Every finding on record at King of Prussia Skilled Nursing and Rehabilitation

Based on observations and staff interviews, it was determined that the facility failed to ensure that food was stored and prepared in sanitary conditions in the main kitchen. Findings: An observation of the main kitchen conducted on August 11, 2026, at 6:59 a.m., in the presence of the food service director Employee E5, revealed the following: The steam table front bottom part had a dark brown/black sticky substance drips covering approximately two by five feet of the table; The wall behind the food preparation table had cracks with black substance scattered on the wall; and the wall by the kitchen entrance had a hole under ripped wallpaper with scattered black substance. An observation of the main kitchen on August 13, 2026, at 9:52 a.m., in the presence of Employee E5, revealed that the above observations made on August 11, 2026, were still present. An interview was conducted with Employee E5 on August 13, 2026, at 9:55 a.m. Employee E5 reported that the steam table was cleaned a week ago, but the bottom part was not cleaned. Employee E5 was unable to say how long the hole, cracks, and black substances on the walls were present. The above was conveyed to the Nursing Home Administrator on August 13, 2026, at 3:00 p.m. The facility failed to ensure that food was stored and prepared in sanitary conditions. 28 Pa. Code: 201.18(b)(3) Management 28 Pa. Code 211.6(d) Dietary services

Based on a clinical records review and staff interviews, it was determined that the facility failed to ensure the resident was free from unnecessary pain medication for two of five residents reviewed (Residents 8 and 9). Findings: Review of Resident 8's quarterly MDS (Minimum Data Set, a federally mandated assessment of a resident's functional capabilities and health needs), dated May 8, 2026, revealed that Resident 8 received scheduled pain medication and reported experiencing pain occasionally. The assessment further indicated that pain occasionally interfered with sleep, participation in rehabilitation therapy sessions, and day-to-day activities.Review of Resident 8's clinical record revealed diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side (weakness or paralysis of the left side of the body following a stroke), depression (a persistent feeling of sadness or loss of interest), anxiety (excessive worry or feelings of apprehension), and lower back pain.Review of Resident 8's August 2026 MAR (Medication Administration Record) revealed a physician's order for tramadol HCl 50 milligrams (mg), two tablets by mouth every eight hours as needed for moderate pain rated 4 through 6 on a numeric pain scale.Further review of Resident 8's August 2026 MAR revealed that the resident's pain was to be assessed every eight hours utilizing a numeric pain scale (a scale used to rate pain from zero through 10, with zero indicating no pain and 10 indicating the most severe pain).Review of the MAR revealed the Tramadol was administered following pain assessments that were documented as NA on the following instances:August 1, 2026, at 5:50 p.m.August 2, 2026, at 6:19 p.m.August 3, 2026, at 8:06 a.m.August 3, 2026, at 5:46 p.m.August 4, 2026, at 6:10 p.m.August 5, 2026, at 6:02 p.m.August 6, 2026, at 6:25 p.m.August 7, 2026, at 6:05 p.m.August 8, 2026, at 8:53 a.m.August 9, 2026, at 5:30 p.m.August 10, 2026, at 10:06 a.m.August 10, 2026, at 7:22 p.m.August 11, 2026, at 5:46 p.m.August 11, 2026, at 8:34 p.m.August 12, 2026, at 6:53 p.m.August 12, 2026, at 8:53 p.m.August 13, 2026, at 10:03 a.m.There was no documented pain rating to establish that Resident R8 was experiencing moderate pain rated 4 through 6 prior to administration of the as-needed tramadol on the identified occasions.During an interview with the Director of Nursing on August 14, 2026, at approximately 12:30 p.m., the Director of Nursing confirmed that nursing staff were not documenting Resident 8's pain level prior to administering the resident's as-needed pain medication.The facility failed to ensure that Resident 8's pain was assessed and documented prior to the administration of as-needed tramadol to determine that the resident's pain met the physician-ordered parameters of moderate pain rated 4 through 6.This finding was shared with the Director of Nursing and Nursing Home Administrator on August 14, 2026, at approximately 1:50 p.m. A review of Resident 9's diagnosis list includes Fibromyalgia (a long-term condition that involves widespread body pain) and Chronic pain syndrome (A condition where physical pain lasts longer than three to six months, continuing past the normal healing time). A review of Resident 9's physician order dated November 4, 2025, revealed an order for Acetaminophen tablet (A medication used to treat mild pain) 325 mg, two tablets by mouth every six hours as needed for mild pain (Pain level 1-3). On May 1, 2026, an order for Oxycodone HCL (A medication used to treat moderate to severe pain) 5 mg: give one tablet by mouth every six hours as needed for moderate pain (Pain level 4-6). A review of Resident 9 July and August 2026, Medication Administration Record (MAR) revealed that from July 6, 2026, until August 12, 2026, the resident was administered seven times with as-needed Oxycodone for a pain level of 0 on the following dates: July 6, 7, 16, 17, August 2, 3, and 12, 2026. An interview with the Director of Nursing (DON) was conducted on August 13, 2026, at 10:00 a.m. The DON confirmed that Resident 9 should not have been administered as-needed Oxycodone for a pain level of 0. The facility failed to ensure Resident 9 was free from unnecessary controlled pain medication. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services

Based on a clinical records review and staff interviews, it was determined that the facility failed to notify the physician of a significant weight gain for three of eight residents reviewed (Resident 3, 4, and 103). Findings: A review of Resident 3's diagnosis list includes Congestive Heart Failure (CHF- when the heart cannot pump enough blood into the body to meet the metabolic needs) and chronic kidney disease (CKD-Gradual loss of kidney function, which can result in renal failure). A review of Resident 3's physician's order dated April 28, 2025, revealed an order for daily weight, notify provider (physician) if gain greater than two pounds in one day, or five pounds in a week in the morning for HF (heart failure). A review of Resident 3's weight and vitals revealed the resident's daily weight on July 26, 2026, was 173.2 pounds. On July 27, 2026, residents' weight was 177 pounds, a 3.8 pounds weight gain in a day. The weight remained at 177 pounds on July 28, 2026. There was no documentation that the physician was notified of the 3.8-pound weight gain on July 27, 2026. A review of Resident 3's weight and vitals revealed the resident's daily weight on August 9, 2026, was 172.8 pounds. On August 10, 2026, residents' weight was 177.4 pounds, a 4.2 pounds weight gain in a day. The weight was 177 pounds on August 11, 2026. There was no documentation that the physician was notified of the 4.2-pound weight gain on August 10, 2026. A review of Resident 4's diagnosis list includes Acute CHF and CKD. A review of Resident 3's physician's order dated May 20, 2025, revealed an order for daily weights, call the physician if the gain is above three pounds in one day or five pounds in one week. A review of Resident 4's weights and vitals revealed the resident's daily weight on July 10, 2026, was 180 pounds. There was no daily weight taken on July 11, 2026. On July 12, 2026, residents' daily weight was 187 pounds, a seven-pound weight gain in two days. There was no documentation of why daily weight was missing on July 11, 2026. There was no documentation that the physician was notified of the seven-pound weight gain identified on July 12, 2026. An interview conducted with the Director of Nursing on August 13, 2026, at 10:00 a.m., confirmed that the facility did not follow the physician's order to call them if Resident 3 had a weight gain of two pounds in one day and if Resident 4 had a weight gain of three pounds in one day. A review of Resident 103's diagnosis list includes a diagnosis of CHF. A review of Resident 103's physician's order dated April 15, 2026, revealed an order to weigh the resident in the morning every Monday, Wednesday, and Friday for CHF. A review of the physician's progress notes dated June 5, 2026, revealed the resident had bilateral lower extremity edema (swelling). A review of Resident 103's weight and vitals revealed a weight of 305 pounds on June 12, 2026. On June 15, 2026, the resident's weight was 317 pounds, 12 pounds (3.93%) weight gain in two days. On June 17, 2026, the resident's weight was 336 pounds. A reweight was done on June 17, 2026, in the afternoon and revealed a weight of 337 pounds, a significant 20-pound (6.31%) weight gain in two days. A review of the physician's progress notes dated June 26, 2026, at 8:36 p.m., revealed the resident had bilateral extremity edema. The note did not indicate that the physician was notified that the resident had a total of 32 pounds (10.49%) significant weight gain from June 12 until June 17, 2026 (five days). A review of the dietitian's notes dated June 30, 2026, at 2:27 p.m., revealed: Resident is triggering for significant weight gain x 1 month. Weight gain is undesirable. The same notes revealed, Weight change is likely r/t (related to) weight fluctuations r/t fluid. An interview with the dietitian, Employee E6, was conducted on August 13, 2026, at 1:00 p.m. Employee E6 reported that upon identifying a significant weight gain, the nursing staff should have completed a change in status assessment and the physician should have been notified. An interview with the director of Nursing conducted on August 13, 2026, at 2:00 p.m., confirmed that the physician was not notified of Resident 103's significant weight gain identified on June 17, 2026. The facility failed to ensure physicians were notified of significant weight gain of Resident 3, 4, and 103. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Service

Based on observations and staff interviews, it was determined that the facility failed to provide appropriate notification of transmission-based precautions and display of personal protective devices for 1 of 27 residents reviewed. (Resident 79)Findings include:Resident 79 has medical diagnoses that include Hemiplegia (paralysis on one side), Hemiparesis (muscle weakness on one side) following Cerebral Infarction, Parkinsonism and the need for assistance with personal care.Review of Resident 79's physician orders revealed an order dated July 30, 2026, to cleanse right buttock sacrum (triangular bone in the lower back) wound with wound cleaner (a substance or solution used to clean and disinfect a wound), honey gel (a semi-solid or liquid honey-based product that can be used to treat wounds), and silicone foam dressing (an advanced wound care product that combines the gentle, skin-friendly properties of silicone with the high absorbency of foam) daily every dayshift for wound care and as needed for soilage/dressing dislodgement.Resident 79 has a care plan focus initiated December 4, 2025, revised on July 23, 2026, for actual skin breakdown related to decreased activity, impaired sensation, incontinence, limited mobility, moisture/excessive perspiration, poor safety awareness, and pressure wound on right buttock. Observations made on August 11, 2026, at 6:40 a.m., revealed no infection prevention Enhanced Barrier Precautions (EBP) signs or Personal Protection Equipment (PPE- gowns and gloves) for Resident 79's room.Observations made on August 12, 20206, at 9:06 a.m., revealed wound care staff preparing for Resident 79's wound care treatment, no EBP signs or PPE was observed for Resident 79's room. During interview conducted on August 12, 2026, at 9:10 a.m., Licensed Nurse Employee E7 confirmed Resident 79 had a stage 3 sacrum pressure ulcer and confirmed there was no EBP or PPE for the resident's room.Further review of Resident 79's physician orders revealed an order dated August 13, 2026, for Infection precautions- enhanced barrier (wounds).Interview conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 13, 2026, at 11:22 a.m., when the above information was presented, the DON confirmed a resident with a stage 3 pressure ulcer should have EBP and PPE in place and stated she would investigate the matter. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based upon clinical record review and interviews, it was determined that the facility failed to ensure that medication irregularities were appropriately acted upon by a physician for two of five residents reviewed (Resident 53, and Resident 108).Findings include: Review of Resident 53's monthly Pharmacist Medication Regime Reviews (MRR) revealed a MD (physician) Recommendation (title of the form used for pharmacy reviews) dated March 3, 2026, recommending evaluation of the continued need for Hydrocortisone cream ( a medicated cream used to relieve itching, redness, swelling, and inflammation of the skin) apply twice daily for rash and Clindamycin (antibiotic used to treat a variety of bacterial infections) apply twice daily for rash, please evaluate if resident's condition has improved/stabilized or underlying causes of symptoms have resolved and discontinuation is possible or that the signs and symptoms are persistent or clinically significant to warrant continued use. The physician agreed with and signed the recommendation. No date of physician signature was notedReview of Resident 53's August 2026, medication administration report revealed and order dated April 29, 2026, for Clindamycin Phos once daily external Gel 1%, apply to chest, back, arms, and legs topically every dayshift for rash was being administered. Review of Resident 53's August 2026, medication administration report revealed an order dated April 29, 2026, for Hydrocortisone external cream2.5%, apply to chest, back, arms, and legs topically every day and evening shift was being administered. No documentation of the pharmacy recommendations being followed was observed in the resident's records. Review of Resident 108's monthly MRR revealed a MD Recommendation dated September 11, 2025, noting the resident received two Nonsteroidal Anti-Inflammatory Drugs (NSAIDS-medications that reduce pain, inflammation, and fever), Diclofenac gel (used to relieve pain, reduce inflammation, and lower fever 2 grams twice daily to neck, and Meloxicam (used primarily to relieve pain, inflammation, swelling, and stiffness) 15mg once daily, which pharmacist notes as being considered duplication of therapy. Per the pharmacist combination usage with oral NSAIDS is not recommended due to increased risk of adverse reactions including rectal hemorrhage and more frequent abnormal labs, do not use concomitantly unless benefit outweighs risk and monitor patient with periodic laboratory evaluations. Please consider discontinuing one of these NSAID orders. The physician checked disagree on the MRR form and signed the form yet provided no rationale for the disagreement. The form was not dated by the physician. Review of Resident 108's physician orders revealed an order dated January 30, 2026, for Meloxicam tablet 7.5 mg give one tablet by mouth one time a day for right knee pain. Review of Resident 108's physician orders revealed an order dated January 15, 2026, for Voltaren Gel 1% (Diclofenac Sodium), apply to right knee topically four times a day for knee pain 2-gram dose. Resident 108 continues to receive combination usage of NSAIDS despite pharmacy recommendation and physician's agreement to discontinue. Interview conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on August 13, 2026, at 11:22 a.m., when the above information was presented, the NHA and DON stated they would follow-up and look into the matter. 28 Pa. Code 211.10(c) Resident care policies Pa Code 211.12 (c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for three of 27 residents reviewed (Resident 2, 12, and Resident 70). Findings Include: Review of Resident 2's clinical record revealed Resident 2 was transferred to the hospital on April 18, 2026, after the resident was found on the floor. Resident 2 was admitted into the hospital on April 18, 2026, with a diagnosis of hypoglycemia. Further review of Resident 2's clinical record revealed Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 2's transfer and admission to the hospital. Review of Resident 12's clinical record revealed Resident 12 was transferred to the hospital on April 13, 2026, after resident indicated suicidal ideations. Resident 12 was admitted into the hospital on April 13, 2026, with a suicidal ideations and hyponatremia. Further review of Resident 12's clinical record revealed Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 12's transfer and admission to the hospital. Review of Resident 70's clinical record revealed Resident 70 was transferred to the hospital on May 3, 2026, at the resident's request due to a fall. Resident 70 was admitted into the hospital on May 3, 2026, with a diagnosis of pneumonia and hypoxic respiratory failure. Further review of Resident 70's clinical record revealed Resident 70 was readmitted to the facility on [DATE]. Review of Resident 70's clinical record revealed Resident 70 was transferred to the hospital on June 7, 2026, due to diarrhea and blood in stool. Further review of Resident 70's clinical record revealed Resident 70 returned to the facility on June 9, 2026. Review of Resident 70's clinical record and facility documentation failed to reveal evidence that the State Ombudsman's office was notified of Resident 1's transfer and admission to the hospital. These findings were shared with the NHA (Nursing Home Administrator) and DON (Director of Nursing) on August 14, 2026, at approximately 1:15 p.m.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that residents were provided the opportunity to formulate an advance directive and failed to provide evidence that the resident and/or resident representative was provided information or assistance, as needed, regarding the formulation of an advance directive for one of 32 residents reviewed. (Resident 49)Findings include:Resident 49 was admitted to the facility on [DATE], with diagnoses that included muscle wasting and atrophy, not elsewhere classified, multiple sites; end stage renal disease (a condition in which the kidneys no longer function well enough to meet the body's needs); and dementia (a group of symptoms affecting memory, thinking, and social abilities).Clinical record review for Resident R49 revealed an active physician's order dated July 3, 2026, indicating the resident was a DNR (Do Not Resuscitate, an order indicating that cardiopulmonary resuscitation is not to be initiated if the resident's heart stops beating or the resident stops breathing).Review of the clinical record revealed no documented evidence that Resident R49 and/or the resident's representative was provided information regarding advance directives, offered the opportunity to formulate an advance directive, or provided assistance in formulating an advance directive, if needed.Review of an admission History and Physical Encounter document dated July 3, 2026, indicated, Advanced Directives were discussed: The patient is a DNR. However, there was no additional documentation indicating that the resident was informed of the resident's right to formulate an advance directive or was offered assistance in developing an advance directive.Additional information and documentation regarding advance directives for Resident R49 was requested during an interview with the Nursing Home Administrator and Director of Nursing on August 13, 2026, at 1:10 PM, and again on August 14, 2026, at 12:15 PM. No additional documentation was provided.The facility failed to implement a process to ensure that Resident R49 was informed of the right to formulate an advance directive and was provided the opportunity and assistance, if needed, to develop an advance directive.28 Pa. Code 201.29(a) Resident rights28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on facility record reviews and staff interviews, it was determined that the facility failed to obtain informed consent for antipsychotic medication use from the legal representative of one of five resident's reviewed. (Resident 102) Findings include:Resident 102 has medical diagnoses that include Anoxic Brain Damage (injury to brain caused by lack of oxygen), Psychosis (experiencing hallucinations, delusions and disorganized thinking), Major Depressive Disorder (a serious mental health condition characterized by persistent feelings of sadness, hopelessness, or emptiness that last for at least two weeks and significantly interfere with daily life) and Paranoid Schizophrenia (a mental health condition where a person experiences fixed, false beliefs or delusions). Resident 102's cognitive quarterly Minimum Data Set (MDS- clinical assessment of residents) dated May 14, 2026, documents the resident has a Brief Interview of Mental Status (BIMS- a standardized cognitive assessment used to evaluate memory, orientation and recall abilities), score of 15 indicating intact cognitive response with minimal or no impairment.Review of Resident 102's miscellaneous records revealed a Court of Common Pleas of Delaware County, Pennsylvania, Orphans' Court Division, decree stating this 12th day of January 2026, it is ordered and decreed that Resident 102 is adjudicated an incapacitated person and is appointed a temporary, emergency Guardian of the Person and Estate, without prejudice and with powers and duties that include to determine any needs for and authorize/consent to the provision of medical treatment.Review of Resident 102's physician orders revealed orders dated July 21, 2026, for Invega Sustenna Intramuscular Suspension (an extended release intramuscular injectable suspension of paliperidone palmitate used for treating schizophrenia and schizoaffective disorder in adults) prefilled syringe 234 milligrams (mg)/1.5 milliliter (ml) inject 234 mg intramuscularly one time a day every 28 days for psychosis. Review of Resident 102's paper chart revealed an informed consent form signed by Resident 102 on April 10, 2026, documenting the resident's consent and understanding of the risks and benefits of antipsychotic medication use. During interview conducted with Social Service Director Employee E4 on August 14, 2026, at 9:25 a.m. Employee E4 confirmed Resident 102 was adjudicated and incapacitated person and was appointed a Guardian of Person and Estate by an Orphans' Court judge in January 2026, who is responsible for making PA Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.10(c) Resident care policies

Based on a review of facility's policy, facility documentation, clinical records, and staff interview, it was determined the facility failed to follow wound physician's treatment orders/recommendations and provide consistent and appropriate treatment for an Unstageable Pressure Ulcer on the right heel (obscured full-thickness skin and tissue loss), resulting in wound deterioration and actual harm for one of four residents reviewed. (Resident 1)Findings include:Review of the facility's policy titled Skin Integrity and Wound Management, reviewed September 15, 2025, revealed Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Review of Resident 1's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anemia (lower than normal amount of healthy red blood cells) and unspecified abnormalities of gait and mobility (person exhibits irregularities in walking and movement but the exact cause cannot be determined or specified). Review of Resident 1's Braden Scale Assessment (assessment tool used for predicting pressure ulcer risk) dated January 26, 2026, revealed a score of 12 (score of 12 or less represents high risk). Review of Resident 1's skin care plan revealed interventions including weekly wound assessment to include measurements and description of wound status, provide wound treatment as ordered, and observing skin for signs of skin breakdown (redness, cracking, blistering, decreased sensation, and skin that does not blanche easily). Review of Resident 1's clinical record revealed weekly skin assessments were conducted and issues with skin integrity were noted. Review of Resident 1's clinical record revealed a progress note dated January 22, 2026 (08:30 a.m.) Skin Issues Late Entry indicating resident had an in-house acquired pressure ulcer (localized damage to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony prominences like the hips, heels, or tailbone) to the right heel. Further review failed to reveal measurements or description of the wound with this assessment. Review of Resident 1's Physician Orders revealed an order dated January 25, 2026, skin prep right heel X shift. Off load right heel every shift for skin alteration which was discontinued on February17, 2026. Review of Resident 1's wound consult report dated January 30, 2026, revealed provider comments Right Heel - Deep tissue injury (type of pressure injury characterized by localized, purple/maroon discolored intact skin or blood-filled blisters) with intact skin and dark purple discoloration. No drainage was noted. Recommend discontinue current wound care orders, see new wound care recommendations. Resident 1's wound right heel pressure ulcer was measuring L(length) x W(width) x D(depth) 2.8 x 4.4 x 0. Review of Resident 1's physician order dated March 21, 2026, revealed Right heel paint with betadine and cover with Foam dressing daily & PRN (as needed) every day and evening shift for wound care. Review of Resident 1's wound consult report dated April 10, 2026, revealed provider comment indicating Right heel unstageable pressure injury is stable noted with 100% lifting eschar (thick, dry, leathery layer of dead, necrotic tissue that forms over severe wounds, burns, infections, or pressure ulcers ) and malodor (a strong indicator of infection, necrotic (dead) tissue, or bacterial buildup ). Peri (around) wound dry/scaly. Targeted debridement (removal) of eschar was performed without complications. Discontinue prior wound care orders, please see new recommendations. Resident 1's wound right heel pressure ulcer was measuring L x W x D 3x 3.2 x 0 and a malodorous odor. Treatment recommendations from wound provider stated cleanse the area with Vashe Wound Solution. Primary dressing: Honey (medical grade) Gel; Secondary Dressing: Silicone foam adhesive dressing. This treatment will be done daily and as needed until discontinued. Review of Resident 1's wound consult report dated April 15, 2026, revealed provider comment indicating Right heel unstageable pressure injury has worsened in appearance. Noted with 100% slough and malodor. Periwound dry/scaly. Auto fluorescent imaging (real-time, non-invasive technology that detects bacterial burden (biofilm/planktonic) in wounds by illuminating them with safe violet light) was utilized and was positive for cyan fluorescence (indicating infection). Targeted sharp debridement (cutting away of dead tissue) was performed without complications. Discontinue prior wound care orders, please see new recommendations. Resident 1's wound right heel pressure ulcer measurement of L x W x D is 2.8 x4.5 x1.2. Treatment recommendations cleanse the area with Dakin's 0.125% (1/4 strength) solution. Primary dressing Dakin's 0.125% solution dampened gauze (1/4 strength). Secondary Dressing: Silicone foam adhesive dressing. This treatment will be done daily and as needed until discontinued. Review of Resident 1's wound consult report dated April 22, 2026, revealed Resident 1's wound right heel pressure ulcer was Stage Unstageable measuring Lx W x D 3x4.5.x1. Unchanged Wound status. There is moderate exudate (drainage) amount; wound margin is well defined; peri-wound is dry/scaly and necrotic material 50%. Granulation (moist soft red bumpty tissue) between 0% and 25%- confluent (where multiple linear scratches or scrapes merge together into a single, large, and often haphazardly shaped wound )-beefy red. Treatment recommendations 'cleanse the area with Dakin's 0.125% (1/4 strength) solution. Primary dressing Dakin's 0.125% solution dampened gauze (1/4 strength). Secondary Dressing: Silicone foam adhesive dressing. This treatment will be done daily and as needed until discontinued. Review of Resident 1's wound consult report dated April 29, 2026, revealed Resident 1's wound right heel pressure ulcer categorized as Stage Unstageable measuring L x W x D 3.7x5.x1. There is malodorous odor Unchanged Wound status. Treatment recommendations 'cleanse the area with Dakin's 0.12.5% (1/4 strength) solution. Primary dressing Dakin's 0.125% solution dampened gauze (1/4 strength). Secondary Dressing: Silicone foam adhesive dressing. This treatment will be done daily and as needed until discontinued'. Review of Resident 1's March 2026 and April 2026, Treatment Administration Record (TAR) revealed the April 10, 2026, and April 29, 2026, treatment recommendation/order of the wound doctor were not followed and the resident continued to receive the original treatment of Betadine and a foam dressing initiated on March 21, 2026, during which the pressure wound deteriorated. Interview with the Director of Nursing on April 30, 2026, at 2:45pm confirmed the wound care recommendations from the wound specialist were not followed and the resident's wound care was never changed as recommended on April 10th, 2026, and April 29th, 2026. The facility failed to ensure Resident 1's wound care changes were followed resulting in a harm of unstageable right heel pressure ulcer with wound deterioration. 28 Pa. Code 211.11(d) Resident care plan28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa. Code 211.10 (d) Resident care policies

Based on clinical records review and staff interview, it was determined that the facility failed to follow the physician's order for one of four residents reviewed (Resident 1).Findings: A review of Resident 1's nursing progress notes dated February 4, 2026, at 8:06 p.m., revealed Resident 1 had a rash on the right front axilla (armpit). A review of Resident 1's physician's order dated February 4, 2026, revealed an order for Permethrin External Cream (A medication used primarily to treat scabies, a contagious skin infestation caused by mites) 5% apply to the body, neck to feet topically one time only for a dermatological rash for one day. Leave for eight hours and shower, repeat in seven days (February 12, 2026). A review of Resident 1's February 2026 Medication Administration Record (MAR) revealed that the medication Permethrin was not administered to the resident on February 4, 2026, and February 12, 2026. A review of Resident 1's nursing progress notes dated February 5, 2026, at 10:21 a.m., revealed medication Permethrin not administered. No further reason was documented. A review of Resident 1's nursing progress notes dated February 12, 2026, at 2:51 p.m., revealed medication Permethrin awaiting delivery. A review of Resident 1's Dermatology (A medical doctors who specialize in the diagnosis and treatment of diseases of the skin, hair, nails, and mucous membranes) consult March 4, 2025, revealed a diagnosis of Anthropod Assault (A dermatological term for an inflammatory skin reaction caused by bites or stings from insects, spiders, ticks, or mites). An order to start Permethrin 5% cream, apply from neck down to feet for eight hours, then rinse off. A review of Resident 1's MAR revealed that the medication Permethrin was not administered on March 5, 2026. A review of Resident 1's nursing progress notes dated March 5, 2026, at 1:45 p.m., revealed medication Permethrin waiting for delivery from pharmacy. There was no documentation that physicians were notified of the missed Permethrin treatment. An interview was conducted with the Director of Nursing (DON) on March 17, 2026, at 1:00 p.m. The DON reported that Permethrin cream was not applied to the resident on the above dates mentioned above because the pharmacy did not deliver the medication. The DON confirmed that there was no follow-up done by the facility to the pharmacy to have the medication delivered. The facility failed to ensure Resident 1's Permethrin treatment ordered by the physician was followed on February 4, 2026, February 12, 2026, and March 5, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa Code 211.5(f) Clinical Records

Based on observation, record review, and staff interviews, the facility failed to ensure residents were free from significant medication errors, resulting in actual harm when Resident R1 required transfer to the hospital with the need for intubation and admission to the Intensive Care Unit, this was found to be a past noncompliance incident for one of 15 residents reviewed. (Resident R1) Findings include:Review of the facility policy titled Medication Administration, dated January 2025, revealed that prior to medication administration, staff are required to review and confirm medication orders for each resident on the Medication Administration Record (MAR) and compare the medication label with the MAR.Review of Rights of Medication Administration, revealed the following:Right patient: you must have 2 resident identifiers prior to administering medications (examples: photo, name band, name/DOB verification)Right drug: this requires a triple check to ensure accuracyRight dose: this requires a triple check to ensure accuracyRight route: in which the medication is given (IV, PO, SQ, Topical, etc)Right time and frequencyRight to refuse: all residents have the right to refuse medications and treatments. If they do refuse, it must be documented as such.Resident R1 was admitted to the facility on [DATE], with diagnoses that include unspecified sequelae of cerebral infarction (stroke). Major Depressive Disorder (persistent feelings of sadness and loss of interest in activities), generalized anxiety disorder (persistent and excessive worry about various aspects of life), and adult Failure to Thrive.Review of information submitted to the state agency on January 12, 2026, revealed that on January 11, 2026, at approximately 8:00 p.m., Resident R1 was administered nine medications prescribed to another resident (Resident R2). The medications administered in error included:Hydralazine 50 mg (for high blood pressure)Buprenorphine 8 mg sublingual (for chronic pain) Quetiapine 25 mg (antipsychotic)Prazosin 1 mg (for high blood pressure)Clonidine 0.3 mg (for high blood pressure)Lorazepam 0.5 mg (antianxiety)Melatonin 5 mg (sleep aid)Mirtazapine 45 mg (antidepressant)Atorvastatin 40 mg (for high blood pressure)Further review of the Electronic Event submitted to the state agency on January 12, 2026 revealed The nurse notified the supervisor that she made a medication error. The supervisor immediately assessed the resident, and V/S (vital signs) were taken. The resident was awake but drowsy, has good po (oral) intake, b/p (blood pressure) 110/61 (normal 120/80), O2 sat (measurement of how much oxygen is in the blood) was 72% (normal above 90%). O2 2L (supplemental oxygen) was placed on the resident and pulse ox went up to 94%. The MD (medical doctor) was notified and gave the order to monitor, give oxygen, start neuro checks (a series of rapid or comprehensive evaluations assessing brain, spinal cord, and nerve function, typically including mental status (alertness/cognition), cranial nerve assessment (vision/pupils), motor strength, coordination, and reflexes) and call with any changes. The resident's RP (responsible party) was notified. Around 10:20 pm the supervisor called the MD back to report the resident is now lethargic and is only arousable to sternal rub and is now snoring. their B/P was 51/73. The MD gave an order to send to the ER (Emergency Room) for evaluation.Review of hospital records revealed Resident R1 was admitted with a diagnosis of accidental drug overdose, required intubation (flexible tube is inserted into the windpipe to maintain an open airway, deliver oxygen, or allow a ventilator to breathe for a patient) in the emergency department, and was subsequently transferred to the intensive care unit (ICU). Hospital records further revealed Resident R1 was discharged [DATE], and transferred to another skilled nursing facility.Interview was unable to be conducted due to Licensed staff member Employee E1 was unavailable for interview due to separation from employment and placement on the facility's do-not-hire list.Review of written statement provided by Licensed staff member Employee E1, dated January 11, 2026, revealed Employee E1 reported entering the Resident R2's room, asking the resident if they were Resident R2, receiving an affirmative response, and administering the 8:00 p.m. medications. The statement further revealed that Employee E1 was later alerted by another resident that the individual was not Resident R2 but Resident R1, after which Employee E1 obtained vital signs of Resident R1 and reported the incident to the supervisor.Interviews conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on January 29, 2026, at approximately 10:50 a.m. revealed the facility implemented facility-wide audits, change-in-condition training, and medication administration training, and the Rights of Medication Administration.Review of training documentation revealed 100% of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) completed the identified training. Interviews conducted with licensed staff Employees E2, E3, E4, E5, E6, and E7 confirmed receipt of the training, which was verified through sign-in sheets.During a follow-up interview conducted with the DON and NHA at approximately 11:13 a.m., facility leadership confirmed the incident was identified as a medication error and acknowledged the resident required hospitalization as a result.The facility failed to ensure Resident R1 was not administered medications prescribed for another resident, resulting in a significant medication error with actual harm to Resident R1 who was transferred to the hospital and required intubation and care in the Intensive Care Unit. This was a past non-compliance situation with the facility completing the above interventions on January 12, 2026.28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.

Based on facility policy review, observations and staff interview it was determined the facility failed to properly store medications for one resident reviewed. (Resident R6) Findings include:Review of facility policy storage of Medication dated January 2025. Revealed The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including those established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers.During an onsite investigation conducted on January 29, 2026, at approximately 10:15 a.m., an unidentified pill on the floor outside the entrance of Resident R6's room.The pill was not labeled, packaged, or stored in a secure medication container.Interview with licensed employee E13 conducted on January 29, 2026, at 12:20 p.m. revealed staff were unable to identify the pill and could not determine which resident, if any, the medication was prescribed to.Interview with the Director of Nursing, conducted on January 29, 2026, at approximately 12:33 p.m. confirmed that medications are required to be secured at all times and acknowledged that an unidentified pill found outside a resident room posed a risk for unintended ingestion.The facility failed to ensure medications were properly controlled. 28 Pa Code 211.12(d)(1) Nursing services28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review, and policy and procedures review, it was determined the facility failed to follow a physician's order for oxygen therapy for one of three residents reviewed (Resident 10). Findings include:Review of facility policy, titled Procedure: OXYGEN: NASAL CANNULA revision date 08/07/2023 revealed place oxygen source in room according to equipment specific procedure.Review of Resident 10's clinical record revealed there was a current physician's order for the resident to be receiving oxygen therapy via a nasal cannula. The cannula was to be used continuously.Review of Resident 10's clinical record revealed the following nursing statement. The resident also is on continuous oxygen, however O2 was not in use during ambulation. Staff and therapist were re-educated on ensuring oxygen is maintained during all mobility activities, including with portable tanks when appropriate.Interview conducted with the Director of Physical therapy, Employee E3, at 07/18/2025 12:51 PM, when they were informed of the above information and deficient practice was identified.The facility failed to follow a physician's order for oxygen therapy for Resident 10. PA Code 211.10(c) Resident Care Policies

Based on observations, review of facility records and staff interviews, it was determined that the facility failed to maintain kitchen equipment (dishwasher and sink faucet) in safe, operating condition. Findings include:Observation of the facility's main kitchen on 7/14/2025, between 6:13p.m. and 6:25 p.m., revealed a puddle of water on the floor by the dishwasher. During an interview at the time of the observation, Employee 6 indicated that the puddle of water was due to a drain issue and that maintenance was made aware three month ago. Observations of the use of the sink faucet by the dishwasher on 7/15/2025 at 9:25am revealed a puddle of water on the floor and leak in the faucet. Interview with the Maintenance Director on 7/15/2025 at 9:36am confirmed that there was a leaking faucet and were made aware of it a month ago (June 2025) and stated that there was an issue with the water line.Review of work orders provided revealed a work order for faucet repair was put in on 7/15/2025.Interview with the Nursing Home Administrator on 7/16/2025 at 2:11pm confirmed the above findings. 28 Pa Code: 207.2(a) Administrator's responsibility.

Based on facility policy, observations and interviews, it was determined that the facility failed to document medication disposition for one of three discharged residents. (Resident 139). Findings include: Review of facility policy titled Disposal of Medication Waste, documents all medications will be disposed of in accordance with applicable federal, state, and local regulations for the disposal of chemical and potentially dangerous or hazardous pharmaceuticals. Medication for disposal includes medications which are not taken with the resident upon discharge. Medications that cannot be returned to the pharmacy, discharged with the resident, or donated will be placed in medication disposal bins labeled controlled substance waste. A licensed pharmaceutical waste disposal company will remove medication waste.Review of resident 139's clinical records revealed physician orders that included Morphine Sulfate Oral Tablet 15 MG (for pain).Review of Resident 139's clinical records revealed a progress note dated April 17, 2025, at 5:54 a.m., documenting the resident was admitted to [NAME] Hospital for observation related to chronic (recurring) mid-line low back pain. No further information was documented concerning Resident 139's discharge. Review of Resident 139's closed records revealed a medication administration form dated April 13, 2025, documenting the resident received 30 Morphine Sulfate Oral Tablets. Per the medication administration form none of the medication was administered to Resident 139. Further review of Resident 139's closed records failed to reveal documentation of the proper disposition of Resident 139's 30 Morphine Sulfate Oral Tablets. Interview on July 18, 2025, at 10:00 a.m., with Director of Nursing (DON) when the above information was presented, The DON confirmed there was no medication disposition sheet for Resident 139. 42 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records.28 Pa. Code 211.9(j) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a review of facility policy, clinical records and staff interviews, it was determined that the facility failed to properly follow physician orders for two of 32 residents reviewed (Resident 6 and 29).Finding include: Review of Resident 6’s clinical record revealed diagnoses including essential hypertension. (Primary (essential) hypertension is high blood pressure that is multi-factorial and doesn’t have one distinct cause.) Review of Resident 6’s physician's orders revealed Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN Hold for SBP < 130 Review of Resident 6’s medication administration record (MAR) for the month of May 2025, June 2025, and July 2025 revealed the facility administered the above medication eight times outside of parameters. The facility failed to ensure Resident 6’s medication order Metoprolol Tartrate Oral Tablet 25 MG was administered as ordered. The above information was conveyed to the Nursing Home Administrator and Director of Nursing on July 17, 2025 at 11:32 am. Review of the facility’s “Pain Management” policy, revised March 24, 2025, revealed at a minimum of daily, residents will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. As needed pain medications will have defined parameters for use. Review of the facility’s “Pain Management” policy, failed to reveal guidance on pain severity levels. Review of facility policy titled Medication Administration General Guidelines dated 01/24 section 7.1. Medication administration: “Medications are administered in accordance with written orders of the prescriber. Review of Resident 29’s clinical records revealed medical diagnosis that include Malignant Neoplasm of Tongue (tongue cancer), and Tracheostomy Status (surgical hole in the B that assists with breathing), and Dysphagia, Oropharyngeal (difficulty transferring food from mouth to throat). Review of Resident 29’s physician orders revealed an order dated December 17, 2018, for NPO diet (nothing by mouth), Morphine Sulfate Oral Tablet (opioid pain reliever) 30 mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, Risperdal Tablet 3 mg (antipsychotic), give 1 tablet by mouth at bedtime give with 0.5mg tablet to equal 3.5 total, Amoxicillin-Po Clavulanate Tablet (antibiotic) 875-125 mg, give 1 tablet by mouth every 12 hours for pneumonia for 5 days give twice daily for 5 days, Docusate Sodium Liquid (stool softener) 50 mg/5ml, give 10 ml by mouth two times a day for constipation and Enteral Feed (intake of nutrition via tube) five times a day Osmolite 1.5 formula, Bolus feeds of 275 ml 5x per day (1375 ml total volume). Review of Resident 29’s June and July 2025 Medication Administration Reports (MAR) revealed nursing staff document administering the Morphine, Risperdal, Amoxicillin and Docusate via mouth although the resident has orders of NPO, and all medications should be administered via the resident’s Percutaneous Endoscopic Gastrostomy (PEG)-Tube (feeding tube inserted wall of stomach). Further review of Resident 29’s June and July 2025 MARs revealed Morphine Sulfate Oral Tablet 30 mg, give 1 tablet every 4 hours as needed for moderate to severe pain was administered to the resident with a documented pain level of 0 to 2 from June 24, 2025, through July 9, 2025. Interview with Resident 29 on July 17, 2025, at 10:00 a.m., Resident 29 confirmed he/she receives nothing by mouth, everything is administered via peg-tube. Interview with Unit Manager Employee E5 on July 17, 2025, at 10:10 a.m., E5 stated Resident 29 only receives medications via peg-tube. E5 confirmed the resident’ s NPO status and confirms the resident receives nothing by mouth. E5 confirmed Resident 29 received Morphine for moderate to severe pain with documented pain levels of 0 to 2. E5 stated staff documents the residents clinical pain level (the resident’s physical appearance of pain), not the resident’s stated pain level, which is usually 7. Interview July 18, 2025, at 10:00 a.m. with Director of Nursing (DON), DON confirmed Resident 29 receives nothing by mouth. DON confirmed documentation errors for Resident 29’s physician orders noting take by mouth. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services

Based on interviews, policy reviews, and clinical closed record review, it was determined the facility failed to ensure ombudsman notification procedures were followed for one of one resident reviewed. (Resident 6), and to document return of personal items upon discharge or death for two of three residents reviewed (Resident 139 and 140).Findings Include: Review of Resident 6’s clinical record revealed diagnoses including pulmonary embolism. (A pulmonary embolism (PE) is a blood clot in one of the blood vessels in your lung.) Interview with Director of Nursing on [DATE] at 10:02 AM confirmed no notification was sent to ombudsman Review of facility policy titled Personal Property: Patient's revealed, personnel will identify and record the resident's belongings upon admission to the facility. Return of any personal property remaining in the facility must be made within 30 days after discharge or death. Review of nursing notes for Resident 139, dated [DATE], documents the resident was discharged to [NAME] Hospital related to lower back pain. No further information was documented regarding Resident 139. Review of Resident 139's closed clinical record revealed a list of the resident’s personal items upon admission. Further review of Resident 139's closed clinical records failed to reveal documentation the resident's personal items were returned after discharge. Review of nursing notes for Resident 140's, dated [DATE], at 4:09 a.m., documenting Resident 140 was found unresponsive, RN on duty called to examine, Resident was pronounced at 03:30 am expired. Review of Resident 140's closed clinical record revealed a list of the resident’s personal items upon admission. Further review of Resident 140's closed clinical records failed to reveal documentation the resident's personal items were returned to family after the resident's death. Interview on [DATE], at 10:00 a.m. with the Director of Nursing (DON), when the above was presented, the DON confirmed there was no documentation of the resident's personal belongings be returned upon discharge or death. 28 Pa Code 201.25 Discharge policy 28 PA Code 211.5(d) Clinical records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based upon review of facility policy and procedure and review of clinical records, it was determined the facility failed to ensure weight loss and weight gain was adequately monitored for two of 15 residents reviewed (Resident 8, Resident 60). Finding include: Review of facility policy and procedure titled Weights and heights, revised July 15, 2025, revealed Based on patients’ comprehensive assessment, the center will ensure that all patients maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the patient clinical condition demonstrates that is not possible for the patients' preferences to indicate otherwise Review of Resident 8’s diagnosis list revealed diagnoses including Gastro-esophageal reflux disease without esophagitis. (Gastroesophageal reflux disease (GERD) happens when acidic stomach contents flow back into the esophagus.) Review of Resident 8’s physician orders dated July seventh, 2025, revealed an order for weights every Monday. Review of Resident 8's Weight Summary revealed July 1, 2025; Resident 8 weighed 127.5 pounds. Further review of Resident 8's Weight Summary revealed on July 14, 2025. Resident 8 weighed 119.6 pounds Resident 8’s weighed 119.6 pounds on July 14, 2025. This indicated a 6.2% weight loss between July 1, 2025, and July 14, 2025. Further review of Resident 8's clinical record failed to reveal evidence of a reweight after the July 14, 2025, was obtained. Further review of Resident 8's clinical record failed to reveal evidence that the facility dietitian was notified of Resident 8's weight loss. Review of Resident 60’s clinical record revealed diagnoses of localized edema (accumulation of fluid in a specific area of the body) and dementia. Review of Resident 60's clinical record revealed that weights were obtained as follows: December 2, 2024 – 140.6 pounds, January 1, 2025- 131.2 and February 2, 2025 – 112.5 pounds indicating a loss 18 pounds (14.25% Loss). Review of Resident 60’s clinical records and nutrition assessment failed to reveal evidence of significant weight loss being identified and interventions being put in place to address the weight loss. Interview with Dietician on July 17, 2025, at 10:50am confirmed the above information was true for Resident 60. Interview with the dietitian on July 17, 2025, at 11:07am confirmed that no reweight was obtained and further confirmed the dietitian was not notified of Resident 8's weight loss. 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(c)(d)(3) Nursing Services

Based on interviews and clinical record reviews, it was determined that the facility failed to report one resident's hospital transfer due to consumption of a liquid soap product. (Resident 2) Findings include: Review of resident's clinical records revealed medical diagnoses that include Dementia (loss of cognitive functions), Heart Failure (heart can't pump enough blood to meet body's needs), Hypertension (pressure in blood vessels are to high), Stage 3 Kidney Disease (mild to moderate kidney damage), Anxiety (overwhelming sense of apprehension or fear), and Major Depressive Disorder (persistent low or depressed mood, loss of interest). Review of facility records revealed an incident report dated December 31, 2024, documenting Certified Nursing Employee E3 reported to Licensed Nursing Employee E4 that a Resident 2 was observed with a bottle of soap up to his/her mouth. Resident 2 was found by Licensed Nursing Employee E4 lying in bed, cringing with eyes closed and clammy to touch. The physician was notified, and orders were given to send Resident 2 to the hospital. Resident 2 was identified as oriented to person only. Review of facility records revealed Certified Nursing Employee E3's, witness statement documenting at approximately 5:45 p.m., Resident 2 was observed in his/her room, large amounts of vomit were observed on the floor and an empty soap bottle was observed in his/her hand. According to the statement Certified Nursing Employee E3 left the room to get supplies to clean the floor. When Certified Nursing Employee E3 returned Resident 2 was in the bathroom, sitting in his/her wheelchair, incontinent with watery stool. Certified Nursing Employee E3 witnessed Resident 2 placing another soap bottle up to his/her lips. Certified Nursing Employee E3 took the bottle away from the resident and reported the incident to Licensed Nursing Employee E4. Interview conducted with Director of Nursing (DON) on January 29, 2025, at 2:00 p.m., when the above information was presented, the DON confirmed the incident did occur, the incident was not reported to the DON at time of occurrence, and the incident was not reported to the Department of Health. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policy, facility documentation, facility personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for new hires and existing staff. Findings include: Interview conducted with the Staff Educator Employee (E7) on August 15, 2024, at 12:45 p.m. reported she was unable to provide a facility policy regarding an effective training program for all new and existing staff. Interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on August 15, 2024, at 1:05 p.m. confirmed the facility failed to develop a training program for all new and existing staff. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development.

Based on review of clinical records, review of facility documentation, review of facility policy and interviews with residents and staff, it was determined that the facility failed to ensure that comprehensive care plans for fall prevention were developed for one of nine clinical records reviewed (Resident R1). This failure resulted in actual harm to Residents R1 who sustained a fall resulting in fracture to the cervical vertebra. Findings include: Review of the facility policy titled Falls Practice Guide dated December 12, 2011, revealed that If, upon completion of the Patient Admission/Readmission Screen, the patient is found to be at risk or has a history of falls, the physician is contacted for orders as appropriate; an initial plan of care is developed and individualized interventions are initiated. Review of Resident R1's Admission Record Report revealed that the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's fall risk assessment dated [DATE], revealed risk factors for falls including incontinence, depression and the presence and/or history of gait, strength and balance factors that impact fall risk. Review of the admission Minimum Data Set (MDS- assessment of resident care needs) dated June 16, 2021, revealed that Resident R1 was identified with a BIMS (Brief Interview for Mental Status-an assessment tool used to identify level of cognitive function) score of 12 out of a possible 15 which indicated that Resident R1 has moderate impairment of cognitive function and was able to be interviewed. Further review of the MDS revealed that the resident was totally dependent on staff for bed mobility requiring the assistance of two staff persons. A review of the Minimum Data Set (MDS) Care Area Assessment for falls dated June 17, 2021 indicated that the patient was triggered for care planning for falls, and that the determination was made to follow through with creating a care plan. Review of nursing note dated September 26, 2021, at 10:34 p.m. stated this nurse was called to room [ROOM NUMBER] by cna (nursing assistant) for a fall. Upon entering room this nurse found patient lying on right side of bed on his right side facing the window. Patient assessed by this nurse and rn. (Registered Nurse) upon assessment patient stated that he hit his head and complained of pain to his right side of head/face, right shoulder, and right hip. patient with reddened spot to top/right side of head and small skin tear to right elbow. Patient able to move all extremities, minimal movement to right arm, as this is baseline for patient. Patient pupils appeared to be pin point and non reactive to light. Patient stated that he was getting changed and rolled out of bed. upon entering room the bed was at waist height. vital signs obtained. bp (blood pressure) 112/63, hr (heart rate) 93, resp (respirations) 18, temp (temperature) 97.9 temporal, oxygen 97% room air. md (physician) called and made aware . new orders to send patient to ER (emergency room ) via 911 (emergency medical services) for ct (computed tomography scan- a diagnostic tool used to assess for internal injury) and evaluation. Further review of nursing notes revealed a second entry dated September 26, 2021, at 11:15 p.m. stated This Nurse was called to assess pt (patient) after fall. Pt was in bed, AAOX2 (alert and oriented to person and place) speech was clear. Pt c/o (complaint) pain allover, but more in his right side arm/shoulder and side. Pt stated he hit the right side of his head face. Pt had a small red area on the top of his skull and an abraded area on the right arm. No redness, swelling or bruising seen on the face or head or right arm. Pt was able to move all extremities, right side with weakness which was baseline. Pt pupils noted to be pinpoint and not reactive to light. Pt noted to be shivering. Review of the facility investigation dated September 26, 2021 stated CNA (nursing assistant) provided incont (sic) care. Turned resident away-motion stopped, resident fell forward. Further review of the facility investigation indicated that Follow up call w/hospital (sic) shows x-ray C1 (first cervical vertebra located just below the skull) fx (fracture). Review of documentation of CT scan results shows a finding of Nondisplaced fracture through the anterior ring of C1. Interview with the nursing assistant, Employee E5 conducted on October 12, 2021 at 12:10 revealed that Employee E5 stated that his previous practice for incontinence care was to turn the patient away from himself. He stated that after the incident with Resident R1, he received inservice training, and that he was told to always turn patients toward himself. Review of Resident R1's current care plan revealed that the facility failed to developed a care plan for fall prevention. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(d) Resident rights 28 Pa Code 201.29(j) Resident rights 28 Pa. Code 211.10 (d) Resident Care Policies 28 Pa. Code 211.11 (b) Resident Care Plan 28 Pa. Code 211.11 (d) Resident Care Plan 28 Pa. Code 211.12(d)(1) Nursing Services

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with residents and staff, it was determined that the facility failed to ensure that Resident R1 was free of neglect for one of nine clinical records reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who was not properly turned in bed while receiving incontinence care, resulting in a fall and sustaining a fracture to cervical vertebra. Findings include: Review of the facility policy titled Incontinence Care dated August 2014, revealed the caregiver is to assist to side lying position by turning towards care giver, unless more than one caregiver is present. After turning patient toward caregiver, assure patient is positioned in the center of the bed before moving to the opposite side of the bed to provide care. Review of Resident R1's admission record report revealed that the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's fall risk assessment dated [DATE], revealed risk factors for falls including incontinence, depression and the presence and/or history of gait, strength and balance factors that impact fall risk. Review of the admission Minimum Data Set (MDS- assessment of resident care needs) dated June 16, 2021, revealed that Resident R1 was identified with a BIMS (Brief Interview for Mental Status-an assessment tool used to identify level of cognitive function) score of 12 out of a possible 15 which indicated that Resident R1 has moderate impairment of cognitive function and was able to be interviewed. Further review of the MDS revealed that the resident was totally dependent on staff for bed mobility requiring the assistance of two staff persons. Review of nursing note dated September 26, 2021, at 10:34 p.m. stated this nurse was called to room [ROOM NUMBER] by cna (nursing assistant) for a fall. Upon entering room this nurse found patient lying on right side of bed on his right side facing the window. Patient assessed by this nurse and rn. (Registered nurse) upon assessment patient stated that he hit his head and complained of pain to his right side of head/face, right shoulder, and right hip. patient with reddened spot to top/right side of head and small skin tear to right elbow. Patient able to move all extremities, minimal movement to right arm, as this is baseline for patient. Patient pupils appeared to be pin point and non reactive to light. Patient stated that he was getting changed and rolled out of bed. upon entering room the bed was at waist height. vital signs obtained. bp (blood pressure)112/63, hr (heart rate) 93, resp (respirations) 18, temp (temperature) 97.9 temporal, oxygen 97% room air. md (physician) called and made aware . new orders to send patient to ER (emergency room ) via 911 (emergency medical services) for ct (computed tomography scan- a diagnostic tool used to assess for internal injury) and evaluation. Further review of nursing notes revealed a second entry dated September 26, 2021 at 11:15 p.m. stated This Nurse was called to assess pt (patient) after fall. Pt was in bed, AAOX2 (alert and oriented to person and place) speech was clear. Pt c/o (complaint) pain allover, but more in his right side arm/shoulder and side. Pt stated he hit the right side of his head face. Pt had a small red area on the top of his skull and an abraded area on the right arm. No redness, swelling or bruising seen on the face or head or right arm. Pt was able to move all extremities, right side with weakness which was baseline. Pt pupils noted to be pinpoint and not reactive to light. Pt noted to be shivering. Review of the facility investigation dated September 26, 2021, stated CNA (nursing assistant) provided incont (sic) care. Turned resident away-motion stopped, resident fell forward. Further review of the facility investigation indicated that Follow up call w/hospital (sic) shows xray C1 (first cervical vertebra located just below the skull) fx (fracture). Review of documentation of CT scan results shows a finding of Nondisplaced fracture through the anterior ring of C1. Review of the facility documentation submitted to the Department of Health on September 29, 2021, revealed that the facility determined that nursing assistant, Employee E5 failed to follow the facility policy for incontinence care. The policy stated that unless there are two caregivers, caregivers should turn residents toward them. Nursing assistant, Employee E5 turned the Resident R1 away from him and therefore did not follow facility policy. Further review of the documentation submitted to the Department confirmed that the facility substantiated the allegation of neglect. During the facility investigation, a statement was obtained from nursing assistant, Employee E5 on September 27, 2021. Review of nursing assistant Employee E5's statement revealed When I turned him, he stopped on his side for a few seconds and then he just turned the rest of the way out of bed. The resident said something like 'oh' or 'whoa' and then proceeded to turn further and fell out of the bed. I had changed him multiple times before and nothing like that had every (sic) happened. Interview with the nursing assistant Employee E5 conducted on October 12, 2021, at 11:16 a.m. stated I provided care to Resident (R1). For getting changed, I turned (Resident R1), I do not remember exactly it, but I think I turned him away from me in bed. Then he stayed that position a few seconds, then accidently the resident fell out of bed. I received orientation and training from other cna's (nursing assistants). Interview conducted with Resident R1 on October 12, 2021, at 11:09 a.m. confirmed He (the nursing assistant) turned me in bed away from him for getting changed, I fell off the edge of the bed. I was sent to the hospital. Came back from hospital with a cervical collar, now waiting to get better, they are treating me okay. Resident R1 was observed on October 12, 2021 during interview with a cervical collar in place. 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.29(d) Resident rights 28 Pa Code 201.29(j) Resident rights 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.12(d)(5) Nursing Services

Based on review of facility policy, clinical record review and interviews with staff and residents, it was determined that the facility failed to ensure that one of 30 residents reviewed (Resident R86) received the appropriate level of assistance during a transfer from the chair to the bed. This failure resulted in actual harm to Resident R86 who sustained a right humerus fracture requiring transfer to the hospital. The facility failed to ensure appropriate staff supervision and maintain an environment free of potential hazards related to an alleged ingestion of hand sanitizer for one of 30 residents reviewed. (Resident R1) Findings include: Review of facility policy entitled ADL documentation decision tree, dated April 21, 2021, revealed that a resident using a mechanical lift, gait belt, support from staff was to be care planned as extensive assistance for transfers. The policy indicated that staff were to determine and implement care, for a resident that required support of two for transfer, which defined how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Review for Resident R86's physical therapist's assessment dated [DATE], revealed that the resident had diagnoses of: functional [CONDITION(S)] (paralysis of all four limbs), ankle contractures, Guillain -barre syndrome (muscle weakness and damage to the peripheral nervous system). The physical therapist's assessment indicated that Resident R86 was dependent on staff and required substantial maximal assistance with transfers. Review of the quarterly Minimum Data Set (MDS-assessment of care needs) dated January 23, 2021, revealed that Resident R86 had clear comprehension and the ability to make decisions was consistent. Further review of the MDS assessment indicated that Resident R86's required extensive assistance (full staff performance) for transfers with the support of two persons. This assessment also indicated that for surface to surface transfer, which was defined as a transfer between bed and chair or wheelchair, Resident R86 was not steady and could only stabilize with staff assistance. Interview with MDS Assessment Coordinators, Employee E19, registered nurse, and Employee E20, licensed nurse, on September 8, 2021, at 1:00 p.m. confirmed that Resident R86 required the support of two staff physically assisting this resident for transfers. Review of Resident R86's care plan dated December 1, 2020, revealed that the resident required maximum assistance for transfers. Interview with Employee E17, licensed nurse, on September 3, 2021, at 1:00 p.m. revealed that the nurse was familiar with Resident R86's care needs for a safe transfer. Employee E17, confirmed that Resident R86 required the physical assistance of two staff members for transfer from the wheelchair to the bed. Review of nursing notes dated on January 29, 2021, revealed that Resident R86 went out of the facility accompanied by her husband for an orthopedic appointment. Review of documentation from the the transportation company confirmed that Resident R86 was picked up from the facility on January 29, 2021, at 12:00 p.m. via wheelchair van and returned to the facility at 4:31 p.m. Review of nursing note dated January 29, 2021, at 10:37 p.m. revealed that the resident returned from the appointment. Further review of this nursing note indicated that the resident requested to be transferred back to bed and upon transferring she complained of right shoulder pain, pain assessment was done and pain medication administer. MD (physician) was called and order x-ray of the right shoulder. X-ray results came back with a conclusion: Fracture of the proximal humerus (bone of the upper arm that connects the shoulder to the elbow). MD was notified, and also faxed, MD order a sling for patient right should and orthopedic appointment to be scheduled. Review of nursing documentation dated January 30, 2021, noted that the resident was sent to the local hospital for evaluation. Further review of nursing notes dated January 30, 2021, revealed that the resident returned to the facility at 7:40 a.m. via Emergency Medical Services. The resident had a sling in place to right upper extremity secondary to right humerus fracture. The resident complaint of a pain level of 10 out of 10 on the pain scale to the right upper extremity. Resident R86 was administered the pain [MEDICATION(S)] as well as a [MEDICATION(S)] patch for pain. Review of the facility investigation into Resident R86's fractured right humerus included a statement by the nursing assistant, Employee E29 who noted that when she went into the room the resident stated that she wanted to lay down in the bed. Employee E29 told another nursing assistant who was present in the room that the resident only required one of them to be put into bed because she was small. Employee E29 described when asked how she transferred the resident the following: I put my hand around her waist and grabbed the back of her pants. I lifted her up and pivoted her onto the bed. I turned to the side to bend down to put her legs up on the bed. at that point she started screaming about her arm. Review of a written statement by licensed nurse, Employee E30 revealed that she was told by a nursing assistant that Resident R86 was crying. Employee E30 indicated in the statement that the upon assessment the resident's right shoulder was a little bit swollen. The statement further noted that Employee E30 spoke with Employee E29 who confirmed that she was transferring the resident, grabbed the resident by the pants and pivoted her to the bed. Interview with the Director of Rehabilitation Services, Employee E18, on September 8, 2021, at 10:00 a.m. revealed that the nursing assistant transferring Resident R86, alone on January 29, 2021, would be required to use a transfer belt, so that most of the muscle of physical assistance was done by the staff member not the resident; because clinically Resident R86 was not able to stand and pivot without full staff support for trunk control. The Director of Rehabilitation Services, Employee E18, verified that the nursing assistant, Employee E 29 failed to transfer Resident R86 safely and properly from chair to bed on January 29, 2021. Observation conducted on September 7, 2021, at 10:30 a.m. of Resident R86 revealed that this resident was dependent on two staff persons for transfers from the wheelchair to the bed. Resident R86 had functional impairments of the lower body with difficulty bending and flexing bilateral knees and bilateral ankle contractures. Resident R86 was also observed with contractures of the bilateral upper extremities. Interview conducted with Resident R86 at the time of the observation confirmed that on January 29, 2021 only one staff member attempted to transfer her from the wheelchair to the bed and that she was injured, with a fractured shoulder. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses of [CONDITION(S)] (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), [CONDITION(S)] with intoxication and other psychoactive substance abuse. Review of Resident R1's Minimum Data Set (MDS- assessment of resident care needs) dated May 18, 2021 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that the cognitive status was intact. Review of the physician admission note dated May 14, 2021 revealed that prior to the admission to the facility, the resident was admitted to hospital after found down surrounded by beer bottles and rubbing alcohol. Review of the nurse practitioner note dated May 18, 2021 revealed that the resident reported to the Nurse Practitioner that he was impaired, and he needed help. The Nurse Practitioner ordered lab work for the resident. Review of nursing note for Resident R1 dated May 22, 2021 revealed that the resident had an [MEDICATION(S)] (a form of alcohol) level of 314. Physician was notified and ordered to repeat lab and to keep hand sanitizers away from the resident. Review of nursing note for Resident R1 dated June 4, 2021 revealed that the resident was observed by night shift taking hand sanitizer from the medication cart to his room without staff's permission. The hand sanitizer was moved to the locked medication cart on the unit as a result. The night shift nursing staff spoke with Resident R1 in regard to obtaining hand sanitizer from the medication cart and the hand sanitizer was recovered. Review of progress notes for Resident R1 dated June 5, 2021 at 8:18 a.m. revealed that the resident fell out of bed and appeared to have drunk hand sanitizer. Review of progress note for Resident R1 dated June 5, 2021 at 8:18 a.m. revealed that the resident was found wheeling onto the first floor. When questioned he stated that he was going in to purchase a ginger-ale. Staff observed him take a plastic cup and attempt to put hand sanitizer in it. He was immediately stopped, and cup was removed. Resident was again reminded of the dangers of ingesting liquid hand sanitizer. Review of physician progress note for Resident R1 dated June 7, 2021 revealed that the physician discussed resident's behavior with nursing, removed all sanitizer and resident was not allowed to leave the unit without chaperone. Review of psychiatric consultation report dated June 7, 2021 revealed that Spoke with DON (Director of Nursing), SW(Social worker) and PNP ( primary nurse practitioner). Discussed concern of possible serious medical effects from ingesting hand sanitizer and patient's safety must be priority. Stated hand sanitizer had been removed from the room and he was observed every time he left the room. Review of care plan for Resident R1 dated June 7, 2021 revealed that the resident was at risk for injury related to the desire to ingest liquid hand sanitizer. Care plan intervention revealed that Staff will make all attempts to ensure hand sanitizer bottles are not within reach of Resident R1. Review of psychiatric consultation report dated June 14, 2021 revealed that Nursing is continuing to keep him(resident) under close supervision if he leaves the room. Review of progress note for Resident R1 dated August 4, 2021 at 6:14 p.m. revealed that the resident was found to have impaired speech and dropping his head. He stated that he was very upset because of his roommate passing away. He admitted to drinking hand sanitizer. He was unsure of how much. Physician was notified and resident was placed on 1:1 observation. Review of facility investigation dated August 4, 2021 revealed that the resident admitted to drinking hand sanitizer that he placed in soda related to the death of the roommate. Review of progress note for Resident R1 dated August 5, 2021 at 4:25 p.m. revealed that the resident was seen by the psych nurse practitioner. Resident was made aware that he was no longer on the one to one but would be monitored by staff. Review of psychiatric consultation report dated August 5, 2021 revealed recommendations to discontinue 1:1 observation and to start q 15 (every 15) minute check for safety. Further review of the report revealed that the detail plan of treatment was provided to other healthcare provider. Review of nursing note for Resident R1 dated August 6, 2021 at 10:42 a.m. revealed that the resident was observed early in the shift calling out and yelling profanities at staff. Resident was slurring his words and appeared confused as to where he was. Resident was again placed on 1:1 staff observation. Resident in his confused state rolled out of bed to the floor. Resident was transported to the hospital as ordered by the physician. Review of physician progress note for Resident R1 dated August 6, 2021 revealed that the resident admitted to filling the cup with hand sanitizer throughout the night and drinking it with soda. Resident was confused and obviously intoxicated. Review of nursing note for Resident R1 dated August 6, 2021, at 2:18 p.m. revealed that the hospital contacted the facility and obtained the ingredients included in the suspected hand sanitizer that the resident drank while at the facility. Interview with licensed nursing staff, Employee E4, on August 6, 2021 at 11:00 a.m. stated Resident R1 was under his care and he saw him impaired in the morning around 8:00 a.m. Employee E4 stated he was not sure how did Resident R1 obtained the hand sanitizer. He also stated there was no hand sanitizer inside resident room and the hand sanitizer on the medication cart was locked. Interview with Director of Nursing, on August 6, 2021 at approximately 1:30 p.m. stated that the resident informed her that he took the hand sanitizer from the wall unit inside the dining room on the first floor. DON stated resident left the floor by himself from the locked ground floor nursing unit without any staff supervision to the dining room on the first floor. DON also stated the residents were not supposed to receive the elevator code, she was not sure how Resident R1 received the elevator code. DON confirmed that the code was not changed after resident ingested hand sanitizer on August 4, 2021. Further review of Resident R1's clinical record revealed no documented evidence that the psychiatric recommendation for every 15-minute check was completed by the staff. Interview with Director of Nursing, on August 6, 2021 at approximately 5:00 p.m. confirmed that every 15 minutes check ordered by the psych nurse practitioner after she discontinued 1:1 observation on August 5, 2021 was not followed. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(c) Nursing services 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 on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of 24 residents reviewed (Resident R146). Findings include: Review of an undated facility document, Requirements and Guidelines for Clinical Record Content, revealed that, Progress notes are electronically documented in the HER (the facilities electronic record) to reflect the patient's condition, significant care issues, response to treatment and change in condition and treatment. Entries are recorded chronologically in the clinical record using either integrated or discipline specific progress notes. In instances of change in condition or significant care issues, progress note entries are made until the point the condition stabilizes or the situation is otherwise resolved. Family notification of patient change in condition is documented in the progress notes, including attempts at notification and, or a synopsis of the discussion. Physician notification of patient change in condition is documented in the progress notes, including the physician response and, if orders were given, information on the orders received, implementation of such orders and the patient's response. Review of Resident R146's care plan focus area included being at risk for adverse effects related to, the use of antipsychotic medication, use of antianxiety/anxiolytic medication with a corresponding intervention to include a Psychiatrist consult and follow up as needed. Review of Resident R146's clinical record revealed that prior to Resident R146's admission there was a consultation note from the hospital dated December 29, 2014, where it was noted, Patient with very significant hyperphagia (an extreme unsatisfied drive to consume food), sexual inappropriateness, odd [MEDICATION NAME] affect . Review of Resident R146's clinical record revealed a progress note dated February 22, 2015 at 2:54 a.m., which revealed, Received resident awake out at nurses station routine med given at 24:00 snack given with juice at this time. Went to bedroom at 02:00 remains awake talking to self. Unable to settle for sleep. Review of Resident R146's clinical record revealed a progress note dated February 22, 2015 at 12:42 p.m., which revealed, CNA reported if (sic) resident have small bleeding noted in the tissue on the trash can in the bath room. Resident resting in bed no discomfort noted. Review of Resident R146's clinical record revealed a progress note dated February 22, 2015 at 2:30 p.m., which revealed, Resident in room [ROOM NUMBER]B with second resident and her family members, refused to leave room. Two attempts encouraging him to leave room and allow second resident to rest, he refuses, instead, signals that the nurse should leave room. Review of Resident R146's clinical record revealed a progress note dated February 22, 2015 at 3:05 p.m., which revealed, Attempting to follow other family members through exit door, informed resident he cannot leave with other resident's family, becomes anxious, speaking loudly in Spanish. Emotional support provided . Further review of Resident R146's clinical record revealed no additional progress notes until February 27, 2015. Review of Resident R146's clinical record revealed a progress note dated April 16, 2015 at 11:39 p.m., which revealed, Pt received alert, verbal. Able to communicate needs however language barrier exists. Pt walked into DR (dining room) before dinner with penis hanging out of his pants. Pt redirected to room to dress appropriately. Pt noted with subtle sexual innuendos, staff continues to redirect pt regarding inappropriate behaviors. Later CNA noted pt walking out of shower room. Pt was redirected not to do so and made aware that the use of the shower room was not permitted without supervision. Pt then went to his room. Review of Resident R146's clinical record revealed a progress note dated April 17, 2015 at 11:22 a.m., which revealed, .received return call from Dr. reported behavior of exposing his private parts in the common area with other residents in attendance. No new orders at this time. f/u (follow up) visitation and note by Psych nurse anticipated today. Further review of Resident R146's clinical record failed to revealed a psychiatric consult or a Psych nurse note. Review of Resident R146's clinical record revealed a progress note dated June 28, 2015 at 2:00 p.m., which revealed, Resident noted with $20.00, asking for change. Second resident reports missing $20.00, and states, I give it to him, second resident wants money back. Nursing supervisor notified. Review of Resident R146's clinical record revealed a progress note dated June 28, 2015 at 2:04 p.m., which revealed, Resident reports $20.00 given to him by second resident, became [MEDICAL CONDITION] angry when asked to give back $20.00 to second resident. Nursing supervisor and Manager on duty, on unit. Further review of Resident R146's clinical record revealed no other progress notes other than a sliding scale (method that varies the dose of insulin based on blood glucose level) mentioned from June 28, 2015 to July 6, 2015 Review of Resident R146's clinical record revealed a mood/behavior note dated August 3, 2015 at 7:24 a.m., which revealed, While administering medication, observed pt going through trash taking medication sleeves trying to find residue from sleeve to consume. 0700 oncoming nurse made aware. Will continue to monitor. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behaviors until August 22, 2015. Review of Resident R146's clinical record revealed a progress note dated August 22, 2015 at 4:04 a.m., which revealed, Resident awake all night in and out of his room. Had radio room (sic) in listening to it. Pleasant stated couldn't sleep due to the other residents making noise. Review of Resident R146's clinical record revealed a progress note dated August 26, 2015 at 3:31 a.m., which revealed, Restless night slept in short intervals kept coming out to nurses station and going back to his room. Snack offered refused but took fluids. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behaviors until September 17, 2015. Review of Resident R146's clinical record revealed a progress note dated October 21, 2015 at 4:03 a.m., which revealed, Resident unable to sleep up all night. Up writing and reading paper or standing at nurses station. Did not settle was very loud at all (sic) refused to sleep. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behaviors until November 12, 2015. Review of Resident R146's clinical record revealed a progress note dated November 12, 2015 at 11:15 p.m., which revealed, .received a call from his roommate's daughter, she reported that (Resident 146) pulled his pants down and exposed his groin while she visited her dad, Supervisor notified, UA, (laboratory test to analyse urine) C&S (laboratory test to determine presence of harmful bacteria in urine) and psych consult ordered. Review of Resident R146's clinical record revealed a progress note dated November 13, 2015 at 3:09 p.m., which revealed, .staff with interpreter spoke in length regarding questionable inappropriate behavior exhibited toward a family visitor. Resident denies any inappropriate behavior reported. Denied any inappropriate contact with any family visitor or otherwise. Staff to observe. Further review of Resident R146's clinical record revealed no other progress notes until November 18, 2015. Review of Resident R146's clinical record revealed a progress note dated November 18, 2015 at 4:32 a.m., which revealed, Resident awake all night writing in his book laughing and being very loud in hallway and in his room. Refused to settle for sleep through night. Further review of Resident R146's clinical record revealed no other progress notes until November 21, 2015. Review of Resident R146's clinical record revealed a progress note dated January 5, 2016 at 4:46 a.m., which revealed, Resident awake all night roaming hallway. Drawing in book in his room. Unable to settle refused to sleep. Review of Resident R146's clinical record revealed a progress note dated January 5, 2016 at 7:15 a.m., which revealed, Resident gave me $14.00 to hold in med cart to hold this shift I put his name on it and locked in draw. At the end of shift he took it back and put in his pocket. Further review of Resident R146's clinical record revealed no other progress notes until January 11, 2016. Review of Resident R146's clinical record revealed a progress note dated January 11, 2016 at 3:13 a.m., which revealed, Awake unable to settle in bed to sleep. Ambulating up down hall unable to sleep. Redirected to bed by staff several times. Snacks and fluids given. Remains restless will continue to monitor. Review of Resident R146's clinical record revealed a mood/behavior progress note dated January 13, 2016 at 4:18 a.m., which revealed, Resident awake all night unable to settle snack and fluids given radio was given to resident to help settle. Staff had to take it away because he had it full blast and disturbing other resident because it was so loud. Review of Resident R146's clinical record revealed a progress note dated January 14, 2016 at 6:50 a.m., which revealed, Resident had restless night slept in short intervals through night. Chanting and saying prays in a very loud voice. Review of Resident R146's clinical record revealed a progress note dated January 15, 2016 at 5:35 a.m., which revealed, Awake at beginning of shift chanting singing ambulating up and down the hallway. 02:00 (sic) Went to slept (sic) until AM. Further review of Resident R146's clinical record revealed no other progress notes until January 17, 2016. Review of Resident R146's clinical record revealed a progress note dated January 17, 2016 at 8:13 a.m., which revealed, .resident continues OOB (out of bed) at nurses station no aggressive behaviors noted, redirection uneffective. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behavior until January 20, 2016. Review of Resident R146's clinical record revealed a progress note dated January 20, 2016 at 4:02 a.m., which revealed, Resident awake all night watching TV in lounge ambulating in hallway. Refused to stay in bed loud at time chanting. Further review of Resident R146's clinical record revealed no other progress notes until January 29, 2016. Review of Resident R146's clinical record revealed a progress note dated February 22, 2016 at 5:17 a.m., which revealed, Resident awake until around 3:30 then went to bed. He showed nurse that he had a cigarette and wanted a light for it. Unknown how or where he got it. Took cigarette from resident and threw it in the trash. Further review of Resident R146's clinical record revealed no other progress notes until February 25, 2016. Review of Resident R146's clinical record revealed a mood/behavior progress note dated February 25, 2016 at 7:11 a.m., which revealed, Resident awake all night went to bed at 0500. Further review of Resident R146's clinical record revealed no other progress notes until March 3, 2016. Review of Resident R146's clinical record revealed a mood/behavior progress note dated March 3, 2016 at 3:53 a.m., which revealed, Restless night only rested in short intervals. Vomited large amount . with undigested food x1. Afebrile (not feverish) denied stomach discomfort. Resting in bed at present time. Review of Resident R146 clinical record revealed a progress note dated March 4, 2016 at 9:13 p.m., which revealed, .client repeating his name and other Spanish phrases, he is restless will continue to monitor. Further review of Resident R146's clinical record revealed no other progress notes until March 8, 2016. Review of Resident R146's clinical record revealed a progress note dated March 8, 2016 at 1:42 a.m., which revealed, Resident had removed Wanderguard (device used to alert staff if resident attempts to wander/elope) and put it in his drawer. Would not let me reapply a new one at this time. Further review of Resident R146's clinical record revealed no other progress notes until March 15, 2016. Review of Resident R146's clinical record revealed a progress note dated March 15, 2016 at 6:41 a.m., which revealed, Resident awake all night until 05:30 and then went to bed. He was in the TV lounge writing on paper and watching the television. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behavior until March 27, 2016. Review of Resident R146's clinical record revealed a progress note dated March 27, 2016 at 6:58 a.m., which revealed, Resident has episodes of wondering (sic - wandering) x3. Continue to shout out without aggression. Redirection uneffective (sic). Medication tolerated well. Will report to oncoming nurse. Further review of Resident R146's clinical record revealed no other progress notes until April 5, 2016. The other notes were from the pharmacy consultant (April 1, 2016) and a note regarding a [MEDICATION NAME] 100 mg (drug for [MEDICAL CONDITION]) order (April 4, 2016). Review of Resident R146's clinical record revealed a progress note dated April 13, 2016 at 7:40 p.m., which revealed, Reported to me if (sic) resident kissing female resident. Will keep eye on resident. Monitoring behaviors. Now resident sitting at different table in dining room. Review of Resident R146's clinical record revealed a progress note dated April 13, 2016 at 10:56 p.m., which revealed, No more incident kissing. Now resident in bed resting. Monitoring behaviors. Now resident sitting at different table in dining room. Review of Resident R146's clinical record revealed a progress note dated April 15, 2016 at 11:53 a.m., which revealed, .resident pleasant and calm this shift. Cooperative with nurse. Easily directable. Appetite good. No adverse behaviors noted. Further review of Resident R146's clinical record revealed no other progress notes until April 22, 2016. Review of Resident R146's clinical record revealed a progress note dated April 29, 2016 at 4:51 a.m., which revealed, Resident is resting quietly in his bed at this time. Resident up until around 0400 had been in and out of his room, yelling loudly, waking up other resident's. Resident was given a snack and a drink, but continued with his loud behavior. Further review of Resident R146's clinical record revealed no other progress notes regarding Resident R146's behavior until May 4, 2016. Review of Resident R146's clinical record revealed a progress note dated May 4, 2016 at 6:52 a.m., which revealed, .resident awake all night in dining room listening to music and singing. Refused to go to bed. Further review of Resident R146's clinical record revealed no progress note on May 5, 2016. Review of Resident R146's clinical record revealed a progress note dated May 6, 2016 at 9:03 a.m., which revealed, Resident refused iron pills. MD notified. Resident was educated on the importance of his iron medication. Further review of Resident R146's clinical record revealed no other progress notes until May 9, 2016. Interview with Licensed Practical Nurse (LPN), Employee E16, on May 13, 2016 at 1:10 p.m., revealed the following regarding Resident R146: he speaks Spanish, so its difficult to say what type of mood resident R146 is in; sleeps a lot during the day; he interacts with residents and staff; he's intrusive with residents and staff; young 46, so he could be flirtatious; resident R146 spoke a little bit of English and as time went on English increased; maintenance and laundry personnel spoke Spanish so would ask them for assistance. He would ramble when speaking in Spanish . red . milk . other utterances.; he sexually pleasured himself in his room with curtain closed; he would do it (masturbate) during AM shift sometimes and curtain was not completely closed and Employee E16 would close the curtain; he was intrusive on spaces; he likes to wear boxers on unit and one person said they thought it was inappropriate. He would wear briefs under boxers. Interview with Nurse Aide (NA), Employee E17, on May 13, 2016 at 1:30 p.m., revealed the following regarding resident R146: he is a ladies man; he likes to flirt a lot ; touchy feely when asked if this was a daily occurrence this NA responded yes he's friendly; he would come up and massage one's arm and he would come close to you .really could be anybodywho he would exhibit these behaviors towards; he has exhibited these behaviors for the three months this NA has worked with him; his bed is by the door and if you would walk past his room and he would be masturbating sometimes. Roommate's family would come in and the family would feel uncomfortable; told by 3-11 p.m. staff that he kissed another resident R90. Interview with NA, Employee E18, on May 13, 2016 at 1:45 p.m., revealed the following regarding Resident R146: he masturbates a lot in his room not in hallway, if you knocked on his door sometimes he would stop masturbating and sometimes he wouldn't. Interview with LPN, Employee E19, on May 13, 2016 at 3:20 p.m., revealed the following regarding Resident R146: sometimes the resident R146 would try to touch the staff to say hello. Interview with Nursing Unit Manager, Employee E7, on May 17, 2016 at 1:30 p.m., revealed Resident R146, had sexual behaviors in his room and staff would extend the curtain in his room; if he came into personal space then I would back up and if necessary end conversation. Review of Resident R146's clinical record revealed no documentation of Resident R146's masturbating in his room with the curtain open, wearing boxer shorts on the unit, flirting behaviors, being touchy feely, massaging one's arm, and invading other individuals personal space. Review of the Minimum Data Set assessment (MDS-a periodic assessment of needs) in Section E Behavior, E0200. Behavioral Symptom - Presence and Frequency, which asks the author of the assessment to note presence of symptoms and their frequency into check boxes for the following categories: A. Physical Behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing other sexually) B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal like screaming, disruptive sounds). Review of the following MDS for the above mentioned Behavior Symptoms, section E0200, revealed R146's scored a zero (zero means that behaviors were not exhibited) in E0200 A, E0200 B, and E0200 C, for each MDS completed since admission to include: January 30, 2015 Admission MDS, May 2, 2015 - Quarterly MDS, July 31, 2015 - Quarterly MDS, October 29, 2015 - Quarterly MDS, January 29, 2016 - Annual MDS, and April 28, 2016 - Quarterly MDS. Review of Resident R146's clinical record revealed a progress note dated May 13, 2016 1:54 p.m., which revealed, . At approximately 0520 I was called into room [ROOM NUMBER]B by the CNA, upon entering the room I saw this resident (Resident R146) fully clothed on top on the resident (Resident R117), moving up and down. I immediately went to resident and told him to get up, he should not be there, when he stood off I noticed that his penis was out of his sweats and he had an erection, he pulled his pants back up, got up went around to the side of the bed next to the air conditioning, laughed and then left the room, and went down to the lounge to watch TV. Went to make a phone call, then I retrieved the resident and kept him with me until the police arrived. The facility failed to reassess Resident R146's behaviors in the above mentioned progress notes, which led to inaccurate MDS assessments and interventions for Resident R146, which also contributed to a lack of a care plan related to Resident R146's inappropriate sexual behaviors. Resident R146 sexually abused Resident 117 and Resident R146 was taken away in hand cuffs by the police on May 13, 2016. Review of the clinical record for Resident R146 revealed no documentation that Resident R146 was evaluated by professional psychiatry services to evaluate and assess the resident's sexual inappropriate behaviors from the time of Resident R146's admission to the facility on [DATE], to the time Resident R146 was taken away in hand cuffs by the police on May 13, 2016. An interview with the Nursing Home Administrator, Employee E1, on May 16, 2016 at 2:00 p.m., confirmed that there was no documentation that Resident R146 was seen by professional psychiatry services to evaluate and assess the resident's sexually inappropriate behaviors from the time of Resident R146's admission to the facility on [DATE], to the time Resident R146 was removed from the facility by the police on May 13, 2016. The failure of the facility to reassess and document Resident's R146's inappropriate behaviors, the failure of the facility to develop adequate care plans related to R146's inappropriate behavior, and the failure of the facility to have documentation of Psychiatric consultation for Resident R146 led to the facility's failure to comprehensively assess Resident R146's mental or psychosocial adjustments. 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/25/15, 06/19/15, 05/09/14 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 06/25/15, 06/09/15, 02/18/15, 05/09/14

Based on observations, review of clinical records, facility documentation, facility policies and procedures and staff interviews, it was determined that the facility failed to assess, monitor or implement interventions for the prevention of pressure sore development and failed to follow the physician's orders for treatment of [REDACTED]. Findings include: Resident R48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders for a pressure sore (localized injury to the skin and/or underlying tissue as a result of pressure or pressure in combination with shear or friction) treatment for [REDACTED]. The physician's order for treatment of [REDACTED]. The wound treatment of [REDACTED]. Additionally, instead of using the full strength Dakins Solution, half strength Dakins Solution was used, instead of two Curlex dressings, only one Curlex dressing was used, and instead of securing the dressing with [MEDICATION NAME] tape, border gauze dressing was used. Observation of the treatment to the left hip showed that even though there was no order to irrigate the wound, the wound was irrigated with NSS. Instead of soaking the cling in full strength Dakins Solution, half strength Dakins Solution was used. During the treatment, it was observed that there was a gaping wound of approximate size of 6.0 cm (centimeters) x 6.0 cm x 3.0 cm on the right buttock cheek. The wound had no dressing and was open and exposed to the brief (adult sized diaper with refastenable tabs) of Resident R48. The wound had yellow slough (separation of dead tissue from living tissue), black eschar (dead tissue, black in color) and was at an unstageable (full thickness tissue loss in which base of ulcer is covered with dead tissues) condition. Employee E4 stated that it was a new wound. The wound was cleaned, a dry dressing was applied to the wound and no medication was applied as there was no physician's order for the treatment of [REDACTED]. It was also observed that Resident R48 had an untreated open area of approximately 4.0 cm x 3.0 cm x 0.3 cm on the left buttock, and another open wound of approximately 1.0 cm diameter and 0.3 cm deep on the right lateral malleolus (prominence on the outer side of ankle). This wound had yellow slough. The facility's policy regarding dressing change stated that physician's orders were to be verified. Employee E11 was not seen reading the physician's order prior to beginning the treatment. During an interview on May 18, 2016 at 1:15 p.m., all the above findings were confirmed by Employees E4 and E11. A review of the facility's various stand-alone wound records of Resident R48 revealed the following findings. According to the admission/readmission skin assessment completed on March 12, 2016, (the day after the admission), Resident R48 had a right ischium (curved bone forming the base of each half of bone to which legs are attached) pressure ulcer of 8.0 cm x 4.5 cm x 4.74 cm, 2 excoriation's (a linear scratch mark on skin) on the left foot and 2 excoriation's of the left hip of sizes 3.0 cm x 1.5 cm and 4.0 cm x 1.0 cm. According to the physician, who examined Resident R48 on March 17, 2016, Resident R48 had only two wounds: (1) a right hip wound of size 4.6 cm x 4.8 cm x 4.0 cm and (2) a right buttock wound of size 1.0 cm x 0.7 cm x 0.2 cm. The note stated that Resident R48 had no other [MEDICAL CONDITION], rashes or ulcers. According to the admission Minimum Data Set assessment (MDS-an assessment of care needs) dated March 18, 2016, indicated that Resident R48 had only two ulcers: (1) a Stage III ulcer (ulcer involving full thickness loss of skin) of 4.5 cm x 5.0 cm x 3.5 cm, and (2) and an unstageable ulcer. According to a nursing skin assessment dated [DATE], Resident R48 had three wounds which included: (1) a right hip wound of 18.0 cm x 11.0 cm x 4.3 cm, (2) a left hip wound of 17.3 cm x 4.4 cm x 4.6 cm and (3) a left heel wound of 2 cm x 1.7 cm x 4.0 cm. According to the facility's pressure ulcer healing chart, monitored by PUSH scores (Pressure Ulcer Scale for Healing), on March 11, 2016, Resident R48 had a right trochanter (part of thigh bone connecting to hip bone) pressure ulcer of PUSH score 14 (the PUSH score ranges from zero to 17, with the score of a healed ulcer as zero and the score of the worst ulcer as 17). The PUSH score indicated that from March 11 to May 8, 2016, this wound was getting worse. On March 24, 2016, the PUSH score showed another wound with a PUSH score of 14 to the left trochanter. The PUSH score indicated that from March 24 to May 16 of 2016, this wound was getting worse. According to the skin assessment done by the Plastic Surgery Specialist (the wound consultant for the facility) as of March 28, 2016, Resident R48 had four wounds which included: (1) an unstageable left hip wound of size 8.0 cm x 9.0 cm, (2) an unstageable left foot wound of unspecified dimensions, (3) a Stage IV (ulver involving loss of skin layers, exposing muscle and bone) right hip wound of size 17.0 cm x 19.0 cm x 5.0 cm, (4) and an unstageable wound of 0.7 cm x 1.3 cm size on an unspecified location. According to the skin assessment done by the Plastic Surgery Specialist as of May 16, 2016, the day previous to the wound treatment observation, Resident R48 had four wounds which included: (1) a left hip Stage IV wound of 12.3 cm x 11.4 cm x 4.6 cm, (2) a right hip Stage IV wound of 18.0 cm x 10.2 cm x 4.3 cm, (3) a Stage II wound (ulcer involving loss of top layers of skin) left heel wound of 2.0 cm x 1.7 cm x less than 1 cm and (4) an unstageable left lateral foot wound of unspecified dimensions. Resident R48 was examined by the Physician Assistant, Employee E12, from the facility's wound consultant agency on May 18, 2016 at 1:15 p.m., and Employee E12 stated that the new wound which was found during the wound treatment observation on May 17, 2016, was a necrotic (dead tissue/skin that is black in color) and unstageable wound and that it needed to be debrided (surgical procedure to cut away dead tissue). The facility could not provide any documentation related to the onset dates of the various wounds that were not present at the time of the admission of Resident R48. There was no agreement among various notes and assessments related to the dimensions of various wounds. The various disciplines/assessments/notes did not agree on the number of wounds that Resident R48 had at a particular point of time. The facility could not explain the nonconformity among varied wound documentation. During an interview with the Unit Manager, Employee E4, on May 19, 2016 approximately at 1:00 p.m., Employee E4 stated that the wound meaurements were subjective and confirmed that the number of wounds documented by various discipines did not match. Review of Resident R48's care plan for the Stage IV pressure areas on the right and left trochanter/hip indicated that the care plan was not revised after a bilateral (both sides) debridement (surgical procedure to cut away dead tissue) to the right and left hip wounds. The comprehensive MDS assessment dated [DATE] for Resident R120 indicated that this resident was independent with decision making. The physician's orders for treatments for the month of May, 2016, indicated that Resident R120 had orders to cleanse a sacral (triangular bone at the base of spine) wound with normal saline solution, apply Santyl (a [MEDICATION NAME] agent to remove dead tissue), gauze and dry dressing twice a day, once on the day shift and once on the evening shift. Observations at 9:30 a.m. on May 19, 2016, of Resident R120's wound treatment with Licensed Nurse, Employee E20, revealed that the physician's orders for treatment was omitted on the evening shift on May 18, 2016. The dry dressing was marked with a date of May 18, 2016, 7-3 nursing shift. Interview with Resident R120, at this time, revealed that the evening shift nursing staff did not complete a treatment to the sacral wound area on May 18, 2016. The facility failed to assess, monitor or implement interventions for prevention of pressure sore development and failed to follow physician's orders for treatment of [REDACTED]. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores Previously cited 05/09/14 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/25/15, 06/19/15, 02/18/15, 05/09/14 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 06/25/15, 06/19/15, 05/09/14

Based on observation, review of clinical records, review of facility documents and interviews with staff, it was determined that the facility failed to provide adequate monitoring and supervision for a resident (Resident R146) with a history of behaviors such as sexually abusing other residents and staff and verbally intimidating staff resulting in actual harm for one of 24 residents reviewed (Resident R117). Findings include: Review of Resident R146's clinical record revealed [DIAGNOSES REDACTED]. illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others), muscle weakness (generalized), [MEDICAL CONDITION], Type 2 Diabetes Mellitus (a disease that results in too much sugar in the blood), Anxiety Disorder (exaggerated anxiety and tension that persists for months on end) and difficulty in walking. Review of Resident R146's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident was admitted to the locked Arcadia unit, which is a designated unit for residents with mental decline. A review of the most recent Quarterly Minimum Data Set assessment (MDS-a periodic assessment of needs) for Resident R146 revealed that the resident was independent for ambulation on the unit and did not use any assistive devices. The MDS also revealed that Resident R146 has a BIMS (Brief Interview for Mental Status, a brief screener that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 8 indicating that he was moderately cognitively impaired. Review of Resident R117's clinical record revealed that the resident was admitted to the facility on [DATE], and was admitted to the locked Arcadia unit. A review of the February 2016 Quarterly MDS for Resident R117 revealed that the resident was not steady and was only able to stabilize with staff assistance. The MDS also indicated that Resident R117 utilized assistive devices such as a walker and a wheelchair. The MDS also revealed that Resident R117 has a BIMS score of 14 indicating that she was cognitively intact Review of Resident R146's clinical record revealed prior to the resident's admission there was a consultation note from the hospital dated December 29, 2014, where it was noted, . Patient with very significant sexual inappropriateness, odd [MEDICATION NAME] affect Review of Resident R146's clinical record revealed a progress note dated April 16, 2015 at 11:39 p.m., which revealed, . Pt (patient) received alert, verbal. Able to communicate needs however language barrier exists. Pt walked into DR (dining room) before dinner with penis hanging out of his pants. Pt redirected to room to dress appropriately. Pt noted with subtle sexual innuendos, staff continues to redirect pt regarding inappropriate behaviors. Later CNA noted resident walking out of shower room. Resident was redirected not to do so and made aware that the use of the shower room was not permitted without supervision. Resident then went to his room. Review of Resident R146's clinical record revealed a progress note dated November 12, 2015 at 11:15 p.m., which revealed, . received a call from his roommate's . daughter, she reported that (Resident R146) pulled his pants down and exposed his groin while she visited her dad Review of Resident R146's clinical record revealed a progress note dated January 14, 2016 at 6:50 a.m., which revealed, . Resident had restless night slept in short intervals through night. Chanting and saying prays in a very loud voice. Further review of Resident R146's progress notes revealed other instances where Resident R146 was up past midnight. Review of Resident R146's clinical record revealed a progress note dated April 13, 2016 at 7:40 p.m., which revealed, . Reported to me if (sic) resident kissing female resident. Will keep eye on resident. Monitoring behaviors. Now resident sitting at different table in dining room. Review of Resident R117's clinical record revealed a progress note dated May 13, 2016 at 2:06 p.m., which revealed, . Around 0520 this morning I was called into this resident's room (Resident R117) by the CNA. Upon entering room, I saw a male resident (Resident R146) laying on top of her moving up and down. I told the resident that he had to leave the room immediately. I talked with the resident and asked her what had happened. She stated she was sound asleep and then she felt someone on top of her, kissing her face, and this person had ripped her panties off and he had penetrated her. She stated she was afraid to yell or do anything as she felt she would be in trouble. I asked the resident if she had wanted to have sex and she stated no. The police and detectives came and went in to speak with the resident. The CNA stayed in the room with the resident until I could get the male resident and keep him with me. Review of Resident R146's clinical record revealed a progress note dated May 13, 2016 at 1:54 p.m., which revealed, . At approximately 0520 I was called into room [ROOM NUMBER]B by the CNA, upon entering the room I saw this resident (Resident R146) fully clothed on top on the resident (Resident R117), moving up and down. I immediately went to resident and told him to get up, he should not be there, when he stood off I noticed that his penis was out of his sweats and he had an erection, he pulled his pants back up, got up went around to the side of the bed next to the air conditioning, laughed and then left the room, and went down to the lounge to watch TV. Went to make a phone call, then I retrieved the resident and kept him with me until the police arrived. Review of Resident R146's clinical record revealed a progress note dated May 13, 2016 at 8:34 a.m., which revealed, . alert verbal cooperative via translator conversation is garbled / disconnected in thought, makes no sense, all am meds offered and accepted. Transported out via police escort. Interview with Licensed Practical Nurse (LPN), Employee E16, on May 13, 2016 at 1:10 p.m., revealed that Resident R146: speaks Spanish, so it's difficult to say what type of mood Resident R146 is in; he sleeps a lot during the day; he's intrusive with residents and staff; he is young 46, so he could be flirtatious; Resident R146 spoke a little bit of English and as time went on his English increased; maintenance and laundry personnel speak Spanish so we ask them for assistance. He would ramble when speaking in Spanish . red . milk . other utterances.; he sexually pleasured himself in his room with the curtain closed; he would do it (masturbate) during AM shift sometimes and curtain was not completely closed and Employee E16 would close the curtain; he was intrusive on spaces; he likes to wear boxers on unit and one person said they thought it was inappropriate. He would wear briefs under boxers. Interview with Nurse Aide (NA), Employee E17, on May 13, 2016 at 1:30 p.m., revealed the following regarding Resident R146: he is a ladies man; he likes to flirt a lot ; touchy feely when asked if this was a daily occurrence this NA responded yes he's friendly; he would come up and massage one's arm and he would come close to you .really could be anybody who he would exhibit these behaviors towards; he has exhibited these behaviors for the three months this NA has worked with him; his bed is by the door and if you would walk past his room and he would be masturbating sometimes. Roommate's family would come in and the family would feel uncomfortable; told by 3-11 p.m. staff that he kissed another resident, Resident R90. Interview with NA, Employee E18, on May 13, 2016 at 1:45 p.m., revealed the following regarding Resident R146: he masturbates a lot in his room not in the hallway if you knocked on his door sometimes he would stop masturbating and sometimes he wouldn't. Interview with Nursing Unit Manager, Employee E7, on May 17, 2016 at 1:30 p.m., revealed Resident R146, had sexual behaviors in his room and staff would extend the curtain in his room; if he came into personal space then I would back up and if necessary end conversation. Review of the clinical record for Resident R146 revealed no documentation that the facility staff developed a plan of care related to the resident's sexually inappropriate behaviors from the time of Resident R146's admission to the facility on [DATE], to the time he was removed from the facility by the police on May 13, 2016. Further review of the clinical record for Resident R146 revealed no documentation that Resident R146 was evaluated by professional psychiatry services to evaluate and assess the resident's sexually inappropriate behaviors from the time of Resident R146's admission to the facility on [DATE], to the time Resident R146 was removed from the facility by the police on May 13, 2016. An interview with the Nursing Home Administrator, Employee E1, on May 16, 2016 at 2:00 p.m., confirmed that there was no documentation that Resident R146 was evaluated by professional psychiatry services to evaluate and assess the resident's sexually inappropriate behaviors from the time of Resident R146's admission to the facility on [DATE], to the time Resident R146 was removed from the facility by the police on May 13, 2016. The facility staff failed to identify/recognize Resident R146's actions of sexual inappropriateness and failed to develop interventions for Resident R146 to prevent inappropriate sexual activity, resulting in Resident R117 being sexually abused. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.20(a)(b) Staff development 28 Pa. Code 201.29(a) Resident rights Previously cited 06/19/15 28 Pa. Code 201.29(c)(d) Resident rights 28 Pa. Code 211.12(a)(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 06/25/15, 06/19/15, 02/18/15, 05/09/14