Every finding on record at Kearsley Rehabilitation and Nursing Center

Based on review of facility policy, observation, and interview with staff it was determined that the facility failed to store food in accordance with standards for food service safety in two of two nourishment rooms observed (ground and 1st floor nursing units). Findings include: Review of undated facility policy Food Receiving and Storage revealed all foods belonging to residents should labeled with the resident's name, the item and the use by date. A tour of the nourishment rooms conducted on May 17, 2026, at 10:00 a.m. with Nursing Home Administrator, Employee E1, revealed the following: Observations in the nourishment room on the 1st floor nursing unit revealed it was equipped with a sink, counters, cabinets, refrigerator, and an ice machine. The ice machine was observed to have a significant build-up of hard water (white, chalky residue appearance) on the dispenser and tray. Further observations in the 1st floor nourishment room revealed there was a tray beneath the sink (inside the cabinet) with stagnant water from the leaking of the sink. The drawers were filled with lose condiments and individually wrapped cookies, with no labels/dates. The refrigerator was tightly packed with a variety of food items that had no labels or dates including premade peanut butter and jelly and turkey sandwiches. Observations in the nourishment room on the ground floor nursing unit revealed it was also equipped with a sink, counters, cabinets, refrigerator, and an ice machine. The ice machine was observed to have a significant build-up of hard water on the dispenser and tray. There was a hole approximately 5 inches in width and 2 inches in height along the baseboard on the left side of the room. Observations in the refrigerator revealed multiple, undated premade turkey sandwiches. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on record review, interview, and staff documentation, the facility failed to ensure one of two residents reviewed resident received necessary care and services to prevent recurrent hypoglycemic events, failed to implement and follow physician/provider orders related to insulin management, failed to adequately monitor and reassess the resident following hypoglycemic episodes, and failed to accurately document interventions and resident response, resulting in repeated symptomatic hypoglycemia requiring emergency hospital transfer. (Resident R109) Review of facility policy management of Hypoglycemia undated revealed that residents with hypoglycemia must be closely monitored for symptoms such as weakness, sweating, confusion, dizziness, behavioral changes, or decreased consciousness. Blood glucose levels should be checked before treatment and rechecked every 15 minutes until the resident is stable and blood glucose is above 70 mg/dL. Vital signs and level of consciousness should also be monitored, and staff should remain with the resident during treatment.The physician/provider must be notified immediately for all hypoglycemic events, persistent low blood sugar, severe symptoms, or emergency situations requiring additional treatment orders. Documentation must include blood glucose readings before and after interventions, treatments provided, follow-up glucose results, monitoring performed, and the resident's level of consciousness and response to treatment.Review of Resident R109's Minimum Data Set (MDS) dated [DATE], revealed that this resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately intact cognition. Continued review of the MDS revealed that Resident 109 had the diagnoses of renal failure (impaired kidney function requiring medical management), diabetes mellitus (a metabolic disorder characterized by elevated blood glucose levels), and malnutrition (a condition resulting from inadequate nutritional intake or absorption). Review of Resident R109's medications include insulin, used to regulate blood glucose levels in diabetes mellitus (failure of the body to produce insulin); anticoagulants, (used to reduce the risk of blood clot formation); and hypoglycemic medications, (used to lower blood sugar levels). The resident also requires ongoing hemodialysis (a lifesaving treatment for renal failure).Review of Resident R109's hospital records revealed the resident was hospitalized on [DATE], after being found unresponsive with blood glucose levels in the 50s related to poor oral intake and insulin use.Review of Resident R109's October 2025 physician orders revealed the following orders:Insulin Glargine (Lantus) 8 units subcutaneously at bedtime for Type 2 diabetes ordered beginning October 14, 2025, through October 22, 2025.Insulin Aspart (Prandial/Short-Acting Insulin) 8 units subcutaneously with meals for Type 2 diabetes ordered beginning October 15, 2025.Glucagon Emergency Kit 1 mg intramuscular injection ordered as needed for blood glucose less than 60 when unconscious or unresponsiveGlucose Gel 40% ordered as needed for blood glucose less than 60 when conscious, with instructions to recheck blood glucose in 15 minutes, repeat once if blood glucose remained below 60, and notify the physician.Review of Physician Assistant/Nurse Practitioner, Employee E14 notes dated October 15, 17, and 18, 2025, revealed the resident was recently hospitalized for severe hypoglycemia related to insulin administration and poor oral intake. Providers repeatedly documented concerns regarding inconsistent intake, diarrhea, dysphagia, and aspiration risk, and specifically instructed staff to hold prandial insulin until the resident demonstrated consistent meal consumption.Review of Physician, Employee E12 progress note dated October 20, 2025, revealed the resident was evaluated for hypoglycemia following a recent hospitalization caused by poor oral intake and inconsistent insulin use. The physician documented the resident remained on Lantus insulin and advised staff to watch diet.Review of Resident R109 's Medication Administration Record revealed that the resident was administered Insulin Aspart (Prandial/Short-Acting Insulin) 8 units subcutaneously with meals from October 15, 2025 through through October 22, 2025 while the resident continued to have poor oral intake, placing the resident at increased risk for hypoglycemia.Review of Resident F109's October 2025 Medication Administration Record revealed that Insulin Aspart (Prandial/Short-Acting Insulin) 8 units subcutaneously with meals was administered on 10/15/26 through 10/20/26. Review of the resident's dietary intake documentation revealed the resident frequently did not consume complete meals during the review period. Documentation showed inconsistent oral intake with multiple meals recorded at less than 50% consumption as follows:-October 15, 2025, the resident consumed only 025% of dinner.-October 16, 2025, the resident again consumed only 025% of dinner.-On October 17, 2025, the resident consumed approximately 2650% of lunch.-On October 19, 2025, the resident consumed only 2650% of both breakfast and lunch.-On October 20, 2025, the resident consumed only 025% of breakfast, and 025% of lunch.Review of nursing notes dated October 20, 2025 at 4:47 p.m.documented the resident was observed during lunchtime to be cold, clammy, difficult to arouse, and not eating from (her/his) meal tray. A blood glucose reading obtained at that time was 64. Nursing documented the resident was fed pudding and juice and that glucose gel was administered. The resident reportedly later awoke and consumed a full plate of food along with sugar-free ice cream. The note additionally documented the resident refused her first scheduled dialysis treatment due to diarrhea and missed the subsequent dialysis session due to the hypoglycemic episode.Review of the Medication Administration Record (MAR) failed to reveal documented administration of glucose gel despite nursing documentation stating it was given. Additionally, the record lacked documented follow-up blood glucose monitoring, reassessment after intervention.Further review of nursing note on October 20, 2025 at 7:45 p.m.revealed the resident's blood glucose level was 226 at 7:22 p.m. The resident's level of consciousness was documented as alert, arousable, and oriented to person, place, and time.Review of nursing note October 21, 2025 at 12:30 a.m. revealed staff heard noises coming from the resident's room, with the roommate calling out that the resident had fallen. The resident was last observed at approximately 11:00 p.m. lying in bed asleep. Following assessment after the fall, the resident was noted to be diaphoretic with a blood glucose level of 55. The resident was reportedly unable to verbally respond to her name. Nursing documentation stated attempts were made to provide diabetic support for hypoglycemia; however, the resident's blood glucose did not improve. Emergency medical services (911) were contacted, and the resident was transferred to the hospital for further evaluation and treatment.Review of Resident R109's hospital transfer documentation revealed the resident's blood glucose level was documented at 35 at the time of transfer to the hospital.Review of blood glucose documentation for October 20, 2025, revealed a blood glucose level of 64 at 11:00 a.m. The last blood glucose check was at 9:00p.m. which read 144.Review of the MAR failed to reveal documented administration of hypoglycemia rescue medications or evidence of required follow-up interventions.Interview with the Director of Nursing (DON), Employee E2 and Regional Nurse Employee E13 on May 15, 2026, at approximately 9:30 a.m. revealed both acknowledged there were significant documentation issues related to the resident's diabetic management and hypoglycemic events. Employees E2 and E3 acknowledged these interventions were not documented in the medical record.The physician assistant, employee E14 was unavailable at time of survey for interview.28 PA. Code 211.10(c) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policy, observations, and staff and resident interviews it was determined that the facility failed to ensure adequate supervision for two of two residents (Resident R104 and R58). Findings Include: Review of facility policy titled, Smoking Policy-Residents with a revision date of October 2023 states, Policy Statement- this facility has established and maintains safe resident smoking practices. Further review of the policy states, 8. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption b. method of tobacco consumption (traditional cigarettes, electronic cigarettes, pipe, etc.) c. desire to quit smoking and d. ability to smoke safely with or without supervision (per completed Smoking Evaluation). Review of Resident R104 clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: Tobacco Use, Hypertension (high blood pressure), Nicotine Dependence, and Opioid Abuse. Review of the resident's History and Physical documentation dated May 6, 2026, stated, Social History- Tobacco Use- Smoking Status: Every Day. Current packs/day: 1.50 Average packs/day 1.5 packs/day for 30.0 years. Types: Cigarettes. Resident R104 was observed smoking outside the facility without staff supervision on May 18, 2026, at 9:00 a.m. The resident was approached and asked if he/she was a resident and he/she stated, yes. Looking around in the area outside of the main entrance there were no staff present. Interview held with Receptionist, Employee E11 on May 20, 2026 at 11:00 a.m. revealed that residents are only permitted to go out front of the facility when they are escorted by staff. When asked who provides the escort, Employee E11 stated that the nurse aids, nurses, or concierges are the ones who go outside with the residents for fresh air or to smoke. Review of Resident R58's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of muscle weakness, respiratory failure, and asthma, and was cognitively intact. Observations on May 17, 2026, at 9:00 a.m. revealed Resident R58 was sitting out front of the facility in his/her wheelchair smoking a cigarette. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.Findings include: Review of facility documentation Facility Assessment reviewed April 2026, revealed individuals who were involved in completing the review included: Nursing Home Administrator (Employee E1), Director of Nursing (Employee E2), Admissions Director (Employee E3), Business Office Manager (Employee E14), Maintenance Director (Employee E4), Rehabilitation Director (Employee E15), Registered Dietitian (Employee E16), House Keeping Director (Employee E17), and Human Resources (Employee E18). Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment revealed no documented evidence that the facility included active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA)). Further review of the facility assessment revealed no documented evidence that the facility considered input from residents, their representative(s), family members, and representatives of direct care staff when formulating their assessment. Interview on May 19, 2026, at 11:15 a.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents. 28 Pa. Code 201.14 (a) Responsibility of licensee.

Based on review of clinical documentation and staff interviews, it was determined the facility failed to ensure adequate supervision during care by ensuring two staff were available for one of two residents reviewed (Resident R56). This failure resulted in actual harm to Resident R56 who fell out of bed and sustained a compound fracture of the right femur (hip). This deficiency was identified as past non-compliance. Findings include: Review of Resident R56's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of cerebral infarction (area of brain tissue that has died ), psychomotor deficit (slowing down of both thoughts and physical movements) following cerebral infarction, Hemiplegia and Hemiparesis (paralysis affecting only one side of the body) affecting the right dominant side, and need for assistance with personal care. Review of Resident R56's quarterly MDS (Minimum Data Set, periodic assessment of resident care needs), section G, Functional Status, dated [DATE], revealed the resident required extensive assistance of two or more staff members for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Further review of of Resident R56's MDS assessment, Section C, Cognitive Patterns, revealed the resident was rarely understood, and a Staff Assessment for Mental Status concluded the resident had long and short term memory deficits and was unable to recall the current season, location of his/her room, names and faces of staff members, or that he/she was a resident in a nursing facility. As such, it was determined the resident was non-interviewable. Review of Resident R56's care plan dated February 12, 2025 revealed the following intervention, I am dependent on 2 staff and a sheet for turning and repositioning. Review of Resident R56's bedside Kardex report (report of information available to nurse aides to alert them to resident care needs) revealed an intervention under the section Bed Mobility/Positioning which indicated I am dependent on 2 staff and a sheet for turning and repositioning. Review of the nursing notes for Resident R56 revealed a note written by Registered Nurse Supervisor, Employee E6, on [DATE], at 6:17 a.m. The nursing note indicated, Called by nurse to assess resident .related to fall. Resident was lying on floor to left side of [his/her] bed. Resident was noted bleeding from left knee from tiny laceration Resident transported to ER (emergency room ) at 6:23 am. Continued review of nursing notes revealed a note from Licensed Nurse, Employee E7, on [DATE], at 8:19 a.m. which revealed, @ 6am I heard a scream, then heard CNA (nurse aide) calling for me, I immediately ran to the room, observing the resident in a sitting position with right knee pulsating with blood, from a small laceration, large amount of blood observed. Review of facility's incident report for Resident R56 revealed a fall occurred on [DATE], at 6:00 a.m. The report indicated the fall was witnessed, and the resident lowered himself/herself to the ground. The report concluded the resident slid from bed while receiving incontinent care. [Resident R56] is dependent on toileting, was being toileted as usual with [his/her] routine CNA (Nurse Aide, Employee E8). [The resident], while holding onto [his/her]right assist rail, [his/her] legs slid off the bed onto the floor .[she/he] held onto the rail, preventing [his/her] top half from falling, the CNA safely lowered [him/her] to the floor. The report further revealed the resident was sent to the emergency department for evaluation. [Resident R56] was admitted to the hospital with a diagnosis of fractured femur (hip), and that he/she underwent surgical fracture repair. Review of the hospital documentation signed by hospital physician, Employee E9, revealed Resident R56 had been admitted to the hospital with an open fracture (where the bone protrudes through the skin) of the right femur, which will require operative fixation. Telephone interview with Employees E6, E7, and E8 were conducted on [DATE]. Interview with RN Supervisor, Employee E6 at 2:38 p.m. revealed on the night of the fall, he was summoned to the room to assess the resident following the incident. He stated that staff was providing care to Resident R56 when he/she fell out of bed, and that upon his entry to the room, the only staff present were the charge nurse, Employee E7, and the nurse aide, Employee E8. Interview with the charge nurse, Employee E7, at [DATE] at 2:44 p.m., revealed, I was outside [the room] and I heard a scream and the CNA (Employee E8) calling for help. I went in and saw the CNA holding the resident up. [He/she] was [rolled] on [his/her] right side, which is [his/her] weak side . [Employee E8] said she had turned [resident], and [he/she] slipped off the bed. The bed was high because it was in position for the CNA. She further stated that this was the first fall for the resident in the three years [he/she]'s been here, and the Nurse aide, Employee E8 was the only staff member present in the room at the time of the fall. She also stated the resident was not on paired care. Charge nurse, Employee E7 had been unaware at the time of the resident's needed level of assistance for bed mobility and turning was a two or more person assist. Interview with the Nurse Aide, Employee E8, on [DATE] at 2:48 p.m., revealed during continence care, I was changing [resident], and [he/she] was on [his/her] side. I don't even really know how [resident's] legs slipped off the bed .it was just me. I rolled [him/her] side to side . I was changing [resident], and [his/her] legs slipped off. Employee E8 revealed the resident had been rolled to the right side of the bed, holding the rail with [his/her] left arm. Employee E8 clarified that she had been standing on the left side of the bed at the time, and that the resident's legs had slid out of the right side of the bed, opposite of where she was standing. She said that she was able to assist the resident to the floor, and then called the charge nurse for help. She revealed that she was not aware at the time of the incident, the resident required assistance of two or more staff for bed mobility and repositioning. On [DATE], the Nursing Home Administrator (NHA), Employee E1, presented documentation indicating that the facility had initiated a plan of correction on [DATE], related to ensuring nursing staff were made aware of the level of assistance required for care of residents and they verified ADL (Activities of Daily Living) care needs including bed mobility and transfer status prior to providing care. Review of facility Action plan/Follow up documentation revealed the following information. 1. [Resident R56] care plan and Kardex have been updated to reflect current needs. 2. Sweep of current residents conducted to ensure ADL care needs reflect their current needs and are reflective in the care plan and Kardex. 3. Contracted Occupational Therapist educated on ensuring changes in care needs are reflective in the care plan and communicated to the resident's charge nurse. Also, it is vital to ensure current care needs are resolved or edited when a change is made [to] any previous bed mobility. 4. NHA or designee will conduct weekly audits to ensure care plan and Kardex clearly indicate the level of care needed. Results of the audits will be reviewed by the QAA (Quality Assurance) committee and the QAA committee will determine continuation of audits. The facility alleged a date of compliance with this plan of correction of [DATE]. Facility education record and subsequent audits were verified for completion. Staff were interviewed to verify education of facility policy on assistance level verification for ADL care. Nursing staff and resident interviews were conducted to verify compliance with the plan of correction. No continuing concerns were identified through record review, interview or observation. This deficiency was cited as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to develop and implement a baseline care plan related to a pressure ulcer for one of two new admissions reviewed (Resident R47). Findings Include: Review of facility policy Care Plans - Baseline revealed a baseline plan of care to meet the resident's immediate health/safety needs is developed for each resident within 48 hours of admission. Review of Resident R47's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 10, 2025, revealed the resident was admitted to the facility on [DATE], and had diagnoses of muscle weakness, malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), and depression (mood disorder which causes persistent feelings of sadness of loss of interest). Continued review of the MDS dated [DATE], included a review of Section M - Skin Conditions which indicated Resident R47 was at risk of developing pressure ulcers/injuries and had an unhealed pressure ulcer/injury. Resident R47 was noted to have an unstageable deep tissue injury. Review of facility wound report dated April 7, 2025, revealed Resident R47 had a left medial heel deep tissue injury that was present at the time of admission on April 4, 2025. Review of Resident R47's clinical record and baseline care plan revealed no documented evidence a baseline care plan was created to include the interventions and treatments for the left heel deep tissue injury that was present at the time of admission. Review of Resident R47's clinical record revealed a care plan for the left heel deep tissue injury was not developed and implemented until April 8, 2025. 28 Pa. Code 211.10 (d) Resident care policies.

Based on observations and clinical record review, it was determined that the facility did not ensure the comprehensive care plan was implemented related to communication for one of 18 residents reviewed (Resident R46). Finding include: Review of Resident R46 's clinical record revealed that Resident R46 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Chronic Respiratory Failure, Cerebrovascular Accident (also known as a stroke), cognitive impairment. Review of Resident R46's care plan revised on October 1, 2024 revealed that Resident R46 has a communication deficit related to Aphasia. Intervention implemented on December 12, 2022 that Resident R46 is able to communicate by: lip reading, writing, communication board, gestures, sign language, translator. Further review of Resident R46's care plan revised on February 1, 2021 revealed that Resident R46 is dependent on staff for activities, cognitive stimulation, social interaction related to immobility, physical limitations. Interventions implemented on February 1, 2021 for all staff to converse with resident while providing care. Observation on May 13, 2025 at 11:45am revealed Licensed Practical Nurse, Employee E3, providing care to Resident R46. Resident R46 appearing agitated and confused, stating I'm scared. Employee E3 preformed care without speaking or addressing the resident, no reassurance or directions provided to the resident.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that weights were monitored for two of 18 residents reviewed (Resident R23, R29) Findings include Review of Resident R23 's clinical record revealed that Resident R23 was admitted to the facility on [DATE] with diagnoses of, but not limited to, fracture of thoracic vertebrae (middle of back) , Type 2 diabetes, malnutrition. Review of Resident R23's care plan revised on December 9, 2024, revealed that resident has a nutritional problem or potential nutritional problem related to past medical history, underweight, fat/ muscle loss, skin breakdown/wounds. Intervention implemented on December 9, 2024 to obtain weights as ordered. Review of Resident R23's physician orders revealed an order dated December 4, 2024 for weights monthly. Review of Resident 23's clinical record revealed on March 4, 2025 Resident R23 weighed 105.4 and April 9, 2025 Resident R23 weighed 102.8 lbs (-2.47%). Further review of clinical record revealed on May 1, 2025, Resident R23 weighed 96.0 lbs (-6.61%). Further review of Resident 23 's clinical record revealed no documented evidence of reweigh or nutritional assessment related to significant weight change. Review of Resident R29 's clinical record revealed that Resident R29 was admitted to the facility on [DATE] with diagnoses of, but not limited to, osteoarthritis, hyperlipidemia, type 2 diabetes. Review of Resident R29's care plan revised on March 13, 2025 revealed that resident has a nutritional problem or potential nutritional problem related to past medical history, bedbound, therapeutic diet, altered diet texture, obesity, difficulty swallowing, abnormal labs, wound. Intervention implemented on March 13, 2025 for Registered Dietician to evaluate nutritional status and make recommendations as applicable as needed. Review of Resident R29's clinical record revealed on April 16, 2025 Resident R29 weighed 219.lbs. Further review of clinical record revealed on May 6, 2025, Resident R29 weighed 203.6 lbs (-7.6%). Further review of Resident 29 's clinical record revealed no documented evidence of reweigh or nutritional assessment related to significant weight change. 28 Pa. Code 211.12(c) Resident care policies 28 Pa. Code: 211.12(c)(d)(1) Nursing services

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that the medication error rate was less than five percent for one of three residents observed during medication administration (Residents R6). Findings include: The facility's medication error rate was 40% based on observation of 25 medication administration opportunities with 10 errors observed. Review of facility policy, Administering Medications revised April 2019, revealed, Medications are administered withing one hour of their prescribed time, unless otherwise specified. Review of Medication Administration Records (MARs) for Resident R6 revealed the following physician's orders: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% 1 inhalation inhale orally via nebulizer four times a day, administration time ordered for May 13, 2025, at 9:00am. Amlodipine Besylate Oral Tablet 10 MG Give 1 tablet by mouth one time a day related to hypertension, administration time ordered for May 13, 2025, at 9:00am. Azithromycin Oral Tablet 250 MG Give 1 tablet by mouth one time a day for bacterial infection, administration time ordered for May 13, 2025, at 9:00am. Aspirin EC Tablet Delayed Release 81 MG Give 1 tablet by mouth one time a day for prophylaxis, administration time ordered for May 13, 2025, at 9:00am. Cholecalciferol Oral Capsule 50 MCG Give 1 capsule by mouth one time a day for supplement, administration time ordered for May 13, 2025, at 9:00am. Budesonide Inhalation Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for Wheezing/Shortness of breath, administration time ordered for May 13, 2025, at 9:00am. Escitalopram Oxalate Oral Tablet 10 MG Give 1 tablet by mouth one time a day related To Generalized anxiety disorder, administration time ordered for May 13, 2025, at 9:00am. Fenofibrate Oral Tablet 160 MG Give 1 tablet by mouth one time a day related to Hyperlipidemia, administration time ordered for May 13, 2025, at 9:00am. Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth three times a day for Nerve pain, administration time ordered for May 13, 2025, at 9:00am. Prednisone Tablet Give 10 mg by mouth one time a day related to age-related osteoporosis without current pathological fracture, administration time ordered for May 13, 2025, at 9:00am. Observation of morning medication pass on May 13, 2025, at 12:00pm revealed that Licensed Practical Nurse, Employee E3, verified physician orders for Resident R6's medications. Interview with Licensed Practical Nurse, Employee E3 confirmed that all medications that will be given were ordered for 09:00am. Observation of all above listed medications being administered to Resident R6 on May 13, 2025, at 12:05pm. Interview with Administrator, Employee E1 on May 13, 2025, at 2:00pm confirmed that medications were being passed late because of staffing issues. Further review of Resident R6's clinical record revealed no documented evidence that physician was notified prior to administering medications related to late administration of medications. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12 (d)(5) Nursing services

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to be free of significant medication error for one of three residents (Residents R6). Findings include: Review of facility policy, Administering Medications revised April 2019, revealed, Medications are administered withing one hour of their prescribed time, unless otherwise specified. Review of Resident R6's clinical record revealed Resident R6 was admitted on [DATE] with diagnosis of, but not limited to COPD (Chronic Obstructive Pulmonary Disease), Diabetes, Hypertension (high blood pressure). Review of Resident R6' s MDS (Minimum Data Set) dated April 9, 2025, revealed that resident has a BIMS (Brief interview for mental status) of 15, indicating resident is cognitively intact. Review of Resident R6's physician orders revealed order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% 1 inhalation inhale orally via nebulizer four times a day, administration time ordered for May 13, 2025, at 9:00am. Further review revealed physician order for Budesonide Inhalation Suspension 0.5 MG/2ML 2 ml inhale orally two times a day for Wheezing/Shortness of breath, administration time ordered for May 13, 2025, at 9:00am. Interview with Resident R6 on May 13, 2025 at 11:30am revealed that resident had not received her morning medications on May 13, 2025 and she was most concerned with her breathing treatments because they help me breathe better, I really need them on time. Observation of Medication Pass on May 13, 2025 at 12:05 p.m. revealed Licensed Practical Nurse, Employee E3 administering Albuterol and Budesonide. Interview with Licensed Practical Nurse, Employee E3 confirmed medications being administered are ordered for May 13, 2025 at 09:00am. Further review of Resident R6's clinical record revealed no documented evidence that physician was notified prior to administering medications related to late administration of medications causing significant medication errors. Review of Medication Administration Records (MARs) for Resident R6, further revealed incorrect documentation for administration times for ten of ten medications passed during observation of medication pass on May 13, 2025, at 12:05pm. Per documentation entered by Licensed Practical Nurse, Employee E3, all medications were administered to Resident R6 on May 13, 2025 between 10:24am and 10:30am. Interview with Licensed Practical Nurse, Employee E3 on May 14, 2025, at 11:45am revealed that medications were not properly signed out at time of administration, I write it all down on paper and go back to document later. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based observations and staff interviews, it was determined that facility did not ensure that opened medications were properly labeled with the date that the medication was opened for two of three medication carts reviewed and one of one medication room reviewed. (Upper Level Med room, Lower Level South Med Cart, Lower Level North Med Cart). Findings include: Observation of Medication cart on Lower-Level South Med Cart on May 14, 2025 at 10:05 a.m. revealed one opened bottle of medication, including Geri-tussin 200ml/10ml Solution, not labeled with an open date. Interview with Licensed nurse, Employee E4 on May 14, 2025 at 10:05am confirmed one opened bottles of medication not labeled with an open date. Observation of Medication cart on Lower-Level North Med Cart on May 13, 2025 at 11:45 am revealed two open packages, Albuterol Sulfate 0.083% nebulizer treatment and Budosemide 0.5mg/2ml nebulizer treatment, not labeled with an open date. Interview with Licensed nurse, Employee E3 on May 13, 2025 at 11:45am confirmed two opened packages of medication not labeled with an open date. Observation in Upper Level Med Room on May 14, 2025 at 11:12am revealed two open bottles including Vancomycin 50mg/ml oral solution and Tuberculin 5tu-0.1ml injectable, not labeled with open date. Interview with Employee E5 on May 14, 2025 at 11:12 a.m. confirmed two open bottles with no open date. 28 Pa. Code 211.12 (d)(1) Nursing services.

Based on review of clinical records and facility provided documentation, it was determined facility failed to develop a care plan related to urinary track infection for one of nine residents reviewed (Resident R1) Findings include: Review of facility policy 'Care Planning - Interdisciplinary Team,' revised March 2022, indicates that comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of Resident R1's electronic medication administration record (e-MAR), revealed physician order for Bactrim DS oral tablet 800-160 milligrams (mg) every 12 hours for urinary tract infection (UTI), for 5 days, starting March 6, 2025. Further review of Resident R1's e-MAR, revealed a physician order for Ciprofloxacin HCL oral tablet 250 mg to administer one tablet every 12 hours for UTI for three days, starting March 7, 2025. Review of incident report, completed on March 18, 2025, indicated that Resident R1 had a change of mental status due to positive UTI. Review of Resident R1's nursing note, dated March 7, 2025, at 11:50 am, indicated that the resident was treated for UTI. Review of Resident R1's care plan revealed no evidence of goals or interventions related to UTI; finding confirmed with facility's director of nursing and administrator. 28 Pa Code 211.12(d)(5) Nursing services

Based on interview with resident and review of facility provided documentation, it was determined that facility failed to ensure that toiletries were provided upon admission to the facility for one of three residents reviewed. ( Resident R4) Findings include: Further interview with Resident R4 revealed that upon admission, she was not provided with any toiletries or basin. During interview it was observed that there was a roll of toilet paper on resident's bedside table, which Resident R4 stated she received when she asked for tissues. Review of Resident R4's additional grievance report, dated March 23, 2025, revealed that resident was observed with no new toiletries upon admission, she was issued a new set up and care nurses re-educated to make sure all resident is issued a setup with toiletries and labeled with their room number. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on interview with residents and review of facility provided documentation, it was determined that facility failed to ensure that call bells were responded to for three of nine residents reviewed ( Residents R2, R3, and R4) Findings include: Review of facility policy ' Answering the Call Light,' indicates that purpose of policy is to ensure staff answer the resident call system as soon as possible. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name, and when answering a visual request for assistance (light above the room door), knock on the room door. When the resident responds, address the resident by his/her name. Interview with Resident R4 on April 3, 2025, revealed that she has to wait extended period of time for assistance after using call bell. Review of Resident R4's grievance report, dated March 23, 2025, revealed that on March 21, 2025 she pulled call bell light on at 7:00 am, informing staff that she wanted to use bed pan. The staff member told her she cannot assist her by herself and that she is going to get help. She turned her call light off and did not return. Further review of grievance report indicated that nursing staff were in-serviced regarding 'call bell response.' Interview with Resident R2, on April 3, 2025, revealed that she has to wait for an extended period of time for assistance after using call bell. Interview with Resident R3, on April 3rd, 2025, revealed that she has to wait for extended period of time for assistance after using call bell. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations and interviews with residents and staff, it was determined that the facility failed to provide a comfortable environment due to clogged bathroom sinks in two of the four nursing units observed (Upper-Level South and North Nursing Units). Findings include: On March 12, 2025, at 10:19 a.m. an interview with the Maintenance Assistant, Employee E8 revealed that facility does have a issue with sinks being clogged. Today he already unclogged bathroom sinks in rooms [ROOM NUMBERS] on the upper-level nursing unit. A review of the maintenance log from December 2024 to March 2025 identified the followings clogged sinks in residents' rooms: December 2, 2024, room [ROOM NUMBER] sink has been clogged December 23, 2024, room [ROOM NUMBER] clogged sink January 9, 2025, room [ROOM NUMBER] clogged sink January 30, 2025, room [ROOM NUMBER] & 61 clogged sink February 11, 2025, room [ROOM NUMBER] clogged sink February 14, 2025, room [ROOM NUMBER] clogged sink On March 12, 2025, at 11:20 a.m., an interview was conducted with Resident R6, who reported an ongoing issue with the sink being clogged in room [ROOM NUMBER]. The Resident R6 mentioned that maintenance had unclogged the sink the previous day, but today, the water still wasn't draining properly. On March 12, 2025, at 11:56 a.m. an observation with the Maintenance Director, Employee E5 confirmed the following clogged sinks: Upper-Level North nursing units: 43-56 Rooms 44, 48, 54, 56 room [ROOM NUMBER]- has a sink full half full of standing water, room [ROOM NUMBER]- had full sink of standing water, Upper-Level South nursing unit: Rooms: 29- still clogged, this room was treated to be unclogged this morning by the maintenance Room: 34 clogged room [ROOM NUMBER]- clogged with half full standing water in the sink On March 12, 2025, at 12:56 p.m., an interview with the Administrator confirmed ongoing sink clogging issues within the facility. 28 Pa Code 201.18(b)(1)(3)Management 28 Pa Code 205.63(b) Plumbing and piping systems required for existing and new construction

Based on clinical record review, facility policy, resident and staff interview, it was determined that the facility failed to ensure complete and accurate medication administration for one of 2 residents reviewed (Resident R2). Findings include: The Facility Policy titled Administering Medication dated 2021, revealed Mediations are administered in a safe and timely manner, and as prescribed. It further under policy interpretation and implementation 4. states Medications are administered in accordance with prescriber orders, including any required time frame . A review of the clinical record for Resident R2 revealed an admitted [DATE], with a diagnosis of Type 2 diabetes mellitus without complications and long-term use of insulin. A review of the physician orders dated July 18, 2024, revealed a NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 Unit/ml (insulin Aspart) Inject 10 unit subcutaneously before meals for dm (diabetes mellitus) at 8:00 a.m., 11:00 a.m., 4:00 p.m. On March 12, 2025, at 10:19 a.m. an interview with Resident R2 revealed that on March 6, 2025, and March 9, 2025, during the afternoon medication pass a license nurse, Employee E4 was not aware of how much insulin Resident R2 was supposed to get. I had to tell her that I get 10 units, and she eventually gave me proper amount. A review of the Medication Administration Report (MAR) showed that March 6, 2025, and March 9, 2025, at 4:00 p.m. revealed that insulin Aspart was not documented as administered. On March 12, 2025, at 1:54 p.m., a telephone interview with Licensed Nurse, Employee E4, revealed that medication was administered to Resident R2 on both March 6 and 9, 2025; however, it was not documented. When asked why the documentation did not reflect this, Employee E4 responded, I don't know. On March 12, 2025, at 2:42 p.m. an interview with the Director of Nursing, Employee E2 confirmed that insulin medication was not appropriately documented for March 6, 9, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records, review of facility policy, and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to wound care for one of 6 residents observed (Resident R1). Findings include: Review of facility policy Care Planning revealed the facility's interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Continued review of facility policy revealed a comprehensive care plan for each resident is developed within seven (7) days of completion of the Resident Assessment (MDS). Review of Resident R1's clinical record revealed that Resident R1 was originally admitted to the facility on [DATE], and was most recently readmitted to the facility on [DATE], with diagnoses of but not limited to Cerebral Infarction, Unspecified Severe Protein Calory Malnutrition, Adult failure to Thrive. Review of Resident R1's admission MDS (minimum data set- a federally required resident assessment completed at a specific interval) assessment dated [DATE], revealed that Section M0150 Risk of Pressure Ulcers/Injuries was coded 1 (yes) indicating that Resident R1 was at risk of developing pressure ulcers/injuries. Section M0210 Unhealed Pressure Ulcers/Injuries was coded 0 (No) indicating that Resident R12 did not have one or more unhealed pressure ulcers/injuries. M1040. Other Ulcers, Wounds and Skin Problems #H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage) was checked. Review of wound note dated December 9, 2024, revealed WOUND ASSESSMENT: Wound: 1 Location: right dorsal foot Primary Etiology: Abrasion Stage/Severity: Full Thickness NEW: Right Dorsal Foot: cleanse with NSS, apply medical grade honey Daily and PRN, cover with bordered foam. Monitor site for signs and symptoms of infection- bogginess, drainage, erythema. The patient was noted to have a suspected abrasion. Recommend preventing further skin injury by avoiding friction/shear, careful handling during ambulation, assistance, and transfer, use of daily emollients, long sleeves and pants when possible, and preventing use of adherent tape directly to skin. Review of Skin and wound note revealed that on December 9, 2024, Nurse Practitioner was asked by facility to see Resident R1 for new skin opening to right dorsal foot, found by nursing. On December 20, 2024, Resident R1 was seen for follow up. Resident R1 with new skin opening to sacrum and right dorsal foot, found by nursing per staff. Assessment: Abrasion, right foot, Pressure ulcer of sacral region, Pressure-induced deep tissue damage of right heel PLAN: Wound # 1 right dorsal foot Abrasion Treatment Recommendations: 1. Cleanse with normal saline. 2. apply Medical grade honey to base of the wound. 3. secure with Bordered foam. 4. change Daily, and PRN (as needed). PREVENTATIVE MEASURES: Monitor skin under braces, prosthetics, splints, casts, and other non-removal devices. Continue to float heels while in bed with use of heel boots. NEW RECOMMENDATIONS: Continue the above treatment plan and recommendations. Debridement completed to sacrum and right dorsal foot. Monitor site for signs and symptoms of infection- bogginess, drainage, erythema. Pain management per PCP (Primary Care Physician). The patient has multiple factors that may impair wound healing, including impaired mobility, impaired nutrition, cognitive impairment, risk of dehydration/malnutrition, Failure to Thrive, previous CVA (Cerebral Vascular Disease- stroke), advanced age, multiple wounds, enteral feeds Review of Resident R1's care plan revealed that the full thickness abrasion on Resident R1's dorsal foot was not addressed in the care plan. Interview with the Director of Nursing Employee E2 conducted on January 22, 2025, at 1:12 p.m. confirmed that care plan to address the full thickness abrasion Resident R1's right dorsal foot was not developed. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.10 (d)(1) Nursing services

Based on interviews, review of facility documentation, and review of clinical records, it was determined that the facility failed to ensure that appealing food options were available for residents for 1 out of 5 residents reviewed (Resident R1). Findings include: Review of information received from the State Survey Agency on Deceembe 2, 2024 reported that facility did not provide alternative meal options for residents who did not want the main entrees offered at meal times. During an interview with Resident R1 on December 10, 2024, the resident reported that she did not want that Thanksgiving Day Meal that was served at lunch on November 28, 2024. Resident R1 reported that she notified her assigned nurse (Employee E3) once she received the meal, asked if she could have a grilled cheese, and reported that the dietary department informed her assigned nurse that they would not be able to provide the grilled cheese sandwich to her. Review of the Thanksgiving Day luncheon menu that was served on November 28, 2024 included turkey, ham, various side items and dessert choices. During an interview with Employee E4 (dietary aide) on December 11, 2024 at 12:45 p.m. Employee E4 reported that when holiday meals are served, such as the most recent Thanksgiving Day meal on November 28,2024, the options that residents have from the Always Available menu if they do not want the holiday meal are the cold sandwich (e.g. tuna sandwich, egg salad sandwich) items only. Employee E4 reported that the hot menu items (e.g. cheeseburgers grilled cheese, pizza) are not available for residents from the Always Available menu because when holiday meals are being provided, the dietary staff have a larger number of plates to prepare because they are feeding both the residents, and the facility staff members. Employee E5 also reported that the dietary department also does not have enough dietary staff members to do all that extra stuff involved with cooking the hot food items off the Always Available menu. Continued interview with Employee E4 indicated that when a holiday meal is being provided for the day, he notifies the nurses on the floor that the kitchen is preparing a holiday meal for lunch, and that if a resident would like something off the Always Available menu instead of the holiday meal, their options are any of the cold sandwiches. During an interview with Employee E8 (licensed nurse) on December 11, 2024 at 2:15 p.m. Employee E8 reported that all residents received the Thanksgiving Day holiday meal for lunch on November 28, 2024. Employee E8 reported that Resident R1 received her lunch meal, did not want it, and asked if she could have a grilled cheese sandwich instead. Employee E8 reported that she (Employee E8) called down to the kitchen, did not remember who she spoke with, but was told that the kitchen could not prepare a grilled cheese sandwich for Resident R1. When asked what the resident ate for her lunch time meal since a grilled cheese was not provided, Employee E8 stated she had snacks in her room. Review of the resident's food intake document for November 28, 2024 lunch meal indicated that the resident did not eat lunch. The food intake document documented the resident as refusing lunch. The facility failed to ensure that appealing food options were available for Resident R1 who requested a different meal option for the lunchtime Thanksgiving Day meal. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.6 (a) Dietary Services

Based on review of clinical records, and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program related to mice infestation on two of four nursing units (LL South Wing, and LL North Wing). Findings include: On November 25, 2024, at 11:59 a.m., interviewed Resident R2 , in her room at LL South Wing. R2 stated that in her room yesterday she saw a mouse on her bed. On November 25, 2024, at 12:09 p.m., interviewed Resident R3, in her room at LL South Wing. R3 stated that through the vent of the AC, mice come into the room. On November 25, 2024, at 12:19 p.m., interviewed Resident R12, in her room at LL North Wing. R12 stated that mice were seen in the room the day before yesterday. On November 25, 2024, at 12:27 p.m., interviewed Resident R13, in her room at LL North Wing. R13 stated that mice were seen in the room three days before. On November 25, 2024, reviewed the work-orders of the facility revealed that on October 1, 2024, in room [ROOM NUMBER]-P, and in room [ROOM NUMBER]-P, mouse sighting was reported; and in room [ROOM NUMBER], dead mouse sighting was reported. Interview with Residents R3, R12 and R13 confirmed that the measures implemented by the facility did not solve the infestation of rodents Review of the log of pest control products including mouse traps, used in the facility on September 4, 2024; September 23, 2024; October 2, 2024; October 16, 2024; November 7, 2024; and November 21, 2024, indicated that the facility used pest control products including mouse traps to eliminate the infestation of rodents in the facility. Interview on November 25, 2024, at 2:42 p.m., with the Director of Nursing, and the Director of Maintenance, Employee E14, confirmed the findings. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(3) Management

Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to ensure that Resident R1 was free of neglect during a transfer via mechanical lift which resulted in actual harm to Resident R1 who was transfered with the assistance of one staff member, the tightening of the sling pad and sustaining a fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and compression fracture of the third vertebra for one of three residents reviewed. (Resident R1) This deficiency was cited as past non-compliance. Findings include: Review of the facility policy, Safe Lifting and Movement of Residents dated 2001, indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents 'needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Under item 9 it [NAME] Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative resident with lifting and movement needs will be provided with single-resident use disposable slings. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with a diagnosis of Occlusion and Stenosis of Right Carotid Artery, Osteoarthritis ( is a degenerative joint disease characterized by the breakdown of cartilage-the protective tissue that cushions the ends of bones), Polyosteoarthritis (is a form of osteoarthritis that affects multiple joints simultaneously), Hemothorax ( typically caused by trauma to the chest, such as a rib fracture or injury from a car accident, but it can also occur due to complications from surgery, tumors, or certain medical conditions), Other intervertebral disc degeneration, lumbar region, (refers to the breakdown of the intervertebral discs located in the lower back (lumbar spine). These discs, which act as cushions between the bones (vertebrae) of the spine, can deteriorate due to aging, wear and tear, or other factors), Nontraumatic subdural hemorrhage, absolute glaucoma, bilateral (advanced, end-stage form of glaucoma where there is total and irreversible vision loss due to severe damage to the optic nerve). Based on the hospital record following the discharge on September 18, 2024, it was also noted that Resident R1 does have a diagnosis of osteopenia (condition characterized by lower-than-normal bone mineral density, but not low enough to be classified as osteoporosis. It occurs when bones lose minerals, such as calcium, faster than the body can replace them, making them weaker and more likely to fracture compared to healthy bone). Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated September 9, 2024, revealed a Brief Interview for Mental Status (BIMS) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment. The MDS's Functional Abilities and Goals revealed that Resident R1's upper (shoulder, elbow wrist, hand) and lower (hip, knee, ankle, foot) extremities have impairment on both sides. Review of facility documentation submitted to the State Survey Agency dated 9/13/24, revealed that , [Resident R1] was assessed today by CRNP (Certified Registered Nurse Practitioner) after brusing was discovered on his stomach. Area was tender to touch. Resident has no known falls or incidents. Resident is not a reliable historian and is rarely understood. [Resident R1] send to emergency department for Evaluation. Resident admitted to hospital with fractured ribs. Facility investigation initiated immediately. Update: 9/16/2024 Facility investigation concluded that CNA (nurse aide) used mechanical lift by herself on 9/11/2024 when injures occurred Facility investigation concluded that injuries occurred during transfer, caused by the tightening of the sling. These injuries occurred due to his osteopenic bones. The resident will be reassessed for transfers when returns. Our investigation unsubstantiated neglect. The aid has been reeducated on ensuring 2 license staff assist with mechanical lift transfers. Injuries sustained are not consistent with a fall. Review of an employee statement written by nurse aide, Employee E3 dated September 16, 2024, indicated, I was the CNA assigned to Resident R1 on 7-3, 9/9/ through 9/12. I wash and dressed him, I used a hoyer lift to transfer him. I do not remember who helped me with the hoyer lift on each of those days. There were no unusual events that happened. When I was helping nursing aid, [Employee E4] transfer [Resident R1] on 9/12 during the 3-11 shift, [Employee E4] and I saw that [Resident R1] had reddened spots on his left side. We reported this to license nurse, Employee E9. Employee E4 reported that he was in pain. During the time that I had him, Resident R1 did not have any incidents, accidents or complaints. On Thursday morning I transferred to him with Employee E4, [Resident R1] did not have any wincing or seemed not to have any pain'. Review of an employee statement written by nurse aide Employee E4 dated September 16, 2024, indicated, I was CNA assigned to [Resident R1] on 9/12 3-11. I transferred him back to bed with [nurse aide, Employee E3] using hoyer lift with no incident. On 9/12, after dinner, I transferred him with [nurse aide, Employee E3] using the hoyer. When he was in bed, I started to change his brief, I noticed a discolored area on the left chest. [Resident R1] was acting like his usual, self and did not seem to be in pain. I told [license nurse, Employee E9] about the discoloration; I saw [licensed nurse, Employee E9] go into his room. I have no knowledge of him failing or having any incident. Review of an employee statement written by Nurse aide Employee E11, dated September 16, 2024, indicated, I routinely have [Resident R1] on my assignment. On 9/11, I have him a bed bath. As I was washing him, I noticed a redden area on his abdomen, I did not think it was out of the ordinary because [Resident R1] routinely has temporary redden areas after bathing. I have no knowledge of him having any recent falls. On October 1, 2024, at 11: 47 a.m. a telephone interview was conducted with nurse aide, Employee E3, who confirmed that Resident R1 was under her care during the day shift (7 a.m. to 3 p.m.) from Monday, September 9, 2024, to Thursday, September 12, 2024. On Wednesday, September 11, 2024, at approximately 10:30 a.m., Employee E3 transferred Resident R1 from bed to a Gerry chair using a full-body sling pad with a Hoyer mechanical lift, performing the transfer by herself because she didn't see anyone in the hallway. Employee E3 admitted , 'I'm at fault for using the Hoyer lift by myself. Resident R1 did not display any signs of pain before or after the transfer. Employee E3 stated that she has transferred residents 'numerous times' using the mechanical Hoyer lift by herself, despite the facility's policy requiring two people for such transfers. The interview further revealed on Thursday, September 12, 2024, nursse aide Employee E3, along with another nurse aide, Employee E4, assisted in transferring Resident R1 from bed to a chair. However, Employee E3 noted that this transfer differed from previous ones because a split Hoyer pad was used instead of a full-body pad to position the resident before attaching him to the Hoyer lift. Employee E3 explained that the full-body pad was unavailable, and only a split pad could be found, even though each resident who uses a Hoyer lift is supposed to have their own designated pad. After locating the split pad, Employee E3 crossed its ends and positioned it under Resident R1's body, including his legs. Employee E3 stated I placed his legs inside the pad. Normally, with the full-body pad, the resident's legs would remain outside the pad, but in this case, Resident R1's legs had to stay inside to ensure he remained securely in the split pad. On October 1, 2024, at 12:40 p.m. a telephone attempt was made to interview nurse aide, Employee E4; however, there was no response or returned call back. Clinical record was reviewed, and it was revealed that Resident R1 was admitted to the hospital on September 13, 2024, with the following diagnosis, fracture of fourth lumbar vertebra, Wedge compression fracture of second lumbar vertebra, Multiple fractures of Ribs left side, Wedge compression fracture of third lumbar vertra, Multiple fractures of ribs unspecify side initial encounter for closed fracture. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R1 was free of neglect during a transfer via mechanical lift which resulted in actual harm to Resident R1 who was transfered with the assistance of one staff member, the tightening of the sling pad as concluded by the facility and sustaining a fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and compression fracture of the third vertebra. On October 1, 2024, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on September 13, 2024. The facility plan of correction included the following: -Conduct competencies for using mechanical lifts with nursing staff. -Interview residents who require full mechanical lifts about feeling safe and confirming 2 staff perform transfer. -Interview nursing staff to ensure they are comfortable in reporting abuse or neglect and if they have any knowledge of an incident or accident not being reported. -Educate staff on reporting abuse and neglect and following plan of care. The facility alleged compliance with their plan of correction as of September 18, 2024. Facility education records and competency records verified for completion. Nursing staff was interviewed on October 1, 2024 verified education related to abuse and neglect. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to ensure the proper transfer of Resident R1 via mechanical lift with the assistance of two staff, which resulted in actual harm to Resident R1 with the tightening of the sling pad, sustaining fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and a compression fracture of the third vertebra. (Resident R1) This deficiency is cited as past non-compliance. Findings include: Review of the facility policy, Safe Lifting and Movement of Residents dated 2001, indicated Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents 'needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Under item 9 it [NAME] Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative resident with lifting and movement needs will be provided with single-resident use disposable slings. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with a diagnosis of Occlusion and Stenosis of Right Carotid Artery, Osteoarthritis ( is a degenerative joint disease characterized by the breakdown of cartilage-the protective tissue that cushions the ends of bones), Polyosteoarthritis (is a form of osteoarthritis that affects multiple joints simultaneously), Hemothorax ( typically caused by trauma to the chest, such as a rib fracture or injury from a car accident, but it can also occur due to complications from surgery, tumors, or certain medical conditions), Other intervertebral disc degeneration, lumbar region, (refers to the breakdown of the intervertebral discs located in the lower back (lumbar spine). These discs, which act as cushions between the bones (vertebrae) of the spine, can deteriorate due to aging, wear and tear, or other factors), Nontraumatic subdural hemorrhage, absolute glaucoma, bilateral (advanced, end-stage form of glaucoma where there is total and irreversible vision loss due to severe damage to the optic nerve). Based on the hospital record following the discharge on September 18, 2024, it was also noted that Resident R1 does have a diagnosis of osteopenia (condition characterized by lower-than-normal bone mineral density, but not low enough to be classified as osteoporosis. It occurs when bones lose minerals, such as calcium, faster than the body can replace them, making them weaker and more likely to fracture compared to healthy bone). Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated September 9, 2024, revealed a Brief Interview for Mental Status (BIMS) not recorded which means the resident was unable to participate in the assessment due to severe cognitive impairment. The MDS's Functional Abilities and Goals revealed that resident R1's upper (shoulder, elbow wrist, hand) and lower (hip, knee, ankle, foot) extremities are impairment on both sides. Review of facility documentation submitted to the State Survey Agency dated 9/13/24, revealed that , [Resident R1] was assessed today by CRNP (Certified Registered Nurse Practitioner) after brusing was discovered on his stomach. Area was tender to touch. Resident has no known falls or incidents. Resident is not a reliable historian and is rarely understood. [Resident R1[ send to emergency department for Evaluation. Resident admitted to hospital with fractured ribs. Facility investigation initiated immediately. Update: 9/16/2024 Facility investigation concluded that CNA (nurse aide) used mechanical lift by herself on 9/11/2024 when injures occurred Facility investigation concluded that injuries occurred during transfer, caused by the tightening of the sling. These injuries occurred due to his osteopenic bones. The resident will be reassessed for transfers when returns. Our investigation unsubstantiated neglect. The aid has been reeducated on ensuring 2 license staff assist with mechanical lift transfers. Injuries sustained are not consistent with a fall. Review of an employee statement written by nursing aide, Employee E3 dated September 16, 2024, indicated, I was the CNA assigned to Resident R1 on 7-3, 9/9/ through 9/12. I wash and dressed him, I used a hoyer lift to transfer him. I do not remember who helped me with the hoyer lift on each of those days. There were no unusual events that happened. When I was helping nursing aid, [Employee E4] transfer [Resident R1] on 9/12 during the 3-11 shift, [Employee E4] and I saw that [Resident R1] had reddened spots on his left side. We reported this to license nurse, Employee E9. Employee E4 reported that he was in pain. During the time that I had him, Resident R 1 did not have any incidents, accidents or complaints. On Thursday morning I transferred to him with Employee E4, [Resident R1] did not have any wincing or seemed not to have any pain'. Review of an employee statement written by nursing aide Employee E4 dated September 16, 2024, indicated, I was CNA assigned to [Resident R1] on 9/12 3-11. I transferred him back to bed with [nurse aide, Employee E3] using hoyer lift with no incident. On 9/12, after dinner, I transferred him with [nurse aide, Employee E3] using the hoyer. When he was in bed, I started to change his brief, I noticed a discolored area on the left chest. [Resident R1] was acting like his usual, self and did not seem to be in pain. I told [license nurse, Employee E9] about the discoloration; I saw [licensed nurse, Employee E9] go into his room. I have no knowledge of him failing or having any incident. Review of an employee statement written by Nurse aide Employee E11, dated September 16, 2024, indicated, I routinely have [Resident R1] on my assignment. On 9/11, I have him a bed bath. As I was washing him, I noticed a redden area on his abdomen, I did not think it was out of the ordinary because [Resident R1] routinely has temporary redden areas after bathing. I have no knowledge of him having any recent falls. On October 1, 2024, at 11: 47 a.m. a telephone interview was conducted with nursing aide, Employee E3, who confirmed that Resident R1 was under her care during the day shift (7 a.m. to 3 p.m.) from Monday, September 9, 2024, to Thursday, September 12, 2024. On Wednesday, September 11, 2024, at approximately 10:30 a.m., Employee E3 transferred Resident R1 from bed to a Gerry chair using a full-body sling pad with a Hoyer mechanical lift, performing the transfer by herself because she didn't see anyone in the hallway. Employee E3 admitted , 'I'm at fault for using the Hoyer lift by myself. Resident R1 did not display any signs of pain before or after the transfer. Employee E3 stated that she has transferred residents 'numerous times' using the mechanical Hoyer lift by herself, despite the facility's policy requiring two people for such transfers. The interview further revealed On Thursday, September 12, 2024, nurse aide Employee E3, along with another nurse aide, Employee E4, assisted in transferring Resident R1 from bed to a chair. However, Employee E3 noted that this transfer differed from previous ones because a split Hoyer pad was used instead of a full-body pad to position the resident before attaching him to the Hoyer lift. Employee E3 explained that the full-body pad was unavailable, and only a split pad could be found, even though each resident who uses a Hoyer lift is supposed to have their own designated pad. After locating the split pad, Employee E3 crossed its ends and positioned it under Resident R1's body, including his legs. Employee E3 stated I placed his legs inside the pad. Normally, with the full-body pad, the resident's legs would remain outside the pad, but in this case, Resident R1's legs had to stay inside to ensure he remained securely in the split pad. On October 1, 2024, at 12:40 p.m. an telephone attempt was made to interview nurse aide, Employee E4; however, there was no response or returned call back. Clinical record was reviewed, and it was revealed that Resident R1 was admitted to the hospital on September 13, 2024, with the following diagnosis, fracture of fourth lumbar vertebra, Wedge compression fracture of second lumbar vertebra, Multiple fractures of Ribs left side, Wedge compression fracture of third lumbar vertra, Multiple fractures of ribs unspecify side initial encounter for closed fracture. This deficiency was identified as actual harm past non-compliance for failure to ensure that Resident R1 was transfer safely via mechanical lift into a chair with the assistance of two staff, tightening of the sling pad as concluded by the facility which resulted in actual harm to Resident R1 who sustained a fracture of the fourth lumbar vertebra, compresion fracture of the second lumbar vertebra, multiple fracture of ribs to the left side, and a compression fracture of the third vertebra. On October 1, 2024, the Nursing Home Administrator presented documentation, indicating that the facility initiated a plan of correction on September 13, 2024, to address the proper staff assistance via transfer of a resident using a mechanical lift. The facility plan of correction included the following: -Conduct competencies for using mechanical lifts with nursing staff. -Interview residents who require full mechanical lifts about feeling safe and confirming 2 staff perform transfer. -Interview nursing staff to ensure they are comfortable in reporting abuse or neglect and if they have any knowledge of an incident or accident not being reported. -Educate staff on reporting abuse and neglect and following plan of care. The facility alleged compliance with their plan of correction as of September 18, 2024. Facility education records and competency records verified for completion. Nursing staff was interviewed on October 1, 2024 to verify education related to the use of mechanical lifts requiring 2 person assist during resident transfer. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa Code 211.12(d)(1)(2)(5) Nursing services

Based on clinical record review, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to ensure that the proper assistive device was use during the transfer of Resident R1. This failure resulted in actual harm to Resident R1, who sustained a fall and reopening of the wound on the left below the knee amputation for one of three residents reviewed. (Resident R1) Findings include: A review of the facility's policy titled Care Planning undated indicated that the interdisciplinary care team was responsible for development and implementation of the resident care plan. A review of the policy titled Fall and Fall Risk Managing undated revealed that it was the responsibility of the staff to identify interventions related to an individual resident's risk factors and develop safety measures to prevent the resident from falling to minimize complications from the fall. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE], with the diagnoses of end stage renal disease, dependency on renal dialysis, acute osteomyelitis (bone infection) of the right and left ankle and foot. Review of Resident R1's admission Minimum Data Set (MDS- assessment of resident's need) dated October 11, 2022, indicated that Resident R1 was assessed with a BIMS (Brief Interview of Mental Status) score of 15 which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident required extensive assistance of two staff members for bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed) and for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). This assessment also indicated that Resident R1 had functional limitations due to impairment of the lower extremity on one side and Resident R1 had a impaired skin condition with a surgical wound. Review of Resident R1's care plan initiated October 1, 2022, revealed Resident R1 required two person assistance and full mechanical lift for transfer related to a below the knee amputation. Review of nursing documentation dated November 1, 2022, revealed that licensed staff was called to resident's room by her daughters who stated that her mother's dressing was saturated with blood also she told them she had a fall therefore she wanted to know if there was a correlation between the two. On entering room dressing to resident left BKA (below knee amputation) was observed bloody, dressing was unwrapped with wound showing sign of being dehiscence (a surgical cut reopening exposing the underlying tissues) . Reported claimed of falling verified and witness. Interview with Licensed nurse, Employee E4, on December 8, 2022, at 1:30 p.m. confirmed that Resident R1's complaint of pain and that the left below the knee surgical wound area was assessed with wound dehiscence. Review of the facility documentation reported to the State Survey Agency revealed that an investigation was initiated on November 1, 2022, at 9:30 a.m. The resident sustained a fall in her room on November 1, 2022, while the resident was being transferred by nursing aide, Employee E8 and a dialysis transporter, a temporary nurse aide, Employee E5. The staff members used a sit to stand lift to transfer her instead of the full mechanical lift. During the transfer, the resident was lowered to the floor which caused the resident's left leg stump incision site to have increased bleeding. The facility concluded that the nurse aide, Employee E8 made the decision to utilize a sit- to-stand lift instead of a full mechanical lift. Interview with the Nursing Home Administrator, Employee E3, on December 8, 2022, at 10:00 a.m. revealed that nurse aides, Employees E8 and Employee E5, failed to safely transfer Resident R1 on November 1, 2022, at 9:45 a.m. Interview with the dialysis transporter, a temporary nurse aide, Employee E5 on December 8, 2022, at 2:00 p.m. confirmed that Resident R1 sustained a fall on November 1, 2022, at 9:45 a.m. and the fall incident was not reported to the licensed nurse on duty. Nurse aide, Employee E5 confirmed that a sit-to-stand lift was the mechanical lift used and that she was following the directions of the nurse aide, Employee E8. Review of nurse practitioner documentation dated November 1, 2022, revealed that Resident R1 sustained a fall in the morning of November 1, 2022, which caused the wound on the left below the knee amputation to dehiscence. The nurse practitioner documented that Resident R1 had bleeding of the surgical wound soaking two ABD pads (abdominal pads are used to treat large wounds that require a lot of absorbencies). The nurse practitioner's assessment indicated that Resident R1 was complaining of newly identified pain at the surgical wound. The nurse practitioner ordered the nursing staff to continue to use a pressure dressing to the surgical wound and elevate this left lower extremity. The facility failed to ensure that Resident R1 was transferred with the use of a full mechanical device as stated in the resident's care plan. This failure resulted in actual harm to Resident R1, who sustained a fall and reopening of the wound on the left below the knee amputation. Pa. Code 211.10(d) Resident care policies Pa. Code 211.11(d) Resident care plan Pa. Code 211.12(c) Nursing services Pa. Code 211.12(d)(1) Nursing services Pa. Code 211.12(d)(5) Nursing services

Based on observations, review of clinical records, facility policies and procedures, facility documentation, and interviews with residents and facility staff, it was determined that the facility failed to provide adequate assessment and monitoring to ensure acceptable parameters of nutritional status resulting in weight loss and harm for one of 19 residents reviewed (Resident R75). Findings include: Review of the facility policy, Weight Assessment and Intervention, adopted March 2016, defined a significant weight loss as five percent in one month and that any weight change of three percent or more since the last weight assessment would be retaken in the presence of a nurse for confirmation. The policy futher stated that upon discovery of a significant weight loss, the physician and multidisciplinary team would identify conditions and medications that may be causing anorexia (loss of appetite) or weight loss including cognitive or functional decline. Review of the clinical record for Resident R75 revealed that the resident was admitted to the facility from an acute care hospital on August 15, 2017, with [DIAGNOSES REDACTED]. is rearranged to connect to both). Review of Resident R75's care plan, dated initiated August 18, 2017, identified a potential risk for altered nutrition related to history of gastric bypass, chronic nausea/vomiting/diarrhea, and varied/poor oral intake (food and fluids), and revealed that staff would monitor the resident for signs and symptoms of dehydration. Review of the nursing progress notes revealed Resident R75 was admitted back to the hospital from August 23, 2017, through September 14, 2017. Review of a Certified Registered Nurse Practitioner (CRNP) progress note, dated September 15, 2017, indicated that during Resident R75's prolonged stay in the hospital, the resident experienced complications of electrolyte (chemical components of the blood necessary for sustained health) imbalance and malnutrition which eventually required a J-tube (jejunostomy tube - a feeding tube inserted through the skin into the digestive tract to administer fluids for nourishment and hydration) to be placed. The CRNP note further added that the resident again developed [MEDICAL CONDITIONS] and diarrhea while in the hospital, requiring treatment with intravenous (IV-tube inserted into a vein to administer medications and fluids) antibiotics. Review of a physician's progress note, dated September 18, 2017, revealed an additional [DIAGNOSES REDACTED]. The physician's progress note stated that the resident had a [DIAGNOSES REDACTED]. Review of Resident R75's care plan for potential risk for altered nutrition, updated September 18, 2017, revealed that staff would provide a tube feeding and flushes (with water) as ordered, and to continue to monitor the resident for signs and symptoms of dehydration. Review of a physician's progress readmission note, dated September 29, 2017, revealed that the resident continued with adult failure to thrive, Resident R75 had a J-tube placed and, we will have nutrition therapy follow along with the patient. Review of a physician's order, dated September 29, 2017, instructed the staff to obtain a nutrition consult for Resident R75's poor oral intake, history of tube feeding, and also for hydration status. Review of a reentry Nutritional Risk assessment dated [DATE], revealed that Resident R75 was readmitted from the hospital due to acute [MEDICATION NAME] and that on the resident's previous admission in the facility (09/18/17), the resident was NPO (abbreviation for nothing to be taken by mouth) with J-tube and noted with poor tolerance to [MEDICATION NAME] (type of tube feeding formula). The Nutritional Risk Assessment stated that Resident R75 was now on a regular oral diet with the resident's oral intake noted as minimal to none. The Nutritional Risk Assessment added that Resident R75 was noted with ongoing nausea, vomiting and diarrhea, the resident had experienced a significant weight loss of 26.4 pounds (20 percent weight loss) in the two weeks since previous admission, and the dietitian spoke with the resident who reported she was not eating. The Nutritional Risk Assessment stated that due to the resident's very poor oral intake and nausea, vomiting, and diarrhea, the dietitian was recommending for staff to initiate [MEDICATION NAME] 1.5 (nutritionally complete formula specifically designed for people who cannot absorb or digest nutrients from conventional foods) to be infused via the resident's J-tube at 45 mL (milliliters) per hour, until a total volume of 900 mL was infused daily, with free water flush of 25 mL/ hour until total volume of 500 mL was reached daily, and will recommend to change the resident's diet to clear liquids (from a regular diet) for improved acceptance. Further review of the clinical record on October 1, 2017, revealed no physician's orders for Resident R75's diet or any orders related to water flushes or initiation of tube feeding formula through the resident's J-tube as recommended by the dietitian on September 29, 2017. Observation of the noon meal on October 1, 2017, at approximately 12:20 p.m. revealed that Resident R75 was lying in bed. Employee E6, Nursing Assistant, was observed to deliver Resident R75's lunch tray from the food cart to the resident's room, and placed the lunch tray on the overbed table that was located next to the resident's bed (not across the resident's bed). Observation of the the tray revealed Resident R75 received a clear liquid tray which included one eight ounce mug of hot water, one tea bag, one six ounce bowl of clear broth with one pack of saltine crackers resting on top of the lid, and one four ounce styrofoam cup of clear juice. Resident R75 was observed to look at the tray, then close her eyes. Employee E6 walked out of the room and stated to a nearby employee, She (resident) refused to eat again. Continued observation on October 1, 2017, at 12:20 p.m. through 1:05 p.m. revealed the resident did not consume any liquids, water or items from the lunch tray. Employee E6 returned to the room at approximately 1:05 p.m., asked the resident if she wanted to eat or drink anything (including offering the resident some water to drink), Resident R75 said no, and Employee E6 removed the tray from the room. Interview with Employee E6 after removal of the tray revealed that Resident R75 had been refusing meals. Review of meal intake data for Resident R75 from readmission from the hospital on September 28, 2017, through October 1, 2017, revealed the following: September 28, 2017, at 5:30 p.m. RR (resident refused); September 29, 2017, at 8:11 p.m. 0 (facility legend 0 equals 0-25 percent consumption); September 30, 2017, breakfast meal 0, lunch meal 0 and dinner meal 0; and October 1, 2017, breakfast meal 0 and lunch meal RR. The facility failed to ensure that Resident R75, a resident at high nutritional and dehydration risk related to complicated gastrointestinal illness and previous necessity for tube feeding, was consistently, accurately and adequately assessed and monitored by staff. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/09/16 28 Pa. Code 201.18(a) Management Previously cited 11/09/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/10/17, 11/09/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(h) Clinical records 28 Pa. Code 211.10(c) Resident care policies Previously cited 11/09/16 28 Pa. Code 211.12(c)(d)(3) Nursing services Previously cited 06/10/17, 12/04/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 11/09/16, 12/04/15

Based on observation, review of clinical records, clinical documentation and interviews with staff, it was determined that the facility failed to ensure a resident at high nutritional and dehydration risk related to complicated gastrointestinal illness and previous necessity for tube feeding, was consistently, accurately and adequately assessed and monitored by staff. This failure to adequately assess and monitor one resident of 19 residents reviewed, resulted in admission to the hospital for dehydration, causing actual harm to the resident (Resident R75). Findings include: Review of the clinical record for Resident R75 revealed that the resident was admitted to the facility from an acute care hospital on August 15, 2017, with [DIAGNOSES REDACTED]. is rearranged to connect to both). Review of Resident R75's care plan, dated initiated August 18, 2017, identified a potential risk for altered nutrition related to history of gastric bypass, chronic nausea/vomiting/diarrhea, and varied/poor oral intake (food and fluids), and revealed that staff would monitor the resident for signs and symptoms of dehydration. Review of the nursing progress notes revealed Resident R75 was admitted back to the hospital from August 23, 2017, through September 14, 2017. Review of a Certified Registered Nurse Practitioner (CRNP) progress note, dated September 15, 2017, indicated that during Resident R75's prolonged stay in the hospital, the resident experienced complications of electrolyte (chemical components of the blood necessary for sustained health) imbalance and malnutrition which eventually required a J-tube (jejunostomy tube - a feeding tube inserted through the skin into the digestive tract to administer fluids for nourishment and hydration) to be placed. The CRNP note further added that the resident again developed [MEDICAL CONDITIONS] and diarrhea while in the hospital, requiring treatment with intravenous (IV-tube inserted into a vein to administer medications and fluids) antibiotics. Review of a physician's progress note, dated September 18, 2017, revealed an additional [DIAGNOSES REDACTED]. The physician's progress note stated that the resident had a [DIAGNOSES REDACTED]. Review of Resident R75's care plan for potential risk for altered nutrition, updated September 18, 2017, revealed that staff would provide a tube feeding and flushes (with water) as ordered, and to continue to monitor the resident for signs and symptoms of dehydration. Review of the nursing progress notes revealed that Resident R75 was again admitted back to the hospital from September 20, 2017, through September 28, 2017. Review of a hospital medicine progress note, dated September 25, 2017, indicated that Resident R75 needed to be started on tube feeds, and staff should also encourage the resident to take food and fluids orally. Review of a nursing readmission progress note, dated September 28, 2017, at 6:40 p.m., revealed that the resident was readmitted from the hospital with a [DIAGNOSES REDACTED]. Review of physician's orders for readmission on September 28, 2017, revealed no orders for diet, no orders related to flushing (instilling water into the feeding tube) the J-tube, and no orders related to tube feeding formula. Review of a physician's order, dated September 29, 2017, instructed staff to empty the percutaneous bag and record the output (how much fluid is in the bag) every shift. Review of a physician's progress admit note, dated September 29, 2017, revealed that the resident continued with adult failure to thrive, Resident R75 had a J-tube placed and, we will have nutrition therapy follow along with the patient. Review of a physician's order, dated September 29, 2017, instructed the staff to obtain a nutrition consult for Resident R75's poor oral intake, history of tube feeding, and also for hydration status. Review of a reentry Nutritional Risk assessment dated [DATE], revealed that Resident R75 was readmitted from the hospital due to acute [MEDICATION NAME] and that on the resident's previous admission in the facility (09/18/17), the resident was NPO (abbreviation for nothing to be taken by mouth) with J-tube and noted with poor tolerance to [MEDICATION NAME] (type of tube feeding formula). The Nutritional Risk Assessment stated that Resident R75 was now on a regular oral diet with the resident's oral intake noted as minimal to none. The Nutritional Risk Assessment added that Resident R75 was noted with ongoing nausea, vomiting and diarrhea, the resident had experienced a significant weight loss of 26.4 pounds (20 percent weight loss) in the two weeks since previous admission, and the dietitian spoke with the resident who reported she was not eating. The Nutritional Risk Assessment stated that due to the resident's very poor oral intake and nausea, vomiting, and diarrhea, the dietitian was recommending for staff to initiate [MEDICATION NAME] 1.5 (nutritionally complete formula specifically designed for people who cannot absorb or digest nutrients from conventional foods) to be infused via the resident's J-tube at 45 mL (milliliters) per hour, until a total volume of 900 mL was infused daily, with free water flush of 25 mL/ hour until total volume of 500 mL was reached daily, and will recommend to change the resident's diet to clear liquids (from a regular diet) for improved acceptance. Further review of the clinical record on October 1, 2017, revealed no physician's orders for Resident R75's diet or any orders related to water flushes or initiation of tube feeding formula through the resident's J-tube as recommended by the dietitian on September 29, 2017. Observation of the noon meal on October 1, 2017, at approximately 12:20 p.m. revealed that Resident R75 was lying in bed. Employee E6, Nursing Assistant, was observed to deliver Resident R75's lunch tray from the food cart to the resident's room, and placed the lunch tray on the overbed table that was located next to the resident's bed (not across the resident's bed). Observation of the the tray revealed Resident R75 received a clear liquid tray which included one eight ounce mug of hot water, one tea bag, one six ounce bowl of clear broth with one pack of saltine crackers resting on top of the lid, and one four ounce styrofoam cup of clear juice. Resident R75 was observed to look at the tray, then close her eyes. Employee E6 walked out of the room and stated to a nearby employee, She (resident) refused to eat again. Continued observation on October 1, 2017, at 12:20 p.m. through 1:05 p.m. revealed the resident did not consume any liquids, water or items from the lunch tray. Employee E6 returned to the room at approximately 1:05 p.m., asked the resident if she wanted to eat or drink anything (including offering the resident some water to drink), Resident R75 said no, and Employee E6 removed the tray from the room. Interview with Employee E6 after removal of the tray revealed that Resident R75 had been refusing meals. Review of meal intake data for Resident R75 from readmission from the hospital on September 28, 2017, through October 1, 2017, revealed the following: September 28, 2017, at 5:30 p.m. RR (resident refused); September 29, 2017, at 8:11 p.m. 0 (facility legend 0 equals 0-25 percent consumption); September 30, 2017, breakfast meal 0, lunch meal 0 and dinner meal 0; and October 1, 2017, breakfast meal 0 and lunch meal RR. Review of the Medication Administration Record [REDACTED]. Interview with Employee E5, Corporate Compliance Nurse, on October 2, 2017, at approximately 8:45 a.m. revealed that Resident R75 had sustained a fall earlier that morning, and during the fall, the resident's J-tube became dislodged, requiring the resident to be sent to the hospital for evaluation. Further review of the MAR indicated [REDACTED]. Review of hospital documentation dated October 2, 2017, at 11:27 a.m. revealed an Admission History and Physical stating that the resident was noted as being cachectic, drowsy, slightly confused . Lips are extremely . dry . Her labs suggest that she is severely volume deplete (not enough fluids causes a decrease in blood volume in the body). The hospital Admission History and Physical went on to state that Resident R75 was, Significantly dehydrated on exam in the setting of removed J tube and poor appetite likely 2/2 (secondary to) dehydration vs. less likely to be infection (despite elevated WBC) (white blood cells-the hospital Admission History and Physical noted that the resident's WBC count was elevated at 23.50 (average normal range 4.8 - 10.8)). Also noted was the resident's serum creatinine (blood test to determine kidney function) was elevated at 2.2 mg/dL (milligrams/deciliter), compared to the resident's baseline of 0.3 mg/dL, stating that the resident was, likely hypovolemic (not enough fluids causes a decrease in blood volume in the body) with an acute kidney injury. The resident's [MEDICATION NAME] (lactic acid is made in muscle cells) level was noted as 4.5 mEq/L (milliequivalents per liter-average normal range is 0.5-1.5 mEq/L) likely elevated secondary to metabolic acidosis (chemical imbalance of acids and bases in the blood). Further interview with Employee E5, Corporate Compliance Nurse, on October 3, 2017, at approximately 9:30 a.m. revealed that after the dietitian's evaluation of Resident R75's nutritional status on Friday, September 29, 2017, the dietitian placed the nutritional recommendations (to initiate [MEDICATION NAME] 1.5 to be infused via the resident's J-tube at 45 mL per hour, until a total volume of 900 mL was infused daily, with free water flush of 25 mL/hour until total volume of 500 mL was reached daily) in the upper level nursing unit manager's mailbox on Friday, September 29, 2017, and did not report the recommendations to either the weekend nursing supervisor or the resident's physician on Friday evening or at any time over the weekend. Further interview with Employee E5 confirmed there was no documented evidence that staff notified the physician of the resident's minimal to zero oral intake over the weekend, and no documented evidence that the physician was aware of the generous amount of bile/fluid that was draining into the resident's percutaneous bag with no fluid replacement (via orally, by tube or intravenously) plan in place. The facility failed to ensure that Resident R75, a resident at high nutritional and dehydration risk related to complicated gastrointestinal illness and previous necessity for tube feeding, was consistently, accurately and adequately assessed and monitored by staff. This failure to adequately assess and monitor Resident R75 resulted in admission to the hospital for dehydration, causing actual harm to the resident. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 11/09/16 28 Pa. Code 201.18(a) Management Previously cited 11/09/16 28 Pa. Code 201.18(b)(1)(3) Management Previously cited 02/10/17, 11/09/16 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c)(d)(3) Nursing services Previously cited 06/10/17, 12/04/15 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 11/09/16, 12/04/15