Every finding on record at Loyalhanna Care Center

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food under sanitary conditions.Findings include: The facility's policy for food safety requirements dated January 1, 2026, revealed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety, which included keeping foods covered or in tight containers. Observations in the kitchen on August 26, 2026, at 9:54 a.m. revealed that the scoop for the powdered sugar was in the plastic powder sugar container, and the lid to the Thick-it (a powdery additive used to thicken liquids for residents with swallowing difficulties) storage container was not secured to the container. Interview with the Dietary Manager on August 26, 2026, at that time, confirmed that the scoop should not have been stored in the plastic powder sugar container, and the lid to the Thick-it container should have been firmly secured. Interview with the Nursing Home Administrator on August 26, 2026, at 14:50 p.m. confirmed that the powder sugar and Thick-it were not properly stored in the kitchen, and they should have been. 28 Pa. Code 211.6(f) Dietary Services.

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to accurately transcribe physician's orders for one of 15 residents reviewed (Resident 2).Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 29, 2026, indicated that the resident was cognitively intact, required assistance with care needs, received antipsychotic and antianxiety medications( psychotropic medications used to treat mental health disorders by altering brain chemistry), and had diagnoses that included depression, anxiety and bipolar disorder (a mental health condition causing mood swings including emotional highs and lows). Physician's orders for Resident 2, dated April 29, 2026, included an order for the resident to receive 20 milligrams (mg) of Olanzapine (Zyprexa) (an antipsychotic medication) daily at bedtime for bipolar disorder. A physician's note for Resident 2, dated August 11, 2026, at 5:17 p.m. included orders for a gradual dose reduction (GDR-the systematic, stepwise lowering of a medication dose over time) of the resident's Zyprexa and to decrease the medication to 15 mg nightly. A nursing note for Resident 2, dated August 12, 2026, at 12:38 a.m. revealed that the resident was seen by the physician and new orders were obtained to decrease the resident's Zyprexa to 15 mg at bedtime. Review of Resident 2's Medication Administration Record (MAR), dated August 2026, revealed that as of August 12, 2026, the resident's Zyprexa was discontinued. Interview with the Director of Nursing on August 25, 2026, at 4:53 p.m. confirmed that Resident 2's Zyprexa was discontinued and not decreased as ordered on August 11, 2026. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident received proper care for an indwelling urinary catheter for one of 15 residents reviewed (Resident 7). Findings include: The facility's policy regarding urinary catheters (a tube inserted and held in the bladder to drain urine), dated January 1, 2026, indicated that the purpose of the policy was to ensure safe handling of the urinary catheter in order to reduce the risk of urinary tract infections, and ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was cognitively intact was understood and able to understand, had an indwelling urinary catheter and had diagnoses that included urinary retention (inability to fully empty the bladder) related to an enlarged prostate gland. Observations on August 26, 2026, at 12:18 p.m. revealed that Resident 7 was in his room sitting in his wheelchair eating his lunch, his catheter drainage bag was attached to the chair by his waist, which made the catheter drainage bag above the level of his bladder. Interview with Nurse Aide 1 on August 26, 2026, at 12:22 p.m. confirmed that Resident 7's catheter drainage bag should not have been attached to his chair at his waist level and that the tubing and bag should have been below the level of his bladder to prevent a backflow of urine. Interview with the Nursing Home Administrator on August 26, 2026, at 2:22 p.m. confirmed that Resident 7's catheter drainage bag should have been below the level of his bladder, and it was not. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for one of 35 residents reviewed (Resident 8).Findings include:The facility's policy regarding psychotropic medication use, dated January 1, 2026, indicated that psychotropic medications used on a PRN (as needed) basis must have a diagnosed specific condition and indication for use documented in the resident's medical record. Orders for PRN psychotropic medications, excluding antipsychotics, were to be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it was appropriate to extend the order beyond the 14 days. The medical record was to include documentation from the physician or prescriber for the rationale for the extended time period and was to indicate a specific duration.A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 8 dated February 28, 2026, indicated that the resident had cognitive impairment, required assistance from staff for daily care needs, received an anti-anxiety medication, and had a diagnosis of dementia.Physician's orders for Resident 8 dated November 27, 2025, included an order for the resident to receive 0.50 milligrams (mg) of Ativan (an antianxiety medication) every four hours as needed for restlessness/anxiety for 14 days.Review of the Medication Administration Records (MAR) for Resident 8 dated December 2025, and January, February and March 2026 revealed that 0.50 mg of Ativan was administered to the resident on December 2, 5-7, 9, 18, 19, 23, 24, and 27, 2025; January 2, 4, 9, 11, 22, 24, 25, 28, and 30; February 4, 5, 7, 9-11, 13, 17, 20, 21, 23-25; and March 2, 4-6, 8, 10, 12, 14, 15, 18-21, and 23, 2026. There was no evidence of a physician's order to continue the as needed Ativan beyond the 14 days ordered on November 27, 2025, and there was no documentation by a practitioner that included the rationale for extending the as needed Ativan beyond 14 days.Interview with the Director of Nursing on April 1, 2026, at 10:02 a.m. confirmed that there was no physician's order to continue the as needed Ativan beyond the initial order of 14 days or documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Ativan for Resident 8 beyond 14 days.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory results as ordered by the physician for one of 35 residents reviewed (Resident 6), failed to ensure that bowel protocols were followed as ordered by the physician for one of 35 residents reviewed (Resident 8), and failed to provide pain medication as ordered by the physician for one of 35 residents reviewed (Resident 9). Findings include:An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 27, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Physician's orders for Resident 6, dated March 17, 2026, included an order to call the dialysis center to obtain most recent lab results.Review of Resident 6's clinical record revealed no documented evidence that lab results were obtained by the facility.Interview with the Director of Nursing on April 1, 2026, at 2:17 p.m. confirmed that the physician's orders to obtain lab results for Resident 6 were not followed.A quarterly MDS assessment for Resident 8, dated February 28, 2026, revealed that the resident was cognitively impaired, was frequently incontinent of bowel movements, and had a diagnosis of dementia.Physician's orders for Resident 8, dated November 21, 2025, included orders for the resident to receive 30 milliliters of Milk of Magnesia as needed for constipation if no bowel movement by the third day; a 10 milligram Bisacodyl suppository rectally as needed if the Milk of Magnesia was not effective ; and a Fleets enema to be given rectally as needed for no bowel movement after the Milk of Magnesia and Bisacodyl suppository was given.Review of Resident 8's bowel records for January and February 2026 revealed that there was no documented evidence that the resident had a bowel movement from January 20 through 23 and February 10 through 13, 2026.Review of the January and February Medication Administration Records (MAR's) for Resident 8 revealed that staff did not initiate or follow the bowel protocol as ordered by the physician.Interview with the Director of Nursing on April 1, 2026, at 2:13 p.m. confirmed that the physician's orders for bowel medications were not followed for Resident 8.The facility's medication administration policy, dated January 1, 2026, indicated that medications were to be administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice.The facility's policy regarding pain management, dated January 1, 2026, indicated that the facility was to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.An annual MDS assessment for Resident 9, dated February 9, 2026, revealed that the resident was moderately cognitively impaired, had pain almost constantly, received routine and as needed pain medications, and had diagnoses that included arthritis.A physician's order for Resident 9, dated June 11, 2025, included orders for the resident to receive 5-325 mg of Hydrocodone-Acetaminophen (narcotic pain medication) every six hours as needed for severe pain (a pain rating of 7-10) or per resident preference.A review of Resident 9's MARs for January, February, and March 2026 revealed that staff administered 5-325 mg of Hydrocodone-Acetaminophen on February 12 at 10:01 a.m. when the resident's pain level was a five, on March 6 at 7:30 p.m. when the resident's pain level was a one, and on January 1 at 8:09 a.m., January 3 at 9:50 a.m., January 7 at 9:32 a.m., January 17 at 9:39 a.m., , January 19 at 1:06 a.m., January 21 at 4:58 p.m., January 22 at 9:21 a.m., January 23 at 9:30 a.m., January 28 at 4:53 a.m., January 29 at 12:11 a.m., and January 31 at 9:41 a.m.; February 1 at 12:57 a.m. and 9:18 a.m., February 3 at 7:23 p.m., February 4 at 9:12 a.m. and 10:24 p.m., February 5 at 9:30 a.m., February 8 at 8:48 p.m., February 9 at 9:53 a.m., February 10 at 9:12 a.m., February 11 at 12:51 a.m. and 12:09 p.m., February 14 at 10:16 a.m., February 15 at 12:20 a.m., February 17 at 7:11 p.m., February 18 at 8:30 p.m., February 19 at 9:15 a.m. and 11:56 p.m., February 20 at 9:08 a.m., February 23 at 7:39 a.m., February 25 at 12:02 a.m., February 26 at 1:52 a.m. and 11:45 p.m., and February 28 at 12:48 a.m.; and March 4 at 8:48 p.m., March 5 at 9:14 a.m., March 6 at 12:42 a.m., March 7 at 3:35 p.m., March 10 at 10:58 p.m., March 12 at 12:47 a.m., March 13 at 1:30 a.m., March 14 at 7:48 p.m., March 17 at 8:59 p.m., and March 18, 2026 at 2:05 p.m. when the resident's pain level was a six.Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that staff did not administer Resident R9's pain medication as ordered by the physician.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, facility contracts, clinical records, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication and collaboration for two of three residents reviewed for dialysis (Residents 6 and 86), and failed to provide a hemodialysis bedside emergency kit for bleeding (a kit that contains several items including a tourniquet, dressings and gloves) for one of three dialysis residents reviewed (Resident 86).Findings include:The facility's policy regarding hemodialysis, dated January 1, 2026, indicated that the facility would provide the necessary care and treatment consistent with professional standards, which includes the ongoing assessment of the residents' condition and monitoring for complications before and after dialysis treatment.Review of the dialysis contract, dated May 3, 2023, revealed that the nursing facility shall provide ongoing communication with the dialysis center in order to maintain safe and appropriate care.An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 27, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Physician's orders for Resident 6, dated November 18, 2025, included an order that the resident was to receive dialysis on Monday, Wednesday and Friday.Review of Resident 6's clinical record, revealed limited evidence resident assessments or communication related to the residents health status before and after dialysis was being shared between the facility and the dialysis centerAn admission MDS assessment for Resident 86, dated January 17, 2026, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and was receiving dialysis.Review of Resident 86's clinical record revealed an readmission date of January 13, 2026, with diagnoses that included end-stage renal disease and diabetes.Current physician's orders for Resident 86 revealed orders that included dialysis every Tuesday, Thursday, and Saturday at 11:00 a.m.Review of Resident 86's clinical record revealed limited evidence of communication between the facility and dialysis clinic. Dialysis communication documentation included January 15, and 21, 2026. Observations on April 2, 2026, at 12:10 p.m. revealed that there was no hemodialysis emergency kit located in the resident's room.Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that Residents 6 and 86 had no or limited evidence of ongoing communication and collaboration between the facility and dialysis clinic, and also confirmed that Resident 86 should have had an emergency hemodialysis kit at bedside.28 Pa. Code 211.5(f)(viii) Medical Records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.Findings include:The facility's policy regarding hemodialysis, dated January 1, 2026, indicated that the facility would provide the necessary care and treatment consistent with professional standards, which includes the ongoing assessment of the residents' condition and monitoring for complications before and after dialysis treatment.Review of the dialysis contract, dated May 3, 2023, revealed that the nursing facility shall provide ongoing communication with the dialysis center in order to maintain safe and appropriate care.An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 27, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had a diagnosis of end-stage renal disease (ESRD - a permanent condition that occurs when the kidneys are no longer able to function properly), and was receiving dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). Physician's orders for Resident 6, dated November 18, 2025, included an order that the resident was to receive dialysis on Monday, Wednesday and Friday.Review of Resident 6's clinical record, revealed limited evidence resident assessments or communication related to the residents health status before and after dialysis was being shared between the facility and the dialysis centerAn admission MDS assessment for Resident 86, dated January 17, 2026, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and was receiving dialysis.Review of Resident 86's clinical record revealed an readmission date of January 13, 2026, with diagnoses that included end-stage renal disease and diabetes.Current physician's orders for Resident 86 revealed orders that included dialysis every Tuesday, Thursday, and Saturday at 11:00 a.m.Review of Resident 86's clinical record revealed limited evidence of communication between the facility and dialysis clinic. Dialysis communication documentation included January 15, and 21, 2026. Observations on April 2, 2026, at 12:10 p.m. revealed that there was no hemodialysis emergency kit located in the resident's room.Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that Residents 6 and 86 had no or limited evidence of ongoing communication and collaboration between the facility and dialysis clinic, and also confirmed that Resident 86 should have had an emergency hemodialysis kit at bedside.28 Pa. Code 211.5(f)(viii) Medical Records.28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for four of 35 residents reviewed (Residents 2, 4, 76, 86). Findings include: The facility's policy for medication administration, dated January 1, 2026, indicated that staff are to sign the Medication Administration Record (MAR) after a medication is administered, and if the medication is a controlled substance, staff are to sign the narcotic book. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 28, 2026, indicated that the resident was cognitively intact, was independent for most daily care needs, had diagnosis that included Fibromyalgia, (long-term condition that involves widespread body pain), and was receiving routinely scheduled and as needed pain medication. Physician's orders for Resident 2, dated January 17, 2026, included for the resident to receive 5-325 milligrams (mg) of hydrocodone-acetaminophen (a narcotic pain medication) to be administered every 12 hours as needed for pain. Review of the controlled drug records (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 dated January 26, 2026, February 12, 2026, and February 26, 2026, revealed that a 5-325 mg hydrocodone-acetaminophen tablet was signed out on February 1, 2026, at 9:30 p.m.; February 7, 2026, at 10:00 p.m.; February 22, 2026, at 9:00 p.m.; March 6, 2026, at 9:00 p.m.; March 7, 2026, at 9:00 p.m.; March 13, 2026, at 9:00 p.m.; March 15, 2026, at 9:00 p.m.; and March 21, 2026, at 9:00 p.m. However, there was no documented evidence in Resident 2's clinical record that the signed-out doses of controlled medication were administered to the resident on the above-mentioned dates and times. A quarterly MDS assessment for Resident 4, dated January 17, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included Multiple Sclerosis (a chronic autoimmune disease where the immune system mistakenly attacks the protective coating of nerves in the brain and spinal cord), and was receiving routinely scheduled and as needed pain medication. Physician's orders for Resident 4, dated May 7, 2025, included an order for the resident to receive 5 mg of oxycodone (a narcotic pain medication) every four hours as needed for moderate to severe pain. Review of the controlled drug record for Resident 4 dated March 2026, revealed that 5 mg of oxycodone was signed out to be administered on March 7, 2026, at 1:30 a.m.; March 13, 2026, at 9:00 p.m.; March 14, 2026, at 11:44 p.m.; March 15, 2026, at 10:00 p.m.; and March 21, 2026, at 6:30 p.m. However, there was no documented evidence in Resident 4's clinical record that the signed-out doses of oxycodone were administered to the resident on the above-mentioned dates and times. A quarterly MDS assessment for Resident 76, dated January 11, 2026, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had diagnoses that included multiple sclerosis, and was receiving routinely scheduled and as needed pain medication. Physician's orders for Resident 76, dated February 5, 2026, included an order for the resident to receive 10 mg of oxycodone every four hours as needed for breakthrough pain. Review of the controlled drug records for Resident 76 dated February and March 2026, revealed that 10 mg of oxycodone was signed out to be administered on February 22, 2026, at 8:00 p.m.; February 28, 2026, at 9:00 p.m.; March 7, 2026, at 1:30 a.m.; March 10, 2026, at 4:25 p.m.; March 13, 2026, at 8:00 p.m.; March 14, 2026, at 1:00 a.m.; March 15, 2026, at 8:10 p.m.; March 16, 2026, at 1:15 a.m.; March 19, 2026, at 8:00 p.m.; and March 20, 2026, at 12:20 a.m. However, there was no documented evidence in Resident 4's clinical record that the signed-out doses of controlled medications were administered to the resident on the above-mentioned dates and times. An admission Minimum Data Set assessment for Resident 86, dated January 17, 2026, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included left hip fracture and chronic renal failure. Physician's orders for Resident 86, dated January 16, 2026, included an order for the resident to receive 5 mg of oxycodone every six hours as needed for pain. Review of the controlled drug record for Resident 86, dated February 2026, revealed that 5 mg of oxycodone was signed out on February 26, 2026, at 4:23 p.m. and February 28, 2026, at 8:15 a.m. However, there was no documented evidence in Resident 86's clinical record that the signed-out doses of controlled medications were administered to the resident on the above-mentioned dates and times. Interview with the Director of Nursing on April 1, 2026, at 2:12 p.m. confirmed that there was no documented evidence in the clinical records of Residents 2, 4, 76 and 86 to indicate that the signed-out doses of controlled medications mentioned above were administered. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on a review of facility policy, resident interviews, observations, and staff interviews, it was determined that the facility failed to ensure that residents received foods that were served at appetizing temperatures. Findings include:The facility's policy regarding Food Temperatures, dated January 1, 2026, revealed that the facility will monitor food temperatures daily to ensure food is at the proper serving temperatures.Interview with a group of residents on March 31, 2026 at 11:00 a.m. revealed that their food is served cold when eating in the dining room. They stated that the food comes from the kitchen to the dining room and it is cold.Observations of tray line on March 31, 2026 at 12:08 p.m. revealed that the dietary staff were preparing the plates for the dining room. The plates were made and then placed on the trays for delivery into the dining room. There were no lids or covers placed over the food to keep it warm and there were times that the plate of food sat on the tray line for approximately five minutes before going to the dining room. The plates were then carried into the dining room with no lid or cover over the food. A test tray was requested from the kitchen on March 31, 2026 at 12:28 p.m. after the last of the residents in the dining room had been served. The test tray was served from the steam tables in the kitchen. At 12:34 p.m. the test tray temperature of the pureed lasagna was 114.9 degrees Fahrenheit and tasted cold, the temperature of the peas and carrots was 120.5 degrees F and tasted cold. The temperature of these items were cold to taste and not appetizing. An interview with the Regional Dietary Manager on March 31, 2026 at 12:30 p.m. revealed that the pureed lasagna and the peas and carrots should have been warm and not cold when served.28 Pa. Code 201.18(b)(1)(e)(1) Management.

Based on a review of facility policy, observations and staff interviews, it was determined that the facility failed to ensure that the proper food consistency was prepared for residents receiving a pureed diet as ordered by the physician. Findings include: The facility's policy regarding Therapeutic Diet Orders, dated January 1, 2026, revealed that residents would be provided food in the appropriate from as prescribed by the physician.The facility's menu for pureed lasagna for the meal served on March 31, 2026, revealed that the pureed lasagna should be placed into a food processor, blended until smooth and then staff should use the fork drip test and the spoon tilt test to confirm the texture is within the specifications.Observations during the lunch meal on March 31, 2026 at 12:28 p.m. revealed that the pureed lasagna had chunks in it that needed to be chewed. Interview with the Regional Dietary Manager on March 31, 2026 at 12:30 p.m. confirmed that the pureed lasagna had chunks in it and that it should not have.28 Pa. Code 211.12(d)(3) Nursing services. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain the dignity of one of 35 residents reviewed (Resident 94) who had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine).Findings include:A facility policy for Catheter Care dated January 1, 2026, indicated it is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.Review of clinical records for Resident 94 revealed he was admitted to the facility on [DATE], with an indwelling urinary catheter, and had diagnosis that included neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). Observations of Resident 94 on March 30, 2026, at 10:50 a.m. revealed the resident laying in his bed with his urinary catheter drainage bag containing urine hanging on his bed frame and visible from the hallway.Interview with Nurse Aide 1 on March 30, 2026, at 10:54 a.m. revealed that the resident should have a privacy bag for his urinary catheter drainage bag. Interview with the Director of Nursing on March 31, 2026, 3:07 p.m. revealed that Resident 94's urinary catheter drainage bag should have had a privacy cover. 28 Pa. Code 201.29(c) Resident Rights.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 35 residents reviewed (Residents 2, 28, 35). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (a mandated assessment of a resident's abilities and care needs), dated October 2025, revealed that Section N0415A1 (Antipsychotic) was to be checked if the resident took the medication during the seven-day look-back period; and Section N0450A (Antipsychotic Medication Review) was to be coded (1) Yes if the resident took an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment, whichever was most recent. If the resident took an antipsychotic routinely, then Section N0450B (Has a gradual dose reduction been attempted) was to be coded (0) for no and (1) yes. If (1) yes was coded, then staff were to include the date that the Gradual Dose Reduction (GDR) was attempted. Section N0450D (Has a physician documented the GDR as clinically contraindicated) was to be coded (0) for no and (1) yes. If (1) yes was coded, staff were to include the date that the GDR was documented as clinically contraindicated. A care plan for Resident 2 dated March 24, 2025, indicated that the resident was receiving antipsychotic medications and that a GDR was documented as contraindicated on January 19, 2026, and February 6, 2026. A psychiatry note for Resident 2, dated February 6, 2025, indicated that a GDR of antipsychotic medications was clinically contraindicated because an attempted reduction would likely cause a recurrence of symptoms, would likely impair the resident's function, and would likely cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Review of the Medication Administration Record (MAR) for Resident 2, dated February 2026, revealed that the resident received antipsychotic medications at bedtime daily for the entire month. A quarterly MDS assessment for Resident 2, dated, February 28, 2026, revealed that Section NO415A1 was checked to indicate that the resident received an antipsychotic medication during the seven day look back period and Section N0450A was coded (1) yes, to indicate that the resident received an antipsychotic medication routinely since admission/entry or re-entry or the prior OBRA assessment; Section 0450B was coded (0) No, indicating that the resident did not receive a GDR and Section N0450D was coded (0) No, indicating that a physician had not documented that a GDR was clinically contraindicated. Interview with the Registered Nurse Assessment Coordinator on February 28, 2026, at 12:06 p.m. confirmed that Resident 2's MDS dated [DATE], was coded inaccurately regarding the GDR of antipsychotic medications. The RAI Manual, dated October, 2025, revealed that Section B0200 was to capture hearing, and the section was to be coded zero (0) adequate, one (1) for minimally impaired, two (2) for moderately impaired, or three (3) for highly impaired. A care plan for Resident 28, dated May 2, 2025, indicated that the resident had a communication problem related to a hearing deficit. Interviews with the resident during the survey March 30 - April 2, 2026, revealed that the surveyor had to speak loudly and directly to the resident for him to hear and understand. Interview with Resident 28's daughter on April 1, 2026, at 9:25 a.m. revealed that her father has never had a hearing aid and that sometimes she must yell repeatedly so he can hear her. However, a quarterly MDS assessment for Resident 28, dated January 24, 2026, revealed that Section B0200 was coded with a zero (0), indicating that the resident's hearing was adequate. Interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC) on April 1, 2026, at 9:30 a.m. confirmed that Resident 28's hearing was impaired during the MDS review period and Section B0200 of the MDS assessment of January 24, 2026, should have been coded three (3) for moderately impaired. The RAI User's Manual, dated October 2025, indicated that the intent of Section N was to record the number of days, during the seven-day assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415G1 was to be coded if the resident received a diuretic medication (water pill) during the seven-day assessment period. Physician's orders for Resident 35, dated February 28, 2026, included orders for the resident to receive 20 milligrams (mg) of Furosemide (diuretic) daily for heart failure. Review of the Medication Administration Record (MAR) for March 2026 revealed that the resident received Furosemide during the assessment period. However, an admission MDS assessment for Resident 35, dated March 2, 2026, revealed that Section N0415G1 was coded to indicate that the resident had not received a diuretic medication. Interview with the Director of Nursing on April 2, 2026, at 12:34 p.m. confirmed that MDS assessment for Resident 35 was coded inaccurately. 28 Pa. Code 211.5(f) Clinical records

Based on review of policies and clinical records reviews, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of one of 35 residents reviewed (Resident 3). Findings include:The facility's policy regarding comprehensive care plans, dated January 1, 2026, indicated that the facility will develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, and all services that are identified in the resident's comprehensive assessment, and meet professional standards of quality. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3 dated March 13, 2026, indicated the resident was cognitively intact, was independent for most of her daily care needs, and was frequently incontinent of bowel. Review of Resident 3's bowel record dated March 3, 2026, through April 1, 2026, indicated that the resident was incontinent of bowel five times.There was no documented evidence that a care plan was developed to address Resident 3's specific and individualized care needs related to being frequently incontinent of bowel.Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that an individualized care plan and interventions was not developed related to Resident 3 being incontinent of bowel and should have been. 28 Pa. Code 211.12(d)(5) Nursing Services.

Review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise/update care plans for three of 35 residents reviewed (Residents 28, 76).Findings include: The facility's policy regarding care plans, dated January 1, 2026, indicated that the purpose was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The care plan will be updated with the new or modified interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated January 24, 2026, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs and had diagnoses that included, benign prostatic hyperplasia (enlargement of the prostate gland that squeezes the urethra, which causes symptoms of frequent urination and difficulty starting urination), and had an indwelling urinary catheter (a flexible thin tube inserted through the urethra and into the bladder to allow for urine drainage) in place. Resident 28 utilized a leg bag (a bag strapped to his upper thigh or leg) to collect the urine during his waking hours. Physician's orders for Resident 28, dated January 21, 2026, included an order for a 16 French foley catheter. Observations of Resident 28, on March 30, 31 and April 1, 2, 2026, at 10:30 a.m., 1:02 p.m., 9:25 a.m., and 12:10 p.m. respectively, revealed that he was wearing a leg bag. Interview with Resident 28's daughter on April 1, 2026, at 9:25 a.m. indicated that her father has had a catheter for years and that the leg bag makes it easier for him to move about during the day. She revealed that staff put the leg bag on in the morning, and remove it at bedtime and place a large drainage bag in its place. Interview with the Director of Nursing on April 1, 2026, at 3:12 p.m. confirmed that Resident 28's care plan should have been updated to reflect that he utilizes a leg beg from the time he gets up until he goes to bed at night, and it was not. A quarterly MDS assessment for Resident 76, dated January 11, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included Multiple Sclerosis (a chronic autoimmune disease where the immune system mistakenly attacks the protective coating of nerves in the brain and spinal cord). A care plan for Resident 76 dated February 28, 2023, indicated that the resident had the potential for impaired skin integrity with an intervention dated July 8, 2026, to have a lymphedema pump system (a prescription-only medical device designed to treat chronic swelling (edema) by promoting the movement of lymphatic fluid out of affected limbs) applied to her bilateral lower extremities at low setting for one hour per extremity. Review of physician's orders revealed that the order for Resident 76's lymphedema pumps was discontinued on August 23, 2025, and there was no documented evidence in the Resident's treatment administration record that she was currently using the lymphedema pumps. Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that Resident 76's care plan was not revised when the lymphedema pumps were discontinued, and it should have been. 28 Pa. Code 211.11(d) Resident care plan.

Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possible for one of 35 residents reviewed (Resident 3), and failed to ensure that physician's orders for an indwelling urinary catheter were followed for one of 35 residents reviewed (Resident 4).Findings include: The facility's policy regarding bowel and bladder management and training, dated January 1, 2026, indicated that the purpose of the policy was to promote continence, maintain resident dignity, prevent complications (skin breakdown, urinary tract infections, constipation, fecal impaction), and meet regulatory requirements through individualized bowel and bladder assessments, training, and management. The bowel training program is a planned bowel evacuation schedule utilizing diet, fluids, activity, positioning, and medications as needed. Bowel assessments were to be completed on admission, quarterly, with a significant change, or post hospitalization. Based on assessments findings and resident goals, the least restrictive and most restorative interventions are used first. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3 dated September 12, 2025, indicated the resident was cognitively intact, required supervision or touch assist for toileting hygiene, was always continent of bowel and had diagnoses that included Schizoaffective disorder, bipolar type (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions) with severe mood episodes (mania and sometimes depression)).A quarterly MDS for Resident 3 dated December 13, 2025, indicated the resident was cognitively intact, required partial to moderate assistance for toileting hygiene, and was occasionally incontinent of bowel. An annual MDS assessment for Resident 3 dated March 13, 2026, indicated the resident was cognitively intact, was independent for most of her daily care needs, and was frequently incontinent of bowel. There was no documented evidence that a bowel assessment was completed quarterly to identify restorative interventions to promote bowel continence and maintain resident dignity. Interview with the Director of Nursing on April 2, 2026, at 10:32 a.m. confirmed that there was no documented evidence that bowel assessments were completed quarterly for Resident 3 per the facility policy. A quarterly MDS assessment for Resident 4, dated January 17, 2026, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling urinary catheter, had diagnoses that included neurogenic bladder (loss of bladder control caused by damage to the nerves, spinal cord, or brain).Physician's orders for Resident 4 dated June 15, 2025, included for staff to change the Resident's suprapubic catheter (an indwelling urinary catheter inserted through a small incision in the lower abdomen/suprapubic area) every 21 days and as needed for blockage or displacement. Review of the Treatment Administration Record and nurses' notes for Resident 4 dated October 2025 through March 2026, revealed there was no documented evidence that the suprapubic catheter was changed in the 42 days between October 18, 2025, and November 29, 2025, and no documented evidence it was changed during the 48 days between February 8, 2026, and March 28, 2026. Interview with the Director of Nursing on April 2, 2026, at 8:22 a.m. confirmed that there was no documented evidence that suprapubic catheter was changed as ordered by the physician on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plan of corrections for an annual survey ending March 20, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 2, 2026, identified repeated deficiencies related to care plan creation, care plan revisions, quality care, pharmaceutical services, food in a form to meet an individuals needs, and infection control.The facility's plan of correction for a deficiency regarding care plan creation, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that care plans were created timely.The facility's plan of correction for a deficiency regarding care plan revision, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that care plans were revised timely.The facility's plan of correction for a deficiency regarding quality care, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that quality care was provided.The facility's plan of correction for a deficiency regarding pharmaceutical services, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that pharmaceutical services were appropriately maintained.The facility's plan of correction for a deficiency regarding food served in a form to meet an individual's needs, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F805, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that food was served to meet an individuals needs.The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending March 20, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that infection control was properly maintained.Refer to F656, F657, F684, F755, F805, F880.28 Pa. Code 201.14(a) Responsibility of Licensee.28 Pa. Code 201.18(e)(1) Management.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications for one of 35 residents reviewed (Resident 67).Findings include:The facility's policy regarding medication administration, dated January 1, 2026, indicated that staff were to remove the medication from the source, taking care not to touch the medication with their bare hand. Observations during medication administration on April 1, 2026, at 8:08 a.m. revealed that Registered Nurse 2 prepared to administer medications to Resident 67 and took out pills from the medicine cup with her bare hands and placed them in a bag to be crushed. She then administered the medications to Resident 67. Interview with Registered Nurse 2 on March 11, 2025, at 8:10 a.m. confirmed that she should not have touched the medication with her bare hands. Interview with the Director of Nursing on April 1, 2026, at 3:04 p.m. confirmed that staff were not to touch residents' medications with their bare hands. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on review of policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed (Residents 2), resulting in a fall with a fractured hip. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding fall prevention, dated September 1, 2024, indicated that each resident will be assessed for their fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 8, 2025, revealed that the resident was cognitively intact, required substantial to maximum assistance for chair to bed and toilet transfers, used a walker, and had diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that cause ongoing breathing problems). The resident's care plan, dated August 1, 2024, revealed that the resident was at risk for falls. A care plan intervention for Resident 2, dated March 31, 2025, revealed that the resident was to be increased to a two person assist for transfers for improved safety. Physician's orders for Resident 2 dated May 27, 2025, included an order for the resident to be transferred with the assistance of two staff using a wheeled walker. The nurse aide task list dated August 9, 2025, indicated that the resident required two staff for transfers. A nursing note for Resident 2, dated August 11, 2025, at 5:35 p.m. revealed that the nurse aide had showered the resident and took her to the toilet to have her brief placed. The resident stood at the bars without difficulty, and the nurse aide slipped in water on the floor and fell, causing the resident to fall. The resident stated she bumped her head, and an assessment revealed that the resident's right leg was visibly shortened and externally rotated. The physician was notified, and orders were received to transfer the resident to the hospital. A nurse's note dated August 11, 2025, at 11:52 p.m. revealed that the resident was admitted to the hospital with a hip fracture. A nurse's note dated August 14, 2025, at 10:47 a.m. revealed that staff called the hospital for an update on Resident 2 and was informed that she had surgery on August 12, 2025. Investigative documents for Resident 2, dated August 12, 2025, revealed that on August 11, 2025, at approximately 4:00p.m. Nurse Aide 1 had showered Resident 2 and had assisted her to stand at a bar so she could apply a brief. Nurse Aide 1 did not have a second staff member present to assist her with standing or transferring the resident, per physician's orders. Nurse Aide 1 slipped in water and fell, causing Resident 2 to fall and sustain a hip fracture requiring surgery. A written statement from Nurse Aide 1 dated August 11, 2025, revealed that she rolled Resident 2 to the bars so the resident could stand, and the aide could put her brief on. The resident was standing ok, but the nurse aide took a small step and slipped on water taking the resident down with her. Nurse Aide 1 revealed that she was unaware of the change in Resident 2's transfer status to an assist of two staff. Education records for Nurse Aide 1, dated February 23, 2025, revealed that she received education on abuse and neglect. Interview with the Nursing Home Administrator on August 20, 2025, at 4:23 p.m. confirmed that because Nurse Aide 1 did not follow the physician's orders and care plan interventions for Resident 2, the resident had a fall causing a fractured hip. Following the investigation on August 12, 2025, the facility's corrective actions included: Nurse Aide 1 was terminated from employment at the facility. Audits were performed of residents' transfer status. Staff education was provided on following care plans, Kardex information, and orders related to each resident's care. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F600 on August 19, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(10 Management. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls for one of five residents reviewed (Resident 2) resulting in a fall with a hip fracture. This deficiency was cited as past non-compliance. Findings include: The facility's policy regarding fall prevention, dated September 1, 2024, indicated that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 8, 2025, revealed that the resident was cognitively intact, required substantial to maximum assistance for chair to bed and toilet transfers, used a walker, and had diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that cause ongoing breathing problems). The resident's care plan, dated August 1, 2024, revealed that the resident was at risk for falls. A new intervention, dated March 31, 2025, indicated to increase Resident 2's assistance with transfers to two staff members for improved safety. Physician's orders for Resident 2 dated May 27, 2025, included an order for the resident to be transferred with the assistance of two staff using a wheeled walker. The nurse aide task list, dated August 9, 2025, indicated that the resident required two staff for transfers. A nursing note for Resident 2, dated August 11, 2025, at 5:35 p.m. revealed that the nurse aide had showered the resident and took her to the toilet to have her brief placed. The resident stood at the bars without difficulty, and the nurse aide slipped in water that was on the floor and fell, causing the resident to fall. The resident stated she bumped her head. An assessment revealed that the resident's right leg was visibly shortened and externally rotated. The physician was notified, and orders were received to transfer the resident to the hospital. A nurse's note dated August 11, 2025, at 11:52 p.m. revealed that the resident was admitted to the hospital with a hip fracture. A nurse's note dated August 14, 2025, at 10:47 a.m. revealed that staff called the hospital for an update on Resident 2 and was informed that she had surgery on August 12, 2025. Investigative documents for Resident 2, dated August 12, 2025, revealed that on August 11, 2025, at approximately 4:00 p.m. Nurse Aide 1 had showered Resident 2 and assisted her to stand at a bar so she could apply a brief. Nurse Aide 1 did not have a second staff member present to assist her with standing or transferring the resident per physician's orders. Nurse Aide 1 slipped in water and fell, causing the resident to fall which resulted in a hip fracture requiring surgical intervention. A written statement from Nurse Aide 1 dated August 11, 2025, revealed that she rolled Resident 2 to the bars so the resident could stand, and the aide could put her brief on. The resident was standing ok, but the nurse aide took a small step and slipped on water taking the resident down with her. Nurse Aide 1 revealed that she was unaware of the change in Resident 2's transfer status to an assist of two staff. Interview with the Nursing Home Administrator on August 20, 2025, at 4:23 p.m. confirmed that Nurse Aide 1 did not follow the physician's orders and care plan interventions for a two person assist with Resident 2, and the resident had a fall resulting in a fractured hip. Following the investigation on August 12, 2025, the facility's corrective actions included: Nurse Aide 1 was terminated from employment at the facility. Audits were performed of residents' transfer status. Staff education was provided on following care plans, Kardex information, and orders related to each resident's care. The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary. Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on August 19, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(10 Management. 28 Pa. Code 201.24(e)(4) admission Policy. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policy, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with the proper food consistency as ordered by the physician for one of five residents reviewed (Resident 1), who choked, requiring a hospital admission for hypoxia and aspiration. Findings include: A facility policy for therapeutic diet orders dated January 13, 2025, indicated that dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 27, 2025, indicated that the resident was understood, could sometimes understand others, had a diagnosis of a stroke, and was on a mechanically altered diet (the texture of food is altered by chopping, grinding, blending, or mashing it to make it easier to chew and swallow). Physician's orders for Resident 1, dated May 22, 2025, included an order for the resident to receive a mechanical soft with ground meat texture diet. Physician's orders dated August 17, 2025, included an order for the resident to receive a pureed texture diet. A nursing note for Resident 1, dated August 1, 2025, at 12:25 p.m. revealed that the resident's husband reported to staff that the resident was served a piece of chicken on her lunch tray. The resident's husband cut it up for her to eat and she started choking on it. The resident verbalized that she felt like there was a lump in her throat. A nurse suctioned mucous from the resident's mouth and administered a breathing treatment, however the resident continued to report feeling a lump in her throat. The nurse provided thickened liquids which caused the resident to cough up more froth and mucous. The certified registered nurse practitioner was notified, and orders were received to send the resident to the hospital for evaluation and treatment. A nurse's note dated August 1, 2025, at 5:36 revealed that Resident 1 was admitted to the hospital with hypoxia (low levels of oxygen in your body tissues), anemia (the blood has an abnormally low level of red blood cells), and aspiration (the accidental inhalation of foreign substances, such as food, liquids, or mucus, into the lungs). A nurse's note dated August 3, 2025, indicated that Resident 1 was in the intensive care unit in the hospital. A nurse's note dated August 5, 2025, at 2:00 pm revealed that the resident returned to the facility from the hospital after being advanced to her baseline diet and had appeared to tolerate a mechanical soft diet. A nurse's note for Resident 1 dated August 16, 2025, at 6:02 p.m. revealed that a nurse aide reported to the registered nurse that the resident was choking on a Brussel sprout, and the resident reported having something in her throat. Coughing and suctioning were unsuccessful to relieve the resident's concern of having something in her throat, and the resident was transferred to the hospital. A nurse's note for Resident 1, dated August 16, 2025, at 9:20 p.m. revealed that the resident returned to the facility in stable condition after a choking episode. A witness statement by Nurse Aide 2, dated August 1, 2025, indicated that the nurse aide took Resident 1's meal tray into the resident's room without lifting the lid and verifying that the resident was being served the correct diet. The resident's husband reported that the resident was provided with regular chicken, not all ground up like it should be, so he cut it up in really small pieces for her. The facility's plan to prevent residents from receiving the wrong diet texture included dietary and nursing staff being educated by the facility's regional dietary manager on August 6, 2025 regarding textured modified diets and mechanical soft diet guidelines. The education indicated that on a mechanical soft diet, foods that may be restricted include vegetables with tough skins or membranes and that Brussel sprouts should be avoided. An interview with Resident 1 on August 20, 2025, at 3:25 p.m. revealed that the resident does not eat hard candy because it has always caused her to choke, and she recalled choking on her evening meal on the previous weekend which was very scary. An interview with the dietary manager on August 20,2025, at 2:50 pm confirmed that the Resident 1 was provided Brussel sprouts during her evening meal on August 16, 2025, and that staff should have followed the guidelines of the most recent education that was provided to them on August 6, 2025, that included avoiding Brussel sprouts on a mechanical diet. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 36 residents reviewed (Residents 1, 21, 75). Findings include: The facility's policy regarding medication administration, dated January 13, 2025, revealed that medications shall be administered in a safe and timely manner, and as prescribed. Vital signs must be checked/verified for each resident prior to administering medications. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 18, 2025, revealed that the resident was cognitively intact, required substantial assistance to dependent with care needs, received insulin, and had a diagnosis of diabetes. Physician's order for Resident 1, dated December 20, 2024, included an order for the resident to receive 16 units of Humalog insulin subcutaneously (medication administered into the subcutaneous fat under the skin) one time a day at 11:30 a.m. if the resident ate greater than 50 percent of her meal. Review of Resident 1's meal intakes from December 20, 2024, through March 18, 2025, revealed that her lunch meal intakes were as follows: 0-25 percent on December 20, January 23, March 9 and 12; and 26-50 percent on December 28, 29, January 1, 13, 14, 16, 19, February 1, 2, 3, 7, 9, 10, 13, 15, 17, 27 and March 15 and 18. Review of Resident 1's Medication Administration Record (MAR) for December 20, 2024, through March 18, 2025, revealed that the resident received 16 units of Humalog insulin subcutaneously on the above-mentioned dates. Interview with the Director of Nursing on March 20, 2025, at 11:18 a.m. confirmed that Resident 1's insulin was administered on the above-mentioned dates and not held per the physician's order. A quarterly MDS assessment for Resident 21, dated January 10, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, had a history of falls without injury since the prior MDS assessment, and had diagnoses that included hypertension (high blood pressure). Physician's order for Resident 21, dated September 27, 2024, included an order for the resident to receive 50 milligrams (mg) of Metoprolol Succinate (a medication for high blood pressure) daily and to hold the medication if her systolic blood pressure was equal to or less than 90 mmHg or if her heart rate was equal to or less than 60 beats per minute. A review of Residents 21's MARs for September 27, 2024, through March 18, 2025, revealed that there was no documented evidence that the resident's blood pressure or heart rate was obtained prior to the administration of Metoprolol Succinate since the medication was ordered on September 27, 2024, through March 18, 2025. An interview with the Director of Nursing on March 20, 2025, at 11:18 a.m. confirmed that there was no documented evidence that Resident 21's blood pressure or heart rate was obtained per physician's orders prior to the administration of Metoprolol Succinate from September 27, 2024, through March 18, 2025. A significant change MDS assessment for Resident 75, dated January 20, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, had an indwelling foley catheter (a soft, flexible plastic tube inserted in the bladder), and had diagnosis that included heart failure, obstructive uropathy, and diabetes mellitus. Physician's order for Resident 75, dated January 12, 2025, included an order for the resident to receive 50 milligrams of Metoprolol Succinate (a medication for high blood pressure) daily and to hold medication if blood pressure systolic is less than 110 mmHg and heart rate is less than 60 beats per minute. A review of Residents 75's January and February 2025 Medication Administration Record revealed that on January 25 the resident's blood pressure was 98/70 mmHg; on January 27 it was 106/65 mmHg; on January 31 it was 102/55 mmHg; on February 2 it was 106/68 mmHg; on February 10 it was 102/62 mmHg; and on February 18, 2025, it was 101/67 mmHg. An interview with the Director of Nursing on March 20, 2025, at 12:31 p.m. confirmed that physician's orders for Resident 75 were not followed and that the medication should have been held. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for one of three residents reviewed (Resident 2) who was at risk for falls, resulting in a fall with multiple fractures. Findings include: A significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 5, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for activities of daily care needs including transfers, and had diagnoses that included dementia and osteoporosis (a condition which causes the bones to become weak and fragile). The resident's current fall risk care plan indicated that she was to wear non-skid socks for ambulation and transfers. An incident note for Resident 2, dated June 12, 2023, at 7:30 a.m. revealed that Hospice Nurse Aide 1 was getting the resident ready for breakfast and she slid out of her wheelchair and landed on her knees. Hospice Nurse Aide 1 heard a pop but assisted her back into her wheelchair. A nursing note for Resident 2, dated June 13, 2023, revealed that she was sent to the emergency room and returned with diagnoses of right and left femur fractures (thigh bone near the knee) and a right femoral neck fracture (hip bone). An interview with Hospice Nurse Aide 1 on July 3, 2023, at 1:35 p.m. regarding Resident's 2 fall revealed that he had transferred the resident to her wheelchair without the resident having footwear on. He stated that he turned to get non-skid socks for the resident and when he turned around, she was sliding out of her wheelchair onto the floor. He tried to catch her but was unable to. He stated that he heard a pop but was unable to call for help because the facility was short staffed and no one would have heard him, so he assisted the resident back into her wheelchair and wheeled her to the nurse's station without first having her assessed by a registered nurse. An interview with Registered Nurse 2 on July 3, 2023, at 11:11 a.m. revealed that she was notified by the licensed practical nurse of Resident's 2 fall and was on her way to assess her. Resident 2 was at the nurse's station on her way to the dining room. She stated when she assessed her, she felt a deformity on her right leg and notified the physician for orders. An interview with the Assistant Director of Nursing on July 3, 2023, at 1: 25 p.m. confirmed that Hospice Nurse Aide 1 failed to follow Resident's 2 care plan for non-skid socks for ambulation/transfers. 28 Pa. Code 211.11(d) Resident care plan. 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 established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Guidelines from the American Heart Association (AHA), dated 2020, revealed that the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer. The facility's policy regarding cardiopulmonary resuscitation (CPR), dated [DATE], revealed that if an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless: it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g. rigor mortis). If an individual is found unresponsive, staff will briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the code status of the individual. Initiate the basic life support (BLS) sequence of events: chest compressions, airway, breathing. A Medicare 5 day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated [DATE], revealed that the resident was usually understood, sometimes understood others, but was very hard of hearing and unable to participate in the cognitive assessment. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note for Resident 2, dated [DATE] at 9:03 p.m. revealed that Registered Nurse 1 was notified by staff that resident was unresponsive. Met resident lying in bed, torso warm to touch. No breath sounds or heart sounds on auscultation. No carotid pulse on palpation. Pupils dilated and fixed. Death pronounced at 8:40 p.m. on [DATE]. Notified DON (Director of Nursing). Daughter notified, will call back with funeral home arrangements. According to Resident 2's Medication Administration Audit Record (MAR) his temperature was assessed at 6:45 p.m. and he was administered his medications at 7:48 p.m. There was no documented evidence that Resident 2 was provided CPR in accordance with his advance directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Registered Nurse 1 on [DATE] at 12:56 p.m. revealed that she does not remember who or why she was called to Resident 2's room, just that he was dead when she arrived. She stated that she thought he was rigid and therefore she called his death at the time she was in the room, 8:40 p.m. She was not aware of who had last seen the resident or when he was last seen. She said she did not consider initiating CPR and she did not document that he had any obvious signs of death and that maybe she should have documented that he was tight. On [DATE], at 2:45 p.m., the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses and licensed practical nurses failing to provide CPR in accordance with a resident's advanced directive, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted and implemented an immediate action plan to ensure each resident's advanced directive and physician-ordered code status was in place. The facility developed an education plan for all licensed nurses regarding the facility's CPR policy and the signs of irreversible death, to ensure that CPR was provided in accordance with each resident's advanced directive and physician orders. The plan also included that all staff will be educated regarding what to do when encountering a resident that is unresponsive and may require CPR. The Immediate Jeopardy was lifted on [DATE], at 11:19 a.m. when it was confirmed that the facility provided licensed nursing staff with education regarding providing CPR in accordance with residents' advanced directives, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any remaining staff were scheduled to receive the education prior to the start of their next shift. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

APPEAL FILED Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's physicians were notified about changes in the condition of a surgical wound for one of 36 residents reviewed (Resident 36), resulting in an infection and the surgical removal of hardware, and failed to ensure that the physician was notified about the status of a wound for one of 36 residents reviewed (Resident 63). Findings include: The facility's policy regarding changes in condition, dated (YEAR), revealed that the charge nurse was to notify the resident's attending physician or on-call physician in a timely manner when there was a significant change in the resident's condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated (MONTH) 8, (YEAR), revealed that the resident was alert and oriented, required extensive assistance with activities of daily living, and had [DIAGNOSES REDACTED]. A nursing note for Resident 36, dated (MONTH) 4, (YEAR), at 2:58 p.m. revealed that the resident was admitted to the facility that day with ankle and leg bone fractures, both with surgical repair and hardware insertion. A nursing note dated (MONTH) 8, (YEAR), indicated that the resident's surgical incisions were healing and well approximated (incision in line and healthy), and a nursing note dated (MONTH) 12, (YEAR), indicated that the resident's surgical incisions at the ankle and knee were intact and had no signs or symptoms of infection. A nursing note for Resident 36, dated (MONTH) 28, (YEAR), revealed that the orthopedic surgeon (bone doctor) ordered [MEDICATION NAME] (antiseptic solution) and a Band-Aid to the open area on resident's left knee, and that since his return from the doctor's office (that day) he had an increase in redness and there was metal visible. There was no further documentation to indicate that the nurse notified the attending physician and orthopedic surgeon that there was a change in the condition of the resident's surgical wound after the resident was seen in the surgeon's office. A nursing note for Resident 36, dated (MONTH) 29, (YEAR), revealed that the left knee had an open area that was red and swollen with a moderate amount of green-yellow drainage which was reported to both physicians' offices. There was no mention of the visible metal and no documented evidence that the licensed nurses follow-up directly with the resident's physicians about this change in the resident's condition. Resident 36 had a prescheduled orthopedic visit on (MONTH) 30, (YEAR) (a delay of two days from the initial symptoms identified on (MONTH) 28, (YEAR)). A nursing note for Resident 36, dated (MONTH) 31, (YEAR), revealed that the resident had to have the (previously placed) screw surgically removed from his left knee. A progress note for Resident 36, dated (MONTH) 19, (YEAR), revealed that the registered nurse spoke to the attending physician and that he would be in the following evening to see the resident for his complaint of knee pain, redness and swelling, following a faxed communication form in which the physician wrote that he may want to get another ortho opinion before he addressed this concern. A subsequent progress note on (MONTH) 20, (YEAR), acknowledged the physician's visit and orders to wait until the ortho appointment on (MONTH) 23, (YEAR), but if the resident becomes worse or shows signs of infection to send him to the hospital. Resident 36 went to a previously scheduled appointment with the orthopedic surgeon on (MONTH) 23, (YEAR). A nursing note for Resident 36, dated (MONTH) 24, (YEAR), revealed that the resident was seen by the orthopedic surgeon on (MONTH) 23, (YEAR), and had since had an increase in drainage from the left knee wound (the dressing had to be changed five times on day shift secondary to copious amounts of tan drainage), and the area was slightly swollen. There was no documented evidence that either the attending physician or the orthopedic surgeon were notified about this change in condition and concerns for possible infection until (MONTH) 27, (YEAR) (a delay of three days). Additionally, there was no documented evidence that the resident was transferred to the hospital for evaluation as ordered on (MONTH) 20, (YEAR). Orders received from both physicians on (MONTH) 27, (YEAR), included advancing Resident 36's orthopedic appointment to (MONTH) 6, (YEAR), instead of (MONTH) 9, (YEAR). Orthopedic physician's orders [REDACTED]. An interview with the Assistant Director of Nursing on (MONTH) 13, (YEAR), at 4:00 p.m. confirmed that there was no documented evidence that the orthopedic surgeon and/or the resident's physician were notified about Resident 36's changes in condition on the above dates, which resulted in a delay in treatment, an infection, and surgical removal of hardware. The facility's policy regarding wound care, dated (YEAR), indicated that the resident's physician was to be notified weekly regarding the status of a resident's wound via the written wound report. A quarterly Minimum Data Set (MDS) assessment for Resident 63, dated (MONTH) 4, (YEAR), revealed that the resident had moderate cognitive impairment, required extensive assistance from two staff for hygiene, and was totally dependent on two staff for bathing. A nursing note written by a registered nurse upon the resident's return from the hospital, dated (MONTH) 27, (YEAR), indicated that the resident had an open area on the buttocks that measured 2.0 x 2.0 centimeters (cm). There was no documented evidence that the physician was notified about the open area that day or weekly thereafter. Observations during morning care for Resident 63 on (MONTH) 14, (YEAR), at 9:11 a.m. revealed that the resident had an open skin wound on her right buttock. Interview with the Assistant Director of Nursing on (MONTH) 14, (YEAR), at 10:58 a.m. confirmed that since (MONTH) 27, (YEAR), when Resident 63 came back from the hospital with an open area, there was no documented evidence that the physician was notified initially or weekly about the status of the resident's wound. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/2/18, 4/24/17, 10/6/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/2/18, 9/21/17, 4/24/17, 2/17/17, 10;/6/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/27/18, 2/22/18, 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17, 11/29/16, 10/6/16.

APPEAL FILED Based on review of clinical records and facility policies, as well a staff interviews, it was determined that the facility failed to ensure that physicians were notified timely about changes in condition for one of 36 residents reviewed (Resident 36), resulting in harm due to an infection and surgical removal of hardware, and failed to ensure that medications were administered as ordered by the physician for three of 36 residents reviewed (Resident 22, 29, 34). Findings include: The facility's policy regarding changes in condition, dated (YEAR), revealed that the charge nurse was to notify the resident's attending physician or on-call physician in a timely manner when there was a significant change in the resident's condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated (MONTH) 8, (YEAR), revealed that the resident was alert and oriented, required extensive assistance with activities of daily living, and had [DIAGNOSES REDACTED]. A nursing note for Resident 36, dated (MONTH) 4, (YEAR), at 2:58 p.m. revealed that the resident was admitted to the facility that day with ankle and leg bone fractures, both with surgical repair and hardware insertion. A nursing note dated (MONTH) 8, (YEAR), indicated that the resident's surgical incisions were healing and well approximated (incision in line and healthy), and a nursing note dated (MONTH) 12, (YEAR), indicated that the resident's surgical incisions at the ankle and knee were intact and had no signs or symptoms of infection. A nursing note for Resident 36, dated (MONTH) 28, (YEAR), revealed that the orthopedic surgeon (bone doctor) ordered [MEDICATION NAME] (antiseptic solution) and a Band-Aid to the open area on resident's left knee, and that since his return from the doctor's office (that day) he had an increase in redness and there was metal visible. There was no further documentation to indicate that the nurse notified the attending physician and orthopedic surgeon that there was a change in the condition of the resident's surgical wound after the resident was seen in the surgeon's office. A nursing note for Resident 36, dated (MONTH) 29, (YEAR), revealed that the left knee had an open area that was red and swollen with a moderate amount of green-yellow drainage which was reported to both physicians' offices. There was no mention of the visible metal and no documented evidence that the licensed nurses follow-up directly with the resident's physicians about this change in the resident's condition. Resident 36 had a prescheduled orthopedic visit on (MONTH) 30, (YEAR) (a delay of two days from the initial symptoms identified on (MONTH) 28, (YEAR)). A nursing note for Resident 36, dated (MONTH) 31, (YEAR), revealed that the resident had to have the (previously placed) screw surgically removed from his left knee. A progress note for Resident 36, dated (MONTH) 19, (YEAR), revealed that the registered nurse spoke to the attending physician and that he would be in the following evening to see the resident for his complaint of knee pain, redness and swelling, following a faxed communication form in which the physician wrote that he may want to get another ortho opinion before he addressed this concern. A subsequent progress note on (MONTH) 20, (YEAR), acknowledged the physician's visit and orders to wait until the ortho appointment on (MONTH) 23, (YEAR), but if the resident becomes worse or shows signs of infection to send him to the hospital. Resident 36 went to a previously scheduled appointment with the orthopedic surgeon on (MONTH) 23, (YEAR). A nursing note for Resident 36, dated (MONTH) 24, (YEAR), revealed that the resident was seen by the orthopedic surgeon on (MONTH) 23, (YEAR), and had since had an increase in drainage from the left knee wound (the dressing had to be changed five times on day shift secondary to copious amounts of tan drainage), and the area was slightly swollen. There was no documented evidence that either the attending physician or the orthopedic surgeon were notified about this change in condition and concerns for possible infection until (MONTH) 27, (YEAR) (a delay of three days). Additionally, there was no documented evidence that the resident was transferred to the hospital for evaluation as ordered on (MONTH) 20, (YEAR). Orders received from both physicians on (MONTH) 27, (YEAR), included advancing Resident 36's orthopedic appointment to (MONTH) 6, (YEAR), instead of (MONTH) 9, (YEAR). Orthopedic physician's orders [REDACTED]. An interview with the Assistant Director of Nursing on (MONTH) 13, (YEAR), at 4:00 p.m. confirmed that there was no documented evidence that the orthopedic surgeon and/or the resident's physician were notified about Resident 36's changes in condition on the above dates, which resulted in a delay in treatment, an infection, and surgical removal of hardware. A comprehensive MDS assessment for Resident 34, dated (MONTH) 19, (YEAR), revealed that the resident was cognitively impaired, required staff assistance for toileting, and was always incontinent of bowel. physician's orders [REDACTED]. Resident 34's bowel records for (MONTH) (YEAR) revealed that she did not have a bowel movement from (MONTH) 14 through (MONTH) 20, (YEAR) (seven days), and the resident's Medication Administration Record [REDACTED]. Interview with the Director of Nursing on (MONTH) 13, (YEAR), at 4:00 p.m. confirmed that Resident 34's physician's orders [REDACTED]. A quarterly MDS assessment for Resident 22, dated (MONTH) 8, (YEAR), indicated that the resident was cognitively impaired and was dependent on extensive assistance for care. A [DIAGNOSES REDACTED]. Original physician's orders [REDACTED]. Resident 22's bowel records for (MONTH) (YEAR), revealed that the resident did not have a bowel movement on (MONTH) 9 through 11, (YEAR), and the resident's MAR for (MONTH) 12, (YEAR), revealed that staff administered a [MEDICATION NAME] suppository instead of Milk of Magnesia as ordered by the physician. The resident's bowel records for (MONTH) (YEAR) revealed that the resident did not have a bowel movement on (MONTH) 10 through 13, (YEAR), and the MAR indicated [REDACTED]. Interview with Licensed Practical Nurse 16 on (MONTH) 14, (YEAR), at 11:15 a.m. revealed that she administered the [MEDICATION NAME] suppository to Resident 5 on (MONTH) 14, (YEAR), at 8:32 a.m. She confirmed that there was no documented evidence that Milk of Magnesia was given to Resident 22 on the third day without a bowel movement. Interview with the Assistant Director of Nursing on (MONTH) 14, (YEAR), at 3:45 p.m. revealed that staff should have administered Milk of Magnesia to Resident 22 on the third day without a bowel movement, as ordered by the physician. physician's orders [REDACTED]. Interview with the Assistant Director of Nursing on (MONTH) 14, (YEAR), at 3:35 p.m. confirmed that [MEDICATION NAME] was not administered to Resident 29 at bedtime on (MONTH) 8, (YEAR), as ordered by the physician. 42 CFR 483.25 Quality of Care Previously cited 9/21/17, 4/24/17, 2/17/17. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 2/2/18, 4/24/17, 2/17/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 2/2/18, 4/24/17, 10/6/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 2/2/18, 9/21/17, 4/24/17, 2/17/17, 10/6/16. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.10(c)(d) Resident care policies. Previously cited 2/2/18. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/27/18, 2/22/18, 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17, 11/29/16, 10/6/16.

APPEAL FILED Based on review of clinical records and facility policies, as well as observations and staff interviews, it was determined that the facility failed to assess, revise the care-planned interventions, and develop new interventions to decrease or prevent repeated falls for one of 36 residents reviewed (Resident 88) resulting in a fall with facial fractures, and failed to ensure resident safety during transportation in a wheelchair for two of 36 residents reviewed (Residents 59, 60). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 88, dated (MONTH) 25, (YEAR), revealed that the resident was alert and oriented, was usually understood, could usually understands others, required staff assistance for ambulation (walking) with a walker, was not steady and only able to stabilize with staff assistance, had a history of [REDACTED]. Resident 88's care plan regarding the potential for injury related to falling, dated (MONTH) 19, (YEAR), included interventions such as, to encourage the resident to stand slowly, remind him to call for assistance, check on him and offer toileting every 30 minutes for safety, and make frequent checks on the resident when in his spouse's room. Incident and accident reports and nursing notes for Resident 88 revealed that the resident fell when ambulating without assistance on (MONTH) 19, (YEAR); fell when rising without assistance on (MONTH) 22, (YEAR); fell in his spouse's room on (MONTH) 2, (YEAR); fell in his spouses's room on (MONTH) 11, (YEAR), causing multiple facial fractures that required surgical repair; and fell on (MONTH) 6, (YEAR), while his daughter was attempting to ambulate him. There was no documented evidence, including on the resident's care plan, that new interventions were initiated following Resident 88's fall on (MONTH) 22, (YEAR). Following the fall on (MONTH) 2, (YEAR), the care plan indicated that staff were to make frequent checks on the resident while he was in his spouse's room; however, there was no documented evidence that staff were completing frequent checks on the resident. Following the fall on (MONTH) 11, (YEAR), the care plan indicated that staff were to check on Resident 88 every 30 minutes; however, there was no documented evidence that staff were checking on the resident every 30 minutes. Resident 88's hospital records, dated (MONTH) 12, (YEAR), revealed that at the hospital the resident was diagnosed with [REDACTED]. Interview with the Director of Nursing on (MONTH) 14, (YEAR), at 12:01 p.m. confirmed that there was no documented evidence that staff were checking on Resident 88 more frequently, and/or every 30 minutes, and that no changes were made to the resident's fall interventions following the fall on (MONTH) 22, (YEAR), as the resident was admitted to the hospital and had insulin changes made while there and she expected the insulin changes to be a fall intervention, even though the facility's investigation of the fall did not determine that low blood sugar was a causative factor. The Director of Nursing also confirmed that Resident 88 continued to experience falls with the care-planned interventions that were in place as of (MONTH) 19, (YEAR), and that there was no documented evidence that any new interventions were implemented following the continued falls, one of which resulted in facial fractures that required surgical repair. The facility's policy regarding transporting a resident in a wheelchair, dated (YEAR), revealed that residents who did not have leg rests on their wheelchairs should not be pushed from behind or pulled from the side, and that residents were to be encouraged to self-propel in the facility as much as possible. A quarterly MDS assessment for Resident 59, dated (MONTH) 1, (YEAR), indicated that the resident was confused, was usually understood, could sometimes understand, and she required the extensive assistance of one person for bed mobility, transfers, hygiene, dressing and locomotion on the unit. The resident's care plan, dated (MONTH) 14, (YEAR), indicated that she was to have bilateral (both sides) non-elevating leg rests on her wheelchair for transport. Observations of Resident 59 on (MONTH) 11, (YEAR), at 12:32 p.m. revealed that Unit Clerk 12 pushed the resident down the hallway to the dining room in her wheelchair. During the transport, there were bilateral footrests in place, but the resident's left foot was off the footrest and was gliding on the carpet, making an audible sound, and the resident's right foot was halfway off the footrest. Interview with Unit Clerk 12 on (MONTH) 11, (YEAR), at 12:32 p.m. revealed that the resident put her left foot up on the left footrest and that she kept putting her right foot up and down on the footrest, and she was not aware that the resident's foot was off the footrest. Interview with the Director of Nursing on (MONTH) 13, (YEAR), at 12:55 p.m. revealed that any staff can transport a resident, and for safety they should always ensure the resident's feet are maintained on the footrests when pushing them. A [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 27, (YEAR), indicated that the resident was confused, required the extensive assistance of two for bed mobility, ambulation (walking) and transfers, and that she had range of motion impairment on one side. physician's orders [REDACTED]. An occupational therapy note for Resident 60, dated (MONTH) 9, (YEAR), indicated that the resident used a wheelchair for mobility with supervision, utilizing her bilateral upper extremities and lower extremities throughout the facility, with assistance over thresholds and doorways. Observations of Resident 60 on (MONTH) 11, (YEAR), at 12:17 p.m. revealed that Restorative Aide 14 transported the resident in her wheelchair to the dining room without footrests in use. During the transport the resident placed the front of her feet up and down on the floor. The aide told the resident to hold her feet up and the resident stated, I can't, I do not have anything to hold them up on. Interview with Restorative Aide 14 on (MONTH) 11, (YEAR), at 12:22 p.m. revealed that Resident 60 could self-propel her wheelchair, and that she was to have leg rests in use when staff transport her; however, she was still looking for the resident's footrests. Interview with the Director of Nursing on (MONTH) 13, (YEAR), at 10:32 a.m. confirmed that residents should have footrests in the bags on the back of their wheelchairs, which were to used when staff transport residents. 42CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 9/21/17, 2/17/17, 10/6/16. 28 Pa. Code 211.11(d) Resident care plan. Previously cited 2/22/18, 9/21/17, 4/24/17, 2/17/17. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/27/18, 2/22/18, 2/2/18, 9/21/17, 5/26/17, 4/24/17, 2/17/17, 11/29/16, 10/6/16.

Based on review of policies, clinical records and investigation reports, as well as staff and family interviews, it was determined that the facility failed to ensure that residents were free from neglect for two of 32 residents reviewed (Residents 1, 4), resulting in a fractured bone for Resident 1. Findings include: The facility's policy regarding abuse and neglect dated (MONTH) 17, (YEAR), indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse. Investigations were to be completed for injuries of unknown origin and allegations of abuse and neglect, and the investigation was to include statements from the victim, witnesses, and all staff who had contact with the resident during that period of time. physician's orders [REDACTED]. A nursing note for Resident 1 dated (MONTH) 27, (YEAR), at 11:45 a.m. indicated that the resident was lowered to the floor for safety by a nurse aide, after the resident lifted her motorized reclining chair into an upright position and she began to slide from the chair. A nursing note for Resident 1 dated (MONTH) 27, (YEAR), at 6:00 p.m. revealed that the registered nurse was notified that the resident had knee pain, that her leg was inverted (turning inward), and that her thigh was swollen. A hospital report, dated (MONTH) 27, (YEAR), revealed that the resident had a right femur (thigh bone) fracture. A written statement by Nurse Aide 17 dated (MONTH) 27, (YEAR), indicated that when she entered Resident 1's room, the resident had her recliner in the highest position and that she began to move so she (the nurse aide) put her left knee under the resident to break her fall. Interview with Registered Nurse 2 on (MONTH) 4, (YEAR), at 2:10 p.m. revealed that a family member of Resident 1's roommate, Resident 31, was in the room on (MONTH) 27, (YEAR), when she entered the room to see Resident 1 after the incident. Registered Nurse 2 confirmed that Resident 1 was to have the assistance of two staff for transfers. An interview with Resident 31's family member on (MONTH) 5, (YEAR), at 10:29 a.m. revealed that she was in the room visiting at the time of Resident 1's accident on (MONTH) 27, (YEAR). Contrary to Nurse Aide 17's written statement, the family member stated that Resident 1 asked to use the bathroom and the nurse aide (Nurse Aide 17) used the reclining chair controller to lift Resident 1 into an upright position. When she saw this, she was taken aback about how straight and forward the chair was. The resident then stated to the nurse aide, Where is your helper? and the nurse aide responded, We can do this. The next thing she knew, Resident 1 was on the floor. Interview with the Director of Nursing on (MONTH) 5, (YEAR), at 12:10 p.m. confirmed that Nurse Aide 17 neglected to transfer Resident 1 in accordance with her physician's orders [REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4 dated (MONTH) 7, (YEAR), indicated that the resident was alert and oriented, was not ambulatory (could not walk), and required assistance with transfers. Physician orders [REDACTED]. A nursing note for Resident 4 dated (MONTH) 5, (YEAR), indicated that the resident complained about left rib pain, frontal head pain, and posterior (back of) neck pain, and that she had pain with palpation of her neck. The resident indicated that her pain was due to a nurse aide placing her into bed. In a written statement from Nurse Aide 3 dated (MONTH) 5, (YEAR), she indicated that she had assistance from Nurse Aide 4 during her transfer of Resident 4. However, a documented interview with Nurse Aide 4, dated (MONTH) 5, (YEAR), revealed that she did not help Nurse Aide 3 with Resident 4's transfer. A documented interview with Resident 4 dated (MONTH) 5, (YEAR), revealed that there was only one nurse aide in the room when she was thrown into bed, striking her head and her rib area on the side of the bed. Interview with Registered Nurse 5 on (MONTH) 3, (YEAR), at 12:30 p.m. revealed that Resident 4 informed her that Nurse Aide 3 picked me out of my chair and threw me in. She confirmed that Nurse Aide 4 said that she was not in the resident's room to assist with any transfers during her shift on (MONTH) 5, (YEAR). Interview with the Director of Nursing on (MONTH) 3, (YEAR), at 10:30 a.m. confirmed that Resident 4 should be transferred with a mechanical lift and the assistance of two staff. The Director of Nursing indicated that Nurse Aide 3's transfer of Resident 4 on (MONTH) 5, (YEAR), was not completed correctly. The facility neglected to provide adequate staff to assist with transfers resulting in harm. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/24/17, 2/17/17. 28 Pa. Code 201.18(b)(1) Management. Previously cited 4/24/17, 10/6/16. 28 Pa. Code 201.18(e)(1) Management. Previously cited 9/21/17, 4/24/17, 2/17/17, 10/6/16. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/21/17, 5/26/17, 4/24/17, 2/17/17, 10/6/16

Based on review of policies, clinical records, and investigation documents, as well as resident, family, and staff interviews, it was determined that the facility failed to ensure that proper pain management was provided for two of 32 residents reviewed (Residents 1, 16), resulting in severe pain for Resident 16. Findings include: The facility's policy regarding changes in condition dated (MONTH) 14, (YEAR), indicated that when a resident experienced a change in condition, which included any discomfort with sudden onset, and which was unrelieved by measures already prescribed, the registered nurse was to assess and notify the physician. The facility's policy regarding pain management dated (MONTH) 14, (YEAR), indicated that a resident should be assessed for pain using a pain scale based on the resident's cognitive status, such as mild pain (1-4), moderate pain (4-6) and severe pain (7-10). The pain level should be documented, non-pharmaceutical (other than medications) interventions attempted, along with the administration of as needed pain medication for efficacy, and the physician was to be notified if the pain control was not acceptable. Admission information and hospital records for Resident 16 revealed that the resident was admitted from the hospital on (MONTH) 6, (YEAR), at 11:31 p.m. with a fasciotomy (surgical excision of muscle fibers) of the left lower leg, and that an [MEDICATION NAME][MEDICATION NAME] therapist (registered nurse who specializes in wound management) applied a [DEVICE] (wound vac, a device that creates negative pressure and consists of a dressing that is fitted with a tube and attached to the wound) dressing over the incision to collect drainage and promote healing. Hospital records indicated that the [MEDICATION NAME][MEDICATION NAME] therapist administered 10 milligrams (mg) of [MEDICATION NAME] (a narcotic pain medication) to the resident prior to replacing the wound vac dressing on (MONTH) 4, (YEAR). Physician orders [REDACTED]. at 125 millimeters of mercury (mmHg). Physician orders [REDACTED]. A nursing note written by Registered Nurse 12 on (MONTH) 7, (YEAR), at 9:34 a.m. revealed that the wound vac was applied to Resident 16's left leg by the Director of Nursing with Registered Nurse 18. Interview with Registered Nurse 18 on (MONTH) 3, (YEAR), at 2:45 p.m. revealed that she assisted the Director of Nursing in completing Resident 16's wound vac dressing change on (MONTH) 7, (YEAR). She indicated that removing the old dressing from the resident's wound caused the resident to become very uncomfortable. She confirmed that the resident was not offered pain medication prior to the dressing change, but was medicated for pain afterward because he had so much pain when the dressing was removed. She indicated that there was bright red drainage in the wound vac container, more than usual, but she was uncertain about the amount. She indicated that she held the sponge during the dressing change; however, the Director of Nursing measured the wound and was responsible for the documentation. There was no documented evidence that the resident's pain or potential for pain during dressing changes was evaluated and that a care plan to address the issue was developed and implemented. A late note written by the Director of Nursing on (MONTH) 12, (YEAR), at 12:27 p.m. revealed that she completed Resident 16's wound vac dressing change on (MONTH) 9, (YEAR), at 2:15 p.m. and that the resident was medicated for pain prior to the dressing change. However, investigation information revealed that Former Nursing Home Administrator 11 interviewed Licensed Practical Nurse 9 on (MONTH) 12, (YEAR), and the nurse indicated that she assisted the Director of Nursing (DON) to change Resident 16's wound vac dressing on (MONTH) 9, (YEAR). The DON asked the licensed practical nurse (LPN) to hold the resident's leg, and he started to moan and grunt as if in pain. When she asked if the resident should have a pain pill, the DON said yes, and the LPN went to get it, returned, and stood by the resident's bed as the DON ripped off the dressing, and there was a large amount of blood dripping from the wound. The LPN indicated that the DON said that she was following the order as she applied skin prep (a liquid that forms a protective barrier) around the wound and rubbed wound cleanser with a dry dressing directly into the wound. Interview with Licensed Practical Nurse 9 on (MONTH) 3, (YEAR), at 11:45 a.m. revealed that at the request of the DON, she assisted with Resident 16's wound vac dressing change on (MONTH) 9, (YEAR), at about 12:45 or 1:00 p.m. The LPN indicated that she stood at the head of the bed and the Director of Nursing asked her to hold the resident's leg up, at which time she observed the ulcer bleeding. The DON started to remove the old taped dressing by ripping it from the resident's leg, and the resident started to hold onto her arm, screamed, and was trembling. The resident replied no when she asked him if he was medicated beforehand. The LPN then indicated that she told the Director of Nursing that the resident was going to pass out from the pain and asked if she could get another nurse to give him his pain medicine. With the permission of the DON, the LPN left the room and requested that Registered Nurse 5 administer pain medication to the resident. The LPN confirmed that the DON said she would continue the procedure (without leaving time for the medication to take effect) and sprayed wound spray onto the wound, rubbed a dry 4x4 (sterile dry gauze) over the wound, then placed skin prep on the skin around the edges of the wound. The wound continued to bleed, so she dabbed the wound with gauze. Following the procedure, the resident commented, I would rather have my leg cut off in Vietnam than go through that dressing again. The facility's investigation information revealed that Former Nursing Home Administrator 11 interviewed the Director of Nursing at 12:00 p.m. on (MONTH) 12, (YEAR), and asked for a statement about Resident 16's dressing change on (MONTH) 9, (YEAR). The Director of Nursing's written statement dated (MONTH) 12, (YEAR), indicated that she tried something new she saw on the internet, which was to apply skin prep on the outside of the foam dressing to keep it from leaking. The DON acknowledged that she knew the resident was yelling out in pain, moaning, grunting, and grabbing the railing during the dressing change and added, What was I to do? The Nursing Home Administrator informed the Director of Nursing that she should have stopped the dressing change, medicated the resident, and called the doctor. The facility's investigation information revealed that Former Nursing Home Administrator 11 interviewed Resident 16's roommate, Resident 32, on (MONTH) 12, (YEAR), at 7:00 p.m., who indicated that the curtain was pulled during the dressing change on (MONTH) 9, (YEAR), but the resident must have been in a lot of pain because he yelled and screamed. The facility's investigation information revealed that Former Nursing Home Administrator 11 interviewed Resident 16's family member on (MONTH) 13, (YEAR), at 9:50 a.m., who indicated that on (MONTH) 9, (YEAR), Resident 16 was not given any pain medication prior to the dressing change that was completed by the Director of Nursing, and he was yelling in sudden, severe pain when she ripped the dressing off, almost causing him to pass out. The family member indicated that the DON did not know what she was doing, because she told Resident 16 that she wanted to do something different with the dressing that she saw on the internet. There was no documented evidence that Resident 16 received pain medication prior to the dressing change on (MONTH) 9, (YEAR). The resident's Medication Administration Record [REDACTED] During a telephone interview with Resident 16 on (MONTH) 8, (YEAR), at 10:00 a.m. he indicated that prior to the wound vac dressing change on (MONTH) 9, (YEAR), the Director of Nursing did not offer him pain medication. The DON told him that she researched the dressing change on the internet the day before and it would be fine. The resident indicated that the DON tore off the prior dressing that was sticking to the wound and refused to stop when he screamed out due to the severe pain that this caused. He indicated that the licensed practical nurse in the room at that time told the DON that he was going to pass out from the pain; however, the DON continued the dressing change, and the licensed practical nurse left the room to find another nurse to give pain medication to him. Another nurse gave him [MEDICATION NAME], but the DON continued the dressing change. The resident commented that the dressing change was miserable and called it, the worst pain I have ever had. Interview with Registered Nurse 5 on (MONTH) 3, (YEAR), at 12:40 p.m. revealed that when she administered the [MEDICATION NAME] to Resident 16 on (MONTH) 9, (YEAR), the dressing change was in progress and the resident, who was alert and oriented, was yelling in pain, so she rated the pain as a 10. She indicated that the resident knew that the pain medication would not take effect right away, and that as a nurse, she knew that the painful procedure should have been stopped to allow the medication to take effect. Interview with Director of Nursing on (MONTH) 3, (YEAR), at 11:20 a.m. revealed that during Resident 16's dressing change on (MONTH) 9, (YEAR), the resident grimaced, and she tried to divert him by talking about hunting. She stated that it was evident that the resident had discomfort at all times during the dressing change. Interview with the Director of Nursing on (MONTH) 5, (YEAR), at 3:00 p.m. revealed that she did not offer Resident 16 pain medication prior to performing the dressing change on (MONTH) 9, (YEAR); however, another nurse administered 5 mg of [MEDICATION NAME] during the procedure. Physician orders [REDACTED]. A nursing note for Resident 1 dated (MONTH) 27, (YEAR), at 11:45 a.m. indicated that the resident's reclining chair was in an upright position and she began to slide so the nurse aide lowered her to the floor. A nursing note and the resident's Medication Administration Record, [REDACTED]. The note indicated that the resident stated she still had pain two hours later. There was no documented evidence that any nonmedicinal interventions or other pain management interventions were provided to Resident 1 for her unrelieved pain on (MONTH) 27, (YEAR), and no documented evidence that a registered nurse or the physician were notified until 6:00 p.m. on (MONTH) 27, (YEAR), when a nursing note indicated that the resident was sent to the hospital to be evaluated. A hospital report, dated (MONTH) 27, (YEAR), revealed that the resident had a fractured right femur (thigh bone). Interview with Registered Nurse 2 on (MONTH) 4, (YEAR), at 2:10 p.m. revealed that when she was notified about Resident 1's change in condition on (MONTH) 27, (YEAR), she assessed the resident and found that she had excruciating pain. She did not recall that the resident was provided with any other interventions for pain prior to her transport to the hospital. Interview with the Director of Nursing on (MONTH) 5, (YEAR), at 12:15 p.m. confirmed that Resident 1 left the facility at approximately 7:30 p.m. on (MONTH) 27, (YEAR). Physician orders [REDACTED]. There was no documented evidence that any other pain relief interventions were initiated for Resident 1, or that her physician was notified when her pain medication was ineffective for pain relief. Interview with the Director of Nursing on (MONTH) 5, (YEAR), at 12:10 p.m. confirmed that there was no documented follow-up interventions provided to Resident 1 when her pain medication was ineffective for pain management on the above dates. She indicated that staff should have attempted and documented further interventions and/or called the physician if there was no pain relief. 42 CFR 483.25(k) Pain Management. Previously cited 9/21/17, 4/24/17, 2/27/17. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 9/21/17, 5/26/17, 4/24/17, 2/17/17, 10/6/16. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 9/21/17, 5/26/17, 4/24/17, 2/17/17

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 26 residents reviewed (Resident R8), resulting in harm to Resident R8 due to a fall that resulted in a [MEDICAL CONDITION]. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R8, dated November 9, 2016, indicated that the resident was confused, required extensive assistance of one for transfers and ambulating in her room, and had limited range of motion of her upper and lower extremities on both sides. The resident's care plan, dated January 4, 2017, revealed that the resident had a history of [REDACTED]. When the resident was in bed, the alarm box was to be placed under the bed. An incident report for Resident R8, dated February 9, 2017, at 5:20 a.m. revealed that the resident was found on the floor, beside her bed and her bed (sensor) alarm was not sounding, and the bed was not in the lowest position. The resident was crying with complaints of left leg pain and had shortening and external rotation of the left lower leg (signs of a [MEDICAL CONDITION]). The resident was transferred to the hospital and admitted with a fractured left hip. A written statement provided by Nurse Aide 7, dated February 9, 2017, revealed that she took Resident R8 into the bathroom and when she returned the resident to bed, she forgot to plug in the bed alarm. Interview with Registered Nurse 10 on February 15, 2017, at 10:30 a.m. confirmed that when she responded to the above incident the resident's bed was not in the lowest position. Interview with the Director of Nursing on February 14, 2017, at 9:00 a.m. revealed that Resident R8's bed alarm was not connected at the time of her fall on February 9, 2017. She confirmed that the sensor alarm was part of the resident's care plan to prevent falls, and that it should have been connected as planned. 28 Pa. Code 201.18(e)(1) Management. Previously cited 10/6/16, 3/12/16. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/29/16, 10/6/16, 8/18/16, 5/5/16, 3/12/16, 1/7/16.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were provided with appropriate pain management for one of 26 residents reviewed (Resident CR2), resulting in severe unrelieved pain for the resident. The facility also failed to ensure that the administration of medications was clarified for two of 26 residents reviewed who received [MEDICAL TREATMENT] (Residents R5, R10), failed to ensure that residents were provided with bowel medications as ordered for three of 26 residents reviewed (Residents R3, R9, R11), and failed to provide medications as ordered by the physician for three of 26 residents reviewed (Residents R1, R10, R13). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR2, dated November 10, 2016, indicated that the resident was able to make her needs known and that she had pain that frequently affected her sleep. A [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A nursing note for Resident CR2, dated December 22, 2016, indicated that the resident had a diagnostic procedure performed and that she was going to need surgery due to a blockage in her leg with poor circulation. A nursing note, dated December 27, 2016, indicated that the resident had a necrotic scab (dead tissue) to a bunion on her left foot that fell off, and that her right foot was cyanotic (bluish in color due to decreased circulation) and was extremely painful. Resident CR2's Medication Administration Record [REDACTED]. However, the medication was not effective for pain relief. There was no documented evidence that any other interventions were attempted or that the physician was notified when the medication was ineffective. A nursing note for Resident CR2, dated December 28, 2016, at 8:00 a.m. revealed that the resident had pain in both of her feet that she rated as a 10, she was medicated for pain, and she went to the pain clinic for an appointment. physician's orders [REDACTED]. The MAR for December 28, 2016, revealed that [MEDICATION NAME] was administered at 1:18 p.m. for pain that the resident rated as a 6; however, it was not effective, and there was no documented evidence that any interventions were attempted or that the physician was notified when the medication was ineffective. A nursing note, dated December 29, 2016, at 11:02 p.m. revealed that Resident CR2 complained of pain throughout her dressing change. There was no documented evidence that any interventions were attempted to alleviate the resident's pain during the completion of the dressing change. The resident's MAR indicated [REDACTED]. Resident CR2's MAR for December 30, 2016, revealed that staff administered a routine 15 mg dose of [MEDICATION NAME] 8:00 a.m., at which time the resident had pain that she rated as a 10 out of 10. A nursing note for December 30, 2016, at 11:30 a.m. indicated that the resident complained of pain in both feet. There was no documented evidence that an assessment of this pain was completed or that any pain relief interventions were provided at that time. A nursing note for Resident CR2, dated December 30, 2016, revealed that the resident was admitted to the hospital and a hospital discharge summary, dated January 20, 2017, revealed that the resident had a below-the-knee amputation of the right leg (surgical removal of the right leg at a level below the knee) on January 17, 2017. physician's orders [REDACTED]. A nursing note for February 4, 2017, indicated that the resident was given [MEDICATION NAME] due to yelling out in pain all over and that at 9:30 a.m. she was still yelling out. There was no documented evidence that any additional pain relief interventions were attempted or that the physician was notified when the resident's pain medication was ineffective. Resident CR2's MAR for February 5, 2017, at 6:30 a.m. revealed that staff administered [MEDICATION NAME] sulfate for pain that the resident rated a 10 out of 10, and the resident was medicated again at 11:00 a.m. for a pain rating of 10, and at both times the medication was ineffective for pain relief. A nursing note, dated February 5, 2017, revealed that staff administered [MEDICATION NAME] due to the resident yelling out in pain all over, and that at 7:10 a.m. she was still yelling out in pain and that staff would monitor. At 11:00 a.m. a nursing note indicated that the resident was yelling in pain and at 12:02 p.m. she was still moaning in pain all over. A nursing note at 5:26 p.m. indicated that the resident had been yelling out in pain throughout the shift and that [MEDICATION NAME] was provided without effectiveness, and the registered nurse was aware. There was no documented evidence that an assessment of the resident's ongoing pain was completed, or that the physician was notified that the resident's pain medication was not effective. Interview with the Director of Nursing on February 14, 2017, at 4:32 p.m. confirmed that there was no documented evidence that a registered nurse completed assessments of Resident CR2's ongoing pain, or that the physician was notified that the resident's pain medications were not effective. She indicated that the physician should have been notified with the first occurrence of ineffective pain medication. physician's orders [REDACTED]. The orders also included that the resident was to receive 1 milligram (mg) of folic acid (B vitamin) daily, 20 mg of [MEDICATION NAME] (for high blood pressure) daily, a 1 mg [MEDICATION NAME] capsule (combination of B vitamins used to treat or prevent vitamin deficiency) daily, 100 mg of [MEDICATION NAME] (a B vitamin) daily, 100 mg of [MEDICATION NAME] (a stool softener) daily, and 0.2 mg of [MEDICATION NAME] (for high blood pressure) three times a day. Resident R5's MAR for January 2017, revealed that on January 24, 26 and 28, 2017 (days the resident received [MEDICAL TREATMENT] treatments), the 8:00 a.m. doses of folic acid, [MEDICATION NAME], and [MEDICATION NAME] were not administered, and on January 24 and 26, 2017, the 8:00 a.m. dose of [MEDICATION NAME] was not administered. physician's orders [REDACTED]. Resident R5's MAR for February 2017, revealed that on February 11, 2017 (a day that the resident received [MEDICAL TREATMENT] treatment), the 8:00 a.m. doses of [MEDICATION NAME], [MEDICATION NAME], multivitamin and [MEDICATION NAME] were not administered. There was no documented evidence that the physician was notified regarding nursing staff routinely not administering the resident's 8:00 a.m. doses of his medications on days that he received [MEDICAL TREATMENT] treatments. Interview with the Director of Nursing on February 13, 2017, at 12:50 p.m. revealed that the medication administration schedule for residents who receive [MEDICAL TREATMENT] should be clarified with the physician when medications are scheduled to be given at times that the resident is at a [MEDICAL TREATMENT] treatment. physician's orders [REDACTED]. to control blood sugar for residents with diabetes) before meals. Resident R10's MAR for January 2017, indicated that on January 4, 9, 11, 13, 16 and 27, 2017 (days the resident received [MEDICAL TREATMENT]), the 11:30 a.m. and 4:30 p.m. doses of Phoslo, [MEDICATION NAME] and [MEDICATION NAME] were not administered as ordered. There was no documented evidence that the physician was notified about nursing staff routinely not administering the resident's 11:30 a.m. and 4:30 p.m. doses Phoslo, [MEDICATION NAME], and [MEDICATION NAME] on days the resident received [MEDICAL TREATMENT] treatments. Interview with the Assistant Director of Nursing on February 13, 2017, at 3:45 p.m. confirmed that Resident R10 left early and/or returned late from [MEDICAL TREATMENT] and did not receive the medications on the above mentioned [MEDICAL TREATMENT] days. physician's orders [REDACTED]. Resident R5's MAR for February 2017, revealed that nursing staff administered five, 10 mg tablets of [MEDICATION NAME] to the resident on February 9 and 10, 2017. However, staff did not administer any [MEDICATION NAME] to the resident on February 11, 2017. Nursing staff then administered four, 10 mg tablets of [MEDICATION NAME] to the resident on February 12 and 13, 2017. Interview with the Director of Nursing on February 13, 2017, at 2:35 p.m. confirmed that staff failed to administer [MEDICATION NAME] to Resident R5 as ordered by the physician. Current physician's orders [REDACTED]. days, and a Fleet enema, if she did not have a bowel movement for five days. Resident R3's bowel records for January 2017, revealed that she did not have a bowel movement on January 17-22, 2017 (6 days). The resident's MAR indicated [REDACTED]. Resident R3's bowel record also revealed that she did not have a bowel movement on January 24-30, 2017 (7 days). There was no documented evidence that staff administered MOM, the [MEDICATION NAME] suppository, or the Fleet enema as ordered. physician's orders [REDACTED]. if there was no bowel movement in five days. The resident's care plan, dated January 14, 2017, revealed that the resident had a history of [REDACTED]. Resident R11's bowel records for January 2017, revealed that the resident did not have a bowel movement from January 18-21, 2017 (four days); however, there was no documented evidence that staff administered MOM until January 22, 2017 (five days), which was ineffective. There was no documented evidence that a [MEDICATION NAME] suppository was given on January 23, 2017, or that a Fleet enema was given on January 24, 2017, as ordered. The bowel records also revealed that the resident did not have a bowel movement from January 28 to February 2, 2017 (6 days), and the resident's MAR indicated [REDACTED]. Current physician's orders [REDACTED]. Resident R9's bowel records for January and February 2017, revealed that she did not have a bowel movement from January 9-12, 2017 (4 days), nor from February 6-9, 2017 (4 days). There was no documented evidence that MOM was administered as ordered. Interview with the Director of Nursing on February 14, 2017, at 9:05 a.m. confirmed that Resident R3, R9 and R11's physician's orders [REDACTED]. The facility's policy regarding pain management, dated December 1, 2015, revealed that on a scale from 0 to 10, moderate pain was ranked as 4-6. physician's orders [REDACTED]. Resident R1's MAR's for October, November and December 2016, revealed that on October 7, 8, 17 and 25, 2016; November 18, 21, 25 and 26, 2016; and December 12, 2016, the resident's pain rating was greater than 6, and staff administered [MEDICATION NAME]/[MEDICATION NAME] for moderate pain. There was no documented evidence that the physician was notified that the resident's pain ratings were above the moderate pain level, and she did not have a medication ordered for severe pain. physician's orders [REDACTED]. Resident R10's MAR's for October, November and December 2016, revealed that on October 7, 8, 17 and 25, 2016; November 18, 21, 25 and 26, 2015; and December 12, 2016, the resident's pain rating was greater than 6 and staff administered [MEDICATION NAME]/[MEDICATION NAME] for moderate pain. There was no documented evidence that the physician was notified that the resident's pain ratings were above the moderate pain level, and she did not have a medication ordered for severe pain. Interview with the Assistant Director of Nursing on February 13, 2017, at 3:45 p.m. confirmed that Residents R1 R10's pain medications were not given as ordered. A quarterly MDS assessment for Resident R13, dated January 25, 2017, revealed that the resident received intravenous medications (IV - directly into a vein). physician's orders [REDACTED]. Resident R13's MAR for January 2017, revealed that staff administered the [MEDICATION NAME] from January 20-26, 2017 (seven days), and there was no documented evidence that it was administered for eight days as ordered. Interview with the Director of Nursing on February 14, 2017, at 2:38 p.m. confirmed that Resident R13 did not receive [MEDICATION NAME] as ordered. 42 CFR 483.24, 483.25(k)(l) Provide Care/Services for Highest Well Being. Previously cited 1/7/16. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 11/29/16, 10/6/16, 8/18/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/29/16, 10/6/16, 8/18/16, 5/5/16, 3/12/16, 1/7/16.

Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that interventions to prevent falls were in place as planned for one of 26 residents reviewed (Resident R8), resulting in harm to Resident R8 due to a fall that resulted in a fractured hip. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R8, dated November 9, 2016, indicated that the resident was confused, required extensive assistance of one for transfers and ambulating in her room, and had limited range of motion of her upper and lower extremities on both sides. The resident's care plan, dated January 4, 2017, revealed that the resident had a history of [REDACTED]. When the resident was in bed, the alarm box was to be placed under the bed. An incident report for Resident R8, dated February 9, 2017, at 5:20 a.m. revealed that the resident was found on the floor beside her bed and her bed (sensor) alarm was not sounding and the bed was not in the lowest position. The resident was crying with complaints of left leg pain and had shortening and external rotation of the left lower leg (signs of a hip fracture). The resident was transferred to the hospital and admitted with a fractured left hip. A written statement provided by Nurse Aide 7, dated February 9, 2017, revealed that she took Resident R8 into the bathroom and when she returned the resident to bed, she forgot to plug in the bed alarm. Interview with Registered Nurse 10 on February 15, 2017, at 10:30 a.m. confirmed that when she responded to the above incident the resident's bed was not in the lowest position. Interview with the Director of Nursing on February 14, 2017, at 9:00 a.m. revealed that Resident R8's bed alarm was not connected at the time of her fall on February 9, 2017. She confirmed that the sensor alarm was part of the resident's care plan to prevent falls, and that it should have been connected as planned. 42 CFR 483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices. Previously cited 10/6/16, 8/8/16, 1/7/16. 28 Pa. Code 207.2(a) Administrator's responsibility. Previously cited 10/6/16, 1/7/16. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 11/29/16, 10/6/16, 8/18/16, 5/5/16, 3/12/16, 1/7/16.

Based on review of clinical records, facility policies, and material safety information, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions to prevent falls were in place and/or initiated for two of 31 residents reviewed (Residents R6, CR19), and both residents experienced falls that resulted in death and/or serious injury. The facility also failed to ensure that safe methods were used when transferring one of 31 residents reviewed (Resident R26), failed to store potentially hazardous materials in a manner that prevented possible resident access in one of two shower rooms observed (the North Wing), failed to provide an environment that was free of hazards to residents in one of two shower rooms observed (the North Wing), and failed to ensure that hot water temperatures were safe at outlets that were accessible to residents. Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident CR19, dated March 15, 2016, indicated that the resident was confused, required extensive assistance with transfers, limited assistance with ambulation (walking), used a wheelchair, and had no recent falls. A nursing note for Resident CR19, dated March 28, 2016, revealed that the resident was found lying on the floor in his bathroom with his head against the nightstand. physician's orders [REDACTED]. A nursing note, dated April 2, 2016, revealed that when the resident was at the nursing station, he stood up and fell backward from a standing position, and staff heard the noise from the resident hitting the floor. The resident complained of head and back pain and was sent to the emergency room . There was no documented evidence that the physician-ordered chair alarm was in place at the time of Resident CR19's fall on April 2, 2016. A hospital discharge summary for Resident CR19, dated April 3, 2016, revealed that the resident had a fall that resulted in a subdural hematoma (collection of blood outside the brain) with mass effect. A death certificate revealed that the resident ceased to breathe on April 8, 2016, and the immediate cause of death was listed as subdural hematoma due to fall. Interview with the Nursing Home Administrator on October 6, 2016, at 1:04 p.m. confirmed that there was no documented evidence that the chair alarm ordered by the physician was in place at the time of Resident CR19's fall on April 2, 2016. A quarterly MDS assessment for Resident R6, dated July 18, 2016, indicated that the resident was confused, required limited assistance with transfers and ambulation (walking), and had a history of [REDACTED]. The care plan did not include interventions to prevent the resident from disabling, removing and/or silencing the bed and chair alarms. Nursing notes for Resident R6, dated April 3 and 15, 2016, revealed that the resident attempted to transfer herself and ambulate, and would disable her alarms or silence the alarm by placing her hand over it or hiding it under a pillow. A nursing note, dated June 2, 2016, revealed that the resident was found self-transferring and ambulating, and the alarm was disabled and not sounding. On June 6 and 12, 2016, the resident was found standing up and silencing her alarm. A nursing note, dated July 27, 2016, revealed that Resident R6 was witnessed attempting to exit her room without using a walker and she fell , striking her head on the door frame; and the resident's chair alarm was noted to be disconnected from the box. On July 28, 2016, the resident continued to transfer and self-ambulate and continued to turn off or disable her alarms. Nursing notes, dated August 6, 2016, at 3:06 p.m. and 9:31 p.m. revealed that the resident was found ambulating in her room and the alarm was turned off. There was no documented evidence that interventions were initiated or revised in an attempt to prevent falls when Resident R6 disabled or silenced her alarms. An incident report and nursing note for Resident R6, dated September 5, 2016, revealed that staff heard a thump from Resident R6's room and discovered the resident lying on the floor. The resident's sensor alarm was intact and alarming, but the resident hid the box under her pillow to muffle the sound, as she frequently did, and she would also disconnect the alarm herself. A nursing note for Resident R6, dated September 6, 2016, revealed that the resident complained of shoulder pain and was noted to have a reddish purple ecchymotic (bruise) area along the right clavicle with edema (swelling). A nursing note, dated September 6, 2016, revealed that the physician from the hospital called the facility and reported that Resident R6 had a fractured right clavicle. Interview with the Director of Nursing on October 5, 2016, at 2:59 p.m. confirmed that there were no interventions in place to address fall prevention for Resident R6 when the resident disabled or hid her alarms in a pillow and ambulated unassisted. The facility's policy regarding transfer techniques, dated August 2016, revealed that during a transfer, staff were to use a gait belt (a cloth-like belt secured around the resident's waist). The gait belt was to provide a firm grasping surface for the staff person, to protect the resident from accidental trauma to the skin, could give the resident a sense of security, and would allow the staff person to lower a resident to the floor, if necessary, without injury. A quarterly MDS assessment for Resident R26, dated August 26, 2016, revealed that the resident required assistance with transfers. Observations on October 6, 2016, at 2:00 p.m. revealed that Licensed Practical Nurse 3 and Nurse Aide 2 transferred Resident R26 from her bed to her wheeled walker and assisted her into the bathroom by holding the resident underneath her arms and pulling up on the back of the waistband of the resident's pants. The resident's legs were bent, and she was not bearing full weight at the time of the transfer. A gait belt was not used during the transfer. Interviews with Licensed Practical Nurse 3 and Nurse Aide 2 on October 6, 2016, at 2:45 p.m. revealed that they should have used the gait belt when transferring Resident R26 and assisting her to walk into the bathroom. Interview with Registered Nurse 5 on October 6, 2016, at 2:46 p.m. confirmed that a gait belt should have been used by staff when Resident R26 was transferred. Observations in the unlocked resident shower room on the North Wing on October 3, 2016, at 12:46 p.m. revealed that an opened container of PDI germicidal wipes was left on the floor unsecured. The Material Safety Data Sheet (MSDS - gives information about handling and safety procedures) for PDI germicidal wipes, dated March 27, 2015, revealed that the product was an eye and skin irritant. Interview with Nurse Aide 1 on October 3, 2016, at 12:50 p.m. revealed that the PDI wipes were to be secured in a locked container. She confirmed that the product was not secured. Interview with the Nursing Home Administrator on October 4, 2016, at 9:10 a.m. confirmed that the PDI germicidal wipes should have been secured. Observations in the shower room on the North Wing on October 3, 2016, at 12:46 p.m. and October 6, 2016, at 12:00 p.m. revealed that there were two broken 4 x 4 inch ceramic tiles at the base of the wall adjacent to the toilet and two broken 4 x 4 inch ceramic tiles at the base of the wall by the sink. The broken tiles had sharp edges. There was also a loose corner protector on the corner of the wall entering the tub room that had a sharp corner. Interview with the Director of Environmental Services on October 6, 2016, at 2:35 p.m. revealed that he was not aware of the broken tiles and loose corner protector in the shower room on the North Wing. Observations on October 3, 2016, at 1:09 p.m. revealed that the hot water temperature of the sink in Resident R28's sink was 117.0 degrees Fahrenheit. Observations on October 4, 2016, at 1:11 p.m. revealed that the hot water temperature at the sink in the North Wing shower room was 119.3 degrees Fahrenheit. Interview with the Director of Maintenance on October 3, 2016, at 1:13 p.m. revealed that he checked hot water temperatures weekly and was not aware that some of the hot water temperatures were elevated. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices Previously cited 8/8/16, 1/7/16, 9/17/15, 7/31/15, 6/4/15 28 Pa. Code 207.2(a) Administrator's responsibility Previously cited 1/7/16, 7/31/15, 6/4/15 28 Pa. Code 211.12(d)(5) Nursing services Previously cited 8/18/16, 5/5/16, 3/12/16, 1/7/16, 9/17/15, 8/20/15, 7/31/15, 6/4/15

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there were no significant medication errors for one of six residents reviewed (Resident CR1). Findings include: Physician's admission orders [REDACTED]. A dietary note, dated July 29, 2015, revealed that the resident weighed 91.4 pounds. A care conference note (care plan meeting) dated July 30, 2015, revealed that the resident was making good progress. physician's orders [REDACTED]. A nursing note, dated July 31, 2015, at 11:50 a.m., revealed that [MEDICATION NAME] was administered to Resident CR1 due to nausea and vomiting. A nursing note, dated July 31, 2015, at 12:21 p.m., revealed that oxygen was applied at a flow rate of two liters per minute because the resident complained of shortness of breath, and [MEDICATION NAME] was administered because the resident complained of nausea and vomited prior to lunch. The note also indicated that the resident's appetite was poor due to nausea. A nursing note, dated July 31, 2015, at 1:10 p.m., revealed that Resident CR1 had five to ten seconds of [MEDICAL CONDITION] (temporary loss of consciousness) that was witnessed by a nurse aide. The physician was on the unit and gave new orders for a 48 hour Holter monitor (a device that continuously monitors various electrical activity of the heart), laboratory tests, and an Electrocardiogram (ECG - a test that checks for problems with the electrical activity of the heart). Results of the ECG revealed sinus [MEDICAL CONDITION] (a heart rate that is lower than normal) at 58 beats per minute and an abnormal heart rhythm. A nursing note, dated August 2, 2015 at 9:49 a.m., revealed that Resident CR1 was given [MEDICATION NAME] for nausea and vomiting. A nursing note, dated August 2, 2015, at 12:41 p.m., revealed that the resident's appetite was poor that shift, the resident was complaining of nausea, and was medicated with [MEDICATION NAME], which was effective for relief, but the resident stated that she just did not feel good. A facsimile (fax) communication sheet to Resident CR1's primary care physician, dated August 3, 2015, revealed that on July 30, 2015, a nurse incorrectly entered an order for [REDACTED]. There was no documented evidence that Resident CR1 had any syncopal episodes, complaints of nausea, or experienced any vomiting prior to the administration of [MEDICATION NAME] on July 30, 2015. Interview with the Vice President of Operations on August 20, 2015, at 2:50 p.m., revealed that the 11 doses of [MEDICATION NAME] more than likely contributed to Resident CR1's change in condition. 42 CFR 483.25(m)(2) Residents Free of Significant Med Errors. Previously cited 7/31/15. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management. Previously cited 7/31/15, 6/4/15. 28 Pa. Code 211.10(c) Resident care policies. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 7/31/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/31/15, 6/4/15, 7/24/14.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide timely and appropriate treatment and services to promote healing for one of 42 residents reviewed who had pressure sores (Resident R1), resulting in the deterioration of two pressure sores for the resident. Findings include: The facility's policy regarding pressure ulcers, dated May 27, 2014, revealed that pressure ulcers were to be assessed and treated in accordance with generally accepted guidelines. Pressure ulcers were to be evaluated at least weekly, and if the condition of the resident's wound deteriorated or if there was no significant progress within a reasonable time frame, the treatment plan was to be re-evaluated. A comprehensive Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs), dated April 17, 2015, for Resident R1 revealed that the resident was admitted to the facility on [DATE], was alert and oriented, frequently incontinent of bladder, always incontinent of bowel, and required extensive assistance for transfers, bed mobility, and activities of daily living. The resident had two Stage I pressure ulcers (intact skin with non-blanchable redness) and one Stage II pressure ulcer (superficially open wound) on admission. An admission nursing assessment, dated April 9, 2015, revealed that the resident had Stage I pressure ulcers on the left buttock and left heel, and a Stage II pressure ulcer on the coccyx (tailbone). admission orders [REDACTED]. There was no documented evidence that a treatment was ordered for the Resident R1's open Stage II pressure ulcer on the coccyx until April 21, 2015, 13 days later, when Chamosyn (a superior moisture barrier that contains Zinc and Menthol) was ordered every shift. A wound note, dated April 22, 2015, revealed that the area on the coccyx was now a Stage III (full thickness tissue loss), the Chamosyn was discontinued, and Santyl (a [MEDICATION NAME] agent) was ordered daily. Interview with Registered Nurse 2 on June 3, 2015, at 10:21 a.m. confirmed that no treatment was ordered to the wound on the resident's coccyx until April 21, 2015. A wound note, dated April 16, 2015, revealed that the Stage I pressure ulcer on the resident's left buttock was now a Stage II pressure ulcer. There was no documented evidence that the physician was notified or that a change in treatment was made until April 22, 2015, six days later when a wound note revealed that the Stage II pressure ulcer on the left buttock was now a Stage III pressure ulcer, and Santyl was ordered daily. Interviews with the Director of Nursing on June 4, 2015, at 11:35 a.m. and 1:16 p.m. confirmed that no treatment was ordered to the resident's coccyx until April 21, 2015, and the physician was not notified or the treatment changed when the resident's left buttock wound became a Stage II, until April 22, 2015, when the area became a Stage III pressure ulcer. She indicated that she would have expected staff to obtain an order for [REDACTED].>28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 7/24/14.

Based on review of policies and clinical records, as well as staff interviews and observations, it was determined that the facility failed to intervene in an attempt to prevent falls for one of 42 residents reviewed (Resident R3) resulting in a fall with a fractured finger, failed to provide adequate supervision to prevent accidents for one of 42 residents reviewed (Resident R3), and failed to maintain a hazard-free environment in two of two shower rooms (North and South units). Findings include: The facility's policy regarding fall prevention, dated May 27, 2014, indicated that if a fall occurred, the incident would be immediately investigated to determine interventions to prevent further falls. A [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment (a required assessment of a resident's abilities and care needs), dated May 3, 2015, indicated that the resident had a history of [REDACTED]. The resident's care plan, last reviewed on March 29, 2015, indicated that the resident's psychoactive medications were to be reviewed and adjusted as needed, and that staff were to frequently monitor the resident and keep him away from outside doors. A nursing note, dated April 16, 2015, indicated that the resident was found on his hands and knees on the floor, and he had a 1 x 3 centimeter (cm) abrasion on his left knee. A nursing note, dated April 16, 2015, indicated that the physician was making adjustments to the resident's medication; however, the physician consultation note, dated April 17, 2015, indicated that the resident was to continue the same medications. A nursing note, dated April 23, 2015, indicated that Resident R3 was found on his knees beside the bed in another resident's room. Following the above falls, there was no documented evidence that the falls were evaluated or that new interventions to prevent further falls were implemented. There was also no documented evidence that frequent monitoring was completed per the resident's care plan. A nursing note, dated May 6, 2015, indicated that Resident R3 fell . His left fifth finger was swollen and appeared dislocated, and he complained of pain in his left hand and wrist area. An emergency room report, dated May 6, 2015, indicated that the resident had a fracture of the left fifth finger that was splinted. Interview with Registered Nurse 12 on June 4, 2015, at 11:40 a.m. revealed that she was unaware of what frequent monitoring meant, and she confirmed that there was no documentation of frequent monitoring in the resident's clinical record. Interview with the Director of Nursing on June 4, 2015, 11:45 a.m. revealed that frequent monitoring meant checking the resident when staff passed by his room, and these checks were not documented. She confirmed that she could not provide evidence that new interventions were implemented after the above falls, and that there were no medication adjustments made. physician's orders [REDACTED]. Observations on June 1, 2015, at 5:55 p.m. and June 2, 2015, at 12:37 p.m. revealed that Resident R3 was in the dining room finishing his meal; and there were no staff members providing one-on-one supervision, assistance, or cues to swallow. Observations during the lunch meal on June 3, 2015, at 12:25 p.m. revealed that the resident ate his entire meal independently in six minutes; and no staff were present to provide one-on-one supervision, assistance, or cues to swallow with each bite. While feeding himself, the resident did not swallow with each bite. Interview with Nurse Aide 16 on June 3, 2015, at 12:34 p.m. revealed that she was aware that Resident R3 ate fast, but she was not aware that he was to have one-on-one supervision. She indicated that staff just kept an eye on the resident during meals. Interview with Speech Therapist 17 on June 3, 2015, at 12:55 p.m. revealed that the resident was at risk for aspiration (breathing in a foreign object, such as food, into the lungs) due to his behavior of rapidly feeding himself, and he was to have direct one-on-one supervision with guidance to slow down and swallow with each bite. Observations in the North shower room on June 1, 2015, at 1:53 p.m. revealed that two bottles of spray disinfectant were sitting unsecured on the top of the handrails in the shower stalls. Observations in the South shower room on June 1, 2015, at 1:55 p.m. revealed that one bottle of spray disinfectant was unsecured. Interview with Registered Nurse 13 on June 1, 2015, at 2:01 p.m. confirmed that the bottles of spray disinfectant should have been secured and should not have been accessible to residents. 42 CFR 483.25 (h) Free of Accident Hazards/Supervision/Devices. Previously cited 7/24/14. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 7/24/14.