Every finding on record at Kingston Court Skilled Nursing and Rehabilitation

Based on review of the clinical record and resident family and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of six residents reviewed (Resident 4).Findings include: Review of Resident 4's clinical record revealed diagnoses that included hypothyroidism (underactive thyroid symptoms include fatigue, weigh gain, sensitivity to cold temperatures muscle weakness and joint stiffness). Review of Resident 4's physician orders included a medication order for Levothyroxine (used to treat low thyroid). Resident 4 had an appointment with an Endocrinologist (a thyroid specialist) on July 16, 2025. Review of the after-visit summary (consultation report) revealed instructions for the facility to obtain a bone density scan, which was ordered, and blood work to be done prior to her next visit. Resident 4 had another appointment with the Endocrinologist on January 20, 2026. Review of the after-visit summary revealed instructions for the facility that stated, She needs thyroid hormone due now to ensure her thyroid levels are normal , repeat thyroid US [ultrasound] next year in 2027, check vit [vitamin] d now and yearly, and she is due for a bone density scan, please have it scheduled, it has been ordered. Review of Resident 4's clinical record revealed a Vitamin D level and TSH was obtained on July 17, 2025. Resident 4 had a follow-up Endocrinology appointment on July 22, 2026. Review of the after-visit summary revealed that concerns addressed were hypothyroidism, vitamin D deficiency, abnormal ultrasound of thyroid, and screening for osteoporosis. Further review was instructions that stated the resident needs all the thyroid blood work and Vitamin D done to ensure levels have normalized and the resident needs a dexa scan (to check bone density). I have placed the order again. Orders placed included a thyroid stimulation hormone progressive lab test complete this on or around January 22, 2027 and July 1, 2027; return in about one year. Review of the clinical record revealed the thyroid stimulating hormone (TSH) wasn't completed until August 6, 2026, = 0.17 mlU/L (Low), and vitamin D level wasn't completed until August 11, 2026. Interview with Resident 4's daughter on August 12, 2026, at 3:30 PM, revealed she had concerns regarding the facility not following Endocrinology instructions/recommendations for lab work and bone density scan to be completed prior to visits dating back to July 16, 2025; they weren't completed prior to the visits, and the bone scan wasn't completed at all. Interview with Employee 4 (Endocrinology office Employee) on August 14, 2026, at 9:50 AM, it was revealed the following visits and their instructions/recommendations: January 20, 2026, DEXA bone scan, ultrasound of thyroid, vitamin D level and thyroid levels now and yearly, follow up 6 months (Vitamin D completed July 18, 2025, however, the thyroid lab work and ultrasound was not documented in the clinical record or provided by the facility). July 16, 2025, instructions/recommendations included DEXA bone density scan, vitamin D level before next visit (Vitamin D level was completed July 18, 2025), thyroid levels now as levothyroxine dose was decreased in March 2025, follow up 6 months (thyroid lab work and ultrasound were not in clinical record or provided by the facility). Further review of clinical record revealed Physician orders that included: thyroid stimulating hormone (TSH), thyroxine (T4), vitamin D lab work ordered July 17, 2025, (which were after endocrinology appt, no bone scan ordered); appointment with Endocrinology January 20, 2026, (no lab work or bone scan ordered after appointment); appointment with Endocrinology July 22, 2026, (no thyroid lab work or DEXA bone scan prior to the appointment, lab work completed after the appointment and bone scan scheduled); appointment with Endocrinology July 27, 2027; DEXA bone density scan October 27, 2026; levothyroxine 88 mcg and 100 mcg one time a day started August 11, 2026. Interview with Director of Nursing (DON) on August 14, 2026, at 3:08 PM, revealed she would investigate the concerns with the bloodwork, however, the facility changed labs, and she wasn't sure if lab work prior to the middle of 2025 would be available. It was also confirmed that the facility couldn't have lab work drawn if there wasn't a physician order to do so. Interview with DON on August 14, 2026, at 5:00 PM, revealed Endocrinology sends the order for the DEXA bone scan within their system, the order is active for one year, the imaging center was to contact the facility to schedule the appointment; this didn't occur after the July 16, 2025, and January 20, 2026, appointments. It was revealed that the facility may evaluate their process to ensure that the facility is contacted when appointments are to be scheduled, and if they are not contacted within a specific timeframe the facility would reach out to the office who placed the order or obtain an order from the Residents' in-house physician. It was also revealed that the TSH and vitamin D levels weren't obtained after the January 20, 2026, Endocrinology appointment and they should've been obtained at that time. The facility failed to ensure requested lab work and DEXA bone density scan were completed prior to Endocrinology appointments. Thyroid and vitamin D levels requested by Endocrinology January 20, 2026, to be completed at that time weren't completed. Request for DEXA bone scan to be completed prior to January 20, 2026, appointment wasn't completed. 28 Pa. Code 201.18(b)(1) Management.28 Pa. Code 211.20(d)(1)(3)(5) Nursing services

Based on policy review, clinical record review, and staff interviews, it was determined that, in accordance with professional standards and practices, the facility failed to ensure that the resident's medical record was complete and accurately documented for one of the three resident records reviewed (Resident 2). Findings Include: Review of the facility's policy, titled Code Status Orders, effective [DATE], read, Code status communicates to the clinical staff whether the patient desires cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Review of Resident 2's clinical record revealed diagnoses that included hypertension (elevated blood pressure), a history of falls, and malignant neoplasm of the bladder ([bladder cancer] is a common, often smoking-related, malignancy of the bladder lining that causes blood in urine, pain, and frequent urination), with an admission date to the facility on [DATE]. Review of Resident 2's admission physician's order summary revealed documentation of a DNR status, effective [DATE]. A Do Not Resuscitate (DNR) order is a legally binding medical document signed by a physician that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops or they stop breathing. It focuses solely on CPR, allowing a natural death rather than artificial, invasive, prolonged life. Review of Resident 2's interdisciplinary plan of care, initiated on [DATE], that read, in part, Residents and family's wishes will be honored . Full Code .start CPR if cardiac arrest. Review of the Social Services Director's (Employee 8) progress notes dated [DATE], read, Advance directive reviewed, Full Code. An interview with the Nursing Home Administrator on [DATE], at 1:15 PM, revealed that the facility recently performed a code status audit of all residents and will complete another audit to ensure the accuracy of the clinical record. The interview also confirmed Resident 2's code status was a DNR, and the clinical record documentation of the full code status was not accurate. 28 Pa. code 211.12 (d) (2) (5) Nursing services

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the care plan for two of 27 residents reviewed (Resident 7 and 135).Findings include:Review of facility policy, titled Person-Centered Care Plan, last reviewed June 18, 2025, read, in part, The care plan will be reviewed and revised by the interdisciplinary team after each assessment.Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (a chronic condition in which heart doesn't pump blood as well as it should) and gastroesophageal reflux disease (GERD-a digestive disease in which stomach acid or bile irritates the food pipe lining).Review of Resident 7's care plan under the focus area for gastrointestinal symptoms revealed an intervention that stated, encourage resident to discuss feelings regarding ostomy (a surgically created opening in the abdomen that reroutes bodily waste, like urine or stool, from its usual path into a prosthetic pouch on the outside of the body).Further review of Resident 7's clinical record revealed the Resident never had an ostomy or had any risk of having an ostomy.During an interview with the Director of Nursing (DON) on September 11, 2025, at 11:30 AM, the DON confirmed Resident 7 never had an ostomy and that the care plan should have been revised to remove this intervention that was entered erroneously on July 7, 2024.Review of Resident 135's clinical record revealed diagnoses that included type 2 diabetes mellitus with hyperglycemia (DM- a metabolic disorder in which the body has high sugar levels for prolonged periods of time), cerebrovascular accident (CVA- occurs when blood flow to a part of the brain is disrupted, either by a blockage or bleeding), and localized edema (fluid retention). Review of Resident 135's physician orders revealed the following orders that had been discontinued: Clopidogrel Bisulfate (Plavix) Oral Tablet 75 MG, Give 75 mg by mouth one time a day, with a discontinued date of December 13, 2022. Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 5 unit subcutaneously at bedtime for DM, with a discontinued date of October 10, 2023.Review of Resident 135's care plan revealed focus areas of The resident is on insulin related to diabetes and The resident is on Anticoagulant therapy related to CVA- Plavix, both with a start date of April 30, 2018.Interview with the DON on September 10, 2025, at 2:11 PM, the surveyor questioned the active care plans for insulin and Plavix, as Resident 135 is no longer receiving those medications. During an interview with the DON on September 11, 2025, at 11:12 AM, she revealed she revised the care plan for Resident 135 to indicate she does not receive insulin or Plavix. 28 Pa. Code 211.10(a) Resident Care Policies

Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and two of three nourishment pantries (stations A and B).Findings include: Review of facility policies, Dry Storage and Refrigeration/Frozen storage, dated May 1, 2023, read, in part, routine cleaning procedures are followed. Food stock is dated on the day of receipt. items removed from the original box are individually dated. Dry bulk items are labeled with product name and date opened. Open packages are stored in closed containers, tightly secured with ties or in food quality storage bags. All foods are labeled with the name of the product, date received and use by date once opened. Individual shakes are labeled with sell by date when removed from the original container. Observation in the walk-in refrigerator on September 8, 2025, at 6:35 AM, revealed sliced turkey wrapped in plastic wrap not labeled or dated; and one bag grated cheese open and not securely closed or dated . In plastic thermal bowls that were not covered or dated were 2 tossed salads and 3 bowls puree red substance. Interview with Employee 1 (Food Service Director) on September 8, 2025, at 7:00 AM, it was revealed that the aforementioned items should be labeled and date marked. Observation in the prep area on September 8, 2025, at 6:37 AM, revealed: plastic container of bulk brown sugar not date marked, and the shelf with the bulk bins splattered with dried food. Under the toaster, one bag raisin bread not securely closed. The blender base was caked with dried food, and the oven contained a thick layer of a charred black substance on the inside. The three top covers to the plate warmer were broken (just laying on top). The shelf under the flat top grill contained one fry pan, one deep full pan and two lids that were visibly dirty with dried food and coagulated oil. Observation on the baker's rack was a pan 1/4 full of coffee cake dated September 8th that wasn't securely covered, one sheet of parchment paper was lying across the top. Additional observation September 9th, 2025, at 11:56 AM, revealed the ceiling above the tray line the vents and frame around the light contained a black fuzzy substance. Interview with Employee 1 on September 8, 2025, at 7:09 AM, it was revealed that bulk items should be date marked, the aforementioned areas are on a cleaning schedule, the top covers to the plate warmer have been broken for a while and Employee 1 was unsure if a maintenance request was submitted. It was also revealed that the items below the flat top should be cleaned. Observation on September 8, 2025, at 6:40 AM, revealed several baseboard tiles missing, grout missing on the floor in several areas, and the ceiling contained a dark grey fuzzy substance. Interview with Employee 1 on September 8, 2025, at 7:12 AM, it was revealed she wasn't sure who's job it was to clean the ceiling, and that she wasn't sure if the floor tiles are grout were scheduled to be repaired. Observation of the steam table on September 8, 2025, at 6:42 AM, revealed dried food dripped down the front of the unit and a potato wedge was on the bottom shelf. Observation in the reach-in refrigerator on September 8, 2025, at 6:43 AM revealed five Styrofoam bowls of diced peaches, one thermal bowl of diced peaches and seven portion-controlled cups of brown sugar weren't dated; and a second bowl of pudding not securely closed dated September 2nd, 2025, with no use by date. Two 46 oz mild thick lemon water and two 46 oz moderately thick lemon water were open with contents partially removed and not dated when opened or with a use by date. Interview with Employee 2 (Diet Aide) revealed there should be a sticker on the aforementioned items, marked when open and with a use by date. Interview with Employee 1 on September 8, 2025, at 7:14 AM, revealed the aforementioned items should be securely closed and date marked. Observation in B station nourishment pantry on September 8, 2025, at 7:36 AM, revealed 1 vanilla mighty shake was thawed and not date marked (the product should be used within 14 days of thawing). Interview with Employee 1 revealed the shake should have a snack label on it with a date. Observation in A station nourishment pantry on September 8, 2025, at 7:40 AM, revealed the inside of the microwave contained dried splattered brown substance. A direct interview with Employee 1 revealed the microwave should be cleaned or replaced and was unsure who was responsible for cleaning it. During an interview with the Nursing Home Administrator (NHA) on September 10, 2025, at 1:50 PM, it was revealed that items should be date marked when opened or pulled from the freezer, items should be stored off the floor and covered, and equipment should be clean. It was also stated that the plastic thermal bowls were ordered, however, the order needed to be submitted to a different purveyor, and she had to verify the cups were ordered. The tile and grout were in house to replace the floor in the dish room. The facility needed to schedule an evening/night to replace the floor. The facility anticipated that it would take one night and expect that the dish room would be utilized the next day as they are utilizing quick dry grout. 28 Pa code 211.6(f) - Dietary Services

Based on observations and staff interviews, it was determined that the facility failed to ensure residents are treated with respect and dignity and cared for in a manner and in an environment that promotes dignity for one of one meals observed (lunch on September 9, 2025).Findings include: Observation of tray line service on September 9, 2025, at 11:56 AM, some residents were served the peach cobbler in plastic thermal bowls and others in Styrofoam bowls. Additionally, some residents were provided with reusable plastic tumblers while other residents were served a disposable plastic cup. During an interview with the Employee 1 (Food Service Director) on September 9, 2025, at 12:11 PM, it was revealed there aren't enough bowls and cups to serve all residents during the meal and, therefore, they utilize Styrofoam bowls and disposable plastic cups for some residents. During an interview with the Nursing Home Administrator (NHA) on September 10, 2025, at 1:50 PM, it was revealed that reusable thermal bowls were ordered, however, the order needed to be submitted to a different purveyor, and she had to verify the cups were ordered. During an interview with the NHA on September 11, 2025, at 11:30 AM, it was revealed that the facility should have enough bowls and cups to serve all residents. 28 Pa code 201.29(d) - Resident Rights

Based on observations, policy review, and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in resident rooms on two of six nursing units (Heritage and A station).Findings include:Review of facility policy, titled Environmental Services Policies and Procedures, last reviewed June 18, 2025, read, in part, All resident/patient areas are cleaned at least daily and include resident/patient rooms.Review of July 2025 Resident Council Minutes revealed there were resident complaints of dirty rooms. Review of the April 2025 facility grievance log listed concerns from three residents (Residents 103, 138, and 144) that had housekeeping concerns regarding resident rooms not being clean and floors in resident rooms and bathrooms not being clean.Observation in Resident 3's room on September 8, 2025, at 10:48 AM, revealed the floor in her room was dirty, the floor under her bed was dirty, there was a collection of grey fuzzy substance in the corner under a chair, and there was a piece of cereal in the corner. Observation in Resident 3's room on September 9, 2025, at 10:08 AM, revealed the floor in her room was dirty, the floor under her bed was dirty, there was a collection of grey fuzzy substance in the corner under a chair, and there was a piece of toasted o cereal and an empty medicine cup in the corner. Observation in Resident 3's room on September 10, 2025, at 10:04 AM, revealed the floor in her room was dirty, the floor under her bed was dirty, there was a collection of grey fuzzy substance in the corner under a chair, and there was a piece of cereal in the corner. During an interview with Resident 3 on September 10, 2025, at 10:04 AM, she revealed the facility staff does not clean her room as well as she would like them to, and they never move the chair in the corner to clean underneath the chair.During an interview with the Nursing Home Administrator (NHA) on September 10, 2025, at 2:10 PM, the surveyor revealed the observations and concerns with Resident 3's room.Interview with the NHA on September 11, 2025, at 11:14 AM, it was revealed Resident 3's room had been cleaned, and she would expect residents to have a clean, comfortable, homelike environment. During an interview with Resident 101 on September 9, 2025, at 10:20 AM, it was revealed the room is not cleaned routinely. The floors and the bathroom are only cleaned twice a week, and they never clean under the dresser or dust the tops of the dresser. When cleaning the bathroom, it takes them less than five minutes to clean it.Observation on September 9, 2025, at 10:28 AM, and September 10, 2025, at 10:30 AM, revealed the bathroom walls contained a dark grey fuzzy substance that was able to be wiped with a paper towel, the floor along the baseboard had a brown film, the wall above the towel bar had two patches on the wall that were not smooth and lacking paint, the fan vent on the ceiling had a dark grey fuzzy substance, and a white streak on the wall tile to the right of the toilet which was able to be wiped with a moist paper towel. In the resident room the television contained a dark grey fuzzy substance, and under the dressers the floor contained a thick black film. The privacy curtain had several areas of dried light brown liquid on the curtain.During an interview with the NHA on September 10, 2025, at 2:09 PM, the surveyor revealed the observations and concerns with Resident 101's room.During an interview with the NHA on September 11, 2025, at 11:15 AM, it was revealed Resident 101's room had been cleaned. It was further revealed that she would expect a clean and comfortable home-like environment. Observation in Resident 135's room on September 8, 2025, at 10:57 AM; September 9, 2025, at 10:09 AM; and September 10, 2025, at 10:05 AM, revealed the floor in her room was dirty, and the wallpaper behind her bed was ripped. During an interview with the NHA on September 10, 2025, at 2:10 PM, the surveyor revealed the observations and concerns with Resident 135's room.Interview with the NHA on September 11, 2025, at 11:14 AM, she revealed Resident 135's room had been cleaned and the wallpaper was being repaired by maintenance staff, and she would expect residents to have a clean, comfortable, homelike environment. 28 Pa. Code 201.18 (e)(2.1) Management

Based on review of the clinical record, policy review, and resident and staff interviews, it was determined that the facility failed to ensure pain management is provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of 30 residents reviewed (Resident 143).Findings include:Review of facility policy, administration of medications and treatments, last revised August 1, 2016, failed to reveal any expectation for a timeframe when meds are to be given around the time that they are ordered.Review of Resident 143's clinical record revealed diagnoses that included displaced fracture of lateral malleolus of right fibula (fracture of the ankle) and unspecified fracture of the upper end of the right tibia (fracture of the shin bone).Review of Resident 143's physician orders revealed an order for Gabapentin (medication used to treat nerve pain) 800 mg four times daily at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM for neuropathy (pain caused by nerve damage).Review of Resident 143's care plan revealed a focus area of, Resident exhibits or is at risk for alterations in comfort related to multiple fractures and a history or migraines, with an intervention of, medicate Resident as ordered for pain and monitor for effectiveness and monitor of side effects.Review of Resident 143's electronic medical record revealed that on September 6, 2025, her 8:00 AM dose of Gabapentin 800 mg was given at 10:50 AM, and the 12:00 PM dose of Gabapentin was given at 2:28 PM. Further review revealed that on September 7, 2025, her 8:00 AM dose of Gabapentin 800 mg was given at 10:32 AM, and the 12:00 PM dose of Gabapentin was given at 2:26 PM.Interview with Resident 143 on September 8, 2025, at 9:45 AM, revealed that over the weekend on September 6 and 7, 2025, she had received her morning pain medication over 2 hours late even though she was ringing her call bell to notify staff that she was in pain and needed her medication and that it was late.Interview with the Director of Nursing on September 11, 2025, at 11:30 AM, revealed that they don't have a policy regarding what timeframe that meds should be given, but she would expect them to be given in the timeframe an hour before until an hour after they are ordered to be given.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 review of select food service committee meeting minutes, staff and resident interviews, observation, and completion of one meal test tray, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures. Findings include: Review of resident council meeting minute dated July 8, 2025, revealed condiments were missing from select menu options, items being missed on resident trays, cooks are inconsistent with cooking the meals, hamburgers were hard, baked ziti was dry, and portion sizes are small for some items. Review of the Resident Council Meeting minutes dated August 12, 2025, revealed concerns with hot food temperatures, vegetables not fully cooked, tough meat, and portion of soup is a half bowl. Interviews with Residents 3, 68, and 101 during the initial pool process revealed concerns regarding the quality, flavor, texture, and temperature of food. During an interview with Resident 3 on September 8, 2025, at 10:58 AM, she revealed the food was terrible and lacks flavor. During a resident interview conducted on September 9, 2025, at approximately 9:30 AM, Resident 68 provided that she felt the food was often cold and not palatable. Interview with Resident 101 on September 9, 2025, at 10:19 AM, it was revealed concerns with the temperature of the hot food, small portion sizes of toast, not receiving items per her request that are listed on her tray ticket, and that the meat is tough. Review of facility provided Test tray evaluation form, not dated, read, in part, hot entree, starch and vegetable should be greater than 140 degrees Fahrenheit (F). A test tray completed on September 9, 2025, revealed the temperature of the turkey, brussels sprouts and mashed potatoes weren't palatable for temperature. The test tray was placed on a meal cart and delivered to 300 unit with other trays being delivered at that time; 19 minutes had elapsed between the time the test tray was prepared from the service line and presented for evaluation. Employee 1 (Food Service Manager) took temperatures of the food items at the time the test tray was served for evaluation (12:35 PM). The following were the recorded highest temperatures: roast turkey 136 Fmashed potatoes 139 Fbrussels sprouts 125.6 F peach cobbler was missing from the tray, but was served to residents at room temperatureiced tea 50.5 F Interview with Employee 1 revealed that the hot food items should be above 140 F, and the cold beverage should be less than 55 F. It was also noted that there should've been a dessert on the meal tray. During an interview with the Nursing Home Administrator on September 10, 2025, at 1:50 PM, it was revealed that meal temperatures would be acceptable and tray tickets should be followed. 28 Pa. Code 201.14(a). Responsibility of licensee

Based on facility policy, review of the clinical record, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice that meet each resident's physical, mental, and psychosocial needs for one of 27 residents reviewed (Resident 101).Findings include: Review of facility policy, Administration of Medications and Treatments, revised August 1, 2016, read, in part, residents shall receive medication ordered by an authorized licensed practitioner at the correct time. Review of Resident 101's clinical record documented diagnoses that included diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Interview with Resident 101 on September 9, 2025, at 10:24 AM, revealed at times, she received insulin and, at times, her blood sugar is checked after meals. Review of resident 101's physician orders included Humulin (long-acting insulin) 20 units one time a day, started August 29, 2025 and Humulin 16 units one time a day, started July 9, 2025, and discontinued August 28, 2025. Review of Resident 101's Medication Administration Record 2025 documented Humulin was scheduled to be administered at 8:00 AM, and on the following dates the medication was administered late: September 10th at 9:59 AM; August 3rd at 10:14 AM; August 10th at 10:30 AM; August 16th at 10:00 AM; August 24th at 9:34 AM; August 31st at 10:19 AM; July 12th at 10:37 AM; July 13th at 9:29 AM; and July 21st at 11:08 AM. Interview with the Director of Nursing (DON) on September 11, 2025, at 11:30 AM, it was revealed that she should expect the medication would be administered on hour before or an hour after the medication was scheduled to be administered. Email communication with the DON on September 11, 2025, at 12:33 PM, revealed no rational for the late administration of Humulin. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.10(a)(c) Resident care policies

Based on clinical record review, staff interview, and Resident's written statement, it was determined that the facility failed to follow accepted professional standards and principles for administering medications to ensure the prevention of significant medication errors for three of 24 residents reviewed (Resident 9, 10 and 14). This failure resulted in harm to Resident 9 and 14 who suffered pain from the omission of mediations. Findings include: Review of Resident 9's quarterly Minimum Data Set (MDS-periodic assessment of needs) revealed a BIMS score (brief interview of cognitive status) of 12 indicating moderate cognitive impairment. In a grievance filed by Resident 9 on December 28, 2024, Resident 9 stated that he/she had to request his/he routine morning pain medications. Resident 9 stated that he/she laid in pain all day. Clinical record review for Resident 9 revealed a physician's order dated December 20, 2024, for the Resident to be administered Methadone (a medication used to treat moderate to severe pain) 10 milligrams (mg), two tablets twice a day. On December 28, 2024, Methadone was ordered to be administered at 8:30 AM, but the Resident didn't receive the medication until 4:50 PM based on the medication administration audit (time medication administered in electronic health record). Clinical record review for Resident 9 revealed a physician order dated December 13, 2024, for Lyrica (anticonvulsant that is used to treat nerve pain) 75 mg, two tablets twice a day. On December 28, 2024, Resident 9 was to receive the Lyrica at 9:00 AM, but didn't receive it until 4:51 PM based on the medication administration audit (time medication administered in electronic health record). Review of Resident 10's clinical record revealed diagnoses that included epilepsy (neurological disorders that cause brief episodes of spasms, unresponsiveness a.k.a. seizures) and hypertension (high blood pressure). Review of Resident 10's physician orders included Phenobarbital tablets 16.2 mg (milligrams), take four tablets daily for seizures. The Resident also received Phenytoin 100 mg tabs, and two tabs are to be administered daily for epilepsy. Review of controlled drug record revealed that Resident 10 was not administered the phenobarbital medication on December 28, 2024. Resident 10 did receive the phenytoin on December 28, 2024. During an interview with the Director of Nursing (DON) on January 7, 2024, at approximately 11:00 AM, the DON informed the surveyor that the Phenobarbital was signed off as administered on the Medication Administration Record; however, the surveyor reviewed the controlled drug record count sheet that confirmed that the medication was never administered on December 28, 2024. Clinical record review for Resident 14 on January 7, 2025, revealed diagnoses that included Hypertension (high blood pressure) and Chronic Pain (persistent pain that lasts for weeks or years). Review of Resident 14's quarterly Minimum Data Set (MDS-periodic assessment of needs) revealed a BIMS score (brief interview of cognitive status) of 15 indicating cognition is intact. Clinical record review for Resident 14 revealed a physician order dated December 3, 2024, for Tramadol 50 mg (opioid to treat moderately severe pain) that may be administered every 8 hours as needed for pain level 4-10. In a written statement filed by Resident 14 on December 28, 2024, the Resident requested her pain medication at 12:00 PM, and, when not provided, she requested them again 2 hours later. A third request was made to another staff person who administered the pain medication upon request at 4:05 PM. The administration time was signed out at 4:05 PM on the controlled medication record. Resident 14's written statement included the following comment, I was considering going to the hospital since my pain was so bad. The Medication Administration Record revealed Resident 14 received the Tramadol on December 28, 2024, at 4:06 PM. During an interview with the Director of Nursing (DON) on January 7, 2025, she agreed that pain medication should be administered timely. The facility failed to administer scheduled pain medications per physcian order resulting in Resident 9 and 14 experiencing pain. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.9(c) Pharmacy services

Based on clinical record review and staff interviews, it was determined the facility failed to ensure pain management was provided that was consistent with professional standards of practice for two of 23 residents reviewed (Residents 9 and 14). This failure resulted in actual harm to Residents 9 and 14, whose pain was not properly relieved and managed and continued to experience uncontrolled pain. Findings include: Review of the clinical for Resident 9 revealed diagnoses that included Polyneuropathy (peripheral nerve disorder that affects multiple nerves throughout the body simultaneously) and Chronic Pain Syndrome (persistent pain that lasts for weeks to years). Review of Resident 9's quarterly Minimum Data Set (MDS-periodic assessment of needs) revealed a BIMS score (brief interview of cognitive status) of 12, indicating moderate cognitive impairment. Review of Resident 9's care plan, last review date December 1, 2024, revealed a focus area to receive narcotics related to chronic pain syndrome with an intervention to administer pain medications as ordered. In a grievance filed by Resident 9 on December 28, 2024, Resident 9 stated that he/she had to request their routine morning pain medications. Resident 9 stated that he/she laid in pain all day. Clinical record review for Resident 9 revealed a physician's order dated December 20, 2024, for the Resident to be administered Methadone (a medication used to treat moderate to severe pain) 10 milligrams (mg), two tablets twice a day. On December 28, 2024, Methadone was ordered to be administered at 8:30 AM, but the Resident didn't receive the medication until 4:50 PM based on the medication administration audit (time medication administered in electronic health record). Clinical record review for Resident 9 revealed a physician order dated December 13, 2024, for Lyrica (anticonvulsant that is used to treat nerve pain) 75 mg, two tablets twice a day. On December 28, 2024, Resident 9 was to receive the Lyrica at 9:00 AM, but didn't receive it until 4:51 PM based on the medication administration audit. Clinical record review for Resident 14 on January 7, 2025, revealed diagnoses that included Hypertension (high blood pressure) and Chronic Pain (persistent pain that lasts for weeks or years). Review of Resident 14's quarterly MDS revealed a BIMS score of 15, indicating cognition is intact. Review of Resident 14's care plan, last review date November 26, 2024, revealed a focus area of at risk for alterations in comfort with interventions to advise Resident to request pain medication before pain becomes severe; evaluate pain characteristics, quality, severity, location, precipitating/relieving factor; medicate Resident as ordered for pain and monitor for effectiveness, side effects, report to physician as indicated. Clinical record review for Resident 14 revealed a physician order dated December 3, 2024, for Tramadol 50 mg (opioid to treat moderately severe pain) that may be administered every 8 hours as needed for pain level 4-10. In a written statement filed by Resident 14 on December 28, 2024, the Resident requested her pain medication at 12:00 PM, and, when not provided, she requested them again 2 hours later. A third request was made to another staff person who administered the pain medication upon request at 4:05 PM. The administration time was signed out at 4:05 PM on the controlled medication record. Resident 14's written statement included the following comment, I was considering going to the hospital since my pain was so bad. During an interview with the Director of Nursing (DON) on January 7, 2025, the grievances regarding pain were discussed with the DON and she agreed that pain medication should be administered timely. During an interview with the DON on January 8, 2025, the DON revealed that the Nurse Practitioner/Physician wasn't informed of the late administrations until Monday December 30, 2024. The nurse that delayed administrations of medications as prescribed was terminated as of December 28, 2024. The facility failed to ensure pain medications were administered at the prescribed time, resulting in pain and suffering for Resident 9 and Resident 14 on December 28, 2024. 28 Pa. Code 211.2 (d)(9)(10) Medical director 28 Pa. Code 201.18(b)(1) Management 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care and follow professional standards of practice for wound care for one of 23 residents reviewed (Resident 9), and failed to follow scheduled medication times based on the documented administration time for 21 of 23 residents reviewed (Residents 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, and 23). Findings include: A review of the facility policy, titled Skin Integrity and Wound Management, last revised October 15, 2024, stated implement wound care treatments, as indicated and ordered. On December 28, 2024, Employee 2 (Registered Nurse) reviewed wound care treatments for the dayshift (7AM to 3PM), due to the dayshift nurse delay in medication pass. Employee 2 provided a written statement to the Director of Nursing (DON) that stated, there were treatments that were signed off completed but the date on the treatment was 12/27/24. I completed the treatment on the evening shift. The wound care that was signed off as completed on dayshift December 28, 2024, but was not completed until evening shift involved Resident 9. Review of Resident 9's clinical record revealed that the Resident had a lateral right ankle vascular ulcer that was ordered to have cleansing, then apply medihoney and alginate (wound dressings) to the wound base, and cover with a foam dressing every dayshift and PRN (as needed). A review of the facility policy, titled medication Administration, last reviewed January 2024, stated, medications are administered within 60 minutes of the scheduled time .the individual who administers the medications records the administration on the residents Medication Administration Record (MAR) immediately for all medications administered. A review of the clinical record for Resident 1 revealed on December 28, 2024, her medications were administered late. Resident 1 was scheduled to receive 13 medications between 7:15 AM and 9:00 AM. Resident received medications 3 to 8 1/2 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 2 revealed on December 28, 2024, medications were administered late. Resident 2 was scheduled to receive 15 medications between 7:15 AM and 9:00 AM. Resident received medications 1 1/2 to 5 1/2 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 4 revealed on December 28, 2024, medications were administered late. Resident 4 was scheduled to receive 14 medications between 7:15 AM and 9:00 AM. Resident received medications 5 1/2 to 9 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 5 revealed on December 28, 2024, medications were administered late. Resident 5 was scheduled to receive 9 medications between 7:00 AM and 10:00 AM. Resident received medications 6 to 8 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 6 revealed on December 28, 2024, medications were administered late. Resident 6 was scheduled to receive 7 medications between 8:00 AM and 2:00 PM. Resident received medications 1 to 3 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 7 revealed on December 28, 2024, medications were administered late. Resident 7 was scheduled to receive 18 medications between 8:00 AM and 10:00 AM. Resident received medications 4 to 6 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 8 revealed on December 28, 2024, medications were administered late. Resident 8 was scheduled to receive 8 medications at 8:00 AM. Resident received medications 8 1/2 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 9 revealed on December 28, 2024, medications were administered late. Resident 9 was scheduled to receive 19 medications between 8:00 AM and 10:00 AM. Resident received medications 4 to 6 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 10 revealed on December 28, 2024, medications were administered late. Resident 10 was scheduled to receive 12 medications between 8:00 AM and 12:00 PM. Resident received medications 2 to 5 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 11 revealed on December 28, 2024, medications were administered late. Resident 11 was scheduled to receive 5 medications at 8:00 AM. Resident received medications 6 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 12 revealed on December 28, 2024, medications were administered late. Resident 12 was scheduled to receive 11 medications between 8:00 AM and 9:00 AM. Resident received medications 8 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 13 revealed on December 28, 2024, medications were administered late. Resident 13 was scheduled to receive 13 medications between 8:00 AM and 12:00 PM. Resident received medications 3 to 8 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 14 revealed on December 28, 2024, medications were administered late. Resident 14 was scheduled to receive 20 medications between 8:00 AM and 12:00 PM. Resident received medications 2 to 7 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 15 revealed on December 28, 2024, medications were administered late. Resident 15 was scheduled to receive 11 medications between 8:00 AM and 9:00 AM. Resident received medications 4 to 5 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 16 revealed on December 28, 2024, medications were administered late. Resident 16 was scheduled to receive 6 medications between 8:00 AM and 9:00 AM. Resident received medications 8 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 17 revealed on December 28, 2024, medications were administered late. Resident 17 was scheduled to receive 12 medications between 8:00 AM and 12:00 PM. Resident received medications 4 to 5 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 18 revealed on December 28, 2024, medications were administered late. Resident 18 was scheduled to receive 7 medications at 8:00 AM. Resident received medications 4 to 5 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 19 revealed on December 28, 2024, medications were administered late. Resident 19 was scheduled to receive 13 medications between 8:00 AM and 12:00 PM. Resident received medications 3 to 8 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 20 revealed on December 28, 2024, medications were administered late. Resident 20 was scheduled to receive 4 medications at 8:00 AM. Resident received medications 2 1/2 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 22 revealed on December 28, 2024, medications were administered late. Resident 22 was scheduled to receive 19 medications at 8:00 AM. Resident received medications 3 to 3 1/2 hours later than scheduled per documentation in the MAR. A review of the clinical record for Resident 23 revealed on December 28, 2024, medications were administered late. Resident 23 was scheduled to receive 5 medications between 8:00 AM and 2:00 PM. Resident received medications 2 to 6 hours later than scheduled per documentation in the MAR. The Nurse Practitioner was notified regarding the late medication administrations on December 30, 2024, but was not notified on December 28, 2024. The following is a written statement from the Nurse Practitioner, On Monday, 10/30/2024, I was informed that an incident at the facility occurred on 10/28/2024 of possible medications not being administered to residents. All residents had no adverse reactions, therefore no further adjustments to treatment was required. During an interview with the Director of Nursing and Nursing Home Administrator (NHA) on January 7, 2024, both agreed that treatments and medications should be administered as ordered and that medications should not be signed off until completed. The NHA did inform the surveyor that the nurse who was assigned to the residents was terminated. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services

Based upon clinical record review and staff and resident interviews, it was determined the facility failed to provide transfer out of bed services per preference for one of 23 residents reviewed (Resident 1). Findings include: Review of the clinical record revealed that Resident 1 had diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and atrial fibrillation (an irregular, often rapid heart rate). Resident 1 was admitted to the facility on [DATE], for long term stay at the facility. A review of Resident 1's Quarterly Minimum Data Set (periodic assessment of needs) dated November 8, 2024, revealed the Resident required extensive assist of 2-persons for transfer out of bed. Resident 1's BIM score (brief interview of mental status) was 15, indicating she is cognitively intact. During an interview with Resident 1 on January 7, 2024, at approximately 11:30 AM, she confirmed that she had placed her call bell on to get out of bed in the morning, but no one transferred her out of bed until 4:30 PM. Resident confirmed that she is usually out of bed by lunch time. Resident stated that she is transferred via a lift, and stated sometimes it's not working, then I have to wait for another lift. Resident 13, who is Resident 1's roommate, confirmed that staff did not respond to the Resident's request to get out of bed until 4:30 PM. Resident 13's BIMS score (brief interview of mental status) was 15, indicating she was cognitively intact. Roommate also confirmed that Resident 1 is typically out of bed by noon. During an interview with Employee 1 (Nurse Aide) on January 7, 2024, she stated that Resident 1 was washed and changed in the AM on December 28, 2024, she added that the Resident gets out of bed at different times. The Employee was unable to explain the delay in getting the Resident out of bed. Interview with the Director of Nursing (DON) on January 7, 2025, at 1:00 PM, agreed that residents should be transferred out of bed upon request and timely. The DON also confirmed that there is no non-functional Hoyer lifts or sit to stand-lifts, and the only time one of the lifts is not available is when they are being charged. 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident receives adequate supervision to prevent accidents for one of five residents reviewed (Resident 2). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). Staff may escort patients, if needed . A review of Resident 2's clinical record revealed diagnoses that included obstructive uropathy (a condition that occurs when urine is unable to drain normally through the urinary tract, resulting in a backup of urine and potential kidney damage) and chronic kidney disease (a condition where the kidneys gradually lose their ability to filter blood properly). A review of Resident 2's interdisciplinary plan of care revealed a problem area, initiated on October 16, 2024, that read, Resident/patient is at risk for elopement related to wandering. Also, Resident/patient will not attempt to leave the facility without an escort . Continued review of Resident 2's plan of care revealed a problem area, initiated October 10, 2024, that read, Resident is at risk for falls: cognitive loss, lack of safety awareness. A review of Resident 2's physician orders summary revealed an order dated October 14, 2024, that read, Wander Guard/Wander Elopement device due to poor safety awareness. A Wander Guard is described as a technology platform that helps keep at-risk patients and residents safe while allowing them to move around freely. It uses a combination of bracelets, sensors, and a technology platform to monitor and alert staff if a patient or resident tries to leave a safe area. A review of Resident 2's interdisciplinary progress notes revealed documentation of an out-of-facility urology consult appointment dated October 7, 2024. An interview with the Nursing Home Administrator on December 2, 2024, at 1:25 PM, revealed Resident 2 was not accompanied or escorted by facility staff for the out-of-facility urology appointment. The interview revealed the Nurse Aide (Employee 3) assigned to be the escort remained at the facility due to a miscommunication. The interview also revealed Resident 2 should not have been left unattended at the appointment and without a staff escort. 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.12 (d) (1) (5) Nursing services

Based on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of five residents reviewed (Resident 5). Findings Include: A review of the facility's policy, titled Transportation and Escort: Patient, effective April 1, 2003, read, in part, Centers will arrange for ambulance and other appropriate transportation services to provide transportation of patients/residents (hereinafter 'patient') for scheduled appointments as well as emergencies. The policy continued, Center staff will provide assistance in scheduling transportation for patients who need transportation outside of the Center (doctor's appointments, etc.). A review of Resident 5's clinical record revealed diagnoses that included muscle weakness and ileus (also known as paralytic ileus or pseudo-obstruction, is a condition where the intestines are blocked and stop working properly. It occurs when the muscles in the intestines stop squeezing to move food and waste through the body). A review of Resident 5's physician's orders revealed a documented telephone order dated October 11, 2024, that read .Gastroenterology Associates 11/15/2024 @ 1400 [2:00 PM]. A review of Resident 5's progress notes revealed a note dated November 18, 2024, written by the Certified Registered Nurse Practitioner (CRNP), that read Of note she [Resident 5] was scheduled to . GI [Gastrointestinal] on 11/15/2024, however, transportation was not set up and the appointment was rescheduled in December. An interview with Resident 5 on December 2, 2024, at 11:01 AM, revealed the CRNP was able to reschedule the appointment on November 22, 2024, instead of waiting until December 2024. An interview with the Nursing Home Administrator on December 2, 2024, at 11:35 AM, confirmed the facility missed scheduling transportation to Resident 5's appointment on November 15, 2024. 28 Pa. Code 211.12 (d) (1) (5) Nursing services

Based on observation, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a skin tear to the posterior right lower extremity for one of 27 residents reviewed (Resident 46). Findings Include: Review of Resident 46's clinical record revealed diagnoses that included multiple sclerosis (a chronic progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord; symptoms include numbness, impaired speech, muscle coordination, blurred vision, and severe fatigue), muscle weakness, and unsteadiness on feet. Review of select facility report detailing the incident that occurred on August 5, 2024, read, in part; that during care last evening the resident was being assisted to the toilet via sit to stand (STS) lift with one assist by [Employee 4 (Nurse Aide)]. A nurse [Employee 5 (Licensed Practical Nurse- LPN)] was present but not assisting due to a lack of room in the bathroom. When STS lift was removed and care started, nurse aide noticed the resident leg developed a bubble of blood under her hand which popped causing a skin tear. LPN evaluated the area and called for [Employee 3 (Registered Nurse- RN Supervisor)] who decided to send the resident out for further treatment. Review of the facility investigation revealed a statement from Employee 4: [Resident 46] is a stand to sit lift, I was using the lift by myself, but my nurse was in the front of the door .When [Resident 46] was ready to go to bed, I was ready to use the lift again, I saw her leg wasn't straight, she was sitting on the toilet, I tried to put her legs straight with my hands, at this time, I felt her skin broken under my hands, I called my nurse over. Employee 5 wrote a statement that said: Writer in doorway of [Resident 46's] bathroom when [Employee 4] transferring [Resident 46] to the toilet using the STS lift. Bathroom too small to accommodate all three of us so writer did not enter the bathroom with nurse aide. Residents foot got caught in the lift second to her lack of flexibility and nurse aide bent down to assist residents foot positioning by lifting her lower leg in an effort to not have resident injure her leg on the lift itself. As she moved lower leg forward she realized that she felt a 'spongy type feeling' and released residents leg. Skin tear visible to right inner calf area. Writer stepped in to apply pressure and assess the wound. Supervisor made aware and she followed up with her own assessment and called the on call [provider]. Review of Resident 46's clinical record revealed the following telehealth nurse practitioner note on August 5, 2024, at 10:50 PM, that stated, Chief complaint: Skin tear to right calf. History of Present Illness: [Resident 46] is [AGE] year-old, female who is being seen today for skin tear to right calf during care. Observed with some bleeding during video visit. Currently prescribed Eliquis. Appears to need stitches with a deep cut during video visit. Resident reported pain of leg. Was given [medicine for pain] recently. Review of Resident 46's progress notes revealed a note that stated the resident was sent to Hospital via ambulance on August 5, 2024, at 11:55 PM, for evaluation of laceration to right inner calf. Further review of progress notes revealed that Resident 46 returned from the hospital on August 6, 2024 at 7:30 AM with Steristrips (thin adhesive bandage to help close wounds as they heal) to the laceration and new treatment orders. Review of Resident 46's physician orders revealed the following: Cleanse skin tear to RLE (right lower extremity) with wound cleanser and apply rolled gauze QD (once daily) and PRN (as needed) for dislodgement, every evening shift and PRN, with a start date of August 6, 2024, and an end date of August 15, 2024. Cleanse skin tear to RLE with wound cleanser and apply Xeroform and wrap with rolled gauze QD and PRN for dislodgement every evening shift and as needed, with a start date of August 15, 2024, and an end date of August 16, 2024. Cleanse to RLE with wound cleanser and apply medihoney and cover with telfa and wrap with kling daily every evening shift for wound care, with a start date of August 17, 2024. During an interview with the Nursing Home Administrator (NHA) on August 28, 2024, at 9:26 AM, he revealed the facility suspended Employee 4 during the investigation, and brought her back after disciplinary action and education was provided. He stated that two nurses should have been utilizing the STS lift together during the transfer and that education was provided to all nursing staff; and that if they feel there is not enough room to use the STS lift in personal bathrooms, the common bathroom on the unit should be used. Review of the facility education revealed the subject of the education said, Every lift requires 2 people at all times. Observation of the STS lift on the unit on August 28, 2024, at 12:37 PM, failed to reveal leg straps or that it makes contact with the posterior calf area during normal use. During a phone interview with Employee 4 on August 28, 2024, at 3:20 PM, she revealed she placed Resident 46 on the toilet and when the Resident was ready to transfer back off of the toilet, Resident 46 told the aide her foot was numb and she needed assistance with her placement on the sit to stand lift. When Employee 4 placed her hand on the Resident's leg to help her position it on the lift, she felt her skin break under her hand, and that is when she called for the RN Supervisor to come and assess Resident 46's wound. She further revealed she knows the lift should be operated by two people and she was operating it by herself at the time due to limited space in the bathroom. She revealed she is able to successfully utilize the lift with two people despite tight space and has done so moving forward. During a follow-up interview with the NHA on August 29, 2024, at 10:40 AM, the surveyor revealed the concern with the lack of two person assist using the STS lift during care on August 5, 2024. No further information was provided. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of personnel training records and staff interview, it was determined that the facility failed to ensure each nurse aide was provided with the required in-service training consisting of no less than 12 hours per year for five of five nurse aide employee records reviewed (Employees 6, 7, 8, 9, and 10); failed to provide annual training that included dementia management and resident abuse prevention for one of five nurse aide employee records reviewed (Employee 7); and failed to provide annual training that included abuse prevention for one of five nurse aide employee records reviewed (Employee 6). Findings Include: Review of personnel information revealed Employee 6's hire date was November 28, 2014; Employee 7's hire date was March 9, 2023; Employee 8's hire date was February 1, 2023; Employee 9's hire date was April 4, 2023; and Employee 10's hire date was December 10, 2022. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. Further review of facility training records failed to reveal evidence that dementia management or abuse prevention training was completed by Employee 7 within the past 12 months. Further review of facility training records failed to reveal evidence that dementia management training was completed by Employee 6 within the past 12 months. During an interview with the Nursing Home Administrator (NHA) on August 29, 2024, at 12:48 PM, the NHA indicated that the former Director of Nursing used to keep copies of staff education files in a binder, but he could not locate the binders. He confirmed that he had no additional information to provide other than the corporate reports of staff education completion, and he confirmed that he would expect nurse aides to complete their annual required training topics and hours. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.19 (7) Personnel policies and procedures 28 Pa. Code 201.20(a)(d) Staff development

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards, and failed to maintain complete and accurate records related to dialysis communication for one of three residents reviewed for dialysis (Resident 93). Findings include: Review of facility policy, titled Procedure: Dialysis: Home Hemodialysis (HHD), last revised January 8, 2024, read, in part, At completion of HHD, Center staff will report and document: Vital signs; Documentation will include: Pre-HHD assessment and vital signs; Condition of AV access site or catheter insertion site with date and time of dressing change; Dialysis facility staff will report to Center staff upon completion of HHD. Review of Resident 93's clinical record revealed diagnoses that included dependence on renal dialysis (a treatment for kidney failure that filters your blood and removes toxins, waste, and excess fluids), hypertension (high blood pressure), and hyperkalemia (high blood potassium). Review of Resident 93's physician orders revealed an order for Hemodialysis with a chair time: 10:30am Tues-Thurs-Sat Transportation via ambulance every night shift every Mon, Wed, Fri for Dialysis, with a start date of July 19, 2024. During an interview with Resident 93 on August 26, 2024, at 11:47 AM, she revealed she does not believe she has an emergency kit related to dialysis at her bedside. Interview with Employee 14 (Licensed Practical Nurse) on August 26, 2024, at 12:52 PM, revealed she is not aware of Resident 93 having an emergency dialysis kit at her bedside. Interview with Employee 2 (Registered Nurse Unit Manager/Acting DON) on August 26, 2024, at 1:25 PM, she revealed the facility policy only speaks to having hemostats (tools used to control bleeding) at bedside for residents with external chest port access; however, Resident 93 now has a hemostat by her bedside, and they will look into changing that process. During an interview with Employee 15 (Physician Assistant) on August 28, 2024, at 11:04 AM, the surveyor questioned where Resident 93's dialysis book with her communication sheets could be found, her response was that she didn't think she had one. Review of select facility dialysis communication sheets revealed the following: Dialysis communication sheet on June 1, 2024, failed to reveal documentation related to her AV shunt assessment at the facility post-dialysis. Dialysis communication sheet on June 4, 2024, revealed the dialysis center had failed to fill their section of the communication sheet. Dialysis communication sheet on June 6, 2024, failed to reveal documentation that vital signs were assessed at the facility pre-dialysis. Dialysis communication sheet on June 8, 2024, failed to reveal documentation that pre-dialysis temperature or pulse were assessed at the facility; and the dialysis center had failed to fill their section of the communication sheet. Dialysis communication sheet on June 11, 2024, failed to reveal facility documentation related to her AV shunt assessment pre-dialysis. Dialysis communication sheet on June 22, 2024, failed to reveal facility documentation that pre-dialysis temperature or pulse were assessed. Dialysis communication sheet on July 23, 2024, revealed the facility post-dialysis assessment data was dated July 25, 2024, and had the same information as her dialysis communication sheet from July 25, 2024. Dialysis communication sheet on July 25, 2024, failed to reveal documentation that pre-dialysis temperature or pulse were assessed at the facility. Dialysis communication sheet on July 30, 2024, failed to reveal pre or post-dialysis assessments at the facility. Dialysis communication sheet on August 8, 2024, failed to reveal documentation that pre-dialysis temperature or pulse were assessed at the facility. Dialysis communication sheet on August 10, 2024, revealed the dialysis center had failed to fill their section of the communication sheet. Dialysis communication sheet on August 15, 2024, failed to reveal facility documentation related to her AV shunt assessment post-dialysis, and the dialysis center had failed to fill their section of the communication sheet. Dialysis communication sheet on August 20, 2024, failed to reveal a facility post-dialysis assessment. Dialysis communication sheet on August 22, 2024, failed to reveal facility obtained pre-dialysis vital signs or a facility obtained post-dialysis assessment. Dialysis communication sheet on August 24, 2024, revealed the dialysis center had failed to fill their section of the communication sheet. During an interview with Employee 2, in the presence of the Nursing Home Administrator (NHA), on August 28, 2024, at 1:27 PM, she revealed if dialysis does not fill their section of the communication sheet, she would call them and have them email the facility the results. Follow-up interview with Employee 2, in the presence of the NHA, August 29, 2024, at 1:12 PM, revealed they were unable to locate the missing documentation from the communication sheets or that dialysis was contacted to email results of their part of the communication sheet on the aforementioned dates. No further information was provided. 28 Pa code 211.5(f) Medical Records 28 Pa Code 211.12(d)(1)(3)(5) Nursing Services

Based on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for two of three residents reviewed (Residents 8 and 60). Findings include: Review of facility policy, titled Restorative Nursing, last revised on August 7, 2023, read, in part, Restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. A licensed nurse must supervise the activities in the restorative nursing program. Purpose: to help the patient attain and maintain optimal physical, mental, and psychosocial functioning. Implement the restorative nursing program according to the specifics on the care plan. Document daily on restorative nursing record in PointClickCare ADL Point of Care. Review of Resident 8's clinical record revealed diagnoses that included muscle weakness, lack of coordination, and dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning). Interview with Resident 8 on August 26, 2024, at 9:58 AM, revealed he doesn't get out of bed much and he wishes he could get more therapy. Review of Resident 8's care plan revealed a focus area Restorative Range of Motion: Patient demonstrates loss of sitting tolerance cognitive loss/dementia, functional deterioration, last revised July 29, 2024, with an intervention for Have resident get up out of bed everyday in the AM for lunch for up to 4 hours using a hoyer lift, initiated on July 29, 2024. Further review of Resident 8's care plan revealed a focus area of Activities of daily living self-care deficit as evidenced by physical limitations related to traumatic brain injury post motorcycle accident, last revised August 29, 2023, with an intervention for Restorative Nursing: Upper body strengthening exercises to all planes of motion using Yellow Theraband; 10 reps 2x/day, initiated on December 7, 2023. Observations of Resident 8 on August 26, 2024, at 9:58 AM; August 27, 2024, at 11:27 AM; and August 28, 2024, at 9:16 AM and 11:16 AM; revealed he was not up out of bed. Review of Resident 8's nurse aid task, titled Restorative Program Bed Mobility: (Record self perform / support under Bed Mobility task) See care plan/kardex for program, failed to reveal documentation to indicate tolerance to the program or minutes captured. During an interview with Employee 13 (Clinical Lead/Resource Nurse), in the presence of the Nursing Home Administrator (NHA), on August 28, 2024, at 10:26 AM, she revealed the nurse aide task was entered into the system incorrectly, so the nurse aides were unable to document minutes and tolerance of the program, but it has been fixed. During a follow-up interview with Employee 2 (Registered Nurse Unit Manager/Acting DON), in the presence of the NHA, on August 28, 2024, at 1:29 PM, she revealed she would expect restorative minutes and tolerance to the program to be documented. Review of Resident 60's clinical record revealed diagnoses that included hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (a stroke-damage to the brain from interruption of its blood supply) affecting the left dominant side and muscle wasting. Review of Resident 60's Occupational Therapy Discharge Summary dated July 12, 2024, indicated that Resident 60 was to be on a Restorative Nursing Program for Range of Motion to bilateral upper and lower extremities (both arms and legs) during AM and PM cares. Review of Resident 60's care plan and kardex revealed the following intervention: Restorative Program ROM Active #1: See care plan/kardex for program description, undated, and Monitor for independence for BLE 3 sets x 10 reps for 3-4 times per week, dated July 25, 2024. Further review of Resident 60's clinical record and care plan/kardex failed to identify the actual program description that was indicated on Resident 60's Occupational Therapy Discharge Summary. Review of Resident 60's clinical record nurse aide task documentation failed to reveal any documentation that the Resident had received their Restorative Nursing Programs or how the Resident tolerated the programs. During an interview with the NHA and Employee 2 on August 29, 2024, at 1:24 PM, the NHA indicated that there was an error in how the restorative program was entered in the electronic health record and, therefore, the task did not trigger for staff to document the provision of the restorative nursing program. He confirmed that he would expect restorative nursing care measures to be provided as recommended and documented accordingly. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(3)(5) Nursing services

Based on review of clinical records and staff interview, it was determined that the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage appropriately, in advance of changes for Medicare covered services, to one of three residents reviewed whose Medicare coverage was discontinued (Resident 341). Findings include: Review of Resident 341's clinical record revealed the Resident was readmitted to the facility on [DATE], after a hospital stay and that their payor source was Medicare A. Skilled services ended on April 14, 2024, and Resident 341's payor source changed to Medicaid at that time, and Resident 341 remained in the facility. Resident 341 was issued a Notice of Medicare Non-Coverage (NOMNC- indicates when your coverage for care is set to end) on April 16, 2024. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, a form provides information that as of a specific date Medicare coverage ends and the specific amount of financial liability passed onto the resident) could not be provided by facility to show that it was provided to Resident 341. During an interview with the Nursing Home Administrator on August 29, 2024, at 1:19 PM, he confirmed that the facility could not provide a copy of the SNF ABN for Resident 341, and confirmed that he would expect that to have been completed and kept on file in Resident 341's medical record. 28 Pa. Code 201.29(c.3)(1) Resident rights

Based on facility policy review, job description review, staff and resident interviews, and clinical record review, it was determined that the facility failed to implement post-discharge needs, including therapy services, nursing services, and medical equipment. This failure resulted in a lack of post-discharge services provided in the community for seven out of 15 discharged residents reviewed (Residents 1, 2, 4, 6, 10, 12, and 15) and placed current residents with active discharge plans in an immediate jeopardy situation (Residents 16-20). Findings Include: Review of the facility's policy, titled Discharge Planning Process, revised November 15, 2022, read, in part, The Center must develop and implement an effective discharge planning process that focuses on the patient's/resident's .discharge goals . and effectively transfer them to post-discharge care. Under the section titled Discharge Planning, the policy continued: Works with patient/resident, family members/significant others and interdisciplinary care team through care planning and utilization management throughout the course of the stay to identify strengths and needs to ensure an appropriate discharge plan is formulated. Develops a system of communication, referral, and collaboration with community-based providers e.g., home health, behavioral health, DME [durable medical equipment] providers, etc. to ensure continuity of care. The Discharge Transition Plan must include a post-discharge plan of care that is developed with the participation of the patient . Where the patient plans to reside, any arrangements that have been made for the patient's follow-up care and any post-discharge medical and non-medical services, also, Liaise with community agencies and care facilities to promote patient access and to address gaps in service. Review of the facility's job description, titled Social Services Specialist 1, revised November 17, 2020, revealed the Social Services Specialist, via discharge planning, Develops a system of communication, referral, and collaboration with community-based providers e.g., home health, behavioral health, DME [durable medical equipment] to assure continuity of care. Based on review of the education and qualifications of the staff person identified as the Social Services Coordinator (Employee 1) it was determined Employee 1 did not meet the requirements to perform those duties, including discharge planning. Review of Resident 1's clinical record revealed diagnoses that included essential hypertension (elevated blood pressure) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). According to documentation, Resident 1 was admitted to the facility on [DATE], and discharged home on January 13, 2024. Review of Resident 1's interdisciplinary progress notes revealed a Social Services note, dated December 21, 2023, that read He [Resident 1] plans to d/c [discharge] to home after skilled nursing and rehab. Will assist with discharge planning needs. The notes continued, He has no current DME [durable medical equipment-Durable medical equipment is any medical equipment used in the home to aid in a better quality of living] and will need all of that set up for him at home. Review of Resident 1's interdisciplinary plan of care revealed the use of a feeding tube (is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation), based on increased nutrient needs related to a diagnosis of Severe Protein-calorie Malnutrition and presence of Pressure Injury. Review of Resident 1's document, titled My Transition Home, revealed a nutrition recommendation to continue education to eat high calorie & protein food for wound healing. Also, recommended feeding tube nutrition for a total of 510 ml (milliliters) per day. The My Transition Home document areas titled My Home Care Agency, My Equipment Provider and My Community Resources and My Primary Care Physician were not completed to detail the after-care agencies set up in the community to include durable medical equipment and other home health services recommended by the interdisciplinary team, including set up and use of the feeding tube. An interview with the staff person identified as the Social Services Coordinator (Employee 1), on January 31, 2024, at 10:19 AM, revealed Resident 1 had been recommended home health services (Health care services given for an illness or injury. Home Health services typically include physical and occupational therapies and nursing services) and follow-up orders for the feeding tube care and supplies; however, those were not set up. Employee 1 stated that Resident 1 refused. Further review of the clinical record revealed no documentation that Resident 1 refused. An interview with the Registered Dietician (Employee 3) on January 31, 2024, at 12:13 PM, revealed the tube feeding was recommended to be continued at home, ordered by the physician due to the Resident's wound healing needs and a lack of sufficient caloric intake. An additional interview with Employee 1 on January 31, 2024, at 12:19 PM, revealed Resident 1 communicated a desire to meet with his Primary Care Physician upon discharge and discuss the facility's recommended home health services and feeding tube orders/supplies. The interview also revealed Employee 1 had not assisted Resident 1 with setting up services, scheduling and documenting an after-care appointment with his Primary Care Physician, providing education on the consequences of not following the recommended discharge planning services, nor communicating this information to the facility's interdisciplinary team, including the physician for continued review and/or evaluation. Review of Resident 2's clinical record revealed diagnoses that included hypertension and chronic kidney disease (a gradual loss of kidney function over time). According to documentation, Resident 2 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the facility's Physical Therapy discharge recommendations revealed Resident 2 to be discharged home with support from others. Also, limited caregiver availability in the morning. Discharge Recommendations included Home with [home health] and family support. Review of Resident 2's My Transition Home document, dated January 13, 2024, revealed no after care instructions or information regarding a Home Care Agency and My Community Resources. Review of a signed physician's order dated January 12, 2024, read, Resident 2 discharged to home on 01/13/24 .Son to set up home health. Review of Resident 2's interdisciplinary progress notes revealed a general note dated January 13, 2024, that read social services to call son about home health referral on Monday. An interview with Employee 1 on January 31, 2024, at 12:19 PM, revealed she doesn't know why home health wasn't set up prior to discharge. The interview revealed an attempt to reach the son post-discharge, however, Employee 1 has not spoken to the son to determine whether the recommended home health and in home services were in place for Resident 2 post-discharge. Review of Resident 4's clinical record revealed diagnoses that included heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen and cellulitis [A common and potentially serious bacterial skin infection]) to the right lower limb and cellulitis to the left lower limb. According to documentation, Resident 4 was admitted to the facility on [DATE], and discharged to home on January 17, 2024. Review of Resident 4's Physical Therapy discharge recommendations read Home with HH [home health] services. Review of Resident 4's progress notes dated January 17, 2024, revealed a general note stating the Resident was referred for home health services for physical therapy, occupational therapy, and nursing services. A phone call placed to the Resident 4 and Resident 4's Representative on February 2, 2024, at 12:21 PM, revealed at discharge they were informed Resident 4 would be provided home health nursing services to include dressing changes for the wounds on Residents 4's leg; however, no home health providers presented to the home post discharge from the facility. According to the follow-up contact with Resident 4's significant other, Resident 4 was readmitted to the hospital and subsequently passed away on January 26, 2024, due to heart failure. Review of Resident 6's clinical record revealed diagnoses that included hypertension and kidney disease. According to documentation, Resident 6 was admitted to the facility on [DATE], and discharged on [DATE]. Review of Resident 6's discharge assessment plan revealed recommendations including: PT/OT (physical therapy and occupational therapy); follow-up with primary care physician in the community; follow-up with outpatient cardiology due to new onset of AFIB (Atrial Fibrillation-An irregular, often rapid heart rate that commonly causes poor blood flow) diagnosis; start Eliquis (Apixaban, sold under the brand name Eliquis, is an anticoagulant medication used to treat and prevent blood clots and to prevent stroke in people with nonvalvular atrial fibrillation); and repeat BMP (basic metabolic panel- a blood test that measures several important aspects of the blood) with primary care physician. Review of Resident 6's clinical record revealed, upon discharge, no evidence of any referrals for home health to include PT/OT services. Also, no evidence of any scheduled appointment or timeframe for an appointment with the primary care physician regarding her laboratory services and medications. Finally, no evidence the Resident was made aware of the necessity of a follow-up with a cardiologist due to the new diagnosis of AFIB and start of an anticoagulant medication. Review of Resident 10's clinical record revealed diagnoses that included chronic pain, opioid dependance, panic disorder and heart disease. According to documentation, Resident 10 was admitted to the facility on [DATE], and discharged to his home on January 9, 2024. Review of a provider note, Resident 10 was recommended to follow-up with his PCP (primary care physician) post-discharge. Review of the provider discharge summary dated January 8, 2024, revealed Meds sent home with patient, states he does not need scripts [prescriptions] sent to pharmacy as he will be following up with PCP soon as has enough to get him to appointment. Review of Resident 10's Transition Home, section H, showed information instructing Resident 10 to follow-up with PCP in one week; however, no date or time for an appointment documented. Therefore, there was no evidence of a follow-up appointment scheduled for Resident 10 to refill his prescriptions upon his return to the community. Review of Resident 12's clinical record revealed diagnoses that included depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities) and secondary malignant neoplasm of the liver (Cancer that begins in the cells of the liver). According to documentation, Resident 12 was admitted to the facility on [DATE] and discharged home on January 26, 2024. Review of Resident 12's progress note revealed documentation by Employee 1 that read Resident's niece requested hospice and a referral was made to a community hospice provider. Additional review of Resident 12's clinical record revealed no documentation of evidence of community hospice services set up for Resident 12 upon discharge. Review of Resident 12's Transition Home document, under Section D, under hospice, read referral made, but failed to include the hospice agency or any contact information for Resident 12 and/or family information upon discharge. Review of Resident 15's clinical record revealed diagnoses that included hypertension and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). According to documentation Resident 15 was admitted to the facility on [DATE], and discharged home on January 31, 2024. Review of Resident 15's progress notes revealed recommendations for home health services as well as a Hoyer lift (an assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power). According to documentation, the Hoyer lift was ordered, however, there was no documentation of when the Hoyer would be arriving at the Resident's home. Continued review of the clinical record revealed home health services were set up on January 29, 2024. According to a progress note post Resident 15's discharge, the selected home health agency did not accept Resident 15's insurance. A social service note dated February 1, 2024, revealed additional home health agency referral, however, Resident 15 was again denied based on his insurance. A final note dated on February 1, 2024, revealed a referral to another home health agency for physical and occupational therapy services. It is not clear if Resident 15 received the recommended home health services or the recommended equipment. An interview with the Nursing Home Administrator (NHA) on January 31, 2024, at 2:15 PM, revealed an acknowledgement of the lack of documentation of aftercare services regarding Resident discharge needs by Employee 1 in the clinical record. An interview with Employee 2 (Director of Rehabilitation) on February 2, 2024, at 10:47 AM revealed that Residents 16 to 20 were anticipating an upcoming discharge to home from the facility at the end of their therapy services. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the NHA on February 2, 2024, at 10:37 AM, for failure to ensure that residents were provided medically related social work services, specifically, discharge planning. The Immediate Jeopardy template was provided to the NHA, and an Immediate action plan was requested. On February 2, 2024, the facility provided the following action plan at 2:04 PM: * The facility will employ a full-time Social Worker. * Social Worker 1 (Employee 6) will be on site 3 days a week. * Social Worker 2 (Employee 7) will be on site 2 days a week. * Residents who were discharged home from January 1st, 2024, to current will be contacted by Employee 6 to ensure their post-discharge nursing and therapy needs and their physical, mental, and psychosocial well-being are being met. * All residents with active discharge planning to home will be reviewed by the social worker to ensure medical equipment, nursing, and therapy services have been arranged, if needed, and accepted by residents for discharge home. * Audits by NHA/Designee will be done daily for one week, and then weekly for one month during interdisciplinary team meetings to ensure medical equipment, nursing, and therapy services have been arranged, if needed, and accepted by residents for residents discharging home. * The social service staff will be educated by the NHA on their responsibility to ensure the physical, mental, and psychosocial needs, as well as equipment and nursing and therapy services, have been arranged upon discharge to home. The implementation of the action plan was verified on February 2, 2024, at 2:19 PM, which included: Acknowledgement of job responsibilities by Employees 6 and 7; Education confirmed with Employees 6 and 7; Employee 6 began contacting all residents discharged [DATE], through current; and Employee 7 began interviewing residents slated for discharge over the weekend to ensure services would be in place. The Immediate Jeopardy was lifted on February 2, 2024, at 3:37 PM. The facility failed to implement post-discharge needs, including therapy services, nursing services, and medical equipment, for three of five discharged residents, resulting in a lack of post-discharge services provided and placed residents with discharge plans requiring medically related social services in an immediate jeopardy situation. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b) (1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services

Based on clinical record review, facility policy review, hospital document review, and staff interviews, it was determined that the facility failed to initiate interventions to prevent wound deterioration and promote wound healing, failed to ensure a wound assessment was conducted weekly, and failed to ensure a worsening wound was assessed by a physician in a timely manner, resulting in harm as evidenced by the worsening of a pressure ulcer for one of four residents reviewed for pressure ulcers (Resident 44). Further, based on observation, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to provide care and services to promote healing and prevent infections for one of four residents reviewed for pressure ulcers (Resident 74). Findings include: Review of facility policy, titled NSG236 Skin Integrity and Wound Management, last reviewed February 1, 2023, revealed the policy stated, A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed . Further review of the policy revealed subsection 6.5 stated, Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. Review of Resident 44's clinical record on October 17, 2023, at approximately 10:30 AM, revealed diagnoses that included central cord syndrome (injury to the spine that results in decreased nerve function for motor and sensory function of the body) and Guillain-Barre syndrome (neurological disorder caused by the immune system attacking the peripheral nervous system that results in possible weakness, paralysis, and sensory deficit). Review of Resident 44's clinical record revealed that, upon admission on August 28, 2023, the Resident was assessed as having a stage I pressure injury (injury to the skin characterized an intact area of skin that is non-blanching redness [turning white when the skin is pressed] caused by pressure over a bony prominence) to the left buttock. Review of Resident 44's comprehensive plan of care revealed Resident 44's plan of care for skin integrity had an incomplete focus and read, At risk for alteration in skin integrity related to [blank]. The care plan was initiated August 28, 2023, and did not identify the actual skin impairment of a stage I pressure injury identified upon admission. Review of the interventions for the plan of care, including any cancelled or resolved interventions, revealed only one intervention of, Pressure redistributing device on bed/chair, which was initiated on September 7, 2023. Review of Resident 44's Bed Mobility (How a resident changes position to and from lying, turning from side to side in bed, and positioning the body) documentation completed by nurse aides, revealed Resident 44 needed extensive staff assistance of one, and sometimes two, staff members and, at times, was totally dependent on staff for bed mobility. Review of Resident 44's Kardex (document that specifies care required for a resident) and nurse aide tasks revealed no turning and repositioning program was in place for Resident 44 during the entirety of Resident 44's stay at the facility. Review of Resident 44's physician orders revealed a treatment ordered for the sacral wound, dated August 28, 2023, to cleanse with normal saline solution, apply Opticell AG (antibacterial dressing used to help control bleeding), and cover with a dressing. Review of a wound assessment conducted by the wound nurse on August 31, 2023, revealed that the pressure ulcer was assessed as a stage II (the wound has loss of skin tissue that extends below the top layer of skin), which was measured at 0.8 centimeters (cm - metric unit of measure) long by 0.8 cm wide and no measurable depth. Review of the assessments Progress section revealed the wound was identified as, New. Review of Resident 44's clinical record revealed no wound assessment (identifying wound/periwound characteristic and/or size) was documented during the following week. Review of a wound assessment dated [DATE], 15 days after the prior wound assessment, revealed the wound had worsened to a Stage III pressure ulcer (wound that extends through the skin into deeper tissue and fat, but does not reach underlying connective tissue of bone, muscle, and/or tendon). Further review of the assessment revealed the wound size had also increased to 2.3 cm in length, 2.2 cm in width, no depth, and 100% slough (dead, moist tissue) at the wound bed. The wound was also assessed as having a moderate amount of serous (clear, thin) drainage. Progress of the wound in the assessment was identified as Deteriorating. Review of Resident 44's wound assessment conducted during the following week on September 20, 2023, revealed the wound had worsened to an unstageable (excessive layer of dead tissue at the wound bed that obstructs the ability to visualize the how deep the wound extends into the body). Review of the assessment revealed the size of the wound increased to 2.6 cm in length, 3.4 cm in width, and no depth. Review of Resident 44's physician orders revealed a change in the pressure ulcer wound dressing to plurogel (gel used on the wound bed to help decrease slough) instead of Opticell Ag on September 20, 2023. Review of physician progress note from September 21, 2023, revealed the physician was assessing Resident 44 for respiratory symptoms. Further review of the physician progress note revealed no physician assessment of Resident 44's worsening pressure ulcer. Review of a physician communication form dated September 21, 2023, completed by facility wound nurse, revealed a request to add a multivitamin, vitamin C, oral zinc supplement, and Prosource 30 milliliters (mL - metric unit of measure) to Resident 44's medication regimen for wound healing. Review of the communication revealed the physician orders were provided on September 25, 2023. Review of wound assessments revealed no wound assessment during the week after the September 20, 2023, wound assessment. Review of Resident 44's clinical record revealed a physician visit conducted by the physician's assistant on October 2, 2023. Review of the progress note by the physician's assistant revealed it was a follow-up visit to the September 21, 2023, visit for respiratory symptoms. Review of the progress note revealed it did not identify or address Resident 44's worsening pressure ulcer. Review of Resident 44's clinical record revealed a referral dated October 3, 2023, referring Resident 44 to Wound Healing Center due to the wound deteriorating. Review of Resident 44's wound assessment conducted on October 5, 2023, 15 days after the prior assessment, revealed the wound continued to be unstageable. The wound also increased in size and was measured at 4.2 cm long, 4.8 cm wide, and 5.0 cm deep. At the time of the assessment, the wound nurse documented tunneling (loss of tissue under the skin from the wound) that was 3.0 cm. The wound also showed signs of infection as evidenced by purulent drainage (white, yellow, or brown thick drainage comprised of white blood cells and bacteria) which was documented as having a strong (foul) odor. Review of Resident 44's physician orders revealed that on October 5, 2023, Resident 44's pressure ulcer dressing treatment was changed to a normal saline wash, soak kerlix with dakins and pack wound, and cover. On October 5, 2023, Resident 44 was also ordered blood work and an x-ray of the wound area to determine the extent of the infection. The x-ray revealed no indication that the infection had spread to Resident 44's bone. Review of Resident 44's clinical record revealed a physician progress note completed by the physician assistant for an assessment conducted on October 6, 2023, which identified Resident 44's sacral wound was assessed by the physician assistant. Review of Resident 44's physician orders revealed that on October 6, 2023, an order was provided to start Resident 44 on Doxycycline 100 mg by mouth (antibiotic) for wound infection. Review of Resident 44's progress notes revealed that on October 12, 2023, during a Wound Healing Clinical outside visit, physicians at the consultative wound clinical sent Resident 44 to the hospital for treatment of pressure ulcer. Review of Resident 44's hospital records revealed evidence that the infection of Resident 44's sacral wound had extended to the bone (osteomyelitis). Review of the hospital interview with Resident 44 revealed that Resident 44 reported lying flat on back without turning for several hours. Review of Resident 44's clinical record revealed physician visits conducted on August 29 and 30, 2023; September 1, 3, 7, 11, 21, and 29, 2023; and October 2, 2023. Review of the physician visit progress notes revealed no assessment or plan for Resident 44's deteriorating sacral pressure ulcer was documented in the progress notes. During a staff interview on October 18, 2023, at approximately 2:35 PM, Director of Nursing (DON) revealed that it was the facility's expectation wound assessments would be conducted weekly. As of October 19, 2023, at 1:00 PM, the facility was unable to provide assessments for the weeks between August 31, 2023, and September 15, 2023; between September 20, 2023 and October 5, 2023; and after October 5, 2023, to transfer out of the facility on October 12, 2023. During the staff interview, the DON revealed it was the facility's expectation that a turning and repositioning program wound be detailed in the Resident's plan of care, nurse aide tasks, and on the Resident's Kardex. As of October 19, 2023, at 1:00 PM, the facility was unable to provide any evidence that a turning and repositioning program was initiated for Resident 44. During the staff interview, the DON was asked what the facility's procedure was regarding when to consult a wound specialist for wound evaluation and care. The DON stated that when a Resident's wound deteriorates and that it is different for each wound and/or Resident. Review of the facility wound management policy revealed no guidance on requesting wound specialist treatment for the management of wounds. Review of facility policy, titled Wound Dressing: Aseptic, last reviewed April 2023, revealed that subsection 27 stated to, Apply prepared label to a clean dressing after applying and securing the dressing to a resident wound. Review of Resident 74's clinical record on October 19, 2023, at approximately 11:00 AM, revealed diagnoses including diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and cerebral infarction (stroke - sudden loss of blood supply to the brain). During wound dressing observation on October 18, 2023, at approximately 1:48 PM, Employee 21 (Facility Wound Nurse) was observed removing the old dressing from Resident 74's sacral pressure ulcer. Observation of the old dressing revealed it did not contain a label, was not dated, and did not have initials of the nurse that applied the dressing. During the observation, Employee 21 confirmed that there was no label, initials, or date on the prior dressing. Further, Employee 21 revealed that it was the facility's policy to label a wound dressing with initials and date it was applied. During a staff interview on October 19, 2023, at approximately 10:30 AM, DON revealed it was the facility's expectation that wound dressings are labeled. 28 Pa code 201.14(a) Responsibilities of licensee 28 Pa code 201.18(b)(1) Management 28 Pa code 211.2(d)(3) Medical director 28 Pa code 211.12(d)(1)(3)(5) Nursing services

Based on clinical record review, facility documentation review and staff interview, it was determined that the facility failed to provide the necessary interventions to ensure residents were free of accident hazards resulting in a fall, laceration to the forehead, transfer to the hospital and sutures for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record on (MONTH) 28, (YEAR), at approximately 1:00 p.m. revealed [DIAGNOSES REDACTED]. Review of Resident 1's comprehensive plan of care revealed Resident 1 was care planned for assistance due to a self-care deficit with activities of daily living (ADLs - bathing, grooming, dressing). Review of the care plan for ADL assistance revealed an intervention, dated (MONTH) 1, (YEAR), for Resident 1 to have assistance of 2 staff for care to meet her ADL needs. Review of facility investigation documentation regarding a fall that Resident 1 experienced on (MONTH) 5, (YEAR), at approximately 11:00 p.m. revealed that Nursing Assistant (NA) 2 was providing incontinence care to Resident 1 without the required second staff person. NA 2 rolled the resident away from her and the resident rolled out of the bed onto the floor. Resident 1 sustained a laceration to the frontal area of the head that required sutures. During an interview with the Nursing Home Administrator on (MONTH) 7, (YEAR), at approximately 2:30 p.m. she revealed that NA 2 did not follow Resident 1's plan of care and should have had the 2nd staff person to perform the ADL care. The facility failed to provide the necessary interventions to ensure residents were free of accident hazards resulting in a fall, laceration to the forehead, transfer to the hospital and sutures to Resident 1. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 1/26/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 1/26/17. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/18/17. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 2/15/18. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/15/18, 7/25/17, 5/23/17, 1/26/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/15/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/15/18, 7/25/17, 6/18/17, 5/23/17, 1/26/17.

Based on clinical record review and staff interview, it was determined that the facility neglected to provide the services to a resident that are necessary to avoid physical harm which resulted in a fall, laceration to the forehead, transfer to the hospital and sutures, for one of three residents reviewed (Resident 1). Findings include: Review of the facility's policy titled, 7 Step Abuse Policy, last reviewed (MONTH) (YEAR), details Prevention, Screening, Identifying,Training, Protecting, Investigating, and Reporting Trigger Events of abuse. During an interview with the Nursing Home Administrator on (MONTH) 11, (YEAR), at approximately 9:00 a.m. she stated the facility doesn't have a specific policy titled neglect and so they utilize the, 7 Steps of Abuse Policy policy for all types of abuse. Review of Resident 1's clinical record revealed [DIAGNOSES REDACTED]. Review of Resident 1's comprehensive plan of care revealed Resident 1 was care planned for assistance due to a self-care deficit with activities of daily living (ADLs - bathing, grooming, dressing). Review of the care plan for ADL assistance revealed an intervention, dated (MONTH) 1, (YEAR), for Resident 1 to have assistance of 2 staff for care to meet her ADL needs. Review of the facility report titled, Incident Report, (a form used by the facility to investigate resident incidents) dated (MONTH) 6, (YEAR), revealed that Nursing Assistant (NA) 2 was providing incontinence care to Resident 1 without the required second staff person. NA 2 rolled the resident away from her and the resident rolled out of the bed onto the floor. Resident 1 sustained a laceration to the frontal area of the head that required sutures. The facility described the laceration to be 4 centimeters (cm) in length (metric measurement 2.5 cm equals 1 inch) and required the resident to be transferred to the hospital. Based on the hospital report dated (MONTH) 6, (YEAR), revealed the laceration measured 5.5 centimeters (metric measurement- 2.5 cm equals one inch) and required seven sutures. During an interview with the Nursing Home Administrator on (MONTH) 7, (YEAR), at approximately 2:30 p.m. she revealed that NA 2 did not follow Resident 1's plan of care and should have had the second staff person to perform the ADL care. The facility neglected to provide the services to a resident that are necessary to avoid physical harm which resulted in a fall, laceration to the forehead, transfer to the hospital and sutures for Resident 1. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 1/26/17. 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 1/26/17. 28 Pa. Code 201.29(a)(c)(d) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. Previously cited 6/18/17. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 2/15/18, 7/25/17, 5/23/17, 1/26/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/15/18. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 2/15/18, 7/25/17, 6/18/17, 5/23/17, 1/26/17.

Based on review of clinical records, resident incident reports and interviews with staff, it was determined that the facility failed to implement planned interventions to prevent an accident which resulted in injury, a laceration to the head, for one of 24 residents reviewed (Resident 24). Findings include: Review of the clinical record for Resident 24 revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 24's comprehensive admission Minimum Data Set assessment (MDS - a tool used to determine care needs) dated August 23, 2017, revealed a BIMS (Brief Interview of Mental Status) of 3 (severely cognitively impaired), bed mobility (the ability to turn side to side) required the assistance of two staff, range of motion (movement) was limited and the resident had a fall prior to admission. Review of the facility's incident reports revealed that Resident 24 had a fall on August 21, 2016, at 11:15 p.m. The new intervention that was put into place following the fall was a bed bolster (a body pillow). Review of Resident 24's task list (part of the care plan that lists the care a resident requires) dated August 22, 2016, revealed bolster with no indication of type and where and when to use. Review of the physician's orders [REDACTED]. Continued review of the incident reports revealed that Resident 24 had another fall on August 22, 2016, at 11:15 p.m. resulting in a laceration to the head. Resident 24 was sent to the hospital for evaluation and returned to the facility with 6 sutures to the head. Review of the facility's investigation revealed that Resident 24 did not have the bed bolster in her bed at the time of the second fall. Review of a witness statement by Nurse Aide (NA) 1 dated August 23, 2016, revealed that Nurse Aide 1 admitted that she did not put the bed bolster in the bed. During an interview on January 24, 2017, at 1:40 p.m. the Nursing Home Administrator confirmed that the bed bolster should have been in place. 28 Pa. Code 211.11(a) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/27/16, 4/25/16, 3/10/16, 2/4/16, 9/8/15, 1/14/15.

Based on a review of clinical records, facility documentation, facility policy and interviews with facility staff, it was determined that the facility failed to develop an appropriate plan of care, provide adequate supervision and monitoring to prevent accidents for four of 14 residents reviewed (Residents 2, 10, 13, 21). Findings include: Review of the facility's Fall Process Flow sheet, reviewed January 2014 indicates that residents are assessed for falls, a care plan is developed or revised, implemented and evaluated. Review of Resident 13's clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her care plan was initiated on November 14, 2013 and she was identified as at risk for falls. A fall care plan was developed that included encourage to transfer and change positions slowly, provide assist to transfer and ambulate as needed and reinforce need to call for assistance. Review of the facility's incident reports dated December 5, 2013, revealed Resident 13 had two falls that day. The first one occurred at 9:40 a.m. when she was found on the floor in the hallway after having been observed standing several times and observed once pushing her wheelchair down the hallway. She sustained no injury. The intervention implemented was to be seen by the nurse practitioner who reviewed the resident's medication and ordered Vitamin D. The second fall occurred at 7:00 p.m. when the resident was found on the floor in the hallway again, having been in a reclining position in her wheelchair. The incident report indicates that 10 minutes prior, the resident had been taken to the bathroom, she then asked to go to bed but was put in her chair and placed in the hallway where a visitor subsequently observed her on the floor. She complained of left shoulder and arm pain. An xray was taken and revealed a non-displaced fracture of the left proximal humerus. Review of Resident 21's clinical record revealed an admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her care plan was initiated on January 30, 2014 and she was identified as at risk for falls. A fall care plan was developed that included reinforce need to call for assistance. Review of the facility's Incident Report dated February 1, 2014 indicates she had a fall at 7:50 a.m. when she got tangled up in the bed sheets causing her to trip and fall. She sustained no injury. Her statement included in the report says that she had called for assistance before getting up to go to the bathroom. The care plan was updated to include educate resident to use call light for assistance. During an interview on February 5, 2014 at 11:15 a.m. with the Director of Nursing and revealed that the intervention for Resident 13 was appropriate but did not prevent the second fall that same day. In an interview with the DON and NHA on February 6, 2014 at 11:00 a.m. they confirmed that the intervention for Resident 21 (to call for assistance) was a duplication of one already included in the care plan. In an interview with the Regional Director on February 6, 2014 at 2:30 p.m., she stated that the interventions implemented for Resident 13's falls on December 5, 2014 (medication review and placement of resident in reclining chair in the hallway) were appropriate. Clinical record review revealed that Resident 10 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident 10's clinical record revealed that Resident 10 is at risk for falls and has a care plan for falls due to unsteady gait and history of falls. Review of fall reports revealed that resident had four falls in March 2013 with no new fall interventions added to the care plan. Resident 10 also had four falls in April 2013 with no revision to fall interventions for plan of care. Resident 10 had five falls in August 2013 with one new intervention to keep head of bed elevated while in bed. In September 2013, Resident 10 had four falls and in October 2013 he had four falls both with no new fall interventions put into place. Clinical record review for Resident 2 revealed a [DIAGNOSES REDACTED]. The resident care plan revealed a focus area of risk for falls due to impaired balance, unsteady gait, syncope, decline in function/mobility and physical impairment due to left below knee amputation. Review of Resident 2's care plan revealed that the last new intervention to prevent falls was initiated on February 13, 2013 for a new antibiotic order. Review of fall reports revealed that resident has had 8 falls with no updated interventions to prevent falls. 28 Pa. Code: 201.18(b)(1)(e)(1) Management. Previously cited 2/21/13, 11/19/13 28 Pa. Code: 211.11(a)(c) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. Previously cited 2/21/13 , 11/19/13