 a.m. during a tour of the kitchen with Employee E3, a large build up of ice was noted in the walk-in freezer. Boxes of food were observed to be covered in ice to the point of not being able to identify what the items were.Interview at the time with Employee E3 confirmed that the ice build up had been an on-going problem.The above information was presented to the Nursing Home Administrator at 1:30 p.m. on July 18, 2025.483.60 Food Procurement, Store/Prepare/Serve - SanitaryPreviously cited 6/7/24

Number of residents sampled: Number of residents cited: Based upon clinical record review, it was determined the facility failed to ensure pharmacy consultant reviews were completed monthly as required for one of five records reviewed (Resident 3).Findings include:Review of Resident 3's clinical record failed to reveal evidence that Pharmacy Consultant reviews were completed for Resident 3 for the following months - July, September, October, November and December 2024 and January, February, March and June 2025.Review of Resident 7's clinical record indicated that the consultant pharmacist identified an irregularity during the drug regimen review of March 27, 2025. There was no documented evidence of the irregularity or that the physician addressed the irregularity.Review of Resident 17's clinical record indicated that the consultant pharmacist recommended Venlafaxine (antidepressant medication) be assessed for a gradual dose reduction on December 8, 2024. There was no documented evidence that the physician addressed the recommendation. Additionally, the consultant pharmacist identified an irregularity during the drug regimen review of May 30, 2025. There was no documented evidence of the irregularity or that the physician addressed the irregularity.Review of Resident 37's clinical record indicated that the consultant pharmacist identified irregularities during the drug regimen reviews of December 8, 2024, May 30, and June 29, 2025. There was no documented evidence of the irregularities or that the physician addressed the irregularities.Interview with the Nursing Home Administrator on July 18, 2025, at 1:00 p.m. confirmed that no documented evidence exists that the Pharmacy Consultant completed medication reviews for the above-mentioned months and no documented evidence that the physician addressed pharmacy recommendations. 28 Pa. Code 211.9(a)(f)(3) Pharmacy Services

Based on review of established guidelines for CardioPulmonary Resuscitation (CPR), facility's policies, staff interviews and residents' clinical records, it was determined that the facility failed to ensure that life sustaining meansures such as CPR were provided in accordance with established facility policy and procedure for one of sixteen residents reviewed (Resident 88), creating a situation in which the residents were placed in Immediate Jeopardy related to failure to perform life sustaining interventions. Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid, Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. Review of facility's policy regarding CPR, undated, states that if a resident was found unresponsive and not breathing normally, determine unresponsiveness, activate in-house emergency communication system, verify residents code status, call 911: If necessary, initiate cardiopulmonary Resuscitation (CPR). Chart completely all events leading up to the situation, what transpired during the situation, and the events that followed. Notification of events shall be communicated to the physician and the responsible party. Review of Resident R88's clinical record revealed the resident was admitted on [DATE], and a Physicians order for Full Code (use of all life sustaining interventions) was written on [DATE]. Further review of the clinical record revealed a nursing note dated [DATE], by Licensed employee E3, CNA (certified nursing assistant) alerted me of resident being unresponsive. Resident was pale and unresponsive to sternal rub, pulse was taken and was not palpable, immediately called code. DON (Director of Nursing) as well as fell ow LPN (licensed practical nurse) quickly responded. I laid resident flat to start CPR, at which point I was informed by DON (Employee E4) resident was cool to touch and [Resident 88] was too far gone to attempt CPR. Review of a nursing note dated [DATE], by Registered Nurse, Employee E4 indicated, This nurse called to resident's room for unresponsiveness. Upon entering room, resident was pale, cool to touch, no respirations or heartbeat audible for a count of 3 minutes. Physician notified. Verbal order to pronounce and release body to funeral home. Time of death pronounced at 9:50 a.m. Further review of Resident 88's clinical record failed to reveal any documented evidence, the resident was provided CPR in accordance with preferred code status or facility policy which indicates if a resident is found unresponsive to Call 911 and initiate CPR. Interview with Licensed Employee E5 was conducted by the surveyor on [DATE], 10:45 a.m. revealed on [DATE], I was on the med cart when I heard the code, I grabbed the crash cart and went running to help. I helped Licensed Employee E3 lower the head of the bed down to initiate CPR and pulled the blankets down. Registered Nurse Employee E4 entered the room and moved Licensed Employee E3 out of the way and listened to the heartbeat while talking to others (in the room) while saying he is cold. Licensed Employee E3 kept trying to put her hands on his chest and Registered Nurse Employee E4 kept moving her hands away. The time of death was called by the Registered Nurse Employee and told everyone to get back to work. When asked why they did not start CPR or argue with the Registered Employee, it was stated, She was our boss. Interview with Employee E6 on [DATE], at 11:40 a.m. by the surveyor revealed, was the nurse aide taking care of Resident 88. I collected the breakfast tray at 9:20 a.m. and spoke to the resident and he was fine. When I returned at 9:40 a.m., to provide care, the resident was unresponsive. I notified the nurse, and she did a sternal rub and called the code to his room. I ran to get Employee E4, Registered Nurse, from her office. We ran back to the resident's room and Registered Nurse Employee E4 listened to [Resident] heart. The nurses wanted to do CPR but Employee E4 stated never mind [resident] is dead. When I performed postmortem care, the resident was still warm to touch and was not stiff. The resident's stomach and thighs were warm and [resident] was easily rolled from side to side. Interview with Registered Nurse, Employee E4, on [DATE]:00 a.m. conducted by surveyor revealed, On [DATE], around 9:45 a.m. I was called to the room and found Resident 88 in bed and visually (resident) looked deceased . The resident was lying flat. Color was pale, waxy yellow, mouth was open, mucous membrane was dry and gray in color, both arms and legs were at the side and the blanket was up to the waist. I palpated (resident) right radial and carotid pulse, non-observed, no respirations. (Resident) eyes were closed, I did not check (resident) pupils. Licensed employee E3 sated the resident was a full code, I stated (resident) is already deceased . I pronounced him at 9:50 a.m. I called the physician after I pronounced the resident. Interview conducted on [DATE], at 8:50 a.m. with the Licensed Practical Nurse, Employee E3, revealed staff knew the code status of Resident 88 when I went into the room and performed a sternal rub and checked [resident] pulse. Noted that the resident was pale in color but still warm to touch. Called a code to the resident's room. I then went to the resident's head of the bed and lowered it, I removed the blankets, and prepared to initiate CPR. I placed my hands to begin chest compressions and Employee E4 stopped me saying, [resident's] gone. Licensed Employee E3 stated she stated the resident is a FULL CODE and placed my hands on the resident's chest again and Registered Nurse, Employee E4 moved my hands away and stopped me from proceeding. Employee E3 further indicated, there was another licensed employee in the room who was stopped from performing CPR as well. Employee E4, Registered Nurse, then listened to (resident) heart with a stethoscope and called (resident) time of death. When asked for clarification if the physician was notified prior to the time of death being called Employee E3 stated no, it was after. Interview with the Nursing Home Administrator on [DATE], at 11:00 a.m. revealed that the Registered Nurse, Employee E4 did not perform CPR in accordance with the code status, and the facility's policy. On [DATE], at 1:30 p.m. the Interim Director of Nursing was informed that the health and safety of residents were in Immediate Jeopardy due to the Registered Nurse failing to provide CPR in accordance with a resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted an acceptable immediate action plan on [DATE], at 4:30 p.m. that included the following actions: A full house audit completed of resident code status to reflect current wishes. Physician orders, and dashboard updated to reflect data. The facility developed an education plan for all licensed nurses regarding elder abuse and neglect, and code status. Education to be provided to all nursing staff regarding the compliance with the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All Staff to be educated prior to the start of their shift regarding neglect/abuse/elder justice. Prior to next shift, licensed nurses will perform CPR under supervision to prove competency via code drills. All staff will be educated prior to the start of their shift in relation to code status and procedure if certified to perform CPR. Audits will be conducted daily, weekly monthly, and submitted to QAA. All new hires will complete all competencies before hands on care with residents. All staff will continue to provide re-education annually, ongoing. The interim DON or designee will complete ongoing audits of code drills daily for 7 days, weekly x 4 weeks then monthly x 2 months. The Immediate Jeopardy was lifted on [DATE], at 2:45p.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on a review of the facility policy, residents' clinical records, and staff interviews, it was determined the facility failed to provide life sustaining treatment (CPR) in accordance with physician orders to a resident who expired (Resident 88), creating a situation in which residents were placed in Immediate Jeopardy situation. Findings include: Review of facility policy labeled, Abuse Protection dated [DATE], defines neglect as the failure of the facility, its employees or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R88's clinical record revealed the resident was admitted on [DATE], and a physician's order for Full Code [all resuscitation interventions will be provided] was written on [DATE]. Further review of the clinical record revealed a nursing note dated [DATE], by Licensed employee E3 indicating, CNA [certified nursing aide] alerted me of resident being unresponsive. Resident was pale and unresponsive to sternal rub, pulse was taken and was not palpable, immediately called code. DON [Director of Nursing] as well as fell ow LPN quickly responded. I laid resident flat to start CPR, at which point I was informed by DON resident was cool to touch and he was too far gone to attempt CPR. Review of a nursing note dated [DATE], by Registered Nurse Employee E4 indicated, This nurse called to resident's room for unresponsiveness. Upon entering room, resident was pale, cool to touch, no respirations or heartbeat audible for a count of 3 minutes. Physician notified. Verbal order to pronounce and release body to funeral home. Time of death pronounced at 9:50 a.m. There was no documented evidence that the resident was provided CPR in accordance with the code status or with the facility policy that states if the resident is found unresponsive Call 911 and initiate CPR. Interview with Licensed Employee E5 was conducted by the surveyor on [DATE], 10:45 a.m. revealed on [DATE], I was on the med cart when I heard the code, I grabbed the crash cart and went running to help. I helped Licensed Employee E3 lower the head of the bed down to initiate CPR and pulled the blankets down. Registered Nurse Employee E4 entered the room and moved Licensed Employee E3 out of the way and listened to the heartbeat while talking to others (in the room) saying [resident] is cold. Licensed Employee E3 kept trying to put her hands on [resident] chest and Registered Nurse Employee E4 kept moving her (Employee E3) hands away. The time of death was called by the Registered Nurse Employee and told everyone to get back to work. When asked why they did not start CPR or argue with the Registered Nurse Employee, it was stated, She was our boss. Interview with Registered Nurse, Employee E4, on [DATE]:00 a.m. conducted by surveyor revealed, On [DATE], around 9:45 a.m. I was called to the room and found Resident 88 in bed and visually he looked deceased . The resident was lying flat. Color was pale, waxy yellow, mouth was open, mucous membrane was dry and gray in color, both arms and legs were at the side and the blanket was up to the waist. I palpated his right radial and carotid pulse, non-observed, no respirations. His eyes were closed, I did not check his pupils. Licensed Employee E3 stated the resident was a full code, I stated he is already deceased . I pronounced him at 9:50 a.m. I called the physician after I pronounced the resident. Interview with Employee E6 on [DATE], at 11:40 a.m revealed, was the nurse aide taking care of Resident 88. I collected the breakfast tray at 9:20 a.m. and spoke to the resident and he was fine. When I returned at 9:40 a.m., to provide care, the resident was unresponsive. I notified the nurse, and she did a sternal rub and called the code to [Resident 88] room. I ran to get Registered Nurse Employee E4 from her office. We ran back to the resident's room and Registered Nurse Employee E4 listened to his heart. The nurses wanted to do CPR but Registered Nurse Employee E4 stated 'never mind he is dead.' When I performed postmortem care, the resident was still warm to touch and was not stiff. The resident's stomach and thighs were warm and he was easily rolled from side to side. An interview on [DATE], at 8:50 a.m. conducted by the surveyor with the Licensed Employee E3 revealed staff knew the code status of Resident 88 when I went into the room and performed a sternal rub and checked his pulse. Noted that the resident was pale in color but still warm to touch. Called a code to the resident's room. I then went to the resident's head of the bed and lowered it, I removed the blankets, and prepared to initiate CPR. I placed my hands to begin chest compressions and Registered Nurse Employee E4 stopped me and said, 'he's gone. Licensed Employee E3 stated she voiced that the resident is a FULL CODE and placed my hands on the resident's chest again and Registered Nurse Employee E4 moved my hands away and stopped me from proceeding. Employee E3 further stated that there was another licensed employee in the room who was stopped from performing CPR as well. The Registered Nurse Employee then listened to his heart with a stethoscope and called his time of death. When asked for clarification if the physician was called prior to the time of death was called, Employee E3 stated no, it was after. Interview with the Nursing Home Administrator on [DATE], at 11:00 a.m. revealed that the Registered Nurse Employee E4 did not perform CPR in accordance with the code status, and the facility's policy. Additional interview with Administrator revealed the Employee E4, Registered Nurse was terminated due to substantiated allegation of neglect for not performing CPR on resident identified as wanting life sustaining interventions. On [DATE], at 1:30 p.m. the Interim Director of Nursing was informed that the health and safety of residents were in Immediate Jeopardy due to the Registered Nurse failing to provide CPR in accordance with a resident's physician's order and the facility policy. The Immediate Jeopardy template was presented to the Interim Director of Nursing at this time. The facility submitted an acceptable immediate action plan on [DATE], at 4:30 p.m. that included the following actions: A full house audit was completed of current resident code status to reflect the residents' wishes. Physician orders, and clinical chart dashboard updated to reflect code status data. The facility developed an education plan for all licensed nurses regarding elder abuse and neglect, and code status. Education to be provided to all nursing staff regarding the compliance with the physician orders related to the provision of CPR when indicated. All Staff to be educated prior to the start of their shift regarding neglect/abuse, and elder justice. Prior to next shift, licensed nurses will perform CPR under supervision to prove competency via code drills. All staff will be educated prior to the start of their shift in relation to code status and procedure if certified to perform CPR. Audits will be conducted daily, weekly, monthly, and submitted to QAA. All new hires will complete all competencies before hands on care with residents. All staff will continue to provide re-education annually, ongoing. The interim DON or designee will complete ongoing audits of code drills daily for 7 days, weekly x 4 weeks then monthly x 2 months. The Immediate Jeopardy was lifted on [DATE], at 2:45 p.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders, and the facility's policy, location of code status and completed a Code drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift. The failure to administer life sustaining treatment is deprivation of goods or services which had the potential to cause significant harm. 483.13 Resident behavior and facility practices [DATE] edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on review of facility policy, clinical records, and interviews with the staff it was determined that the facility failed to monitor, timely notify physician, and address changes in condition of increased weight for three residents out of 19 records reviewed, resulting in Resident 38's hospital admission to the intensive care unit for [CONDITION(S)] and acute kidney injury (build-up of waste products in your blood and making it hard for the kidneys to maintain appropriate balance of fluid in the body) and weight gain for Resident 27 and Resident 36. Findings include: Review of the facility policy labeled Resident Weights revealed Weights must be obtained routinely to monitor the parameters of nutrition overtime and identify residents at risk for significant weight change. Re-weights will be obtained within 72 hours of monthly weight if a weight change is greater than 3%. The Licensed Nurse will notify the interdisciplinary team for assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the Physician, Dietician, and family will be notified. Review of Resident 38's clinical record revealed a physician's order for weights to be taken every Monday and Thursday with showers starting March 17, 2022. Review of Resident 38's clinical record revealed a physician note dated May 11, 2022. Included in the physician note was past medical history listed as: Hypertension (high blood pressure), [CONDITION(S)] (excessive body/lung fluid caused by a weakened heart muscle), Cardiac Arrhythmias/[CONDITION(S)] (irregular heartbeat), and [CONDITION(S)] (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system). Further review of physician's progress note dated May 11, 2022 revealed resident's weight 235.0 lbs (pounds), mild chronic [CONDITION(S)] in both legs. Blood pressure is stable, and weight is being monitored. Review of Resident 38's clinical record including weights revealed on May 12, 2022, resident's recorded weight was 239.5 pounds. Further review of Resident 38's clinical record revealed that on May 16, 2022, a weight of 322.6 lbs. was recorded which is an 83.1 lbs. increase in 3 days. Review of Resident 38's clinical record failed to reveal documentation that the physician was notified of the 83.1 pound increase from May 12, 2022 to May 16, 2022. Review of clinical record for Resident 38 revealed a nursing note dated June 20, 2022, that indicated Resident 38 had roughly a 17 lbs. (pounds) weight gain (340.4 lbs.). Weights have drastically increased, and MD (medical doctor) contacted to address this issue. Instructed to fax over recent weights to provider's office. On June 21, 2022, new order to send to emergency room for eval (evaluation) and treat due to swelling. Review of Resident 38's hospital records revealed the resident was admitted to the intensive care unit of the hospital with [CONDITION(S)] and acute kidney injury. Interview with Regional Corporate Employee E7 on September 28, 2022, at 1:35 p.m. revealed that the nurses did not report to the physician of the 80-pound three-day weight gain due to the residents increased appetite. Interview with the Nursing Home Administrator and the Director of Nursing on September 29, 2022, at 9:40 a.m., confirmed that the weight gain in May should have been reported to the physician. The facility failed to notify the physician of a change in condition resulting in the resident having to be hospitalized in a critical state for [CONDITION(S)] and acute kidney injury. Review of Resident 27's clinical record revealed an admitted [DATE], with a recorded weight of 192 lbs. On May 29, 2022, the resident's weight is recorded as 215.2 lbs. (a 23.2 lbs. weight gain). On June 1, 2022, the resident's weight was 222 lbs. and on July 2, 2022, the resident's weight was 229.5 lbs. July 14, 2022, the resident's weight was 237.5 a total of 45.5 lbs. increase. Further review of the clinical record revealed on July 14, 2022, a nursing progress note stating, during the skin assessment the resident's legs were noted to be very swollen. Will continue to monitor. Further review of Resident 27's clinical record revealed a progress note dated July 19, 2022, the resident was seen by the Nurse Practitioner and note [CONDITION(S)] in (resident) legs and ordered [MEDICATION(S)] 20mg daily x 2 days (treat fluid retention), no added salt diet, elevate both lower legs as able, apply tubigrips stockings (elasticized tubular bandage that provides firm but comfortable support for sprains, strains and swelling) to legs in the morning and remove at bedtime. Interview with the Nursing Home Administrator on September 30, 2022, indicated the staff did not perform a reweigh, on Resident 27, or notify the physician of the May 2022 weight increase of 23.2 lbs or subsequent weight gain (equaling 45.5 lbs) until July 19, 2022. Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical records review revealed resident was followed by a kidney specialist and last seen on July 8, 2022, with blood work ordered. Review of Resident 36's weights and vitals report revealed a weight of 213 lbs. on July 26, 2022, and 226 lbs. on August 1, 2022, a 13 lbs. (6.10%) significant weight gain in six days. The clinical records review failed to reveal that the physician was notified of Resident 36's significant weight gain identified on August 1, 2022. Review of the Nurse Practitioner's (NP) notes dated August 23, 2022, revealed Resident 36 was reported with mild swelling in the left arm. The same note revealed Mild Left arm [CONDITION(S)]- likely positional, elevate on the pillow. The note did not mention the resident's significant weight gain identified on August 1, 2022. Review of the weight and vitals report revealed a weight of 232 lbs. on September 1, 2022. The clinical records review failed to reveal physician was notified of Resident 36's continued weight gain. Review of the nursing progress notes dated September 1, 2022, at 6:23 p.m., revealed resident went for a scheduled follow-up with the kidney specialist blood work was ordered, and changed [MEDICATION(S)] to [MEDICATION(S)] (medication to treat Hypertension). There was no documentation that the kidney specialist was notified that the resident had a significant and continued weight gain. Review of the progress notes dated September 5, 2022, at 2:46 p.m., revealed MD was made aware of Resident 36's increasing [CONDITION(S)] and weight gain, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on September 30, 2022, at 11:12 a.m., confirmed that the physician was not notified of Resident 36's significant weight gain until September 5, 2022. The facility failed to notify the physician regarding Resident 36's significant weight changes timely. 28 Pa. Code 211.12(c) Nursing services Previously cited 9/1/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 9/1/21 Based on review of facility policy, clinical records, and interviews with the staff it was determined that the facility failed to monitor, timely notify physician, and address changes in condition of increased weight for three residents out of 19 records reviewed, resulting in Resident 38's hospital admission to the intensive care unit for [CONDITION(S)] and acute kidney injury (build-up of waste products in your blood and making it hard for the kidneys to maintain appropriate balance of fluid in the body) and weight gain for Resident 27 and Resident 36. Findings include: Review of the facility policy labeled Resident Weights revealed Weights must be obtained routinely to monitor the parameters of nutrition overtime and identify residents at risk for significant weight change. Re-weights will be obtained within 72 hours of monthly weight if a weight change is greater than 3%. The Licensed Nurse will notify the interdisciplinary team for assessment if the weight change is significant (a weight loss or gain of 5% in a month, 7.5% in 90 days, or 10% in 6 months), the Physician, Dietician, and family will be notified. Review of Resident 38's clinical record revealed a physician's order for weights to be taken every Monday and Thursday with showers starting March 17, 2022. Review of Resident 38's clinical record revealed a physician note dated May 11, 2022. Included in the physician note was past medical history listed as: Hypertension (high blood pressure), [CONDITION(S)] (excessive body/lung fluid caused by a weakened heart muscle), Cardiac Arrhythmias/[CONDITION(S)] (irregular heartbeat), and [CONDITION(S)] (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system). Further review of physician's progress note dated May 11, 2022, revealed resident's weight 235.0 lbs. (pounds), mild chronic [CONDITION(S)] in both legs. Blood pressure is stable, and weight is being monitored. Review of Resident 38's clinical record including weights revealed on May 12, 2022, resident's recorded weight was 239.5 pounds. Further review of Resident 38's clinical record revealed that on May 16, 2022, a weight of 322.6 lbs. was recorded which is an 83.1 lbs. increase in 3 days. Review of Resident 38's clinical record failed to reveal documentation that the physician was notified of the 83.1 pound increase from May 12, 2022 to May 16, 2022. Review of clinical record for Resident 38 revealed a nursing note dated June 20, 2022, that indicated Resident 38 had roughly a 17 lbs. (pounds) weight gain (340.4 lbs.). Weights have drastically increased, and MD (medical doctor) contacted to address this issue. Instructed to fax over recent weights to provider's office. On June 21, 2022, new order to send to emergency room for eval (evaluation) and treat due to swelling. Review of Resident 38's hospital records revealed the resident was admitted to the intensive care unit of the hospital with [CONDITION(S)] and acute kidney injury. Interview with Regional Corporate Employee E7 on September 28, 2022, at 1:35 p.m. revealed that the nurses did not report to the physician of the 80-pound three-day weight gain due to the residents increased appetite. Interview with the Nursing Home Administrator and the Director of Nursing on September 29, 2022, at 9:40 a.m., confirmed that the weight gain in May should have been reported to the physician. The facility failed to notify the physician of a change in condition resulting in the resident having to be hospitalized in a critical state for [CONDITION(S)] and acute kidney injury. Review of Resident 27's clinical record revealed an admitted [DATE], with a recorded weight of 192 lbs. On May 29, 2022, the resident's weight is recorded as 215.2 lbs. (a 23.2 lbs. weight gain). On June 1, 2022, the resident's weight was 222 lbs. and on July 2, 2022, the resident's weight was 229.5 lbs. July 14, 2022, the resident's weight was 237.5 a total of 45.5 lbs. increase. Further review of the clinical record revealed on July 14, 2022, a nursing progress note stating, during the skin assessment the resident's legs were noted to be very swollen. Will continue to monitor. Further review of Resident 27's clinical record revealed a progress note dated July 19, 2022, the resident was seen by the Nurse Practitioner and note [CONDITION(S)] in (resident) legs and ordered [MEDICATION(S)] 20mg daily x 2 days (treat fluid retention), no added salt diet, elevate both lower legs as able, apply tubigrips stockings (elasticized tubular bandage that provides firm but comfortable support for sprains, strains and swelling) to legs in the morning and remove at bedtime. Interview with the Nursing Home Administrator on September 30, 2022, indicated the staff did not perform a reweigh, on Resident 27, or notify the physician of the May 2022 weight increase of 23.2 lbs or subsequent weight gain (equaling 45.5 lbs) until July 19, 2022. Review of Resident 36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical records review revealed resident was followed by a kidney specialist and last seen on July 8, 2022, with blood work ordered. Review of Resident 36's weights and vitals report revealed a weight of 213 lbs. on July 26, 2022, and 226 lbs. on August 1, 2022, a 13 lbs. (6.10%) significant weight gain in six days. The clinical records review failed to reveal that the physician was notified of Resident 36's significant weight gain identified on August 1, 2022. Review of the Nurse Practitioner's (NP) notes dated August 23, 2022, revealed Resident 36 was reported with mild swelling in the left arm. The same note revealed Mild Left arm [CONDITION(S)]- likely positional, elevate on the pillow. The note did not mention the resident's significant weight gain identified on August 1, 2022. Review of the weight and vitals report revealed a weight of 232 lbs. on September 1, 2022. The clinical records review failed to reveal physician was notified of Resident 36's continued weight gain. Review of the nursing progress notes dated September 1, 2022, at 6:23 p.m., revealed resident went for a scheduled follow-up with the kidney specialist blood work was ordered, and changed [MEDICATION(S)] to [MEDICATION(S)] (medication to treat Hypertension). There was no documentation that the kidney specialist was notified that the resident had a significant and continued weight gain. Review of the progress notes dated September 5, 2022, at 2:46 p.m., revealed MD was made aware of Resident 36's increasing [CONDITION(S)] and weight gain, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing on September 30, 2022, at 11:12 a.m., confirmed that the physician was not notified of Resident 36's significant weight gain until September 5, 2022. The facility failed to notify the physician regarding Resident 36's significant weight changes timely. 28 Pa. Code 211.12(c) Nursing services Previously cited 9/1/21 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 9/1/21

Based on clinical record and facility documentation review and staff interview, it was determined that the facility failed to assess a resident for risk of falls and failed to provide interventions to prevent falls for one of five residents reviewed for falls resulting in actual harm to Resident 31, who fell , sustained a right [CONDITION(S)], requiring hospitalization and surgical repair. Findings include: Review of Resident 31's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] (a progressive nervous system disorder that affects movement), muscle weakness, [CONDITION(S)] (decrease in blood pressure when going from a sitting to standing position), and history of repeated falls. Review of Resident 31's admission MDS (Minimum Data Set - periodic assessment of resident care needs) completed April 13, 2021, revealed the resident was cognitively intact, required limited assistance of one staff person for transfers and bed mobility (how the resident moves in bed), and supervision of one staff person for ambulation. Further review of Resident 31's admission MDS revealed the resident had a fall within the last two to six months prior to admission to the facility, and the resident had a fracture related to a fall within the six months prior to admission to the facility. Further review of Resident 31's admission MDS revealed that the assessment triggered a care area for falls, indicating that a care plan for falls was needed. Review of Resident 31's admission assessment dated [DATE], revealed the section for assessing the resident for fall risks was not completed with blank sections noted. Review of Resident 31's entire care plan from the time of admission (April 6, 2021) through the last day of the survey (September 1, 2021) failed to reveal a care plan addressing the resident's risk for falls. Review of Resident 31's progress notes revealed a note dated August 13, 2021 at 2:57 p.m., which stated Resident [complained of] severe right side rib pain. No bruising noted but does state she didn't fall to the ground but did lose balance and hit her ride side into the bed rail. Review of Resident 31's care plan failed to reveal that the resident's care plan was updated following the resident losing balance and hitting her right side into the bed rail. Review of facility documentation failed to reveal an investigation into Resident 31 losing balance and hitting her right side into the bed rail. Further review of Resident 31's progress notes revealed a note dated August 17, 2021 at 9:00 p.m. which stated [nurse aide] notified [nurse] that resident needs assessed because she fell . Assess resident and asked what happened and she stated that she fell but doesn't remember how she fell . Vital signs stable .she has a slight skin tear on her right elbow. Further review of Resident 31's progress notes revealed a note dated August 17, 2021, at 9:28 p.m. which stated Resident fell earlier this shift, had a slight skin tear on her right elbow, did not complain of any pain status post fall. [Vital signs stable]. Aid went to assist resident to the bathroom and she is now complaining of muscle/ leg pain on her right upper leg. Leg was assessed, good range of motion, no bruising, swelling or obvious deformities. Pain treated with ice pack, Tylenol, and repositioning. Resident was educated that she could have more aching-like pain tomorrow from the fall in general. [Physician] aware, ordered for an x-ray of the right upper leg and right hip. Resident's daughter informed on incident. States that she agrees with the plans and would prefer for her to not be sent out unless absolutely necessary. Review of facility documentation revealed that at the time of the fall on August 17, 2021, Resident 31 stated she was at her closet folding clothes when she lost her balance and the closet pushed her on the floor. Resident 31's room was assessed for clutter; and the armchair was noted to be right up against the closet, created a cramped space. Further review of facility documentation revealed the predisposing physiological factors to Resident 31's fall were gait imbalance, impaired memory, confused, incontinent, and history of recent fall. Facility documentation failed to reveal any interventions in place to prevent Resident 31 from falling. Further review of Resident 31's progress notes revealed a note dated August 18, 2021 at 5:06 p.m. which stated right hip/pelvic xray shows: greater and lesser trochanteric fragments adjacent to right hip arthroplasty. Reviewed with [physician.] New order for Ortho consult and resident to be seen by [therapy] for pain management. Further review of Resident 31's progress notes revealed a note dated August 18, 2021, at 6:14 p.m., which stated Resident continues to be in severe pain. Reports [8 out of 10 pain] at rest and [10 out of 10 pain] with movement. Resident has no appetite; she is tearful .and having confusion. [Physician] notified; new order to send to [emergency department.] Further review of Resident 31's progress notes revealed a nurse's note dated August 18, 2021, at 9:12 p.m., which stated Resident complaining of severe pain right femur. Area appears swollen and warm to touch. Resident crying in pain. [Physician] notified, said to send resident out to hospital for assessment .Resident was transported out via ambulance at approximately 6:30 [p.m.] Writer called hospital for update at 9:00 p.m. resident admitted for [fracture] right hip. A follow up progress note at 9:51 p.m. stated Resident admitted to [hospital] with right hip [fracture], will be having surgery. Further review of Resident 31's progress notes revealed the resident returned to the facility on [DATE], following surgical repair of the right [CONDITION(S)]. Review of Resident 31's clinical record failed to reveal a plan of care in place for the resident's risk for falls, despite having an admitting diagnosis of repeated falls and the admission MDS indicating the resident needed a care plan for falls. Interview with the Director of Nursing on September 1, 2021, at 9:44 a.m. confirmed that Resident 31 was not assessed for fall risk on admission and there was no care plan in place to prevent falls for Resident 31. The facility failed to assess Resident 31 for falls and failed to have a plan of care addressing fall prevention in place resulting in Resident 31 falling, experiencing severe pain, and requiring hospitalization for the surgical repair of a right [CONDITION(S)]. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of documentation submitted by the facility, clinical record review, observations, review of facility incident documentation, and resident and staff interviews, it was determined that the facility failed to ensure the safety of one of 11 residents reviewed (Resident R1) who was repeatedly in possession of medication not prescribed by the facility. Additionally, the facility failed to ensure that supervision and safety interventions were planned and implemented for Resident R1 who was known to exit the facility to smoke, placing the health and safety of the residents in Immediate Jeopardy. Findings include: Review of Resident R1's clinical record documented that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R1's current [DIAGNOSES REDACTED]. Review of Resident R1's quarterly Minimum Data Set assessment (MDS- an assessment of care needs) dated August 10, 2016, documented that the resident required limited assistance from two staff to move on and off the nursing unit and required limited assistance of one staff for eating. Review of Resident R1's skin integrity form (a facility form utilized to document the identification of a skin area) dated July 25, 2016, documented the resident with a blister of the right thumb from smoking and the blister on the right thumb was located where the resident would hold a cigarette and the resident had a history of [REDACTED]. Facility documentation indicated that the resident was witnessed outside several times in the alleyway smoking cigarettes. Documentation indicated that Resident R1 was educated on the importance of following smoking safety during smoking and was educated that he should not be smoking due to the fact that he was unable to correctly hold a cigarette. There was no other facility documentation regarding Resident R1's wound to the right thumb. Review of Resident R1's skin integrity form dated September 4, 2016, documented the resident with a blister noted to the right palm, was fluid filled measuring 3 centimeters by 4 centimeters, that the resident stated was from a cigarette burn and the resident was unable to hold a cigarette properly secondary to quadriplegia. There was no subsequent facility documentation regarding the resident's right palm blister until September 15, 2016. Review of Resident R1's Non-pressure Skin Condition (facility form utilized to evaluate the resident's skin condition) form dated September 15, 2016, documented the evaluation of the third and fourth fingers of the right hand that were described as scabbed areas to the third and fourth fingers. Facility documented one measurement as 0.4 centimeters by 0.5 centimeters. There was no other documented measurements for these scabbed areas of the third and fourth fingers of the right hand. Review of Resident R1's Non pressure Skin Condition form dated September 15, 2016 documented the evaluation of the wound to the right palm of the hand and measured 1.6 centimeters by 2.0 centimeters with a depth of 0.3 centimeters. Review of Resident R1's wound care specialist evaluation dated September 16, 2016 documented the resident with a wound of the right plantar (palm) of the hand measuring 0.9 centimeters by 1.6 centimeters by 0.1 centimeter on a surface area measuring 1.44 centimeters squared. Review of Resident R1's wound care specialist evaluation dated September 23, 2016 documented the resident's wound of the right plantar hand of at least eight days duration and measured 1 centimeter by 0.5 centimeters by 0.1 centimeter with a surface area of 0.50 centimeters squared and twenty percent with necrotic (dead) tissue. The wound was debrided via a surgical incision and subcutaneous (under the skin) tissue removed along with necrotic tissue. Review of Resident R1's wound care specialist evaluation dated September 30, 2016 documented that Resident R1's wound of the right plantar hand was of at least 14 days duration and measured 0.5 centimeter by 0.1 centimeter by 0.1 centimeter with a surface area of 0.50 centimeter squared. Documentation indicated that Resident R1's wound of the right plantar hand was debrided by surgical excision and subcutaneous tissue was removed along with necrotic tissue. Review of Resident R1's nursing note dated October 7, 2016, at 11:39 a.m. documented that the resident's area to the right hand was healed. Review of Resident R1's Skin Integrity form dated October 26, 2016, documented the resident with complaints of pain and needing a bandage to the resident's middle finger right hand blister. Documentation indicated that Resident R1 had stated that he burned himself while smoking. The Skin Integrity form dated October 26, 2016, documented that Resident R1's burn measured 2 centimeters by 1.5 centimeters. Review of Resident R1's wound care specialist evaluation dated November 4, 2016, documented the resident with a burn of the right, third finger of at least one day duration measuring 1.9 centimeters by 0.9 x centimeter and surface area that measured 1.7 centimeters squared. Further procedural documentation indicated that the wound was surgically debrided of subcutaneous tissue and also removed necrotic (dead) tissue. Review of Resident R1's care plan initiated on September 17, 2016, documented that the resident was at risk for side effects/injury from smoking due to sensory deprivation and that the resident would exhibit safe smoking habits and follow safe smoking practices set up by the staff. Those interventions documented that Resident R1 was non compliant with smoking safely and had been educated on the importance of not smoking due to the fact that the resident was not able to correctly hold a cigarette or feel if he was receiving a burn. Interventions also included that Resident R1 was aware that the facility was a smoke free facility and the resident would smoke off the property and that the facility would not supply the resident with cigarettes or a lighter. An interview with Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on November 2, 2016, at approximately 2:30 p.m. confirmed that the facility was a smoke free campus facility for residents, staff and visitors. Residents were educated prior to admission and were re-educated upon admission of the smoking practices of the facility. In regard to those staff that smoked, staff were educated to smoke off campus in a designated area. The DON and the ADON both confirmed that no current residents were involved in a smoking cessation program. The DON and the ADON confirmed that Resident R1 was known by nursing administration to smoke and was burning himself while smoking; and was educated on safe smoking habits and the smoking practices of the facility, however the resident was not compliant. The DON confirmed that the resident had smoked prior to admission to the facility but did not resume smoking until the summer months of 2016. The DON indicated that Resident R1 was educated last week on safe smoking, facility being smoke free and to smoke off campus but if Resident R1 desired to smoke it would have to be off campus. DON further confirmed that it was known that Resident R1 knew the door keypad code and that Resident R1 was frequently seen smoking outside and was non complaint with the resident sign out of facility procedure. The DON also confirmed that the facility had no documented evidence that a smoking cessation program was offered to Resident R1 when it was known that the resident was asserting that he would continue to smoke in the facility. The DON confirmed that the facility failed to coordinate any safe smoking alternatives or interventions to prevent the resident from causing harm to self during smoking. The NHA, the DON and the ADON confirmed on November 2, 2016, at approximately 2:30 p.m. that Resident R1 was not to be smoking on facility property and that the resident was previously observed smoking at the main entrance into the facility. The NHA confirmed that Resident R1 smoked off campus in a designated area but was unable to define the designated area for smoking. The DON and the ADON indicated that Resident R1 had access to smoking products by obtaining these products from visitors. The ADON indicated that Resident R1 was not currently in possession of any cigarettes or smoking paraphernalia as these products are secured in the medication room. The DON confirmed that concerns received from the nursing staff were that Resident R1 could not light or hold a cigarette safely and burned self. The ADON indicated that Resident R1 needed maximum assistance of one staff for wheelchair mobility and secondary to having minor finger movements of the right hand, needed maximum assistance with lighting a cigarette. The DON further indicated that only visitors were lighting the resident's cigarettes and denied that staff would be lighting the resident's cigarettes. Observation of Resident R1 on November 2, 2016, at approximately 3:15 p.m. was of the resident sitting outdoors on the patio area of the facility's main entrance. Resident R1 was in a manual wheelchair and was observed with obvious total loss of function in upper and lower arms and legs. The patio area was observed with a cigarette recepticle and no posted signage notifying residents, visitors or staff that the facility was smoke free. The entrance door was equipped with a keyless entry system/numerical code door lock and signage to press the doorbell for entrance into facility. Prior to the surveyor introducing self to Resident R1, the resident displayed a cigarette and a lighter and requested for the surveyor to light the cigarette. The surveyor observed a wound to Resident R1's third finger of the right hand and Resident R1 confirmed that the wound was a burn that Resident R1 sustained last week while smoking a cigarette. Resident R1 confirmed that Resident R1 burns self during smoking all the time. Resident R1 confirmed that the facility staff were aware of Resident R1 burning himself and were aware of this recent burn to the right hand third finger because Resident R1 had to request a Band-Aid. Resident R1 explained to the surveyor that although he was paralyzed, he could write, but could not independently light a cigarette. Resident R1 was not satisfied that the surveyor did not light the cigarette and alleged that if a stranger walked by he could get a stranger to light the cigarette, but first the surveyor would have to push him off the property and into the public alley. Resident R1 continued to reveal to the surveyor on November 2, 2016, at 3:15 p.m. that he used to get the staff that smoked to light his cigarettes. Resident R1 further alleged that the NHA told Resident R1 that he could only smoke off campus and not on the facility's property. Resident R1 pointed out to the surveyor those public areas that he smoked which included the public roadway, a public alley and in the parking lot behind the trash dumpsters. The resident confirmed that due to paralysis, he also needed assistance from the staff to push the wheelchair off campus and then back onto campus. Resident R1 confirmed that he was to sign out when leaving the building but did not always comply. The resident confirmed that he did not purchase cigarettes but received lighters and cigarettes from visitors and that he was never educated to return smoking products to the facility. Further observation of Resident R1 on November 2, 2016, at approximately 3:35 p.m. revealed the arrival of direct care staff Employee E6. Employee E6 was having difficulty accessing entrance to the facility by way of the keyless entry system and Resident R1 was overheard providing Employee E6 with the facility's numerical access door code. However, prior to Employee E6 entering the facility, the resident had Employee E6 move him off the patio onto the public roadway. Employee E6 was observed using the resident's lighter to light his cigarette, and then handed the lighter back to the resident. Employee E6 was observed walking away from the resident, who remained in the roadway smoking a cigarette. Employee E6 had to request a second time from the resident the numerical access code and entered the facility. Subsequent observation of Resident R1 on November 2, 2016, at approximately 4:00 p.m. revealed the resident being moved by the nursing staff (name and position unknown) from the roadway to the patio. An interview with direct care staff, Employee E6, on November 2, 2016, at 3:40 p.m. confirmed that Employee E6 did not have the access code to enter the facility and rather than using the doorbell, Employee E6 requested the numerical door access code from Resident R1. Employee E6, on November 2, 2016, at 3:40 p.m. confirmed that this employee was not aware if Resident R1 could smoke, could smoke safely or could smoke independently. Employee E6 could not explain to the surveyor why it would be safe to leave Resident R1 to smoke without staff supervision in the road. Finally, Employee E6 indicated no concern to the surveyor knowing that Resident R1 had the numerical access door code memorized, but Employee E6 was aware not to give out the code to visitors or family. An interview with Licensed Nursing Staff, Employees E5, E7, E8 and E9 on November 2, 2016, at approximately 3:45 p.m. confirmed it was known that Resident R1 smoked and the resident would be observed by these licensed staff smoking on the patio or off campus (road or alley), and that the resident would burn self while smoking. Employees E5, E7, E8 and E9 confirmed that the facility was a no smoking facility and Resident R1 was supposed to smoke off campus. It was further confirmed by Employees E7 and E8, on November 2, 2016, at approximately 3:45 p.m. that Resident R1 sometimes needed assistance with the wheelchair on and off the unit and with lighting cigarettes and indicated that sometimes the staff who also smoked would light the resident's cigarettes. Employees E5 and E7 also confirmed that the resident was supposed to sign out/in in the resident specific registry log (which was secured in the resident's clinical record) when leaving the facility, including sitting on the patio, but Resident R1 did not comply with the sign out/in registry log. Additionally, Employees E5, E7 and E8 comfirmed that resident is known to go outside without staff assistance and/or supervision. Review of Resident R1's clinical record revealed a form entitled, Release of Responsibility for Leave of Absence, which logged those dates that Resident R1 would have signed out of building. Review of this log revealed that the resident only documented five dates in September 2016 one date in October 2016 and no dates for the current month of November 2016. During this onsite survey on November 2, 2016 there was no documented leave of absence for Resident R1. Employees E7 and E9 further stated during an interview on November 2, 2016, at 3:45 p.m. that the facility locked Resident R1's cigarettes in the medication room. Observation of the medication room accompanied by Employee E9 on November 2, 2016, at approximately 3:50 p.m. confirmed only the storage of one pack of cigarettes (which contained one cigarette) and no evidence of a lighter. The pack of cigarettes was not labeled with a resident's name. An interview with Social Services, Employee E11, on November 2, 2016, at approximately 4:30 p.m. revealed that the facility would not know if Resident R1 was in possession of a lighter or cigarettes because the facility did not routinely check the resident's room. Employee E11 confirmed that Resident R1 had burned himself on a cigarette and knew the numerical access door code. An interview with the NHA, the DON and the ADON on November 2, 2016, at approximately 4:20 p.m. confirmed that Resident R1 was not smoking upon admission to the facility on [DATE]. The DON confirmed that it was known by the facility that the resident was smoking and was non-compliant with the facility's no smoking campus in the summer months of 2016. The DON confirmed that the resident was not assessed for smoking because the facility was smoke free and if the smoking assessment was completed the resident would fail the assessment for being able to smoke safely. The DON and the ADON both confirmed on November 2, 2016, at 4:30 p.m. that Resident R1 had a history of [REDACTED]. The DON further confirmed that Resident R1's smoking care plan was not developed until September 17, 2016, at approximately 5:00 p.m., which was in correlation to a burn the resident sustained [REDACTED]. The DON was unable to explain why the facility was not safeguarding the resident's smoking products when the resident was not smoking. The DON could not explain or define what safe smoking practices the facility had implemented for this resident as documented in the smoking care plan dated November 2, 2016. In an effort not to violate Resident R1's rights to smoke, the NHA revealed on November 2, 2016, at approximately 5:00 p.m. that the facility educated the resident that he would have to leave the facility property to smoke in a designated area. The facility had no documented evidence that Resident R1 was educated and agreed to leave the facility property to smoke on a public area that was designated by the facility NHA. The NHA, the DON and the ADON were unable to define the designated, public smoking area for Resident R1. Finally, the NHA and the DON were unable to explain how Resident R1 would be able to manage to exit the facility when the staff were not to disclose the numerical key pad code to the residents or family and why nursing staff would allow the resident to exit the facility without signing the sign out/in registry log. During an interview with the NHA, the DON and the ADON on November 2, 2016, at approximately 5:10 p.m. it was confimed that when it was known by the facility that Resident R1 was non-compliant with smoking and burning self, the facility did not offer the resident any safe devices to protect self when smoking and did not coordinate any alternatives to smoking. In addition, the NHA, the DON and the ADON confirmed that for the safety of all residents, Resident R1 should not have knowledge of the facility's numerical access door code, and it was unknown if the resident was sharing this numerical access door code with visitors or other residents. Immediate Jeopardy was identified to the Nursing Home Administrator on November 2, 2016, at 7:05 p.m. secondary to the facility's knowledge that Resident R1 was known to burn self during smoking, and continued failure to ensure the safety of this resident by not providing alternate safety measures or implementing safety interventions to supervise and safeguard Resident R1 while smoking on facility and on public property. An action plan was requested on November 2, 2016, at 7:05 p.m. to immediately put a system in place to ensure the safety of Resident R1 during smoking. The facility submitted an acceptable plan of action on November 2, 2016, at 10:00 p.m. which included: -Room check of Resident R1's room to verify that there were no cigarettes, lighter or smoking materials in the resident's room. -No smoking sign was placed on the front door. -All door codes were changed. -Resident R1 was educated as to the dangers of smoking and the resident may not leave the facility at any time without direct supervision and the resident was not allowed to have cigarettes, lighters or smoking materials. -Facility staff were educated not to allow the resident to be out of the facility without direct staff supervision and that the resident was not allowed to have any cigarettes, lighters, nonsmoking materials in his possession and those materials were to be confiscated. -Education to any people visiting the resident. They were to be informed and educated that any cigarettes, lighters or smoking materials were not to be in the resident's possession. -Resident R1 was placed under 1:1 supervision until further notice. -Resident R1 was offered and provided with a Smoking Cessation program from the facility interdisciplinary team, which the resident agreed to in writing. -Smoking alternatives were secured for Resident R1's use and the resident was notified that they were available upon request. -In the event that Resident R1 chose to discontinue the Smoking Cessation program, the facility was to initiate an individualized smoking program protocol. -Equipment necessary for this individualized smoking program would include: a smoking apron and adaptive equipment which were onsite and available. -The facility defined and designated a smoking area on the facility property (main entrance patio area) and included a receptacle for safe disposal of cigarettes and a fire extinguisher mounted to the exterior of the building. A review of documentation provided by the facility reported that Resident R6 was observed by direct care nursing staff in Resident R1's room, on September 7, 2016, at 10:45 a.m. and witnessed Resident R6 removing three unknown small white tablets from a plastic bag and placing them on Resident R1's bedside table and then assisting Resident R1 with the ingestion of these pills. Resident R6 was described to be cognitively impaired and Resident R1 was described as cognitively intact. Administrative staff were dispatched to Resident R1's room and requested to search the room but the resident requested that the local police be present for the room search. During the search of Resident R1's room, the search revealed the presence of eight small white tablets enclosed in a plastic bag. Resident R1 disclosed to the facility that the pills were Lorazepam 1 milligram tablets (a prescription antianxiety medication) and were provided by visitors. A review of facility documentation for Resident R1 revealed that on October 24, 2016, at 8:16 p.m. the resident was found to have eight white tablets in a coat pocket which the resident identified as Ativan (an antianxiety medication) in his possession. Resident R1 denied ingestion of any pills. Resident R1 reported that a family member brought the pills during a visit. Facility indicated that they re-educated Resident R1 on the dangers of self-medicating. Interview with the DON and the ADON, on November 2, 2016 at approximately 5:00 p.m. alleged that the facility educated Resident R6 on one occasion and Resident R1 on two occasions on the dangers of taking and handling medications that were not prescribed by the attending physician. Surveyor request to review the education that was allegedly provided to Residents R1 and R6 on the dangers of taking and handling medications that were not prescribed by the attending physician revealed that the facility had no documented evidence associated with these incidents. Interview with facility NHA, the DON and the ADON, on November 2, 2016, at approximately 6:00 p.m. confirmed that facility had no documented evidence. The NHA and the DON confirmed on November 2, 2016, at approximately 6:00 p.m. that the facility's response to repeated incidents involving Resident R1's non compliance with smoking and being in possession of pills not prescribed by the physician, was to issue Resident R1 a 30 Day Notice to Discharge from the facility. The facility failed to adequately assess, intervene and provide appropriate supervision to maintain resident safety, placing the health and safety of the residents in Immediate Jeopardy. Immediate Jeopardy was called on November 2, 2016, at 7:05 p.m. The facility submitted and implemented an acceptable plan of action and the Immediate Jeopardy was removed on November 3, 2016, at 5:06 p.m. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 12/22/14 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.14(c) Responsibility of licensee 28 Pa. Code 201.18(a) Management Previously cited 11/19/15 28 Pa. Code 201.18(b)(1) Management Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.18(e)(1) Management Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 12/22/14 28 Pa. Code 209.3(c) Smoking 28 Pa. Code 211.5(f) Clinical records Previously cited 12/22/14, 09/18/15, 11/19/15, 06/06/16, 09/14/16, 10/19/16 28 Pa. Code 211.10(a) Resident care policies Previously cited 12/22/14 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies Previously cited 12/22/14, 09/18/15, 11/19/15, 06/06/16, 09/14/16, 10/19/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/22/14, 11/19/15 28 Pa. Code 211.11(a)(e) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 211.12(c) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15, 09/14/16, 10/19/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15, 09/14/16, 09/30/16, 10/19/16 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15

Based on resident and staff interviews, observation and clinical record review, it was determined that the facility failed to to ensure that [MEDICAL CONDITION] prevented for a resident who smoked independently, resulting in actual harm to Resident R1. Findings include: Review of Resident R1's clinical record documented that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R1's current [DIAGNOSES REDACTED]. Review of Resident R1's quarterly Minimum Data Set assessment (MDS- an assessment of care needs) dated August 10, 2016, documented that the resident required limited assistance from two staff to move on and off the nursing unit and required limited assistance of one staff for eating. Surveyor observation of Resident R1, on November 2, 2016 at 3:15 p.m. revealed resident in possession of a cigarette and lighter. Observation of a wound to Resident R1's third finger of the right hand, and subsequent interview with resident on November 2, 2016, at 3:15 p.m. confirmed that the open area to the third finger of the right hand was a burn that was sustained last week while smoking a cigarette. Resident R1 confirmed that he was burning himself all the time during smoking, and that the staff were aware of [MEDICAL CONDITION] this recent burn. Resident R1 revealed that cigarettes and lighters are provided to the resident by visitors. Surveyor interview with Licensed Nursing Staff, Employees E5, E7, E8 and E9, on November 2, 2016, at approximately 3:45 p.m. confirmed that it was known that Resident R1 smoked and would burn self during smoking. Further, it was known by Employees E7 and E8 that those staff who also smoked would light the resident's cigarettes but were not supervising resident. Interview with the Director of Nursing (DON) and the Assistance Director of Nursing (ADON) on November 2, 2016, at approximately 4:20 p.m. confirmed that it was known by nursing administration that Resident R1 was smoking since the summer months of 2016. The DON confirmed that she did not complete a smoking assessment on Resident R1 because if the assessment was completed the resident would fail the assessment for being able to smoke independently and safely. The ADON further confirmed that Resident R1 had mobility and dexterity impairments and no modifications were made for resident to smoke safely. The DON and ADON both confirmed on November 2, 2016, at 4:30 p.m. that during smoking, Resident R1 was always at risk for [MEDICAL CONDITION] self with the most recent incident being last week. The DON further confirmed that the facility offered no safe smoking options based on the resident's risk and provided no adaptive equipment or staff assignment for lighting resident's cigarettes, holding teh cigarette and supervision. The Nursing Home Administrator (NHA) confirmed in an interview on November 2, 2016, at 4:30 p.m. that he was aware of a burn that Resident R1 sustained but was not informed that the recent burn was secondary to smoking. The NHA further indicated that in an effort for the facility to find ways to respect resident rights, the facility educated Resident R1 that he would have to leave the facility campus to smoke. The NHA confirmed that no other safe smoking options or adaptive equipment was offered to the resident to manage the risk of burning self and responding with procedures to prevent a burn. Review of Resident R1's skin integrity form dated September 4, 2016, documented the resident with a blister noted to the right palm was fluid filled measuring 3 centimeters by 4 centimeters and that the resident stated was from a cigarette burn as the resident was unable to hold a cigarette properly secondary to [MEDICAL CONDITION]. There was no subsequent facility documentation regarding the resident's right palm blister until September 15, 2016. Review of Resident R1's, Non-pressure Skin Condition (facility form utilized to evaluate the resident's skin condition) form dated September 15, 2016, documented for the evaluation of the third and fourth fingers of the right hand that were described as scabbed areas to the third and fourth fingers. Facility documented one measurement as 0.4 centimeters by 0.5 centimeters. There was no other documented measurements for these scabbed areas of the third and fourth fingers of the right hand. Review of Resident R1's, Non pressure Skin Condition form dated September 15, 2016, documented the evaluation of the wound to the right palm of the hand and measured 1.6 centimeters by 2.0 centimeters with a depth of 0.3 centimeters. Review of Resident R1's wound care specialist evaluation dated September 16, 2016, documented the resident with a wound of the right plantar (palm) of the hand measuring 0.9 centimeters by 1.6 centimeters by 0.1 centimeter on a surface area measuring 1.44 centimeters squared. Review of Resident R1's wound care specialist evaluation dated September 23, 2016, documented the resident's wound of the right plantar hand of at least eight days duration and measured 1 centimeter by 0.5 centimeters by 0.1 centimeter with a surface area of 0.50 centimeters squared and twenty percent with necrotic (dead) tissue. The wound was debrided via a surgical incision and subcutaneous (under the skin) tissue removed along with necrotic (dead) tissue. Review of Resident R1's wound care specialist evaluation dated September 30, 2016, documented that Resident R1's wound of the right plantar hand was of at least 14 days duration and measured 0.5 centimeter by 0.1 centimeter by 0.1 centimeter with a surface area of 0.50 centimeter squared. Documentation indicated that Resident R1's wound of the right plantar hand was debrided by surgical excision and subcutaneous tissue was removed along with necrotic tissue. Review of Resident R1's nursing note dated October 7, 2016, at 11:39 a.m. documented that the resident's area to the right hand was healed. Review of Resident R1's, Skin Integrity form dated October 26, 2016, documented the resident with complaints of pain and needing a bandage to the resident's middle finger right hand blister. Documentation indicated that Resident R1 had stated that he burned himself while smoking. The Skin Integrity form dated October 26, 2016, documented that Resident R1's burn measured 2 centimeters by 1.5 centimeters. Review of Resident R1's wound care specialist evaluation dated November 4, 2016, documented the resident with a burn of the right, third finger of at least one day duration measuring 1.9 centimeters by 0.9 x centimeter and surface area that measured 1.7 centimeters squared. Further procedural documentation indicated that the wound was surgically debrided of subcutaneous tissue and also removed of necrotic tissue. Review of Resident R1's wound care specialist evaluation dated November 4, 2016, documented the resident with a burn of the right, third finger of at least one day duration measuring 1.9 centimeters by 0.9 x centimeter and surface area that measured 1.7 centimeters squared. Further procedural documentation indicated that the wound was surgically debrided of subcutaneous tissue and also removed of necrotic tissue. The facility failed to effectively communicate with the interdisciplinary team the need for a comprehensive smoking assessment to ensure that [MEDICAL CONDITION] prevented for resident, which resulted in resident continuing to experience injury and pain resulting in actual harm to Resident R1. F309 483.25 Quality of Care 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.14(c) Responsibility of licensee 28 Pa. Code 201.18(a) Management Previously cited 11/19/15 28 Pa. Code 201.18(b)(1) Management Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.18(e)(1) Management Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.5(f) Clinical records Previously cited 12/22/14, 09/18/15, 11/19/15, 06/06/16, 09/14/16, 10/19/16 28 Pa. Code 211.10(a) Resident care policies Previously cited 12/22/14 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies Previously cited 12/22/14, 09/18/15, 11/19/15, 06/06/16, 09/14/16, 10/19/16 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/22/14, 11/19/15 28 Pa. Code 211.11(a)(e) Resident care plan 28 Pa. Code 211.11(d) Resident care plan Previously cited 12/22/14, 09/18/15, 11/19/15 28 Pa. Code 211.12(c) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15, 09/14/16, 10/19/16 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15, 09/14/16, 09/30/16, 10/19/16 28 Pa. Code 211.12(d)(2) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 12/22/14, 09/18/15, 11/19/15

Based on clinical record review, staff interview, and the facility's policy and procedure review, it was determined that the facility failed to ensure that the physicians' orders were followed and that care was being provided with the order of a physician for three out of 3 residents reviewed (Resident R1, R2 and R3) which resulted in actual harm to one resident (Resident R1). Findings include: Review of facility's policy and procedure titled, Nursing Care of the Diabetic Patient, last reviewed on September 12, 2014, included a [DIAGNOSES REDACTED] (low blood sugar) protocol, stated for residents with a blood sugar less than 70 milligrams/deciliter (mg/dL) or with a physician's orders [REDACTED]. Repeat blood sugar in 10-15 minutes, if above 70 mg/dL, then give diabetic meds, if below 70 mg/dL repeat juice and blood glucose level again and notify physician and obtain specific follow-up orders. The physician should be notified per ordered parameters and documentation should include an assessment of resident's condition, finger stick blood glucose levels, physician notification and response and follow-up if indicated. Review of the facility's policy and procedure titled, Protocol- When to Call the Doctor, last revised on September 21, 2014, revealed that during an emergency you should notify the physician at the time of the event. In the event that an urgent situation is not addressed by the attending physician, the nurse must notify the facility Medical Director for resolution. Review of Resident R1's [DIAGNOSES REDACTED]. Review of Resident R1's physician's orders [REDACTED]. The staff were to notify the physician as needed for [DIAGNOSES REDACTED] (low blood sugar levels) treatment when there has been no improvement after two administrations of hypoglycemic interventions. Which directed nursing staff to give [MEDICATION NAME] (a hormone that is produced by the pancreas to increase the concentration of sugar in the blood), one milligram (mg) Intramuscularly (IM- through the skin, into the muscle using a needle) as needed for [DIAGNOSES REDACTED] of less than or equal to 70 mg/dL to residents who are unresponsive or cannot swallow. To give an applicator full of Glucose gel 40% by mouth, as needed for [DIAGNOSES REDACTED] of less than or equal to 70 mg/dL, to residents who are asymptomatic (without symptoms) or symptomatic and able to swallow. Review of Resident R1's Medication Administration Record (MAR) for August 2015, revealed that the resident had a blood glucose level of 47 mg/dL on August 31, 2015, at 6:30 p.m. Further review of the MAR revealed that the resident did not receive the ordered dose of [MEDICATION NAME] (long acting insulin) which was due at that time. Further review of the MAR revealed that the resident did not receive either the [MEDICATION NAME] injection or the Glucose gel as ordered by the physician indicated on the MAR and there was no notification to the physician. Review of a medication administration note dated August 31, 2015, at 8:30 p.m., stated that the resident did not receive the [MEDICATION NAME] dose due to the blood sugar being very low at 47 mg/dL. Review of the clinical record revealed that there was no evidence of the resident's condition at the time of this low blood sugar, no interventions completed to increase the blood sugar as ordered and no documentation that the resident's physician was notified of this incident of [DIAGNOSES REDACTED]. Further review of Resident R1's nursing notes revealed a note titled, Nursing: Change in Condition dated September 3, 2015, at 7:26 a.m., which revealed that the resident presented with cold and clammy skin, and was unresponsive with a blood sugar of 33 mg/dL. The writer was unable to locate the [MEDICATION NAME] in the emergency medication box consequently 911 was notified. The resident was administered [MEDICATION NAME] when the Emergency Medical Technicians (EMT - the emergency transport staff) arrived at the facilty. Further review of the progress notes revealed an entry on September 3, 2015, at 10:10 a.m., indicating that the resident was going to return from the hospital on hospice services and that the resident remained in a coma. A nursing note on September 5, 2015, at 2:27 p.m., indicated that the resident had ceased to breath. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on September 18, 2015, at 2:00 p.m., confirmed that the resident did have a hypoglycemic incident on August 31, 2015, and that there were no interventions provided as ordered by the physician, the physician was not notified of the incident and there was no documentation as to the condition of the resident at the time of the low blood sugar level. Further interview with the DON and NHA on September 18, 2015, at 2:00 p.m., confirmed that this resident was hypoglycemic on September 3, 2015, and that the Registered Nurse (RN) who was taking care of this resident was unable to find the [MEDICATION NAME] in the emergency box, which delayed the treatment to the resident and caused actual harm due to the need to call for emergency medical treatment and the resident being transferred to the hospital. Review of Resident R2's [DIAGNOSES REDACTED].), diabetes and obesity (a medical condition in which excess body fat has accumulated to the extent that it may have a negative effect on health). Review of the information submitted to the state agency on July 17, 2015, revealed that Resident R2 was complaining of chest pain and arm pain. The RN assessed the resident and called the physician but the physician did not answer so the RN left a message. The RN then administered a nitro stat ([MEDICATION NAME] is for the treatment of [REDACTED]. Review of Resident R2's physician's orders [REDACTED]. An interview with the DON and the NHA on September 18, 2015, at 2:00 p.m., confirmed that the resident was given a medication without a physician's orders [REDACTED]. Review of Resident R3's [DIAGNOSES REDACTED]. Review of Resident R3's physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. The resident was also ordered to have accu-checks at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 7:00 p.m. Review of the information submitted to the state agency on June 15, 2015, revealed that on June 13, 2015, at 2:00 p.m., the resident had a blood sugar of 509 mg/dL and the physician was notified of the high blood sugar and there were no new orders given. About 45 minutes later the resident's blood sugar was 48 mg/dL. Review of Resident R3's progress notes for June 13, 2015, revealed that there was no documentation that the resident had an episode of [DIAGNOSES REDACTED], that the resident was given [MEDICATION NAME] as ordered by the physician or that the resident's physician was notified of the [DIAGNOSES REDACTED] at the time of the incident. Interview with the DON and the NHA on September 18, 2015, at 2:00 p.m., confirmed that there was no evidence that the resident was treated for [REDACTED]. 42 CFR 483.25 Provide Care/Services for Highest Well Being. Previously cited 11/15/13, 12/22/14 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 02/21/14, 12/22/14 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 11/15/13, 02/21/14, 12/22/14 28 Pa. Code 211.5(f) Clinical records. Previously cited 11/15/13, 12/11/13, 12/22/14 28 Pa. Code 211.10(c) Resident care policies. Previously cited 11/15/13, 02/21/14, 12/22/14 28 Pa. Code 211.12(c) Nursing services. Previously cited 11/15/13, 12/22/14 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 11/15/13, 12/11/13, 02/21/14, 12/22/14

Based on a review of clinical records, facility policy, facility documentation and staff interview, it was determined that the facility failed to provide interventions and monitoring to prevent repeat falls for for two of ten residents reviewed resulting in actual harm to one resident (Resident A7) (Residents A7, A8) Findings include: Review of the facility policy entitiled Dining Experience (reviewed January 31, 2013) revealed that appropriate supervision is provided in the dining room. Review of Resident A7's current physician orders revealed a [DIAGNOSES REDACTED].) Review of the significant change MDS (a periodic assessment of resident's identified needs) of August 14, 2013 revealed a cognitive BIMS (brief interview of mental status) level of 2 indicating severe cognitive impairment. In addition, the resident had behaviors including being inattentive and difficulty concentrating or following what was being said. Resident A7's hospital documentation dated May 21, 2013 revealed that the resident was admitted to the hospital from home with a urinary track infection and had sustained a fall from bed in the hospital resulting in a fractured right hip. The resident was admitted to the facility on [DATE] for care and rehabilitation. Review of Resisdent A7's progress notes dated June 30, 2013 revealed that at 5:00 a.m. the resident was found on the floor by the bed. On July 1, 2013 at 9:30 p.m. the resident was found on the floor in her room with bruising on the left forehead. On July 8, 2013 Resident A7's progress notes indicated that the resident was observed trying to ambulate independently in the hallway prior to the supper meal. The resident was assisted to the dining room by staff. At approximately 5:30 p.m., the resident attempted to transfer independently and fell to the floor. The resident was transferred to the hospital and admitted for a refracture of the right hip. The Director of Nursing confirmed during an interview on November 14, 2013 at 10:00 a.m. that nursing staff were not present in the dining room to monitor residents at risk for falling but were in and out bringing residents in and passing trays in the hallway. Despite Resident A7's previous falls with injury and observed restless behavior prior to the meal, Resident A7 was left unsupervised in the dining room resulting in a fall causing actual harm to resident. Review of Resident A8's current care plan revealed [DIAGNOSES REDACTED]. Review of the quarterly MDS (assessment of resdient care needs and status) dated November 6, 2013, revealed a cognitive BIMS level of 4 indicationg severe cognitive impairment. In addition, the resident had behaviors including insomnia, decreased energy, poor appetite and difficulty concentrating at least several days during the assessment period. Review of Resident A8's progress notes dated August 5, 2013 at 1:00 p.m. revealed that the resident was assisted into the hallway by dietary staff following the noon meal and fell out of the wheelchair. She was transported to the hospital secondary to hip and shoulder pain. Resident A8's progress notes dated August 8, 2013 at 5:15 a.m. revealed that the resident was observed getting out of bed unassisted and falling to the floor. In addition to the intervention of toileting in the early a.m., the progress notes revealed an intervention to prevent a repeat incidence was to remind the resident to ring for assistance; however, the resident was severely cognitively impaired as indicated above. Resident A8's progress notes of September 14, 2013 at 5:30 p.m. revealed that the resident was observed falling between the wheelchair and the bed, hitting her head against the bedrail. The progress notes further revealed that the intervention to prevent a reoccurence was to reeducate the resident. Two incidents documented in the progress notes on October 15th and October 22 revealed that Resident A8 fell in her room walking unassisted. Both incidents resulted in the resident hitting her head on furniture and equipment; however, there were not interventions identified in the nurses notes or in the care plan to prevent a reoccurence. Review of Resident A8's progress note of November 10, 2013 at 3:00 p.m. revealed that the resident tried to use the bathroom independently and was found seated on the floor. The intervention to prevent a reoccurence was to educate the resident to ask for assist for transfers. Resident A8 sustained seven falls between August 5 and November 10, 2013. Review of the documentation in the resident's record and the care plan revealed that for four of these falls, the intervention to prevent a reoccurence was to provide education that the resident probably could not understand or remember secondary to her assessed cognitive impairment. Licensed nursing, Employee E4 confirmed on November 15, 2013 at 1:30 p.m. that no additional interventions were identified for these fall incidents for Resident A8. The facility failed to develop and implement interventions that were appropriate to meet the assessed needs of Resident A8 to prevent repeat falls and potential injury. 28 PA Code 211.5(f) Clinical records Previously cited 12/21/2012 28 PA Code 211.10(c) Resident care policies Previously cited 12/21/2012 28 PA Code 211.12(d)(1)(5) Nursing service Previously cited 12/21/2012