Every finding on record at Mahoning Operating LLC

Based on a review of the facility's infection prevention and control policies, infection surveillance documentation, clinical records, and staff interviews, it was determined the facility failed to establish, maintain, and implement an effective infection prevention and control program designed to identify, monitor, investigate, and prevent the transmission of communicable disease. The facility failed to implement an effective infection surveillance system and infection control practices after multiple residents developed signs and symptoms consistent with scabies, resulting in delayed recognition, investigation, and implementation of measures to prevent potential transmission for 5 of 5 residents reviewed. (Residents 1, 2, 3, 4 and 5). Findings include:A review of the facility's policy, Infection Control Program, last reviewed February 2026, revealed the facility established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases. The policy identified the Infection Preventionist as responsible for oversight of the infection prevention and control program, including surveillance of infectious diseases, epidemiological investigation of potential disease transmission, implementation of isolation precautions, resident placement, monitoring resident and staff exposures, and providing consultation to staff regarding infectious diseases. The policy further indicated all staff were responsible for following the facility's infection prevention and control policies and procedures.A review of the facility's policy, Infection Control, Pediculosis and Scabies: Recognition and Treatment, last reviewed February 2026, revealed the facility's policy required residents diagnosed with scabies to receive treatment in accordance with current standards of practice to eradicate the infestation and prevent further exposure and transmission. The policy requires staff to:assess residents exhibiting signs and symptoms of scabies, including itching, scratching, rash, or burrows;notify the practitioner to obtain appropriate treatment orders;administer treatment according to the Physician's orders and the manufacturer's instructions;implement appropriate transmission-based precautions, including the use of personal protective equipment (PPE), such as gowns, gloves, and face masks, when providing care to affected residents;ensure individuals with scabies were treated simultaneously, when indicated;decontaminate contaminated clothing, bedding, towels, and linens;bag non-washable items for the recommended period to eliminate mites;perform appropriate environmental cleaning; andassess residents and staff with potential exposure for signs and symptoms of scabies.Scabies is a contagious skin infestation caused by the human itch mite and is primarily transmitted through prolonged skin-to-skin contact with an infested individual. An infected person may transmit scabies before symptoms develop, making timely identification, surveillance, and implementation of infection prevention measures essential to prevent transmission within a healthcare facility. A review of the facility's infection surveillance documentation provided during the survey on July 21, 2026, revealed the facility failed to maintain an effective infection surveillance system capable of identifying, monitoring, investigating, and responding to communicable diseases. The surveillance records did not demonstrate a systematic process for identifying infection trends, investigating the manner of disease transmission, recognizing clusters of residents with similar symptoms, or implementing timely corrective actions to prevent additional transmission. Further review revealed the facility failed to demonstrate an effective system for the routine and ongoing collection, analysis, interpretation, and dissemination of infection surveillance data necessary to identify healthcare-associated infections, community-acquired infections, communicable disease outbreaks, and infection risks. The facility was unable to demonstrate how infection surveillance information was analyzed to identify potential outbreaks or how surveillance findings were used to implement corrective actions to protect residents from the transmission of infection. Clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a condition in which the heart does not pump blood as effectively as it should), diabetes mellitus, and anxiety. An annual Minimum Data Set (MDS a federally required standardized assessment used to evaluate a nursing home resident's clinical status and care needs, dated April 6, 2026, revealed a Brief Interview for Mental Status (BIMS, an assessment used to assess cognitive function) score of 12, indicating moderately impaired cognition (a score of 8 to 12 indicates moderate impaired cognition). Nursing documentation beginning February 13, 2026, revealed Resident 1 repeatedly complained of generalized itching involving her extremities. The Certified Registered Nurse Practitioner (CRNP) was notified and initially ordered Claritin (an antihistamine used to treat allergy symptoms) 10 milligrams by mouth daily for seven days. Later the same day, the CRNP was notified again due to continued complaints of itching and ordered Atarax (Hydroxyzine, an antihistamine used to relieve itching) 25 milligrams by mouth every eight hours as needed for seven days. Nursing documentation dated February 25, 2026, at 6:48 AM, revealed Resident 1 continued to complain of severe itching. The nurse observed the resident scratching her breasts and the sides of her torso. Resident 1 stated, If no one can figure out why I am itchy, I want to go to the hospital, and Even my head is itchy. I can't take this anymore. The Registered Nurse was notified. Nursing documentation dated February 27, 2026, at 3:23 AM, revealed Resident 1 again requested transfer to the hospital because of persistent itching. Later that day, at 3:54 PM, nursing documentation indicated Resident 1 complained of itching all over. Benadryl (Diphenhydramine, an antihistamine) 25 milligrams by mouth was administered without relief. The CRNP was notified and ordered an additional 50-milligram dose of Benadryl, Hydrocortisone cream (a topical corticosteroid), and Prednisone (an oral corticosteroid) 30 milligrams daily for five days beginning February 28, 2026. Nursing documentation dated March 2, 2026, indicated a dermatology consultation (evaluation by a skin specialist) was requested due to the resident's persistent symptoms. Nursing documentation dated March 4, 2026, revealed Resident 1 continued to complain of itching involving her back and upper arms throughout the shift. Body lotion provided only temporary relief. Resident 1 attended a dermatology appointment on March 5, 2026. The dermatology consultation documented complaints of itching involving the arms, neck, breasts, and trunk that had persisted for approximately three weeks. The dermatologist noted persistent itching could be associated with dry skin, mite infestation, or other causes and prescribed Triamcinolone Acetonide 0.1 percent cream (prescription steroid cream to reduce skin inflammation and itching) to affected areas twice daily as needed for itching, with follow-up scheduled in three weeks. Resident 1 returned to dermatology on March 26, 2026. The dermatology report documented the resident's symptoms remained unchanged despite treatment. The dermatologist changed the Triamcinolone Acetonide cream from an as-needed order to a scheduled application every 12 hours. Physician documentation dated April 20, 2026, continued to describe generalized itching involving the back, arms, breasts, and abdomen. The prescribed topical treatment was continued. Nursing documentation dated May 6, 2026, at 8:59 PM, revealed Resident 1 again complained of itching all over, declined additional Benadryl, and stated she wanted to go to the hospital. The on-call Physician was notified and ordered Cetirizine (an antihistamine) 10 milligrams by mouth immediately and laboratory testing.A weekly skin assessment completed June 1, 2026, documented a rash involving both upper extremities and the trunk. Nursing documentation throughout June 2026 continued to reflect persistent itching and rash despite multiple medication regimens without documented resolution. A Physician's order dated June 16, 2026, directed staff to apply Permethrin 5 percent cream to the resident's entire body one time for treatment of itching. Permethrin is the first-line treatment for scabies and is intended to remain on the skin for approximately 8 to 12 hours before being washed off. Review of the June 2026 Medication Administration Record (MAR) revealed staff documented application of the medication on June 16, 2026, at 8:49 PM; however, the clinical record contained no documentation the medication was removed after the recommended application period. Other than the MAR entry documenting application, the clinical record contained no nursing documentation describing the treatment, resident response, or completion of the manufacturer's recommended instructions. Nursing documentation dated June 19, 2026, at 11:12 AM, revealed Resident 1 continued to complain of worsening itching after receiving Permethrin treatment. Resident 1 stated she did not know what to do and believed her dermatology appointment was too far away. The nurse documented the resident declined an oral antihistamine and would continue the current treatment until the dermatology appointment. Resident 1 returned to dermatology on June 25, 2026. The dermatology report documented continued complaints of itching despite recent Permethrin treatment. The resident's daughter informed the dermatologist that other residents within the facility had developed rashes and itching and were undergoing evaluation. The dermatologist ordered another course of Permethrin 5 percent cream with instructions to leave the medication on overnight and shower the following morning, launder clothing and bedding, and prescribed Ivermectin (an oral antiparasitic medication used to treat scabies) immediately with a second dose one week later. Facility documentation confirmed Resident 1 received Ivermectin on June 26, 2026, and July 7, 2026. A health status progress note dated July 8, 2026, at 11:08 AM, documented Resident 1 continued to experience itching involving both arms and the torso. During an interview and observation conducted on July 21, 2026, at 1:00 PM, Resident 1 stated she had experienced constant itching involving her arms and torso since February 2026. She reported the topical creams provided only temporary relief and stated she can't stand the constant itching. Observation revealed a light pink to red rash involving both arms and the torso. Clinical record review revealed Resident 2, who was cognitively intact, developed a rash involving the upper extremities and trunk in April 2026. The resident received multiple topical treatments; however, the rash and itching persisted throughout the month. Resident 2 was referred to dermatology and evaluated on June 1, 2026. The dermatologist ordered a tapering course of Prednisone (an oral corticosteroid), obtained biopsies from two affected areas, and recommended further evaluation. Biopsy results dated June 2, 2026, confirmed scabies infestation. The dermatologist ordered Permethrin 5 percent cream for treatment. Review of the clinical record revealed the medication was applied on June 3, 2026; however, there was no documented evidence that the medication was removed after the manufacturer's recommended 8- to 12-hour application period. During an interview and observation conducted on July 21, 2026, at 12:15 PM, Resident 2 stated he continued to experience itching involving his arms and upper body and reported the rash had persisted for several months despite treatment. Observation revealed a red, raised rash involving the torso and upper extremities with scratch marks present. A healing scab was observed at the abdominal biopsy site. Clinical record review revealed Resident 3 was admitted to the facility on [DATE], with diagnoses that included chronic pain, diabetes mellitus, and difficulty walking. An admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Nursing documentation dated May 5, 2026, at 6:42 AM, revealed Resident 3 complained of itching involving both his back and buttocks. Additional nursing documentation identified a rash consisting of small red bumps on the backs of the legs, lower back, and buttocks. Hydrocortisone 1% cream was ordered for seven days. On May 12, 2026, the Physician Assistant evaluated the resident and diagnosed contact dermatitis (skin inflammation caused by irritation or an allergic reaction) and ordered Dove soap for bathing. A progress note dated May 15, 2026, at 1:00 AM, documented a diffuse maculopapular rash (a rash containing both flat and raised areas) involving the lower back, legs, and trunk. Treatment was changed from Hydrocortisone cream to Triamcinolone acetonide cream twice daily for 10 days. On May 19, 2026, the Nurse Practitioner documented that the resident should be referred for a dermatology consultation if no improvement occurred. Clinical documentation throughout May and June 2026 revealed Resident 3 continued to experience persistent rash and itching despite multiple oral and topical medication changes, with no documented resolution of symptoms.A dermatology consultation dated June 11, 2026, documented a generalized itchy rash that had been present for approximately three weeks. Resident 3 reported the rash began after admission to the facility and had not improved with Tacrolimus ointment (a prescription topical medication used to treat inflammatory skin conditions) or Hydroxyzine (an antihistamine used to relieve itching). A punch biopsy (removal of a small circular sample of skin for laboratory examination) was obtained. A follow-up dermatology report dated June 25, 2026, confirmed the diagnosis of scabies. The dermatologist ordered Permethrin 5% cream to be applied from the neck to the toes, including the soles of the feet, with the treatment to be repeated one week later. During an interview and observation conducted on July 21, 2026, at 1:00 PM, Resident 3 stated he continued to experience an itchy rash involving his body. Clinical record review revealed Resident 4 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus and arthritis. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, indicating moderately impaired cognition. Nursing documentation dated June 11, 2026, at 4:40 PM, revealed Resident 4 reported she had been unable to sleep due to persistent itching. The Certified Registered Nurse Practitioner (CRNP) was notified and ordered Hydroxyzine (an antihistamine used to relieve itching) 25 milligrams by mouth at bedtime for 14 days. Nursing documentation continued to reflect persistent itching throughout June 2026. The Physician ordered Permethrin cream on July 3, 2026, for treatment; however, Resident 4 refused the medication. The resident again refused treatment when it was offered on July 7, 2026. A nursing note dated July 8, 2026, at 1:30 PM, documented the resident's family requested a dermatology consultation due to her persistent itching. A dermatology consultation dated July 9, 2026, confirmed a diagnosis of scabies involving the trunk and recommended treatment with Ivermectin (an oral antiparasitic medication used to treat scabies), four tablets immediately followed by four tablets one week later. Clinical record review revealed Resident 5 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular accident (stroke), dementia, and diabetes mellitus. An annual MDS assessment dated [DATE], revealed a BIMS score of 12, indicating moderately impaired cognition.Nursing documentation dated June 23, 2026, at 8:23 PM, documented the resident's rash and itching persisted. The Certified Registered Nurse Practitioner ordered Permethrin 5% cream, which was administered on June 26, 2026. Nursing documentation dated July 8, 2026, at 1:38 PM, revealed that the resident's family requested a dermatology consultation because the rash had not been resolved. The Physician was notified, and Resident 5 was evaluated by dermatology on July 16, 2026. The dermatology consultation dated July 16, 2026, documented persistent itching despite two courses of Permethrin treatment. A skin scraping and skin biopsy were obtained, confirming scabies infestation. The dermatologist recommended treatment with Ivermectin 3 milligrams, six tablets immediately followed by a second dose one week later. A review of the facility's infection surveillance documentation revealed a facility-wide skin assessment conducted on July 3, 2026, identified sixteen residents with body rashes. Documentation indicated all sixteen residents were receiving treatment; however, none demonstrated improvement in their rash or itching. A subsequent facility-wide skin assessment completed on July 10, 2026, again identified sixteen residents receiving treatment, with documentation indicating no improvement in their symptoms. A review of infection surveillance documentation dated July 17, 2026, revealed no additional residents with newly identified rashes or complaints of itching. Documentation indicated three previously identified cases had resolved and the remaining residents were noted to be improving. During an interview on July 21, 2026, at 2:00 PM, the Infection Preventionist (IP) stated that multiple residents developed rashes and were subsequently identified with suspected or confirmed scabies between February and June 2026. The IP confirmed the residents with persistent rashes and itching were not included on the facility's monthly infection surveillance logs as suspected or confirmed infections. The IP further confirmed the clinical records contained no documentation that residents treated with Permethrin cream were showered or that the medication was removed in accordance with the manufacturer's application instructions. The IP also confirmed the facility did not complete a facility-wide skin assessment until July 3, 2026. The IP stated there was no available documentation demonstrating staff were assessed for symptoms following potential exposure to residents with suspected or confirmed scabies. The IP further confirmed that the facility did not perform contact tracing to identify potential exposures or the source of transmission. The IP acknowledged the infection surveillance logs were incomplete and confirmed the infection prevention and control program did not reflect the residents identified with persistent rashes and suspected or confirmed scabies. During an interview on July 21, 2026, at approximately 2:15 PM, the Assistant Director of Nursing (ADON) confirmed multiple residents experienced persistent rashes and itching and were subsequently treated for suspected or confirmed scabies. The ADON confirmed the facility did not implement all infection prevention and control measures identified in the facility's infection control policies after multiple residents developed similar symptoms, including timely facility-wide skin surveillance, documentation of staff exposure assessments, and contact tracing to evaluate potential disease transmission. 28 Pa Code 211.10 (c)(d) Resident Care Policies. 28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services. 28 Pa. Code 201.18 (b)(1)(e)(1) Management

Based on a review of select facility policy, clinical records, medication administration audit reports, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure licensed nurses administered medications within required timeframes for 1 of 11 residents reviewed (Resident CR1). Findings included: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse (RN) was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care including Medication Records. A review of facility policy entitled: Medication Administration last reviewed by the facility on September 1, 2025, indicated that medications are administered within 90 minutes of the scheduled time. A review of the clinical record for Resident CR1 revealed the resident was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a long-term condition in which the lungs cannot adequately provide oxygen to the body) and muscle weakness (reduced strength which may impair mobility or daily functioning). A review of the Medication Administration Record (MAR) revealed Resident CR1 was prescribed the following medications, including medications scheduled for administration at 09:00AM: Vitamin D3 25 mcg oral tablet -administer one tablet by mouth once daily for supplement (Vitamin supplement used to support bone strength and calcium balance).Oyster Shell Calcium 500 mg oral tablet -administer one tablet by mouth twice daily for supplement (Calcium supplement used to maintain bone strength).Ascorbic Acid (Vitamin C) 1000 mg oral tablet -administer 1000 mg by mouth once daily for supplement (Vitamin supplement used to support immune function).Multivitamin oral tablet -administer one tablet by mouth once daily for supplement (Vitamin supplement used to prevent nutritional deficiency).Aspirin 81 mg oral tablet -administer one tablet by mouth once daily for cardiac health (Medication used to reduce blood clot formation and support heart health).Bumetanide 1 mg oral tablet -administer two tablets by mouth twice daily for edema (Diuretic, also called a water pill, used to remove excess fluid from the body).Biotin 5 mg oral tablet -administer one tablet by mouth once daily for supplement (Vitamin supplement used to support normal metabolism).Ropinirole 4 mg oral tablet -administer one tablet by mouth three times daily for restless leg syndrome (Medication used to treat uncomfortable sensations in the legs causing urge to move).Potassium 20 mEq oral tablet -administer one tablet by mouth once daily for low potassium (Mineral supplement necessary for normal heart and muscle function).Sildenafil citrate 20 mg oral tablet -administer two tablets by mouth three times daily for pulmonary hypertension (Medication used to treat high blood pressure in the lungs by improving blood flow).Lexapro (escitalopram) oral tablet - administer one tablet by mouth once daily for anxiety (Antidepressant medication used to treat anxiety).Tyvaso (treprostinil) inhalation solution - administer one inhalation four times daily for pulmonary hypertension (Medication inhaled into the lungs to treat high blood pressure in the lungs). A review of the medication administration audit report for February 2026 revealed medications were administered outside the facility's required 90-minute administration window, including: February 23, 2026, 09:00AM scheduled Biotin 5mg tablet was administered at 2:18PM, 318 minutes after the scheduled time. February 28, 2026, 09:00AM Tyvaso Inhalation Solution was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Lexapro was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM vitamin d3 was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Potassium was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Oyster Shell Calcium tablet was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Bumetanide was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Aspirin was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Ropinirole 4mg was administered at 10:41AM, 101 minutes after the scheduled time.February 28, 2026, 09:00AM Biotin was administered at 10:56AM, 116 minutes after the scheduled time.February 28, 2026,1:00PM Tyvaso was administered at 2:35PM,95 minutes after the scheduled time.February 28, 2026, 1:00PM Sildenafil was administered at 4:22PM, 202 minutes after the scheduled time. Interview with the Nursing Home Administrator on April 7, 2026, at 02:00PM confirmed review of the late medication administration findings and acknowledged medications are expected to be administered timely in accordance with professional standards of practice and facility policy. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services. 28 Pa. Code 211.9(1) Pharmacy services. 28 Pa. Code 211.10 (c) Resident care policies.

Based on clinical record review, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 27 residents sampled (Resident 57).Findings include: A review of the facility policy titled Restorative Nursing, last reviewed by the facility on September 1, 2025, revealed it is the facility's policy to provide maintenance and restorative services designed to maintain or improve a resident's ability to the highest practicable level. Further review of the policy revealed that the restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible and that residents may receive restorative nursing services upon admission, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy. Restorative nursing refers to nursing-implemented programs that are planned, monitored, and carried out by nursing staff to maintain or improve a resident's functional status, mobility, strength, endurance, or ability to perform activities of daily living after formal therapy services have ended, in accordance with the resident's assessed needs, care plan, and professional recommendations.A review of the clinical record revealed Resident 57 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis affecting the left side (conditions involving paralysis or significant weakness and loss of muscle function on one side of the body) and rheumatoid arthritis (a chronic inflammatory disorder that primarily affects joints and can impact mobility and function). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 22, 2025, revealed that Resident 57 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A review of care plan dated September 25, 2025, indicated Resident 57 required restorative programs to address muscle weakness, with goals that included ambulating safely and consistently using a rollator walker. A review of a physical therapy Discharge summary dated [DATE], revealed that Resident 57 was discharged from physical therapy services with recommendations for nursing to implement a restorative ambulation program. The discharge recommendations specified that the resident was to ambulate using a platform rollator walker with the assistance of two caregivers and a wheelchair follow for safety. A review of Resident 57's task report, an electronic record used to outline and track planned resident-centered nursing tasks, indicated that the resident was to ambulate in a straight path for 30 to 50 feet with the assistance of two caregivers using a platform rollator walker, with additional assistance required to place and remove the resident's left upper extremity on and off the platform of the walker. During an interview on December 9, 2025, at 11:05 AM, Resident 57 stated that she had exercised regularly while receiving physical therapy; however, after therapy services ended, no staff had provided restorative ambulation services. The resident stated that no one had walked with her since physical therapy was discontinued.A review of Resident 57's Documentation Survey Report v2, which reflects care tasks completed for the resident, for November 2025 and December 2025, revealed inconsistent, incomplete, and conflicting documentation of restorative ambulation services, including multiple entries of not applicable, blank documentation, limited distances ambulated that did not align with the restorative plan, and documentation of ambulation on dates the resident later denied occurred. Specifically, documentation revealed the following:On November 27, 2025, documentation indicated that during the day shift the resident was documented as unavailable. Documentation for the evening shift and night shift reflected NA (not applicable).On November 28, 2025, documentation for the day shift was left blank. During the evening shift, documentation indicated that 15 minutes were spent providing ambulation, and the resident ambulated a distance of 10 feet. No documentation was recorded for the night shift.On November 29, 2025, documentation indicated NA for the day shift. For the evening shift, documentation reflected that the resident refused ambulation. Documentation for the night shift reflected NA.On November 30, 2025, documentation reflected NA for the day shift. During the evening shift, documentation indicated that 15 minutes were spent with ambulation and that the resident ambulated 30 feet. Documentation for the night shift was left blank.On December 1, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 2, 2025, documentation reflected NA for the day shift and evening shift. Documentation for the night shift indicated that 15 minutes were spent providing ambulation and that the resident ambulated 50 feet.On December 3, 2025, documentation reflected NA for the day shift. During the evening shift, documentation indicated that 15 minutes were spent with ambulation and that the resident ambulated 50 feet. Documentation for the night shift reflected NA.On December 4, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 5, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 6, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 7, 2025, documentation for the day shift indicated that zero minutes were spent ambulating and that the resident ambulated zero feet. Documentation for the evening shift and night shift reflected NA.On December 8, 2025, documentation for the day shift indicated that 15 minutes were spent ambulating; however, the distance ambulated was documented as NA. Documentation for the evening shift reflected that the resident refused ambulation. Documentation for the night shift reflected NA.On December 9, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 10, 2025, documentation reflected NA for the day shift, evening shift, and night shift.On December 11, 2025, documentation reflected NA for the day shift and evening shift. Documentation for the night shift indicated that 15 minutes were spent ambulating and that the resident ambulated 50 feet.During an interview on December 12, 2025, at 9:00 AM, Resident 57 stated that she did not ambulate the night prior, despite documentation indicating that she ambulated for 15 minutes and 50 feet. The resident further stated that she had not ambulated since physical therapy services ended and denied refusing ambulation services. During an interview on December 12, 2025, at 11:00 AM, the Assistant Director of Nursing confirmed that it is the facility's responsibility to ensure restorative nursing services are implemented and provided as planned following discharge from therapy services to maintain or improve resident function. 28 Pa. Code: 211.10(c) Resident care policies. 28 Pa Code 211.12(d)(5) Nursing services.

Based on a review of clinical records, select facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered per physician's orders for three residents out of 27 sampled (Residents 1, 26, and 38). Findings include: A review of the facility's policy titled Oxygen Administration, last reviewed September 1, 2025, revealed it is the facility policy that oxygen is administered to residents who need it is consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. The policy indicates oxygen is administered under orders of a physician, except in the case of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to, (1) the type of oxygen delivery system, (2) monitoring of blood oxygen saturation levels (SPO2, the percentage of red blood cells that are carrying oxygen, indicating how well oxygen is being delivered to the body's tissues; normal levels are typically 95 to 100%) and vital signs, and (3) monitoring of complications associated with the use of oxygen. Further review of the policy revealed that staff should perform hand hygiene and put on gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include changing and dating oxygen tubing and masks/cannulas every two weeks and as needed. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Further review of the clinical record revealed a physician's order dated April 3, 2025, for respiratory care directing staff to administer oxygen at 2.0 liters per minute (L/min) by way of nasal cannula/mask (a device, a flexible tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen) initiated on April 3, 2025. A review of the resident's care plan indicated that oxygen therapy related to ineffective gas exchange was initiated on July 15, 2024. Interventions included maintaining oxygen delivery via nasal cannula or mask at 2.0 L/min with humidification. On December 9, 2025, at 12:39 PM, an observation revealed Resident 1 was seated in the dining room in his wheelchair and connected to a portable oxygen tank via nasal cannula. The oxygen tank was observed to be empty. Employee 3, Licensed Practical Nurse (LPN), confirmed the oxygen tank was empty and stated the resident had physician's orders for continuous oxygen. Employee 3 further stated that oxygen tank levels should have been checked prior to the resident leaving his room for the dining room. On December 9, 2025, at 12:47 PM, Employee 3 LPN replaced Resident 1's oxygen tank and measured the resident's oxygen saturation (SpO ), defined as the percentage of oxygen in the blood, which measured 96%. A clinical record review revealed Resident 26 was admitted to the facility on [DATE], with diagnoses that include acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs). Further review revealed a physician's order dated October 22, 2025, directing staff to administer oxygen at 3.0 L/min continuously via nasal cannula. A review of the care plan indicated that Resident 26 had an altered respiratory status related to acute respiratory failure, initiated on October 1, 2025. Interventions included administering medications as ordered, monitoring for signs and symptoms of respiratory distress, and reporting changes to the physician as indicated. On December 9, 2025, at 10:05 AM, an observation revealed Resident 26 sitting in her room with her oxygen turned off. Employee 2, LPN, stated that the resident had physician's orders for continuous oxygen therapy and that the oxygen should always be in use. Employee 2 further stated that staff had not informed her that the resident had returned to her room and required her oxygen to be reapplied or adjusted. On December 9, 2025, at 10:13 AM, Employee 2 measured Resident 26's oxygen saturation (SpO ), which was 92%. During an interview on December 9, 2025, at 1:00 PM, the above findings were reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA confirmed that it is the facility's responsibility to ensure that oxygen therapy is administered and maintained in accordance with physician orders. A clinical record review revealed Resident 38 was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure and asthma (a chronic lung disease causing inflammation and narrowing of the airways). Further review of the clinical record revealed a physician's order dated October 29, 2025, for oxygen administration at 2.0 L/min via nasal cannula and for oxygen tubing, including nasal cannula or mask, to be changed every two weeks on Monday night and as needed. On December 9, 2025, at 11:10 AM, an observation revealed an oxygen concentrator in Resident 38's room. The oxygen tubing attached to the concentrator was dated November 20, 2025, as confirmed by Employee 5, LPN. An interview conducted on December 9, 2025, at 2:15 PM, with the Assistant Director of Nursing confirmed that the oxygen tubing for Resident 38 had not been changed in accordance with the physician's order and facility policy 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Based on a review of clinical records and select facility policy and staff interviews, it was determined that the facility failed to ensure residents are informed and provided written information regarding the right to formulate advance directives and failed to determine whether residents had advance directives upon admission for four out of 27 residents sampled (Residents 15, 26, 54, and 111).Findings include:A review of the facility's policy titled Advance Directives, last reviewed [DATE], indicated that it is the policy of the facility to encourage residents to make their own decisions for all aspects of their care. The Facility shall provide residents and/or resident representatives with information related to the right to complete an Advance Directive for Health Care (Living Will) and assignment of a Health Care Agent or identification of a Health Care Representative to serve as medical treatment decision-makers should they become incapable of making their own medical treatment decisions. The facility will provide written information regarding the resident's right to make healthcare decisions and information concerning the right to complete an Advance Directive for Healthcare and to appoint a Healthcare POA Agent or Healthcare Representative. Resident's Advance Directives, Healthcare Agents, and/or Healthcare Representatives documents shall be requested from the resident and/or the family at time of admission and intermittently. If the resident does not have an advance directive or wishes to change their directive, nursing will complete a healthcare directive form (a facility form that reflects life-sustaining treatments desired by the resident). The process of obtaining documents shall be a joint effort on the part of nursing, social services, admission personnel, and physician services. A review of Pennsylvania Statutes, Title 20, Chapter 54, Health Care, indicated that an advance health care directive is defined as a health care power of attorney, a living will, or a written combination of a health care power of attorney and a living will.A review of Resident 15's admission Minimum Data Set (MDS, a federally mandated standardized assessment process completed periodically to plan resident care) dated [DATE], revealed that the resident was cognitively intact with a BIMS (brief interview mental screening tool used to screen and identify cognitive impairment) score of 13 (13 to 15 indicates cognitively intact). A review of Resident 15's quarterly MDS dated [DATE], revealed that the residents had a BIMS score of 9 (a score of 8 to 12 indicates moderate cognitive impairment). Further review of Resident 15's clinical record revealed a Health Care Declaration form (facility form) which indicated the resident's chosen special treatment concerns included cardiac resuscitation (CPR), mechanical respiration (breathing machine), tube feedings or other artificial nutrition, artificial or invasive forms of hydration, blood or blood products, surgery or invasive tests, renal dialysis, and antibiotics and was signed on [DATE] (30 days after admission), by the resident's representative.A clinical record review revealed Resident 26 was admitted to the facility on [DATE], with diagnoses that include acute respiratory failure (a condition where the lungs fail to adequately oxygenate the blood or remove carbon dioxide, leading to insufficient oxygen to meet the body's needs).A review of an admission Minimum Data Set assessment dated [DATE], revealed that Resident 26 was moderately cognitively impaired with a BIMS score of 12 (a score of 8 to 12 indicates cognition is moderately impaired).A clinical record review revealed Resident 111 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function).A review of a quarterly MDS assessment dated [DATE], revealed that Resident 111 was moderately cognitively impaired with a BIMS score of 10 (a score of 8 to 12 indicates cognition is moderately impaired).A clinical record review revealed Resident 54 was admitted to the facility on [DATE], with diagnoses that include acute kidney failure (a condition in which the kidneys suddenly are not able to function to meet the body's needs) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).A review of a quarterly MDS assessment dated [DATE], revealed that Resident 54 was cognitively intact with a BIMS score of 13 (a score of 13 to 15 indicates cognition is intact).A review of the clinical records for Residents 15, 26, 54, and 111 revealed no documented evidence that written information regarding the right to formulate advance directives was provided upon admission. Additionally, there was no documented evidence that the facility determined whether these residents had existing advance directives, health care powers of attorney, or health care representatives at the time of admission.During an interview on [DATE], at 10:35 AM, the Director of Social Services confirmed there was no documented evidence that Residents 15, 26, 54, and 111 were provided with written information regarding the right to formulate an advance directive for health care or to appoint a health care power of attorney agent or health care representative. The Director of Social Services further confirmed there was no documented evidence indicating whether these residents did or did not have advance directives upon admission.During an interview on [DATE], at 12:10 PM, the above findings were reviewed with the Nursing Home Administrator (NHA). The facility failed to ensure that Residents 15, 26, 54, and 111 were provided with written information concerning the right to formulate advance directives and failed to document whether advance directives were in place upon admission.28 Pa. Code 201.14 (a) Responsibility of licensee.28 Pa. Code 201.18 (b)(2) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 221.10 (c) Resident car polices

Based on clinical record review, select facility policy, and resident representative and staff interviews, it was determined the facility failed to ensure a comprehensive care plan was developed and revised with the participation of the resident and the resident's representative for one resident out of 27 residents sampled (Resident 89).Findings include: A review of the facility's Resident Care Plan policy last reviewed September 1, 2025, indicated that the facility will develop a comprehensive care plan, for each resident, that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan will be developed by the facility's interdisciplinary team in conjunction with the resident and, or the resident's responsible party, surrogate, or family, as designated by the resident. Review of the facility Care Conference policy last reviewed September 1, 2025, indicated it is the policy of the facility to conduct care conferences to promote resident-centered care through interdisciplinary communication, resident and/or resident representative involvement, and ongoing evaluation of the resident's needs, goals, and preferences. Care conferences provide an opportunity for the interdisciplinary team to review and coordinate care, discuss changes in condition, evaluate outcomes, and involve the resident and/or resident representative in care planning and decision-making. Residents and/or resident representatives will be invited to participate in care conferences. Reasonable efforts will be made to accommodate availability and preferences. If the resident or representative declines or is unable to attend, this will be documented. A clinical record review revealed Resident 89 was admitted to the facility on [DATE], with diagnoses which included heart failure (condition in which the heart muscle cannot pump enough blood to meet the body's need for blood and oxygen) and diabetes (a disorder in which there are high levels of sugar in the blood). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 14, 2024, revealed that Resident 89 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderately impaired cognition). A review of Resident 89's clinical record revealed no documented evidence Resident 89 and resident representative were invited to participate or participated in the development of the resident's person-centered care plan. During an interview on December 9, 2025, at 12:00 PM, Resident 89's resident representative indicated that she has not been invited to participate in the development and revision of the resident's person-centered care plan. Resident 89's resident representative indicated that she had not been invited to any care plan meetings at the facility. During an interview on December 11, 2025, at 10:00 AM the Social Services Director (SSD) indicated that care planning conferences are completed for newly admitted residents and at least quarterly for each resident following admission to the facility. The SSD could not provide evidence that Resident 89's resident representative was being provided the opportunity to participate in the development and revision of the resident's comprehensive resident-centered care plan. The SSD confirmed it is the facility's responsibility to ensure comprehensive care plans are developed and revised with the participation of the resident and the resident's representative. The SSD was unable to provide documented evidence that Resident 89 and Resident 89's resident representative were being provided with an opportunity to participate in the development and revision of comprehensive resident-centered care plans. During an interview on December 12, 2025, at approximately 9:30 AM, the Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents and resident representatives are provided an opportunity to participate in development and revisions of their comprehensive care plans. The NHA confirmed the interdisciplinary team meets quarterly to discuss, revise, and develop each resident's plan of care. The NHA was unable to provide documented evidence that Resident 89's resident representative was offered the opportunity to participate in care conference meetings or the development and revision of the resident's comprehensive resident-centered care plan. The NHA confirmed the facility must include residents and resident representatives in the development and revision of their care plans to the greatest extent possible. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa Code 211.12(d)(3) Nursing services.

Based on review of clinical records, the Resident Assessment Instrument Manual, and staff interview, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments (MDS, a federally mandated standardized assessment process completed periodically to plan resident care) were completed within the required time frame for two of 27 residents reviewed (Residents 48 and 105). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that the assessment reference date (ARD, the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. Review of a quarterly MDS assessment for Resident 48 revealed an ARD of November 8, 2025. The MDS was signed as completed by the RNAC (Registered Nurse Assessment Coordinator, who is responsible for the completion of MDS assessments) on December 3, 2025 (25 days after the ARD date). Review of a quarterly MDS assessment for Resident 105 revealed an ARD of November 10, 2025. The MDS was signed as completed by the RNAC on December 10, 2025 (30 days after the ARD date). Interview with the RNAC on December 11, 2025, at 10:45 AM confirmed that the above quarterly MDS assessments were not signed as completed in the required time frames. 28 Pa. Code 211.5(f) (ix) Medical records.

Based on a review of clinical records, select facility policy, and staff and resident interviews, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to maintain skin integrity for one resident out of 27 sampled (Resident 54).Findings include:A review of the facility policy titled Alteration in Skin Integrity Identification and Treatment, last reviewed by the facility on September 1, 2025, revealed it is the facility policy that the physician or practitioner will be notified of all new alterations in skin integrity. A clinical record review revealed Resident 54 was admitted to the facility on [DATE], with diagnoses that include acute kidney failure (a condition in which the kidneys suddenly are not able to function to meet the body's needs) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 9, 2025, revealed that Resident 54 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 to 15 indicates cognition is intact). A care plan indicating Resident 54 had the potential for skin impairment and was prone to bruising with slight pressure was initiated on August 17, 2022. Interventions developed to assist Resident 54 to be free from potential skin injury included assessing skin integrity, noting color, texture, temperature, redness, scaling, breaking, or ulcerations, and reporting to the charge nurse. A physician's order for weekly skin checks with directions to document no new areas of skin impairment, new areas of skin impairment, or existing areas of skin impairment every Thursday day shift was initiated on July 31, 2025. During an interview and observation on December 9, 2025, at 10:31 AM, Resident 54 explained that her arms have been irritated for weeks. Her left arm presented with erythema (redness) and inflammation along her forearm, 8 abrasions with dried blood measuring under 0.5 inches, and bright red blood from a scratches measured 0.25 inches. Resident 54 indicated that her arms were very itchy, and she thinks she may be allergic to the facility detergent. She explained she has reported the issue to nursing staff, but they only give her a moisturizer that does not help. A review of Resident 54's Medication Administration Record (MAR) dated December 2025 revealed skin checks were performed as ordered by the physician on December 4, 2025, and December 11, 2025. There was no documentation indicating if the resident had no new skin impairment, new skin impairment, or existing areas of skin impairment on either date. Further review of Resident 54's clinical record revealed no documentation of an ongoing issue with upper extremity skin irritation or inflammation or ongoing assessment monitoring her upper extremity irritation, inflammation, or injuries. During an interview on December 12, 2025, at 11:00 AM, Employee 4, a Licensed Practical Nurse (LPN), confirmed there was no documentation in Resident 54's medical record indicating findings of Resident 54's weekly skin checks on December 4, 2025, or December 11, 2025, consistent with the facility policy to identify when there are no new areas of skin impairment and new or existing areas of skin impairment. Employee 4, LPN, confirmed Resident 54's medical record should contain information describing Resident 54's skin integrity status. During an interview on December 12, 2025, at 11:20 AM, the above findings were reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence that the facility was monitoring Resident 54's skin consistent with facility policy. The facility failed to ensure Resident 54 received care and treatment to maintain skin integrity. 28 Pa. Code 211.5(f)(ii) Medical records. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of clinical records, select facility policy, and staff interview, it was determined that the facility failed to ensure that one of 27 residents sampled (Resident 2) received a psychotropic medication only when medically necessary and supported by adequate clinical justification, documentation of behavioral symptoms and attempts of nonpharmacological interventions were prior to administration. Findings include: A review of the facility policy titled Psychoactive Medication, last reviewed by the facility on September1, 2025, revealed it is the facility's policy that psychoactive medications will be utilized for the purpose of adding quality of life for those residents who require psychoactive medications. Initiation of drug therapy will be done after non-pharmalogical interventions have been attempted and documented as ineffective. A review of the resident's clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia with other behavioral disturbance(a disease that is characterized by a decline in cognitive abilities that affects a person's ability to perform everyday activities ) and major depressive disorder(a mental disorder that is characterized by persistent feeling of sadness, hopelessness, and loss of interest or pleasure in activities that were once found enjoyable) A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 5, 2025, revealed that Resident 2 was severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 to 7 indicates severe cognitive impairment). A review of Resident 2's physician orders revealed the following:July 28, 2025: Ativan (a medication used primarily for anxiety and panic disorders) 0.5 mg one tablet by mouth every 12 hours as needed (PRN) for anxiety or agitation for 3 months. A review of the electronic medication administration record (eMAR) revealed Resident 2 received PRN (as needed) Ativan 0.5 mg on eight occasions between October 5 and October 26, 2025. The administrations occurred on:October 5, 2025, at 12:48 PM; October 9, 2025, at 7:51 PM; October 13, 2025, at 9:31 PM; October 15, 2025, at 9:12 PM; October 17, 2025, at 12:58 AM; October 20, 2025, at 7:16 PM; and October 23, 2025, at 4:57 AM and 7:46 PM. For each of the eight administrations, the clinical record lacked documentation identifying specific behavioral symptoms, distress, or clinical indicators that would support the need for PRN administration of Ativan.Additionally, for each administration, the clinical record lacked documentation indicating that nonpharmacological interventions were attempted prior to medication use. Nonpharmacological interventions are individualized approaches that do not involve medication, such as redirection, reassurance, therapeutic communication, structured activities, or environmental modification. The absence of documented behavioral symptoms, medical necessity, and attempted nonpharmacological interventions indicated that the administration of Ativan was not supported by adequate clinical justification, resulting in the use of an unnecessary psychotropic medication for Resident 2. An interview with the Director of Nursing was conducted on December 11, 2025, at 1:28 PM regarding the facility's failure to provide documentation supporting medical necessity for the PRN use of Ativan and evidence that nonpharmacological interventions were attempted prior to administration. 28 Pa. Code 211.5(i)(ii)(viii)(xi) Clinical records. 28 Pa. Code 211.9(b)(2) Pharmacy services. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services.

Based on a review of clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure medications were properly stored and administered in accordance with physician orders and accepted standards of nursing practice, resulting in a medication error that caused pain and discomfort for one of one resident out of 27 residents sampled (Resident 82).Findings include:A review of the facility policy titled Medication Administration, last reviewed by the facility on September 1, 2025, revealed it is the facility policy to administer medications to all residents in a timely fashion and within prescribed parameters. Resident medications will be stored in appropriate areas of the medication room, carts, or medication room refrigerator. The nurse will verify the resident has taken or received all medications before the nurse leaves the bedside. Medications are never to be left at the bedside, on a resident's meal table, etc. A clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease (gradual loss of kidney function).A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 5, 2025, revealed that Resident 82 is moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 08 to 12 indicates moderate cognitive impairment).A review of physician orders revealed:An order dated December 8, 2025, to apply zinc oxide paste to the groin, abdominal folds, bilateral buttocks, posterior thighs, and right anterior thigh every shift and as needed until resolved.An order dated September 17, 2025, to apply muscle rub external cream (Menthol-Methyl Salicylate 10%/15%) to the right knee topically two times daily for pain. Menthol-Methyl Salicylate is a topical analgesic intended for application to intact skin and may cause irritation or burning if applied to wounds or compromised skin.A review of a progress note dated December 10, 2025, at 9:16 AM, revealed Resident 82 had a chronic open wound under the right abdominal fold. The wound was described as stable and measured 1.0 cm by 0.7 cm by 0.2 cm with exposed subcutaneous tissue (below the top layer of the skin) and a moderate amount of serosanguineous exudate (a mixture of clear fluid and blood).During an interview on December 11, 2025, at 10:20 AM, Resident 82 explained that she was upset because yesterday (December 10, 2025) she needed an ice pack after a male nurse aide, Employee 7, put muscle rub cream on her wound. She indicated that the cream immediately started to burn, and she told the nurse aide. Resident 82 explained that the nurse aide cleaned off the muscle rub cream with water and then gave her an ice pack for the discomfort. She indicated that she lay in bed for an hour before the pain subsided. Resident 82 indicated that it was an awful experience, and the nurse knows about what happened.A review of the clinical record revealed no documented evidence that:Muscle rub external cream was administered to the resident.The resident's pain or discomfort was assessed or monitored.Nursing interventions were implemented following the event.The physician was notified of the medication error or the resident's response.During an interview on December 11, 2025, at 10:26 AM, Employee 6, Licensed Practical Nurse (LPN), indicated that she heard something about Resident 82 experiencing pain after a muscle rub cream was applied. She provided the name of the nurse aide that was assigned to provide care to Resident 82 on December 10, 2025. Employee 6, LPN, explained that the muscle rub external cream Menthol-Methyl Salicylate (10% Menthol and 15% Methyl Salicylate) should not be left at the resident's bedside. She indicated it is the nurse's responsibility to apply the medication. An interview statement dated December 11, 2025, revealed the Director of Nursing (DON) identified that Employee 7, Agency Nurse Aide, applied a cream to Resident 82 from a cup. The DON stated the resident reported the cream caused burning. The DON indicated the nurse aide washed the cream off and provided ice to relieve the discomfort. The DON stated the nurse aide was educated that topical medications are to be applied from their original containers and only those identified on the resident's Kardex (a quick-reference tool used by nursing staff to summarize essential resident care information). During a phone interview on December 12, 2025, at 11:50 AM, Employee 7, Agency Nurse Aide, stated he accidentally applied muscle rub external cream to Resident 82's abdominal folds and peri-area, believing it was zinc oxide paste. He stated the medication had been left at the resident's bedside. He reported that the resident immediately experienced a burning sensation, after which he washed the cream off and provided a cold, wet washcloth. He stated he reported the incident to a nurse but was unable to identify the nurse by name.During an interview on December 12, 2025, at 12:10 PM, the above findings were reviewed with the Nursing Home Administrator (NHA). The facility failed to ensure medications were securely stored and administered only by licensed nursing staff in accordance with physician orders, resulting in a medication error that caused Resident 82 pain and discomfort. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 211.5 (ii) Medical records.28 Pa. Code 211.10 (c) (d) Resident care policies. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Based on a review of select facility policy, clinical records, and staff interviews, it was determined the facility failed to timely notify the physician of abnormal lab results for one resident out of 27 sampled (Resident 119). Findings included: A review of the facility policy entitled Laboratory Testing and Notification, last reviewed on September 1, 2025, indicated that physicians will be notified of abnormal laboratory results in a timely fashion. Further review revealed that all laboratory testing results will be reviewed by a nurse as they are received by the facility, and the nurse who receives the laboratory result will be responsible for notifying the resident's physician of abnormal or critical results, with documentation of same in the resident's medical record. A review of the clinical record revealed that Resident 119 was admitted to the facility on [DATE], and had diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and hypertension (blood pressure that is higher than normal). A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 22, 2025, revealed that Resident 119 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of a physician's order for Resident 119 dated November 30, 2025, revealed a laboratory order for urinalysis (UA) and C & S (culture and sensitivity, a urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection). ). A review of the final urine culture (C&S) results dated December 4, 2025, identified abnormal findings of greater than 100,000 colonies per milliliter of Escherichia coli (E. coli, a bacterium). A review of nursing progress notes for Resident 119 revealed that the abnormal C&S results from December 4, 2025, were not communicated to the physician by staff until December 7, 2025, at 1:45 PM, three days after the result was available. During an interview on December 11, 2025, at 10:00 AM, the Assistant Director of Nursing confirmed that laboratory results are sent to the nursing department, and it is the responsibility of nursing staff to notify the physician of any abnormal results in a timely fashion, and confirmed that the urine culture results were not relayed to the physician in a timely manner for Resident 119. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa Code 211.10 (a)(c) Resident care policies.

Based on observation, a review of clinical records and facility investigative reports, resident and staff interview it was determined the facility failed to consistently provide care and services consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of 10 sampled residents. (Resident 1) Findings: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including dementia, respiratory failure, and a history of falling at home. Resident 1 was discharged home on March 13, 2025. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 5, 2025, indicated the resident was moderately impaired with a BIMS score of 3(brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment). The MDS further identified the resident as requiring staff assistance for activities of daily living (ADLs) and at risk for pressure ulcer development. A review of Resident 1's care plan-initiated January 29, 2025, identified the resident as being at risk for impaired skin integrity related to aspirin therapy (a medication with anticoagulant, bleeding, properties), which made the resident prone to bruising with slight pressure, decreased mobility, history of falls, and incontinence. Interventions included assessing skin integrity for changes (noting color, texture, temperature, redness,) keeping the skin clean and dry, applying protective creams or lotions, preventing friction, and toileting the resident after meals. An additional care plan problem identified on January 29, 2025, indicated the resident experienced decreased ADL performance due to muscle wasting and atrophy (breakdown of body tissue). Interventions included the use of a mechanical lift for all transfers and assistance of two staff for toileting. A review of facility investigative documentation dated February 16, 2025, at 3:00 AM, revealed that Employee 3 (RN) was called to Resident 1's room by nurse aide staff to assess a new open area on Resident 1's left inner gluteal fold. Upon assessment the area measured 1.5 cm x 0.5 cm x 0.1 cm, with red granulation tissue and minimal serosanguinous drainage (combination or blood and fluid). The physician was called, and a treatment was ordered. The report noted that the resident was resistive when staff tries to reposition him on his side. Documentation indicated the resident was resistant to repositioning, utilized a mechanical lift for transfers, was confused, and was incontinent of urine at the time of discovery. Witness statements dated February 16, 2025, at 3:00 AM from Employees 1 and 2 (Nurse Aides) confirmed they observed the area during care on February 16, 2025, and reported it to the nurse. A subsequent facility investigative report dated February 16, 2025, at 9:30 AM, revealed that Employee 4 (Nurse Aide) observed additional open and discolored areas on the resident's buttocks and sacrum during care. Employee 6 (RN) assessed the areas, which included: Sacrum: open area measuring 1 cm x 1 cm, no drainage. Left buttock: open area measuring 1.5 cm x 1.5 cm with surrounding dark purple, non-blanchable skin measuring 7 cm x 3.5 cm. Left outer buttock: open area measuring 3 cm x 1 cm with surrounding dark purple, non-blanchable skin. Left upper outer buttock: intact, non-blanchable purple area measuring 1 cm x 0.5 cm. The physician was notified of these additional areas. Witness statements from Employee 5 indicated that the resident was last observed at 8:00 AM on February 16, 2025, lying in bed. A physician's order dated February 17, 2025, directed the use of an alternating air mattress and Juven nutritional supplement (used to promote wound healing). Weekly wound assessments documented the progression of wound status as follows: February 21, 2025 Sacrum: 1 cm x 1 cm x 0.1 cm, deep tissue injury (DTI) (damage beneath intact skin, typically presenting as a dark purple area). clean the area with normal saline and apply silver alginate (protect the wound from external contaminants, maintain a moist environment conducive to healing, and help manage exudate, drainage) and cover with a foam dressing every shift and as needed. Left buttock: 4 cm x 3 cm x 0.1 cm, DTI. with scant serosanguinous drainage Right buttock: 5 cm x 3 cm x 0.1 cm, DTI. the peri wound noted as deep purple in color with scant serosanguinous drainage. Treatments included cleansing with normal saline and applying silver alginate dressings (used to manage exudate and support healing), covered with foam dressings. February 28, 2025 Sacral wound resolved. Left and right buttocks: unstageable pressure injuries (wounds obscured by slough - soft, yellow dead tissue - or eschar - hard, black dead tissue). The left buttock measured 4 cm x 3 cm x 0.1 cm, and the right buttock measured 5 cm x 3 cm x 0.1 cm Wounds contained 20% granulation tissue and 80% slough. Treatment changed to cleanse with normal saline and wet-to-dry dressings (used to assist with gentle debridement). March 7, 2025 Wounds remained unstageable with the same measurements and tissue composition. Treatment regimen unchanged. A review of a nurses note dated March 10, 2025, at 12:25 PM revealed, described the resident being combative during care, striking staff. The eschar from one wound was dislodged, revealing 1 cm depth and red granulation tissue. Minor drainage was noted. The resident's wife was informed at the time of observation. A review of a nurses note dated March 12, 2025, at 11:58 AM documented providing the resident's wife with education about the wounds to the resident's buttocks and provided treatment supplies. The resident's wife verbally acknowledged understanding the wound condition and treatment needs. A review of interdisciplinary discharge instructions dated March 13, 2025, revealed wound care treatment instructions. However, no measurements or detailed descriptions of the wounds were documented as being provided to the resident's wife prior to discharge An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 10, 2025, at approximately 1:00 PM, confirmed the facility failed to implement timely and adequate preventive measures necessary to prevent the development of pressure ulcers to the sacrum and buttocks for Resident 1. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services

Based on review of select facility policies and procedures and clinical records, observations, and staff interviews, it was determined the facility failed to provide supplemental oxygen administration care consistent with professional standards of practice for three out of 19 residents sampled (Resident 2, 16, and 82). Findings include: Review of facility policy entitled Oxygen Administration, last reviewed November 13, 2024, revealed that oxygen is administered under orders of a physician, except in the case of an emergency. Infection control measures performed during the administration of oxygen include change and date oxygen tubing and mask/cannula every two weeks and as needed. Change and date humidifier bottle every 72 hours and keep delivery devices covered in plastic bag when not in use. Observation of Resident 2 on February 19, 2025, at 10:57 a.m. revealed the resident was receiving oxygen via nasal cannula set (tube with two prongs placed in the nostrils to deliver oxygen) at 3.0 liters per minute (l/m) with humidification. The humidifier bottle, dated February 15, 2025, was empty, and the oxygen tubing was not dated as per facility policy. Observation of Resident 16 on February 19, 2025, at 10:45 a.m. revealed nebulizer tubing and mask in a clear bag on the resident's nightstand. The tubing was dated January 26, 2025-indicating that it had not been replaced for over 25 days, exceeding the recommended timeframe. Observations were confirmed by Employee 2, licensed practical nurse (LPN), on February 19, 2025, at approximately 9:30 a.m. Resident 82: On February 20, 2025, at 9:32 a.m., the resident was observed resting in bed while the oxygen concentrator was on. The nasal cannula was placed in a clear bag attached to the concentrator rather than applied to the resident. The oxygen tubing was also not dated. An interview with Employee 1, a licensed practical nurse, revealed the resident was being evaluated for discontinuation of oxygen therapy; however, a review of the resident's clinical records showed no physician order to withhold oxygen therapy, as a current order dated January 29, 2025, prescribed 2.5 liters/min via nasal cannula. Additional interview with Employee 1 on February 20, 2025, confirmed that Resident 82 was not receiving oxygen as prescribed and acknowledged the lack of a physician's order for discontinuation. Interview with Nursing Home Administrator (NHA) and the Director of Nursing on February 21, 2025, at 1:00 p.m. confirmed that nursing staff failed to adhere to facility policies concerning oxygen administration and infection control practices. The Director of Nursing further confirmed that nursing staff failed to consistently provide oxygen therapy to Resident 82 in accordance with the physician's order. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on review of facility documents and staff interview, it was determined the facility failed to ensure the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of four quarters (April 2024 and January 2025). Findings include: A review of QAPI Committee meeting sign-in sheets for the period of April 2024 through January 2025, revealed the Medical Director or designee was not in attendance at the quarterly QA meeting held on April 25, 2024, and January 30, 2025. Interview with the director of nursing on February 21, 2025, at 11:00 AM confirmed the Medical Director or designee failed to attend the facility's QAPI meetings on a quarterly basis. 28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical director. 28 Pa. Code 201.18 (e)(1)(3) Management.

Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to the physician's parameters for two out of 19 sampled residents. (Resident 75 and 11). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. Review of the facility policy titled Medication Administration last reviewed by the facility on November 13, 2024, revealed that medications are administered as prescribed to all residents in a timely fashion and within prescribed parameters. Medications are administered in accordance with written orders of the attending physician. Prior to administering a medication to a resident, the nurse will verify: 1) The correct resident 2) The correct medication, dosage, and route, as per physician order 3) The correct time for the medication 4) Any special instructions are followed 5) Required parameter (s) are obtained prior to administration, as per order A review of the clinical record revealed Resident 75 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and chronic kidney disease (gradual loss of kidney function). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 15, 2025, revealed that Resident 75 had moderately impaired cognition with a BIMS score of 9 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired). A review of the physician's order dated January 4, 2025, revealed an order for Humalog injection (medication used to treat high blood glucose) 5 units twice a day and 8 units once daily, HOLD for BS<120 mg/dl (a blood sugar less than 120 mg/dl) for diabetes. A review of the physician's order dated January 19, 2025, revealed an order for Humalog injection 8 units in the morning, 12 units in the afternoon and 15 units in the evening, HOLD for BS<120 (a blood sugar less than 120) for diabetes. Review of the Medication Administration Record (MAR) for January 2025, and February 2025, revealed Resident 75's Humalog was administered on the following dates two times outside of the physician ordered parameters: January 8, 2025: 5 units of Humalog administered at 7:45 AM despite a blood glucose level of 117 (below the prescribed threshold). February 10, 2025: 8 units administered at 7:34 AM with a blood glucose level of 102. (below the prescribed threshold). During an interview on February 21, 2025, at approximately 12:30 PM, the Director of Nursing (DON) confirmed that nursing staff failed to follow the physician-ordered parameters and did not adhere to professional nursing standards during medication administration. A clinical records review revealed that Resident 11 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease, benign prostatic hyperplasia (BPH enlarged prostate), and history of COVID-19. A physician order, initially dated February 17, 2025, was noted for Midodrine (medication to treat low blood pressure) 5 mg one tablet by mouth two times a day for hypotension (low blood pressure) with instructions to hold the medication if the resident's systolic blood pressure (measures pressure inside the arteries and is the top number of a blood pressure reading) is greater than 120 mm/Hg. According to the resident's February 2025 Medication Administration Record, nursing administered Midodrine 5mg tablet on February 17, 2025, at 5:00 p.m. Further review of the MAR revealed that the medication was administered when Resident 11's systolic blood pressure was 132 mm/Hg, exceeding the prescribed threshold of 120 mm/Hg. During an interview on February 21, 2025, at approximately 1:00 p.m., the Nursing Home Administrator and Director of Nursing confirmed the medication was improperly administered, contrary to the physician's orders. The facility failed to adhere to professional standards of nursing care by not ensuring prescribed medications were administered according to the specific physician-ordered parameters for two residents. 28 Pa. Code 211.5 (f) (ix) Medical Records 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for one out of five residents reviewed (Resident 56). Findings include: A review of the clinical record revealed that Resident 56 was transferred to the hospital on September 17, 2024, and was readmitted to the facility on [DATE]. Resident 56 was also transferred to the hospital on September 28, 2024, and was readmitted to the facility on [DATE]. Although written notices were provided to the resident and resident representative of the facility-initiated transfers, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the social services director (SSD)on February 21, 2025, at approximately 9:30 AM confirmed there was no documented evidence that copies of facility-initiated transfer notices for Resident 56 were sent to a representative of the Office of the State Long-Term Care Ombudsman. The SSD further confirmed there was no evidence that copies were sent to a representative of the Office of the State Long-Term Care Ombudsman during the months of May 2024 (for facility-initiated transfers in the month of April 2024), July 2024 (for facility-initiated transfers in the month of June 2024), August 2024 (for facility-initiated transfers in the month of July 2024), and October 2024 (for facility-initiated transfers in the month of September 2024). 28 Pa. Code 201.14(a) Responsibility of Licensee

Based on a review of clinical records and select facility policy and resident and staff interviews, it was determined that the facility failed to provide person-centered pain management consistent with professional standards of practice for two out of the 20 residents sampled (Residents 8 and 43). Findings include: A clinical record review revealed Resident 43 was admitted to the facility on [DATE], with diagnoses that included cervical and intervertebral disc disorders (conditions characterized by the breakdown of one or more of the discs that separate the bones of the spine and neck, causing pain in the back, neck, or frequently in the legs and arms). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 16, 2024 revealed that Resident 43 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). The MDS Section J-Health Conditions indicated that the resident almost constantly experiences pain or was hurting. Resident 43's care plan noted the resident's potential for pain related to his disc disorders, which was initiated on November 10, 2023. Interventions developed to assist the resident with his pain included monitoring, recording, and reporting complaints of pain or requests for pain treatment, evaluating the effectiveness of pain treatment, and offering and encouraging non-pharmacological pain relieving methods such as repositioning, back rubs, soothing or distraction activity, guided imagery, breathing exercises, offering pillows or blankets, bathing, or elevation. A physician's order was initiated on November 9, 2023, for Resident 43 to receive oxycodone HCL oral tablet 5 mg (an opioid medication) with instructions to give 1 tablet every 6 hours as needed for moderate to severe pain. The resident's medication administration record (MAR) for March 2024 revealed that Resident 43 received oxycodone 5 mg on 22 occassions from March 1, 2024, through March 21, 2024. There was no evidence that staff attempted any non-pharmacological attempts to relieve Resident 43's pain prior to administering as-needed opioid medication. There was no documented evidence that the facility had consistently assessed Resident 43's level of pain to ensure that the opioid medication was administered as per physician's orders, for moderate to severe pain. A review of progress note documentation and Resident 43's MAR for March 2024 revealed that the resident received oxycodone 5 mg on 18 occassions without documentation of the resident's pain level prior to administration of the medication. During an interview on March 19, 2024, at 10:10 AM, Resident 43 stated that he experiences consistent back pain. The resident explained that the facility provides a medicated ointment and pain medication that helps with the pain but further stated that the facility is not offering alternative non-pharmacological interventions to assist with his pain relief. During an interview on March 22, 2024, at approximately 10:00 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence that the facility consistently attempted non-pharmacological interventions prior to pain medications prescribed on an as needed basis. The NHA and DON were not able to provide evidence that the facility was consistently assessing the resident's pain levels prior to medication administration to ensure medications were being administered consistent with physician's orders. A review of the clinical record revealed that Resident 8 was admitted to the facility on [DATE], with diagnoses to include pyogenic arthritis, and spondylosis (degenerative arthritis of the spine). A review of Resident 8's physician order's initially dated January 11, 2024, revealed an order for oxycodone (a narcotic opioid pain medication) 5 mg tablet, give two tablets by mouth, every four hours, as needed, for severe pain. A review of the resident's February 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 48 times during the month of February. Of the 48 doses given, all were administered without non-pharmacological interventions attempted prior to giving the pain medication. A review of the resident's March 2024 Medication Administration Record (MAR) revealed that staff administered the pain medication 12 times during the month of March Of the 12 doses given, 11 were administered with no non-pharmacological interventions attempted prior to giving the pain medication. Interview with the Director of Nursing on March 22, 2024, at approximately 1:30 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of as needed pain medication. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services 28 Pa. Code 211.5 (f) Medical records

Based on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 4). Findings include: A clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of an annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2024 revealed that Resident 4 has severe cognitive impairment with a BIMS score of 02 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). Nursing progress notes dated January 10, 2024, at 11:25 AM that indicated that Resident 4 was having increased behaviors that morning, incessantly calling out different things at staff, yelling for help, and yelling for different people. A progress note dated January 13, 2024, at 4:46 AM indicated that the resident was calling out and yelling, Get me the hell out of here! On January 23, 2024, at 4:30 PM progress notes indicated that the resident was consistently yelling out help, entering other residents rooms, arguing with other residents, and stating, I am going to throw myself to the floor. Nursing noted January 24, 2024, at 12:38 PM that the resident was agitated during a shower. The note indicated that the resident was swinging a shower head and attempting to bite and kick staff. On February 16, 2024, at 12:34 AM, nursing noted that the resident was calling out continually, Help! Help! Who the hell am I? Does anybody know me? Nursing progress notes dated February 28, 2024, at 10:43 PM indicated that the resident was agitated and restless throughout the shift, wheeling herself into other residents' rooms, yelling, and pulling apart her oxygen tubing and on February 29, 2024, at 5:25 PM the resident hit her roommate with the back of her hand. Resident 4 stated that she wouldn't knock it off! I want her to shut up! Nursing documentation dated 2, 2024, at 1:57 AM indicated that the resident was screaming and yelling throughout the shift; on March 7, 2024, at 10:30 PM it was noted that the resident was entering other residents rooms, yelling at other residents, and attempting to open locked doors like the maintenance closet; and on March 15, 2024, at 3:50 AM it was documented that the resident was continually calling out and disrupting other residents. A review of Resident 4's care plan, conducted during the survey ending March 22, 2024, revealed that the resident's plan of care did not include the resident's behaviors, such hitting, biting, yelling out, screaming, and entering other residents' rooms. The facility failed to demonstrate the provision of necessary care and services, including individualized interdisciplinary non-pharmacological approaches to care, purposeful and meaningful activities, that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. There was no evidence that the facility provided the resident with specialized services and supports, such specialized activities, nutrition, and environmental modifications, based on the individual's abilities and dementia related behaviors. During an interview on March 21, 2024, at approximately 1:10 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to demonstrate the development or implementation of an individualized interdisciplinary person-centered care plan that addressed Resident 4's dementia care and behaviors. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.12 (d)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to develop a comprehensive person-centered plan of care to meet the individualized needs of one resident out 20 sampled (Resident 19). Findings include: Review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include heart failure (a condition in which the heart fails to sufficiently pump blood throughout the body) and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest). A review of a cardiology progress note dated January 26, 2024, revealed that the resident had a single AICD implanted for heart failure. The cardiologist indicated that the resident was seen due to a planned move to the skilled nursing facility. He further indicated that a note was sent to the facility to ensure that the move does not affect his AICD device. A review of the resident's current comprehensive care plan, conducted during the survey ending March 22, 2024, indicated that the facility identified a problem area of Resident 19's diagnosis of coronary artery disease (damage or disease in the heart's major blood vessels) due to hypertension, atrial fibrillation, AICD, and ischemic cardiomyopathy. However, the resident's care plan did not include AICD checks or monitoring for signs and symptoms of AICD complications. The resident's care plan did not include any emergency care of the AICD device and actions to be taken if the AICD was activated (i.e., consulting the physician, obtaining vital signs [clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] and keeping the resident and staff safe from the electrical shock. The resident should notify staff if a shock is felt, and staff should be aware not to touch resident is being shocked since the shock can be felt). Interview with Employee 1 (RN, MDS Coordinator) on March 20, 2024, at 2:16 PM confirmed that the facility failed to fully address the care and management of Resident 19's AICD on the resident's person-centered plan of care. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.

Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report resident physical abuse to the State Survey Agency for one of the 20 residents reviewed (Resident 5). Findings include: A review of the facility's Prevention of Abuse/Neglect/Involuntary Seclusion/Exploitation: The Facility Procedures Policy, last reviewed by the facility in October 2023, revealed that the facility's policy is for staff to report any allegations of abuse, neglect, misappropriation of property, exploitation, or involuntary seclusion to their supervisor immediately. The facility administrator or designee will be responsible for the follow-up investigation and reporting to the required agencies within the required time frames. The policy indicated that the investigation results will be reported to the State Survey Agency and all other required agencies within five days of the allegation. Facility investigation documents dated February 29, 2024, indicated that a nurse aide observed Resident 4 use the back of her hand to hit Resident 5 in the mouth. A Resident Incident Investigation form dated February 29, 2024, revealed that Employee 2, a Nurse Aide, observed Resident 4 in the hallway telling Resident 5 to shut up and was holding her {Resident 5's} left wrist. {Resident 4} let go of Resident 5's wrist and slapped {Resident 5} with the backside of her hand across {Resident 5's} mouth. The residents were separated, and the incident was reported to supervisory staff. A progress note dated February 29, 2024, at 5:25 PM indicated that {Resident 4} hit her roommate with the back of her hand. Resident 4 stated that she wouldn't knock it off! I want her to shut up! A progress note dated February 29, 2024, at 5:25 PM indicated that Resident 5 was unable to describe details of the interaction but indicated to staff that I'm okay. Resident 5 was assessed with no skin impairments, open areas, bruising, swelling, or dental issues. During an interview on March 21, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to report physical abuse of Resident 5 perpetrated by Resident 4 to State Survey Agency within the required time frames. 28 Pa Code 201.14 (c) Responsibility of licensee 28 Pa Code 201.18 (e)(1) Management

Based on a review of clinical records and select incident reports and resident and staff interviews, it was determined that the facility failed to provide sufficient staff supervision and assistance during the provision of resident care to prevent a fall with serious injury, a fractured distal femur (thigh bone fracture which occurs just above the knee joint), for one of two residents reviewed (Resident 18). Findings include: A review of the clinical record revealed that Resident 18 had diagnoses, which included chronic [MEDICAL CONDITION] (airways that carry air to the lungs become narrow and damaged which limits air movement through the body), [MEDICAL CONDITION] (progressive [MEDICAL CONDITION] that affects the pumping action of the heart muscles), right distal femur fracture and right knee replacement. Resident 18's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 17, 2019, revealed the resident had a BIMS score of 9 (Brief Interview for Mental Status- a tool to assess cognitive status; a score of 8-12 indicates moderately cognitively impaired), required extensive two person physical assistance for bed mobility (which includes how move to and from lying position and turning side to side), transfers and walking. The MDS assessment indicated that the resident's balance during transitions (moving from seated to standing position) and walking was not steady. Interview with Resident 18 on September 9, 2020, at 9:40 AM revealed that the resident was able to answer questions regarding the resident's care. Resident 18 stated that she is no longer able to ambulate or bend the right leg since a fall last December, which resulted in a leg fracture. The resident stated that at the time of the fall there was only one staff member present instead of two staff. A review of the resident's care plan, revised by the facility August 23, 2019, revealed that for transfers the resident required the moderate assist of two staff and a rollator walker (an assistive walking device with wheels). Review of a facility report dated December 17, 2019, at 5:45 PM, revealed that while being transferred from bed to the wheelchair for supper Resident 18 slid from the chair seat to the floor. At the time the resident stated, I was not sitting back far enough and slid down. The report noted that the resident was an assist of two staff for transfers. Further review of the facility report noted that Employee 1 (nurse aide) transferred the resident without the assistance of another staff member as required based on the resident's care plan and assessed needs for transfers. At the time of the fall no injuries were noted. However, an x-ray was ordered due to the resident's complaints of pain to the right knee. Review of the x-ray results dated December 18, 2019, concluded there was an acute fracture involving the right distal femur with moderate displacement. An intact right knee arthroplasty (replacement) without dislocation was also noted. A nurses note dated December 18, 2019, indicated that a physician order [REDACTED]. A physician extender progress noted dated December 18, 2019, revealed that resident had sustained a right distal femur fracture with moderate displacement and that the resident noted the pain was tolerable. The resident's responsible party did not want the resident transferred to the emergency room or to have surgery based on the resident's comorbidity factors and risks of chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] (lack of oxygen) related to mechanical ventilation. Interview with Employee 1 on September 10, 2020, at 3:30 PM confirmed the resident slid out of the chair as a result of not being properly positioned in the chair. Employee 1 confirmed that a second staff member was not present during the transfer as required based on the resident's MDS assessment and care plan in effect at the time of the fall. During an interview on September 11, 2020, at 9:00 AM, the administrator confirmed that the facility failed to provide the required assistance as assessed and care planned for Resident 18 to prevent the fall with serious injury. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices Previously cited 4/13/18 28 Pa. Code 211.11(b)(d) Resident care plan 28 Pa. Code 211.12(a)(c)(d)(5) Nursing services Previously cited 12/27/19, 4/26/19, 4/13/18

Based on observation, a review of clinical records and select facility policy and staff and resident interviews, it was determined that the facility failed to provide timely care and necessary services designed to promote healing and prevent further deterioration of a pressure sore, resulting in the worsening condition of the pressure sore for one out of 24 residents reviewed (Resident 35). Findings include: A review of the clinical record revealed that Resident 35 was admitted to the facility on [DATE], from the hospital after surgical repair of a right [MEDICAL CONDITION]. The resident arrived at the facility with 65 staples (specialized staples used in surgery to close skin wounds) to her right hip and an abductor pillow (a wedge shaped foam pillow placed between the legs with straps to hold the legs in place to maintain proper alignment of the hips to prevent dislocation) in place. According to the nursing documentation dated December 30, 2016, at 7:34 a.m. the resident had a Stage II pressure sore (a partial thickness loss of dermis {skin} presenting as a shallow open ulcer {break in skin} with a red pink wound bed, without slough {shedding dead skin}) to her sacrum (a triangular bone in the lower back formed from fused vertebrae {a series of small bones forming the backbone} and situated between the two hipbones of the pelvis}) measuring 0.7 cm (centimeter) x 0.3 cm x 0.1 cm. upon admission to the facility. Upon admission to the facility the resident was placed on fortified (food to which extra nutrients have been added) foods and a liquid protein dietary supplement was added to her diet twice a day to increase healing. Nursing documentation dated December 31, 2016, at 10:59 a.m. indicated that the resident's physician's orders [REDACTED]. The resident's comprehensive care plan dated January 2, 2017, indicated that the facility was to monitor, document the location and size of the skin injury (pressure sore) and report abnormalities and failure to heal, also to note any signs of infection, to the physician. The resident's 14 day admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 12, 2017, indicated that the resident's BIMS was 13 (Brief Interview for Mental Status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and required extensive assistance of two persons for bed mobility. A review of the resident's treatment records indicated that the resident was to be turned and repositioned every two hours, in and out of bed, to relieve the pressure on her sacrum beginning January 6, 2017. Review of the facility's Pressure Skin Records revealed the following measurements of the resident's sacral pressure sore: January 2, 2017 - Stage II - 0.7 cm by 0.3 cm by 0.1 cm, January 10, 2017 - Stage II - 1.2 cm by 0.5 cm by 0.1 cm January 18, 2017 - Stage II - 1.2 cm by 0. 5 cm by 0.1 cm The facility's Pressure Skin Records revealed a slight increase in the size of the resident's pressure sore and the continuation of the [MEDICATION NAME] wound treatment. A review of the nursing documentation dated January 20, 2017, at 2:40 p.m. written by Employee 2, LPN ( Licensed Practical Nurse) the Wound Care Nurse, indicated that, the resident is agreeable to receive treatment from the CWS (Employee 3, Certified Wound Specialist, a Certified Registered Nurse Practitioner contracted by the facility) for her sacral wound. There was no additional documentation at that time to indicate the resident's need for a wound evaluation by Employee 3. There was no documented evidence that the resident's [MEDICATION NAME] dressing was changed on January 20, 2017, and that Employee 2 had evaluated the pressure sore on that date and had determined that the wound had worsened. According to Treatment Administration Records, the resident's [MEDICATION NAME] dressing was changed on January 14, 2017, and was due to be changed again on January 21, 2016. Employee 2, LPN, did not document a description of the resident's pressure sore on January 20, 2017, although she had asked the resident if the resident was agreeable to treatment from Employee 3. During an interview on March 29, 2017, at 1:00 p.m. the Director of Nursing (DON) stated that the resident needed to be evaluated by a wound specialist because the resident's wound got worse. The facility's policy entitled, Policy and Procedure Pressure Wound Evaluation and Measurement, dated as reviewed on October 17, 2016, indicated that pressure wounds will be evaluated, measured and assessed by a Registered Nurse or Licensed Practical Nurse on admission, re-admission, upon discovery, and weekly thereafter until healed. Employee 2 determined that the resident's wound had deteriorated on January 20, 2017, but failed to document the appearance of this wound or why she had determined it had worsened and required additional evaluation and treatment by a wound care specialist. The DON stated during an interview on March 29, 2017, at 1:00 p.m. that Employee 2 identified a decline in the resident's pressure sore on January 20, 2107, which was a Friday. Employee 2 consulted Employee 3, however, Employee 3 only comes to the facility on Tuesdays. Therefore, Employee 3 would not be at the facility until January 24, 2017, to evaluate the resident's pressure sore; four days after the decline was reportedly identified by Employee 2. The DON also confirmed that the DON was not aware of the decline in this resident's pressure sore on January 20, 2017, and did not inform the physician prior to Employee 3's evaluation. A review of Employee 3's note dated January 24, 2017, revealed that the resident's Stage II pressure sore had deteriorated to an unstageable pressure sore (full tissue loss in which the base of the ulcer is covered in slough which is dead tissue, the true depth of the area is difficult to assess at this stage) to her sacrum measuring 4.8 cm by 2.5 cm by 0.3 cm with 80% fixed (not shedding dead skin) yellow slough 20 % pink surrounding area with a small amount of odor noted. Employee 3 changed the resident's treatment to discontinue the [MEDICATION NAME] dressing and to rinse the wound with a Dakin's solution (chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION]) after each dressing change and to apply Silver Alginate (a dressing to absorb drainage) dressing to the wound base to absorb drainage and initiate autolysis (destruction of the slough/dead tissue). An interview with the resident on March 28, 2017, at 9:45 a.m. revealed that when she was first admitted to the facility it was difficult for her to be repositioned from side to side due to the presence of the abductor pillow between her legs. An interview with two Nurse Aides, Employee 5 and Employee 6, on March 28, 2017, at 10:00 a.m. revealed that these nurse aides also explained that it was very difficult to reposition this resident completely off her sacrum due to the abductor pillow. Observation of this resident's pressure sore conducted on March 30, 2017, at 10:00 a.m. revealed a Stage III pressure area (full thickness tissue loss - subcutaneous {under the skin}fat may be visible, but bone, tendon or muscle are not exposed. Slough {shedding dead skin}may be present but does not obscure the depth of tissue loss. May include undermining {wound is spread out underneath the skin that surrounds the visible part of the sore} and tunneling {opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space}). The pressure sore was approximately 2.4 cm x 1 cm x 1 cm with undermining and tunneling approximately from 1 o'clock to 4 o' clock (when looking at the wound compared to a face of a clock to determine location). There was no documented evidence that the facility had evaluated the adequacy and appropriateness of the resident's turning and repositioning to ensure that it was consistently implemented and effective in promoting healing of the resident's pressure sore and preventing decline or to determine if alternate or additional measures were necessary to prevent worsening of the resident's pressure sore. The DON and Nursing Home Administrator confirmed during an interview on March 31, 2017, at 9:32 a.m. that it was not until four days after Employee 2 had reportedly identified the decline in the resident's pressure sore (on January 20, 2017) that the treatment to the resident's pressure sore was changed to promote healing and prevent further decline. 28 Pa. Code 211.10(a)(c) Resident care polices Previously cited 3/12/15 28 Pa. Code 211.10(d) Resident care polices Previously cited 2/4/16, 3/12/15 28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services. Previously cited 4/6/16, 2/4/16, 3/12/15 28 Pa. Code 211.12 (d)(1) Nursing services. Previously cited 2/4/16, 3/12/15

Based on clinical record review and staff interview it was determined that the facility failed to effectively implement a resident's plan of care to prevent dehydration and meet the resident's goal of adequate hydration status for one resident out of 14 sampled residents (Resident CR1). Findings include: A review of the clinical record revealed that Resident CR1 had [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. The resident's comprehensive plan of care, initiated on September 16, 2013, and revised on February 25, 2016, revealed that the resident had a potential for decline in nutritional status with a goal to consume greater than 75% of fluids through the next review to prevent signs/symptoms of dehydration. The facility planned the intervention, to assist in meeting this goal, of having the RD/CDM (registered dietitian/certified dietary manager) evaluate the resident and make diet change recommendations as needed. Review of a Nutritional Evaluation dated February 25, 2016, revealed that that the resident was on a soft easy chew, small portion diet. The resident's usual body weight was noted as 99 pounds. The resident's weight at the time of that evaluation was 140 pounds. The resident's meal completion was described as good at 75%-100%. The resident's estimated daily fluid needs were noted as 1250-1500 ml/day. The evaluation noted that the resident was meeting 75% of her estimated fluid requirements. The evaluation summary indicated that the resident was consuming 1331 ml/day. The resident also continued to receive [MEDICATION NAME] (diuretic) therapy. The evaluation noted that the resident's nutritional status was stable. Review of the resident's fluid intake, which included the Med Pass nutritional supplement, revealed that the resident's fluid intakes were documented as follows: 2/23/16 - 1410 ml/day 2/24/16 - 1230 2/25/16 - 1200 2/26/16 - 720 2/27/16 - 580 2/28/16 - 840 2/29/16 - 960 03/01/16 - 630 03/02/16 - 700 03/03/16 - 300 03/04/16 - 320 03/05/16 - 360 03/06/16 - 210 03/07/16 - 540 03/08/16 - 600 03/09/16 - 450 03/10/16 - 60 According to a review of interdisciplinary progress notes dated March 3, 2016, the resident's weights, fluids and calorie intakes were reviewed. The resident had experienced a significant weight loss. The resident's weight weight was 128 pounds at the time of the review. The interdisciplinary team noted that the resident's weight loss was secondary to possible severe cognitive deficits. The plan was for staff to assist the resident with meal completion and continue to monitor and follow up with resident needs. According to an interdisciplinary progress note dated March 3, 2016, at 10:56 AM, it was revealed that the resident had a decrease in weight and the physician was made aware. A new physician order [REDACTED]. Interdisciplinary progress notes dated March 6, 2016, at 6:04 PM, indicated that the resident refused and spit out the Med Pass supplement. On March 6, 2016, at 10:11 PM, a UA/C&S (urine analysis/culture & sensitivity) was obtained via straight catheterization due to the resident being incontinent of urine. 40 ml of cloudy mucous amber urine with a musky foul odor was noted. The resident was uncooperative in taking medications during the 1st medication pass, refused dinner and alternatives. The U/A laboratory results were received on March 7, 2016, which indicated that the resident had many bacteria in the urine. On March 9, 2016, at 2:19 PM, nursing noted that the resident was very lethargic; not eating and barely drinking today. A phone call to the physician was made to make the physician aware of the resident's status. New orders were obtained for a CBC, CMP, [MEDICATION NAME] for the a.m. Review of laboratory results received on March 10, 2016, indicated that the urine C&S revealed that the resident had greater than 100,000 CFU/ml of gram-negative rod bacteria. The resident's BUN was 136 mg/dl - (normal 7-25 mg/dl), creatinine 4.09 mg/dl- (normal 0.6-1.2 mg/dl), sodium 167 mmol/L- (normal 134-143 mmol/L). Interdisciplinary Progress Notes dated March 10, 2016, at 11:00 AM noted that the facility received the resident's lab results and reported the findings to the physician. The resident was transferred to the hospital for an evaluation and treatment. Review of RESIDENT TRANSFER INFORMATION SHEET for transfer to the hospital, which was dated March 10, 2016, indicated that the resident has poor kidney function, was lethargic and was refusing to eat/drink the past week. Review of the hospital record from her hospital admission on March 10, 2016, revealed that the resident was brought to the emergency room after becoming lethargic and essentially unresponsive yesterday. Upon admission to the hospital the resident's blood pressure was 65/41. The resident was found to be in acute [MEDICAL CONDITION] with significant dehydration. A review of the resident's fluid intake records indicated that she was consuming less than 75% of fluids provided, including Med Pass supplements, but there was no documented evidence that the facility had promptly identified and acted upon the resident's decreased fluid intake and increased risk for dehydration as identified on the resident's plan of care. The facility failed to provide the necessary services, including a timely evaluation of the need for alternate approaches, to promote sufficient fluid intake to maintain adequate hydration status, meet the resident's fluid needs and care planned goal of preventing dehydration. There was no documented evidence available for review by the end of the survey that the facility had consulted with the physician in a timely manner to ensure physician awareness of the resident's poor fluid intake to determine if more aggressive measures, such as intravenous therapy, were warranted to maintain adequate hydration status. The facility's assistant administrator also stated during interview at the time of the survey ending April 6, 2016, that a physician's orders [REDACTED]. The facility did not implement that approach to accurately assess the adequacy of resident's fluid intake in meeting the resident's estimated fluid needs and evaluate the resident's fluid balance and recommend changes as necessary according to the resident's plan of care. The facility failed to implement the resident's plan of care for the resident's risk for dehydration and failed to demonstrate that the resident was effectively monitored for signs/symptoms of dehydration based on the resident's identified risk factors, including decreased fluid intake, diuretic use and urinary tract infection. 28 Pa Code 211.11(c)(d) Resident care plan. 28 Pa Code 211.12 (a)(c)(1)(d)(3)(5)Nursing services. Previously cited: 2/4/16.

Based on a review of clinical records, select facility policy, an Event Report, and facility investigative report and staff interview, it was determined that the facility failed to timely identify a serious injury to ensure prompt and necessary treatment for one of 24 sampled residents (Resident 87). Findings include: A review of the clinical record revealed that Resident 87 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set Assessment (MDS - a federally mandated assessment process conducted at specific intervals to determine resident care needs) dated November 29, 2014, revealed that the resident was cognitively intact, required assistance for activity of daily living activities. The resident's pain was identified as moderate and almost constant; relieved by medication. Nursing documentation revealed that Resident 87 required assistance of one for transfers and utilized a sit to stand lift (a mobile lift that allows for patient transfers from a seated position with some assistance of the resident). Current physician's orders [REDACTED]. A review of an Event Report submitted to the State Survey Agency and a resident incident report dated January 15, 2015, at 10 AM revealed that while at physical therapy, staff was assisting the resident with ambulation. The resident was standing in front of her wheelchair, when her knees buckled. The physical therapy assistant was unable to maintain the resident's position and lowered the resident to the floor. Staff lifted the resident into her wheelchair. The resident complained of bilateral knee pain. Her knees were noted to be red at that time. A review of nursing notes dated January 15, 2015, at 11:15 PM revealed that staff attempted to use the sit to stand lift for transfers, but the resident was non-compliant. The resident was transferred by means of a hoyer lift (a mechanical total lift utilized when a resident cannot participate in a transfer). The nurse observed that the resident presented with light blue ecchymosis ( black and blue area) to right shin area; swelling of the same was noted. The resident complained of pain to bilateral knees throughout that nursing shift. Pain medication was given to the resident. At 4 AM on January 16, 2015, nursing notes revealed that the resident had been asking for pain medication hourly through the night. Nursing noted that the resident's right shin was swollen and ecchymotic. An X-ray of the resident's right knee was planned for the next morning. A X-ray of the resident's right knee dated January 16, 2015, revealed that the resident's knee joint was intact. No fracture or dislocation of the resident's knee was seen. A review of nursing notes and physical therapy notes dated from January 16, 2015 through January 25, 2015, revealed that the resident complained of increased pain and exhibited a decreased ability to assist in transfers. Physical therapy notes dated January 23, 2015, indicated that the resident was having difficulty participating and her ankles were bruised. Nursing documentation dated January 24, 2015, at 8 PM noted that the resident had ecchymotic areas on her bilateral lower extremities and [MEDICAL CONDITION] ( swelling and fluid retention ). A nurses note dated January 25, 2015 at 1:15 PM revealed that the physician was contacted and X-rays and Doppler studies of the resident's right lower leg were ordered. At 11:30 PM on January 25, 2015, nursing noted that the resident's bilateral lower extremities were yellow ecchymotic in color (indicating an aging bruised area). The resident's bilateral outer ankles were dark purple, ecchymotic and the resident had 4 plus [MEDICAL CONDITION] to bilateral feet (swelling). The physician was notified and the resident was sent to the hospital. On January 27, 2015, the resident was admitted to the hospital with [REDACTED]. and fibula (the outer and usually smaller of the two bones between the knee and the ankle) and fractures of the right and left ankles. The facility's investigation revealed that the initial X-ray of the resident right knee dated January 16, 2015 was read incorrectly and the resident in fact did have a fracture at that time. A review the resident's daily pain assessments conducted from January 1, 2015, through 14, 2015 revealed that the resident's pain level ( on a scale on 1-10, 1 indication the least amount of pain and 10 the worst ) was expressed as a 4 or less on most days. The resident's pain level increased from January 15, 2015, through January 19, 2015, with the resident's pain level at a 10 from January 20, 2015, through January 26, 2015. physician's orders [REDACTED]. The pain medication was increased on January 25, 2015, to [MEDICATION NAME]/APAP 5-325 mg, 2 tabs every 6 hours as needed for severe pain. Reviewing the resident's medication administration records for January 2015 revealed that the resident's complaints of pain and associated medication usage increased in the 10 days from the resident's fall to the discovery of the resident's multiple fractures. There was no evidence at the time of the survey that the facility had timely identified the resident's signs and symptoms of serious injury and provided prompt and sufficient treatment of the resident's fractures and increasing pain. Cross refer F520 28 Pa Code 211.12(c)(d)(3)(5) Nursing Services Previously cited 10/23/14, 2/14/14 28 Pa. Code 211.10(d) Resident care policies previously cited 10/23/14, 2/14/14 28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services previously cited 10/23/14, 2/14/14

Based on review of clinical records and staff interview, it was determined that the facility failed to effectively monitor the medication usage for the potential and/or presence of adverse consequences for one resident (Resident 43) out of 24 residents sampled. Findings include: A review of the clinical record revealed that Resident 43 had diagnoses, which included [MEDICAL CONDITION] disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), depression, and [MEDICAL CONDITION] (the heart muscle does not pump blood as well as it should). A Pharmacy Potential Drug Interaction note dated, May 16, 2014, indicated that the resident was receiving both [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] disorder) and [MEDICATION NAME] (a diuretic). The note indicated that residents should be monitored closely for both [MEDICATION NAME] toxicity (condition which, can result in cases of dehydration, interactions with other medications, and other conditions which may cause [MEDICATION NAME] to build up in the body) and decreased effectiveness of [MEDICATION NAME]. A physician order [REDACTED]. laboratory results dated , June 3, 2014, indicated that the resident's [MEDICATION NAME] level was in the critical high range at 1.5 mmol/L (the reference range- 0.6-1.2 mmol/L). Further review of the clinical record revealed no documented evidence that the facility ensured that the physician was made aware of the resident's critical high [MEDICATION NAME] level. A physician order [REDACTED]. A nurses note dated, June 10, 2014, at 4:30 a.m., noted that the resident was sitting up on the side of the bed and slurring speech a little. The resident was found to be pale, skin warm and dry. The resident's pulse rate was noted to be decreased at 28-26. The charge registered nurse was notified and the resident was transferred to the hospital. Review of a hospital History and Physical dated, June 10, 2014, revealed that the resident was admitted to the hospital with [REDACTED]. The resident's [MEDICATION NAME] level was noted to be 1.9 mmol/L. The resident's BUN (blood urea nitrogen) was elevated at 70 (indicative of altered fluid status and/or kidney failure); Creatinine level was elevated at 3.31 (indicative of altered fluid status and/or kidney failure). The resident was admitted with acute or [MEDICAL CONDITION] and symptomatic [MEDICAL CONDITION] secondary to [MEDICATION NAME] toxicity. An order was given to hold the resident's [MEDICATION NAME] medication. The resident was started on intravenous fluids at 125 cc/hour. The resident's status was listed as critical. Interview with the president of nursing services on March 11, 2015, at 10:30 a.m., confirmed that there was no documented evidence that the facility had promptly ensured that the physician was notified of the critical lab results. There was no documented evidence that the facility had identified the resident's signs and symptoms of potential adverse consequences of the medication use in a timely manner and provided necessary and timely care to prevent [MEDICATION NAME] toxicity. Refer to F505 28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services Previously cited 2/14/14, 10/23/14 28 Pa Code 211.5 (f)(g)(h) Clinical records Previously cited 2/14/14, 10/23/14