Every finding on record at Manatawny Center for Rehabilitation and Nursing

Based on observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of three nursing units (Unit A Medication Cart).Findings include:During an observation conducted on A Wing on March 18, 2026, at 8:33 a.m., a medication cart assigned to a licensed nurse (Employee E8) was observed unattended with the computer screen open, displaying residents' personally identifiable information (PII). Employee E8 was not present in the hallway or in the immediate vicinity of the medication cart, creating the potential for unauthorized access to resident information.During a second observation conducted on A Wing on March 19, 2026, at 8:45 a.m., a medication cart assigned to a licensed nurse (Employee E9) was again observed unattended with the computer screen open, displaying residents' personally identifiable information. Employee E9 was not present in the hallway or near the medication cart, creating the potential for unauthorized access.During an interview on March 19, 2026, at approximately 2:10 p.m., the Nursing Home Administrator (NHA) confirmed that the facility did not ensure the confidentiality of residents' medical information in accordance with regulatory requirements.28 Pa Code 211.5(b) Medical records

Based upon policy review and observation, it was determined that the facility failed to ensure infection control practices related to transmission-based precautions were implemented on one of four nursing units.Findings include:Centers for Disease Control (CDC) Guidance on Transmission-Based Precautions dated April 3, 2024, recommend Contact Precautions for patients with known or suspected infections that represent an increased risk of for contact transmission (the spread of infection through direct or indirect contact with contaminated environments). The recommendations advise wearing personal protective equipment (PPE) appropriately, including gloves and gown for all interactions that may involve direct contact with the resident or the resident's environment. The CDC recommends Droplet Precautions for patients known or suspected to be infected with pathogens (disease causing germs) transmitted by respiratory droplets, that are generated by a patient who is coughing, sneezing, or talking.The facility's Infection Prevention and Control Program policy (revised in October 2018) indicated that Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures .and implementing appropriate isolation precautions when necessary.Observation of Unit C on March 18, 2026, between approximately 1:00PM and 1:15PM revealed a sign on the door to the entrance of the unit instructing staff and visitors to wear a mask due to a respiratory outbreak on the unit. Further observation revealed staff not wearing masks, entering resident rooms to deliver clean laundry. Additional observation revealed the same staff entering a room with a Contact Precaution sign (Resident 2's room), without protective equipment. These same staff entered rooms that were not on any precautions and subsequently entered rooms with droplet precautions in place (Residents 26's, Resident 52's, and Resident 116's rooms) without any protective equipment. Personal protective equipment was available in bins outside every unit where there were transmission precautions in place.Interview with the DON, who is the current Infection Prevention Nurse and E3 on March 19, 2026, at approximately 9:15AM, revealed that the outbreak of respiratory virus on Unit C was confirmed on March 11, 2026, and whole house education including hand-washing audits, the use of personal protective equipment and infection prevention was performed on March 12, 2026.Interview with the DON and E3 on March 19, 2026, at approximately 1:30 confirmed that all staff should be wearing masks when on a unit where there is an outbreak and following posted transmission-based precaution signs. 28 Pa Code 211.12(d)(1)(5) Nursing services

Based on observations, and staff interviews it was determined that the facility failed to properly secure medications in two of two medication carts located in nursing unit A.Findings include:Review of the facility policy Administering Medication last revised April 2020 states During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medication are kept on top of the cart.During an observation on Nursing Unit A on March 16, 2026, at 9:50 a.m., a medication cart was observed unlocked in the hallway outside a resident room with no nursing staff present in the immediate vicinity.During an interview on March 16, 2026, at 9:52 a.m., a licensed nurse (Employee E8) stated that the medication cart should have been locked. Employee E8 then secured the medication cart before responding to a resident call bell.During an observation on Nursing Unit A on March 17, 2026, at 8:37 a.m., a medication cart was observed unlocked in the hallway outside Resident 29's room. Crushed medication in a plastic cup was observed on top of the cart. The assigned licensed nurse (Employee E9) was at the opposite end of the hallway speaking with other staff.During an interview on March 17, 2026, at 8:39 a.m., Employee E9 confirmed that the medication cart should have been locked and that medications should not be left unattended on top of the cart.During an observation on Nursing Unit A on March 18, 2026, at 8:19 a.m., a medication cart was observed unlocked in the hallway between Resident 5's and Resident 90's rooms. An unidentified blister pack was observed beneath two pieces of paper on top of the cart. The assigned licensed nurse (Employee E9) was at the end of the hallway speaking with other staff.During an interview on March 19, 2026, at 1:20 p.m., the Director of Nursing (DON) confirmed that nursing staff are required to lock medication carts when unattended and are not permitted to leave medications unsecured on top of medication carts.28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.28 Pa. Code: 211.10(c) Resident care policies.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical records review, and staff interviews, it was determined that the facility failed to implement the comprehensive care plan intervention to prevent alteration in nutrition and/or hydration for one of eight residents reviewed (Resident 89).Findings include: Review of Resident 89's medical diagnoses revealed diagnoses that include Parkinson's Disease (a disorder that affects movement caused by degeneration of nerve cells in the brain), Congestive Heart Failure, (CHF), (a condition when the heart cannot pump blood effectively), Chronic Obstructive Pulmonary Disease, (COPD), (a progressive lung disease that makes it difficult to breathe), and Gastroesophageal Reflus Disease, (GERD), (a condition where stomach acid flows back into the esopagus). Review of Resident 89's records revealed a care plan dated March 9, 2026, documenting the resident is at nutritional risk related to Parkinson's CHF, COPD, GERD, and BMI (body mass index) of 35.9 indicating class II obesity. Interventions included monitor /record/report to MD signs/symptoms of malnutrition: including significant weight loss of 3 pounds (lbs) in a week, greater than 5% in one month, greater than 7.5% in three months, and greater than 10% in six months. Review of Resident 89's 30-day weights, revealed an admission weight of 171.4 on March 5, 2026, 172 on March 9, 2026, and 165 on March 16, 2026 indicating a 7 lb weight loss in 7 days. Review of Resident 89's progress notes revealed no documentation of the physician being notifed regarding the resident's weight loss. During an interview with Dietician Employee E6 on March 18, 2026, at 10:53 a.m., Employee E6 stated dietary staff only assess residents who trigger for a 5% or greater weight loss or if requested by nursing staff. Employee E6 stated he/she was not aware of Resident 89's 7 lb weight loss because it was only -4.07% and did not reach the -5% required to trigger a red flag. Employee E6 confirmed creating the interventions but denied knowledge of the intervention requiring notification to the physician of a 3lb weight loss in a week. Employee E6 stated the intervention was generic and confirmed it was not resident centered. Employee E6 confirmed the physician was not notified of the weight loss. 28 Pa. Code 211.5(f) Clinical records28 Pa Code 211.11(d) Resident care plan3/26/18, 8/4/21, 9/29/2128 Pa. Code 211.12(d)(1)(5) Nursing services

Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide dignity for the use of an indwelling urinary catheter for one of 32 residents reviewed (Resident 80). Findings include: Observations of Resident 80's room on March 17, 2026, at 11:34a.m., 12:00 p.m., 1:16p.m., and 2:08 p.m. revealed Resident 80 in bed, with catheter bag hooked to the side of his bed visible from the door with no privacy bag cover. Interview with Employee 5 on March 17, 2026, at 2:08 p.m. confirmed that Resident 80 did not have a privacy cover on catheter bag. Interview with Nursing Home Administrator on March 19,2026 at 11:15 a.m. confirmed the above findings. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, medication regimen review, and staff interview, it was determined the facility failed to ensure the physician's medication order was followed for one of the eight residents reviewed (Resident 86).Findings include:Review of facility policy titled Administering Medications, last revised April 2020, states Medications are administered in accordance with prescriber orders, including any required time frame.Review of Resident 86's physician order dated November 29, 2024, revealed an order for midodrine hcl oral tablet 5 milligrams (MG) (rases blood pressure), Give 5 mg by mouth two times a day for orthostatic hypotension (a condition characterized by a significant drop in blood pressure upon standing) BP HOLD for systolic blood pressure (top number) greater than 130.Review of the January's 2026 Medication Administration Record (MAR) revealed that for the month of January 2026, Resident 86 received midodrine 5 mg ten times outside of the written parameters. The dates are as follows Date Time SBPJanuary 08, 2026, 8:00 a.m. 132January 08, 2026, 5:00 p.m. 132January 13, 2026, 5:00 p.m. 134January 14, 2026, 9:00 a.m. 134January 14, 2026, 5:00 p.m. 134January 16, 2026, 8:00 a.m. 133January 16, 2026, 5:00 p.m. 138January 25, 2026, 5:00 p.m. 131January 26, 2026, 8:00 a.m. 138January 29, 2026, 8:00 a.m. 131 Review of medication regimen review dated February 6, 2026, states under recommendation 1 Resident 86 is ordered midodrine administered outside hold parameters on several dates in JanuaryInterview conducted with Resident 86 on March 18, 2026, at 8:45 a.m. reported that she was not aware of receiving their medication outside of the prescribed hold parameters.Interview with the Nursing Home Administrator (NHA) conducted on March 19, 2026, at 2:10 p.m. confirmed that staff administered midodrine 5 mg outside of the prescribed hold parameters. 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure proper monitoring of fluid restrictions for two of eight residents reviewed for nutrition/hydration needs (Resident 3 and Resident 9).Findings include:Review of facility policy, titled Weight Assessment and Interventions last revised September 2008 states the physician, and the multidisciplinary team will identify medical conditions and medications that may cause fluid and nutrient loss and/or inadequate availability of food or fluids.Review of Resident 3's clinical record revealed diagnoses that included chronic diastolic heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs).Review of Resident 3's physician orders revealed an order for 1500 ml (milliliters) fluid restriction in 24-hour period, with an original start date of February 12, 2026. Per the order 840 ml of fluid was to be provided with meals and 660 ml to be provided by nursing staff.Review of Resident 3's February and March 2026 Medication Administration Report (MAR) and 30-day task documentation for amount of fluid intake obtained from nursing staff for the past 30 days, in addition to the amount of fluids provided with meals, revealed that the combined fluid intake exceeded the restriction of 1500 ml 30 out of 30 days.Review of Resident 9's clinical record revealed diagnoses that included chronic kidney disease stage 3 (kidneys filtering blood at about half the normal capacity), and chronic diastolic congestive heart failure (heart failure in which the heart cannot fill properly).Review of Resident 9's physician orders revealed an order for 2000 ml fluid restriction in 24-hour period, with an original order date of February 4, 2026. Per the order 1080 ml should be provided with meals and 920 ml obtained from nursing staff.Further review of the physician orders revealed an order for Medication Pass (a procedure used to administer medications safely and efficiently) two times a day 60 cc (cubic centimeter) BID (twice a day).Review of Resident 9's February and March 2026 MARs and 30-day task documentation for amount of fluid obtained from nursing staff in addition to the amount of fluids provided with meals, revealed that the combined fluid intake exceeded the restriction of 2000 ml for thirteen out of thirty days.Further review of Resident 9's February and March MARs revealed the resident's 120 cc daily medication pass was exceeded on nineteen out of thirty days.During an interview with Dietician Employee E6 on March 18, 2026, at 10:53 a.m., revealed dietary staff are not involved in ordering or monitoring fluid restrictions. During an additional interview with Employee E6 and Culinary Director Employee E7, Employee E7 provided a standard fluid restriction breakdown for nursing and culinary departments according to restriction amount. Employee E7 stated the culinary department provides fluids with meals per the guidelines but no documentation is made in resident records.During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on March 19, 2026, at 11:26 AM, the DON stated that nurses were documenting fluid amounts in the MAR while nurse aides were documenting the task forms. The DON stated going forward only the nurses would document fluid intake amounts. The DON confirmed it was hard to determine the exact amount of fluids the resident received.201.18(b)(1) Management211.10(c) Resident care policies211.12(d)(1)(2)(5) Nursing services

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that necessary treatments were provided for two of five residents with a pressure ulcer (Residents 71 and 177). Findings include: Review of Resident 71's wound consult of January 27, 2025, revealed resident presented with a stage 3 pressure ulcer (full thickness tissue loss) of the left heel. The consult indicated a new order recommendation to cleanse with wound cleanser, apply betadine (antiseptic solution used to disinfect open wounds), and leave open to air daily and prn (as needed). Review of the physician's orders and TAR (treatment administration record) revealed that the order was not implemented. Interview with the Director of Nursing (DON) on January 31, 2025, at 11:17 a.m. confirmed that the treatment order was changed during wound rounds, but the order was not put into place. Review of Resident 177's wound consult of January 20, 2025, revealed resident presented with a stage 2 pressure ulcer (shallow wound with partial thickness skin loss) of the sacrum (large, triangular bone at the base of the spine). The consult indicated a new order recommendation to clean with wound cleanser, apply house barrier cream, and leave open to air daily and prn. Review of the physician's orders and TAR revealed that the order was not implemented. Interview with the DON and Nursing Home Administrator on January 31, 2025, at 1:05 p.m. confirmed that the order to change the treatment was not implemented. 28 Pa. Code 211.5(f) Clinical records Previously cited 2/15/24 28. Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 2/15/24

Based upon clinical record review, it was determined the facility failed to revise a care plan to reflect changes in nutrition for a resident with weight loss for one of 25 residents reviewed (Resident 84). Findings include: Review of Resident 84's clinical record revealed between December 14, 2024 and January 6, 2025 Resident 84 had a 5.89 % weight loss. Further review of the clinical record revealed weight warning note from the dietitian dated January 6, 2025 identifying the weight loss and suggesting adding pudding to lunch and dinner and to also add desert for additional calories. Review of Resident 84's care plan failed to reveal that the care plan was revised to include the changes in nutrition from the dietitian. Interview with Director of Nursing on January 31, 2025 at 9:45 a.m. confirmed that the care plan was not revised to include changes from the dietitian. 28 Pa. Code 211.5(f) Clinical records Previously cited 4/30/24, 3/8/24 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 6/11/24, 4/30/24, 3/8/24

Based on review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for two of 25 residents reviewed (Residents 22 and 108). Findings include: Review of Resident 22's CRNP's (certified registered nurse practitioner) progress note of January 10, 2025, revealed that the resident was seen and examined for complaints of urinary retention. New order to insert foley catheter (sterile tube inserted into the bladder to drain urine) if needing straight catheterization (intermittent emptying of urine from the bladder using a small tube) for all three shifts. Additional progress note of January 10, 2025, revealed that a foley catheter was inserted for urinary retention. Review of CRNP progress note of January 21, 2025, revealed an order to remove the resident's catheter and complete a bladder scan (procedure used to assess the amount of urine retained within the bladder) every shift for three days related to a voiding trial. Review of progress note of January 22, 2025, revealed resident continues to retain urine per bladder scan and foley catheter placed as ordered. Interview with the Nursing Home Administrator and Director of Nursing on January 31, 2025, at 1:13 p.m. confirmed that a care plan had not been developed for urinary retention or a foley catheter. Review of Resident 108's CRNP progress notes dated January 30, 2025 revealed Patient seen and examined today to review labs drawn yesterday and to follow up on CHF [congestive heart failure - excessive body/lung fluid caused by a weakened heart muscle]. Further review of Resident 108's CRNP progress notes dated January 30, 2025 revealed [resident] has been taking Furosemide [Lasix - diuretic used to reduce fluid] 20 mg [milligrams] daily x 3 days. Given only mild decrease, will increase Furosemide. [Resident] continues with edema to right elbow. Review of Resident 108's care plan failed to reveal evidence of a care plan for the increase in Lasix and failed to reveal evidence of a care plan for right elbow edema. Interview with Director of Nursing on January 31, 2025 at 9:45 a.m. confirmed that no care plan existed for Resident 108's right elbow edema and also confirmed there was no care plan for Resident 108's increase in Lasix. 28 Pa. Code 211.5(f) Clinical records Previously cited 2/15/24 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 2/15/24

Based on observations and staff interviews, it was determined that the facility failed to provide a safe and homelike environment for one of the four units observed (Milestone Unit). Findings include: An observation on the Milestone unit conducted on January 28, 2025, revealed the following: At 11:51 a.m., room [ROOM NUMBER]'s wall by the window was observed with two holes measuring 3.0 x 5.0 inches and the other hole measuring 2.0 x 5.0 inches; 11:58 a.m., room [ROOM NUMBER]'s wall by the window was observed with one hole measuring 5.0 x 7.0 inches; and at 12:01 p.m., room [ROOM NUMBER]'s wall by the window was observed with two holes one measuring 2.0 x 11 inches and the other was 2.0 x 2.0 inches. An observation conducted on January 31, 2025, at 11:20 a.m., in the presence of Employee E3 revealed that the above observations on Milestone unit rooms [ROOM NUMBER] were still present. An interview conducted with Employee E3 on January 31, 2025, at 11:30 a.m. revealed that he/she was not aware nor informed of the holes in the walls in rooms [ROOM NUMBER]. The above findings were discussed with the Nursing Home Administrator on January 31, 2025, at 1:00 p.m. The facility failed to ensure a safe and homelike environment in the Milestone Unit. 28Pa Code 201.14(a) Responsibility of licensee. 28Pa Code 201.18(b)(e)(1)Management

Based on clinical record review and staff interview it was determined the facility failed to report results of laboratory studies to the physician for one of 24 residents reviewed. (Resident 21) Findings Include: Review of Resident 21's progress notes revealed a nursing entry dated January 23, 2024 at 9:43 p.m. stating INR 5.5 (lab resulting indicating how long it takes for blood to clot) new order obtained to hold warfarin (blood thinner) dose and recheck on January 25, 2024. Review of Resident 21's labs revealed a PT/INR was drawn on January 25th 2024 and the results were reported to the facility on the same day. Review of Resident 21's clinical record revealed the results of the PT/INR drawn on January 25, 2024 were not reported to the physician until January 29, 2024. Interview with the Director of Nursing on February 14, 2023 at 11:30 p.m. confirmed the lab result from January 25, 2024 were not reported to the physician until January 29, 2024. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to obtain laboratory services as ordered for one of 24 residents reviewed. (Resident 21) Findings Include: Review of Resident 21's physician orders revealed an order dated January 25, 2024 for a PT/INR (blood test to determined how fast blood clots) every Thursday for monitoring Coumadin (blood thinner). Review of the clinical record revealed there was no PT/INR drawn on Thursday February 8, 2024. Interview with the Director of Nursing on February 14, 2023 at 11:30 a.m. confirmed resident 21 did not have a PT/INR drawn on Thursday February 8th, 2024 as ordered. 28 Pa. Code 211.12(c)(d) (1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for one of two residents reviewed (Resident 80) and failed to provide record of disposition of a controlled drug for one of three closed records reviewed (Resident 130). Findings include: Review of Resident 80's clinical medical record revealed the following diagnoses: Encephalopathy Unspecified (a disease that affects brain structure or function. It causes altered mental state and confusion.), Methicillin-resistant staphylococcus aureus (MRSA- Infections caused by specific bacteria that are resistant to commonly used antibiotics), Sepsis (occurs when the body's immune response to an infection causes widespread inflammation, damaging its own tissues and organs.), UTI (urinary tract infection). Review of Resident 80's comprehensive assessment Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], in section O (special treatments, procedures, and programs) revealed Resident 80 was receiving IV medications (intravenous injection is an injection of medication or another substance into a vein and directly into the blood stream). Further review revealed Resident 80 was also receiving antibiotics (medicines that fight bacterial infections in people). Additional review of Resident 80's clinical record revealed an order for Vancomycin (antibiotic used to treat bacteria) 500 mg (milligrams) IV Q8 (every 8 hours) for 7 days with a start date of [DATE], and an end date of [DATE]. Review of Resident 80's clinical medical record revealed a progress note dated [DATE], stating as per md (medical doctor) extended iv vancomycin through [DATE], due to missed doses regarding to pharmacy. Further review of Resident 80's progress notes revealed a note dated [DATE], stating Vancomycin HCl Intravenous Solution Use 500 mg intravenously every 8 hours for MRSA urine until January, 5, 2024, 11:59 p.m. SASH protocol with med (medications) administration unavailable. Review of Resident 80's eMAR (electronic medication administration record) revealed Resident 80 missed two doses of Vancomycin. The first missed dose was on [DATE], and the second dose was on [DATE]. Review of closed record revealed Resident 130 was admitted to Manatawny Center for Rehabilitation and Nursing on [DATE], and expired on [DATE]. Review of Resident 130's clinical medical record revealed an order for Morphine Sulfate (medication used to treat moderate to severe pain) solution 20 ML (milliliters) with a start date of [DATE]. Further review of Resident 130's clinical medical record failed to find documentation of disposition (disposal) of Resident 130's morphine Sulfate. Interview conducted with the Director of Nursing (DON) on February 15, 2024, at 11: 50 a.m. confirmed the above information. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code: 211.9 (a)(1) Pharmacy services

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor and address weight loss in a timely manner for two of four residents reviewed for nutrition (Residents 105 and 112). Findings include: Review of facility policy, Weight Assessment and Intervention, undated, revealed: Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. Review of Resident 105's clinical record revealed on October 11, 2023, the resident was recorded as weighing 334.6 pounds (lbs.) On November 1, 2023, the resident was recorded as weighing 305 lbs., a 29.6 lb., or 8.85% weight loss in three weeks. Further review of Resident 105's weights revealed the next available weight was recorded on November 8, 2023, at 293.3 lbs. Review of Resident 105's progress notes revealed a Weight Note on November 17, 2023, where the dietitian, Employee E5, requested a reweight be obtained. Further review of Resident 105's weights revealed the next weight obtained was on November 21, 2023, with the resident recorded as weighing 278.6 lbs. Further review of Resident 105's progress notes revealed the physician was notified of Resident 105's weight loss on December 6, 2023, and requested the resident's fluid restrictions be discontinued and the resident started on comfort measures. The delay in obtaining a reweight to verify Resident 105's weight loss and the delay in the dietitian and physician being made aware of Resident 105's significant weight loss was discussed with the dietitian, Employee E5, on February 15, 2024, at approximately 11:15 a.m. Review of Resident 112's clinical record revealed that on December 20, 2023, the resident weighed 135.2 lbs. On December 27, 2023, the resident weighed 127.3 pounds which is a 5.84 % loss in one week. Further review of Resident 112's weights revealed the next recorded weight was January 2, 2024, where the resident was recorded as weighing 124.9 lbs. Review of Resident 112's progress notes revealed the Dietitian, Employee E5, did not address the resident's weight loss until January 9, 2024, where they documented that the resident was currently on antibiotic therapy for a urinary tract infection. Further review of Resident 112's progress notes revealed the next Weight Note was on January 26, 2024, where the Dietitian, Employee E5, stated that Resident 112 had a 6.5% weight loss since December 20, 2023. The dietitian recommended nursing notify the physician and that Resident 112 be started on a supplement. The delay in obtaining a reweight for Resident 112 and the delay in addressing Resident 112's significant weight loss was discussed with the dietitian, Employee E5, on February 15, 2024, at approximately 11:15 a.m. 28 Pa. Code 211.5(f) Clinical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services 28 Pa Code: 211.10(c) Resident care policies

Based on observations, review of clinical records and facility documentation, and interviews with residents and staff, it was determined that the facility failed to provide proper continence care for one of one resident reviewed (Resident 70). Findings include: Review of Resident 70's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated January 19, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including Encounter for attention to gastrostomy (tube feed- artificial external opening into the stomach for nutritional support or gastric decompression), Scoliosis (sideways curvature of the spine or back bone), Intellectual disability (a condition that limits intelligence and disrupts abilities necessary for living independently). Continued review revealed that the resident was dependent for toileting hygiene. Further review revealed that the resident was always incontinent of bowel and bladder. Review of Resident 70's care plan revealed the following intervention for potential for constipation: Bowel meds as ordered and Following facility bowel protocol for episode of constipation with a date initiated of April 20, 2022. Further review of Resident 70's clinical medical record revealed an order for Milk of Magnesia (used to treat occasional constipation) 400MG/5ML, Give 30 ml orally as needed for Constipation ON 3-11 SHIFT IF NO BOWEL MOVEMENT BY THE EVENING OF 3RD DAY. Review of Resident 70's bowel function (task used to track bowel movement) from January 17, 2024, through February 14, 2024, revealed Resident 70 did not have a bowel movement on the following days: January 18, 2024, January 19, 2024, January 20, 2024 January 22, 2024, January 23, 2024, January 24, 2024 February 1, 2024, February 2, 2024, February 3, 2024 February 5, 2024, February 6, 2024, February 7, 2024 Review of Resident 70's eMAR (electronic medication administration record) revealed the facility did not administer Milk of Magnesia on the evenings of January 20, 2024, January 24, 2024, February 3, 2024, or February 7, 2024. Interview conducted with the Director of Nursing (DON) on February 15, 2024, at 1:15 p.m. confirmed Resident 70 did not receive Milk of Magnesia on the dates listed above. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to provide care and services for pressure ulcer for one of six residents reviewed. (Resident 21) Findings Include: Review of Resident 21's Admission Nursing Assessment, dated January 16, 2024 revealed there was a stage 1 pressure ulcer (intact reddened skin), measuring 3 centimeter (cm), 1cm wide and 1cm deep on the coccyx (small triangular bone at the base of the spinal column). Review of Resident 21's physician orders on admission revealed there was no order for wound care to this wound. Review of Resident 21's wound consult note, dated January 24, 2024 revealed the resident had a stage 3 pressure ulcer (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) measuring 2cm long, 1cm wide, and 0.2cm deep. The wound specialist recommended a treatment of Triad paste and to leave open to air daily. Review of Resident 21's physician orders revealed the triad paste as recommend by the wound specialist was not ordered for Resident 21 and they continued to have no treatment on the wound. Review of Resident 21's wound consultant note, dated January 31, 2024, revealed the resident had a stage 3 pressure ulcer measuring 0.5cm long, 0.5cm wide, and 0.1cm deep. The wound specialist recommended a treatment of Triad paste and to leave open to air daily. Review of Resident 21's physician orders revealed the triad paste as recommend by the wound specialist was not ordered for Resident 21 and they continued to have no treatment on the wound. Interview with the Director of Nursing and Licensed Nursing Employee E4 on February 15, 2023 at 12:00 p.m. revealed when Resident 21 was admitted to the facility the pressure ulcer identified was incorrectly assessed as a stage one due to the measurement of depth and the facility failed to provide wound care to the wound upon admission and when recommended by the wound consultant on January 24th and January 30, 2024. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and staff interview it was determined the facility failed to develop baseline care plans for two of 24 residents reviewed. (Resident 182 and 183) Findings Include: Review of Resident 182's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident 182's Nursing admission screener, dated February 2, 2024 revealed the resident should have had a basic care plan for Activities of Daily living, Allergies, Communication, Discharge planning, falls, neurological, oral/nutrition, skin, sleep pattern, and smoking cessation. Review of Resident 182's care plan revealed the only care plan initiated in the 48 hours after admission was a nutrition care plan. All other care plans were initiated between February 5th and February 12, 2024. Review of Resident 183's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident 183's Nursing admission screener, dated February 1, 2024 revealed the resident should have had a basic care plan for Activities of Daily living, Allergies, Communication, Discharge planning, falls, neurological, oral/nutrition, skin, sleep pattern, and smoking cessation. Review of Resident 183's care plan revealed the only care plan initiated in the 48 hours after admission was a nutrition care plan. All other care plans were initiated between February 8th and 11th 2024. Interview with the Director of Nursing on February 15, 2024 at 12:00 p.m. revealed Residents 182 and 183 did not have an initial care plan developed on admission. 28 Pa Code 201.18(b)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Based on clinical record, facility policy and procedure, hospital record reviews and staff interview, it was determined the facility failed to monitor and assess a pressure ulcer present upon readmission causing actual harm to Resident 1 when the wound deteriorated and became infected causing septic shock for one of three residents reviewed. (Resident 1) Findings Include: Review of facility policy and procedure titled Prevention of Pressure Ulcer/Injuries, revised July 2017, revealed conduct a comprehensive skin assessment upon admission, including skin integrity- any evidence of existing or developing pressure ulcers or injuries. Skin assessments should be done weekly by a licensed nurse. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Review of Resident 1's clinical progress notes revealed nursing entry dated August 17, 2023 at 7:15 p.m. stating Resident 1 was readmitted to the facility from the hospital and the left buttock noted to have an open area 1.2 x 1 x 4. Other wounds noted upon admission included the residents left foot, left ankle, right foot, and excoriation (skin becomes red and often painful and begins to come off) to the buttock and sacrum (bone at the base of the spine in the middle of the lower back). Further review of Resident 1's clinical record including readmission documentation failed to document condition, or stage for wound of the left buttock. Review of Resident 1's documentation from the hospital upon readmission to the facility on [DATE] revealed the resident had left ischial (lower and back region of the hip bone) deep tissue injury (DTI-an injury to the soft tissue under the skin due to pressure and is usually over bony prominence). Review of Resident 1's Nursing Admit/Readmit assessment, dated August 17, 2023, the skin integrity section had no documentation of wounds with a comments section stating left buttocks measuring 1.2 x 1 x 4. Additional review of Resident 1's assessments revealed Weekly Skin assessments completed on August 20, 2023, September 2, 2023, September 10, 2023 and September 14, 2023. Review of Resident 1's skin assessments mentioned above revealed in the section for observation of skin wound or open ulcers (indicate even if being treated) were documented as no indicating the resident had no current wound. Review of Resident 1's progress notes revealed a Skin/Wound note dated August 29, 2023 at 1:29 p.m. revealed the other wounds noted upon readmission were addressed but failed to mention the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a Skin/Wound note dated September 9, 2023 at 2:26 p.m. stating wound rounds with wound physician assessed sacrum MASD (Moisture Associated Skin Damage- superficial irritation and damage caused by long term exposure to moisture) continue current tx (treatment) and interventions. Further review of Skin/Wound note dated September 9, 2023 failed to mention the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a Skin/Wound note dated September 12, 2023 at 1:16 p.m. revealed the wounds the resident was admitted with were addressed but failed to indicate the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a nursing note dated September 13, 2023 at 11:21 p.m. stating L (left) ischium wound measuring 2.8x4x2, wound bed with slough (dead tissue with a yellow/white color that can be wet or dry) and necrosis (dead tissue) and moderate drainage. Wound cleansed with NSS (Normal Saline Solution- sterile salt water), gently packed with hydrogel gauze (used to keep the wound moist to promote healing), applied triad (paste applied directly to skin to provide protection to area) to peri (surrounding) wound and covered with border gauze (sterile gauze with adhesive surrounding to hold to the skin). Further review of Resident 1's clinical record revealed there was no documented evidence whether the wound had a deterioration documented in the same location on admission or identified a new wound. Review of the entire clinical record revealed there was no physician's order for the wound care provided as stated in the progress note of September 13, 2023 and no documented evidence the physician was notified of the wound status. Further review of Resident 1's progress notes revealed a Skin/Wound note dated September 14. 2023 stating wound rounds with wound physician .assessed left ischium/buttock area. Review of the wound physician consult report, dated September 14, 2023 revealed left buttock is an Unstageable pressure ulcer injury (bed sore that occurs due to prolonged pressure on a specific area where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) .measurements are 2cm (centimeter) length x 3cm width x 2cm depth .there is moderate amount of sero-sanguineous (thin watery fluid pick or red in color due to presence of blood) drainage noted which has no odor) with 100% slough. Further review of Resident 1's progress notes revealed a nursing entry dated September 19, 2023 at 5:40 p.m. stating assessed the resident and noted temperature 102.3 resident diaphoretic (sweating). Resident B/P (Blood Pressure) has been running low, call placed to 911 to send to hospital. Review of Resident 1's hospital documentation from his admission on September 19, 2023 revealed an Infection Disease consult on September 20, 2023 at 9:34 a.m. with an impression of septic shock/severe sepsis (widespread infection causing organ failure and dangerously low blood pressure) secondary to presumed infected left buttock and sacral decubitus ulcer (pressure ulcer) with probable osteomyelitis (infection of the bone). Stage 4 (extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments) left buttock/sacral decubitus ulcer/presumed osteomyelitis I believe the patient has severe sepsis to primarily be from secondary to his necrotic stage 4 sacral and left gluteal wound which will need debridement (surgical removal of dead tissue) as soon as possible- hopefully once he is more hemodynamically stable (the blood pressure and heart rate are at safe levels). Interview with the Director of Nursing and the Nursing Home Administrator on October 3, 2023 at 1:00 p.m. confirmed the resident clinical record has no complete documentation of the wound upon readmission from the hospital on August 17, 2023 until seen by the wound consultant on September 14, 2023 which the ischial wound was documented as an unstable wound and a larger size then what was documented on readmission. The facility failed to thoroughly assess Resident 1's wound upon readmission from the hospital on August 17, 2023 so a clinical baseline was unable to be established to determine the need of changes to the status of the residents wound to determine proper care of the wound. The facility also failed to assess weekly, per policy, to determine the appropriateness of the current wound treatment and whether healing was being achieved or not. This caused harm to Resident 1 when they were admitted to the hospital with a diagnosis of septic shock and osteomyelitis secondary to a presumed infected stage four pressure ulcer present when admitted to the hospital needing surgical debridement when stable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review and interviews with the staff it was determined that the facility failed to follow physician orders for one of three residents reviewed. (Resident CL1). Findings include: Review of the clinical record revealed that Resident CL1 was admitted to the facility on [DATE] with the following but not limited to, diagnosis: severe aortic stenosis (is the narrowing of the exit of the left ventricle of the heart (where the aorta begins), ascending thoracic aortic aneurysm (a weakened area in the body's main artery in the chest) and chronic interstitial lung fibrosis (A group of lung conditions that causes scarring) and pneumonia. Further review of the clinical record a nursing note dated [DATE], states that Resident CL1, met with palliative medicine prior to hospital discharge and elected DNR (do not resuscitate) status. Review of the POLST (Pennsylvania Orders for Self-Sustaining Treatment) revealed on [DATE], the spouse signed it and marked that Resident CL1 is a DNR. The CRNP also signed the document. A nursing note dated [DATE], that the resident was not breathing with no pulse. CPR was initiated. An interview with the Nursing Home Administrator and Director of Nursing was conducted on [DATE] at 1:15 a.m., confirmed that CPR should not have been started on Resident CL1 due to the DNR status. The facility failed to follow physician orders for Resident CL1. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services

Based on clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to implement interventions to prevent pressure ulcers for three of 10 residents reviewed (Residents 12, 16, and 99) causing actual harm of a Stage 3 and two unstageable Pressure ulcers for Resident 12. Findings Include: Review of facility policy and procedure titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, Revised March 2014, revealed the nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility. Review of Resident R12's significant change MDS (periodic assessment of resident needs) dated February 6, 2023 revealed the resident was recently placed on hospice service (end of life care) and determined to be at risk of developing pressure ulcers. Review of Resident 12's Progress Notes revealed a nursing note on January 8, 2023 at 10:37 a.m. stating x-ray results received and show suspected right femur fracture, RP (Responsible Party) notified and requested to be sent to the ER (emergency room ). Review of documentation from the hospital stay revealed Resident 12 was seen by an Orthopedic physician on January 9, 2023 due to fracture of the right distal femur (knee). They were going to continue with conservative measures with bracing. Review of Resident 12's Progress Notes revealed a nursing note dated January 11, 2023 at 9:41 p.m. stating patient readmitted at 5: 15 p.m. from the hospital with Fx (fracture) Femur .brace to right knee to be worn at all times. Review of Resident 12's physician orders revealed an order dated January 12, 2023 for RT (right) leg immobilizer on at all times, observe for redness or skin integrity. Review of Resident 12's Skin Integrity care plan failed to reveal goal/interventions to address newly ordered leg immobilizer or monitoring of right leg for redness and skin integrity under the immobilizer. Review of Resident 12's Medication and Treatment Administration Records for January, February, and March 2023 failed to reveal any skin integrity or redness observation documentation. Review of Resident 12's Progress Notes revealed a nursing note dated April 6, 2023 at 5:39 p.m. revealed open R (right) knee areas and posterior (back) ankle areas observed under residents leg brace Review of Resident 12's Weekly Wound Observation Tool dated April 6, 2023 at 3:48 p.m. revealed an unstageable pressure wound (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) on the top of the right knee cap that was 40% slough (dead white or yellow tissue) with a small amount of bloody drainage that was 5 centimeters wide and 4 centimeter long. Another wound on the right side of the kneecap was an unstageable pressure wound that was 40% slough and was 4 centimeters wide and 4 centimeters long with no drainage. Another wound on the posterior right ankle was a stage 3 (full-thickness skin loss potentially extending into the subcutaneous (fat) tissue layer), there was no description of the wound base on the assessment, with no drainage and 3 centimeters long and 2 centimeters wide. Interview with Licensed Nursing Employee E5 on April 12, 2023 at 11:32 a.m. revealed the wounds that were found on Resident 12's knee and ankle were significant wounds that were caused by pressure of the brace. Employee E5 further stated staff would be expected to remove the brace twice a day to check for skin integrity but there was no documented evidence this was occurring as expected. Interview with Licensed Physical Therapy Employee E6 on April 13, 2023 at 9:30 a.m. revealed they were not consulted until after the wounds were discovered. Employee E6 further stated that the type of immobilizer Resident 12 was wearing had straps that could be undone to allow staff to check Resident 12 skin integrity under the immobilizer as needed. Interview with Licensed Practical Nurse Employee E7 on April 13, 2023 at 9:45 a.m. revealed he/she was currently assigned to Resident 12 and had been assigned to Resident 12 prior to the development of the pressure ulcers. Employee E7 reported he/she did not check under Resident 12's immobilizer for skin integrity because there was no order in the system to do so. Interview with Licensed Nursing Employee E4 on April 13, 2023 at 12:30 p.m. revealed staff completed a weekly skin assessment on April 2, 2023 at 3:50 p.m. and this was the last documented evidence Resident 12's skin integrity had been checked under the immobilizer until the discovery of the wounds on April 6, 2023. The facility failed to assess Resident 12's skin integrity under an immobilizer on the right leg resulting in actual harm to Resident 12 when two unstageable and one stage 3 pressure ulcer were discovered on April 6, 2023. Review of Resident 16's clinical record revealed a diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (stroke) affecting the resident's dominant right side. Review of Resident 16's progress notes revealed a nurse's note dated March 17, 2022, which stated: This nurse alerted by therapy of a 1cm x 1cm area to R outer foot. [Suspected Deep Tissue Injury (persistent non-blanchable deep red, purple or maroon area of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues)] is purple in color with red peri-wound. Therapy suspects it is from an ill-fitting brace, and a call was placed by PT to have brace fitted/replaced. Resident [complains of] pain when area is touched. Resident is unsure of how injury was acquired but states it's been hurting for like 4 days. NP and supervisor notified, new order entered to apply skin prep to area until seen and evaluated by podiatry. Review of Resident 16's physician orders, care plan, and Medication/Treatment Administration Records failed to reveal evidence that the resident was ordered a brace, how often the brace should be worn, or that skin checks were being done while the resident was wearing the brace. Interview with the Nursing Home Administrator and Director of Nursing on April 13, 2023, at approximately 10:40 a.m. confirmed there was no documented evidence related to any orders for Resident 16's right foot brace or skin checks for the brace. Review of Resident 99's clinical record revealed diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), generalized muscle weakness, and reduced mobility. Further review of Resident 99's clinical record revealed the resident had a pressure ulcer that healed on March 13, 2023. Review of Resident 99's progress notes revealed a nurse's note dated December 16, 2022, which stated: Reviewed with IDT [(Interdisciplinary Team)] has a [stage 2 pressure ulcer (superficial with a pale pink wound bed and serous, or clear, drainage and presents itself as an abrasion or blister or shallow crater)] on sacrum. [Resident 99] is incontinent of [bowel and bladder], prefers to lay on her back will order a air mattress. A Skin/Wound note on the same date stated: Wound rounds with IDT ST2 sacrum 5x2x0.1cm. Wound bed pink and with small amt (amount)of yellow material. No drainage noted and no [signs or symptoms] of infection. [Nurse Practitioner] aware of area and husband notified. New order for Xeroform dressing daily. Further review of Resident 99's progress notes revealed a nurse's note dated December 29, 2022, which stated: Wound rounds with IDT and [Wound Physician] [unstageable] 2x1x0.1cm. [Deterioration] with peri wound breakdown. Continue with therahoney daily cover with bordered gauze. Further review of the nurse's notes from December 29, 2022, revealed: air mattress requested for worsening wound. Further review of the resident's clinical record failed to reveal a date when the air mattress was provided to Resident 99. Interview with the Nursing Home Administrator and Director of Nursing on April 13, 2023, at approximately 10:40 a.m. failed to reveal an explanation for the delay in obtaining an air mattress for Resident 99, or what was done in the meantime while awaiting an air mattress for Resident 99. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, facility documentation, family and staff interview and facility policy, it was determined that the facility failed to ensure two of four residents reviewed were provided adequate staff supervision and assistance to prevent accidents, resulting in actual harm to Resident 181 after sustaining a fall, transfer to the hospital and [DIAGNOSES REDACTED]. (Resident 181 and Resident 26) Findings include: Review of facility policy tilted Admission Assessment and Follow Up: Role of the Nurse undated revealed that the purpose of this procedure was to gather information about the resident's physical, emotional, cognitive and psychological condition upon admission for the puropse of managing the resident, initiating the care plan and completing required assessment instruments. The policy further stated that supplemental assessments including activity level, fall risk assessment and functional assessment- ability to perform ADLs (activities of daily living) were to be conducted. Review of Resident 181's face sheet revealed that she was admitted from home on (MONTH) 14, (YEAR). Review of Resident 181's [DIAGNOSES REDACTED]. Interview with a family member and power of attorney on (MONTH) 6, (YEAR), at approximately 12:30 p.m. revealed that the resident fell on (MONTH) 20, (YEAR), in the afternoon and was sent out to the hospital, at that time, and admitted with a [MEDICAL CONDITION]. The family member indicated that she was told by staff that the resident was sitting in the lounge on the loveseat with her walker, located adjacent to the loveseat, but not in front of her. The family member indicated that the resident got up without using her walker, as it was not in front of her, and proceeded to walk into the hallway where she fell . The family member stated that the resident would ordinarily have her walker in front of her which would remind her to use the walker to ambulate. Review of the nursing admission assessment dated (MONTH) 14, (YEAR), identified the resident with full range of motion of upper and lower extremities, transfer ability was ambulatory with the use of a walker. Review of the nursing fall risk evaluation dated (MONTH) 14. (YEAR), revealed that the resident was disoriented times three (person, place and time) at all times and Resident 118 was assessed at high risk for falls. Review of the resident's initial care plan for falls effective (MONTH) 14, (YEAR), revealed that the resident was at risk for falls related to dementia and poor safety awareness. Further review of the resident's care plan revealed that the resident demonstrated moderate to severe impairment in cognitive skills for daily decision making. The fall prevention interventions developed in the resident's care plan included supervision with rolling walker, encourage use of call bell, slipper socks at bedtime, keep areas free of obstructions and encourage the use of non-skid footwear at all times. Further review of the resident's care plan identified the resident with a self care deficit related to weakness. Interventions included for the resident transfer status to be with the assistance of two nursing assistants with the use of a walker. Review of the facility investigation related to the fall sustained by the resident on (MONTH) 20, (YEAR), included witness statements which indicated that the resident was seated in the lounge prior to 3:00 p.m. with no staff present. The resident was found at 3:05 p.m. on the floor in the hall, approximately 30 steps away from the lounge. The documentation further revealed that the resident's walker was found to the side of the loveseat in the lounge. Review of nursing notes dated (MONTH) 20, (YEAR), at 3:51 p.m. noted that the nursing assistant reported at 3:01 p.m. that the resident was on the floor in the hallway. Resident has dementia and did not call for assistance. Resident exited lounge unassisted, leaving her walker and w/c (wheel chair) in lounge. She ambulated approximately 30 feet before falling . She stated she forgot her walker and fell with her hand on her hip .Resident was last seen at 1450 (2:50 p.m. resting in lounge with husband. on assessment at time hall VS (vial signs); 189/91 (normal 120/80), HR 78 (normal 60-00 beats per minute), RR 20 (normal 12-16 breath per minute), T 98.2 degrees Fahrenheit (normal 98.6 degrees Fahrenheit), 95% RA (room air-normal oxygen saturation rate 95 to 100 percent), L (left) hip with limited ROM (range of motion), legs unequal (R (right) longer than L (left)). Resident c/o (complaint) 10/10 pain to L hip. Further review of the nursing note indicated that the certified nurse practitioner was in the facility and gave an order to send the resident to the emergency room for evaluation. The resident was left in place until emergency medical services arrived and was transferred to the hospital at 3:20 p.m. Review of Resident 181's hospital discharged instructions dated (MONTH) 28, (YEAR), confirmed the [DIAGNOSES REDACTED]. Interview with the Nursing Home Administrator on (MONTH) 10, (YEAR), at approximately 1:30 p.m. confirmed that a physical therapy screen should be done for each new admission, but there was no documented evidence that a screening was done for this resident during the admission process. Interview with the Director of Nursing on (MONTH) 10, (YEAR), at approximately the same time stated above, confirmed that the interventions in place including encouraging the use of a call bell to request assistance were not, by themselves, appropriate for a resident with a moderate to severe cognitive decline. The facility failed to provide Resident 181 with adequate staff supervision and assistance to prevent accidents in the lounge area, resulting in actual harm to Resident 118 sustaining a fall, transfer to the hospital via emergency medical services and [DIAGNOSES REDACTED]. Review of Resident 26's clinical record revealed that the resident was admitted to the facility on (MONTH) 21, (YEAR) with the [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS- assessment of resident care needs) dated (MONTH) 28, (YEAR) identified the resident with adequate vision and a BIMS (Brief Interview of Mental Status) score of 3 out of 15 which place this resident with severe cognitive impairment. The resident was assessed as requiring supervision for transferring, ambulation, surface to surface transfers and turning around. Review of the resident's care plan dated (MONTH) 22, (YEAR) revealed the resident was identified has an elopement risk related to [DIAGNOSES REDACTED]. The interventions included for the resident to be redirected from high risk area, wandering management system (system that alert/alarm when resident is exit or entering a protected area), check placement and function of wander management system (wrist or bracelet designed to activate an alarm system). Review of information submitted by the facility to the State Agency revealed that on (MONTH) 19, (YEAR), at 4:02 p.m. Resident 26 was observed by an activities assistant eloping from the Milestone unit through the window of a resident's room. Review of Resident 26's progress notes revealed a nurse's note on (MONTH) 19, (YEAR), which stated, An activities assistant observed him leaving the building from a window in another resident's room. At that time he was half way out of the window, she tried to talk the resident to coming back inside but he continued to try to leave the building. She then held onto his jacket and was able to detain him for a short period of time but had to let go when he picked up a rock and hit her hand. The resident then ran to a wooded area approximately 70 feet from the building. The activities assistant watched him enter the woods and then directed the staff to the point where he entered the woods. The staff proceeded to that area and quickly found the resident. The resident was out of (sight) for approximately 10 seconds. Review of the facility's investigation revealed that the locking mechanism that limits the opening of the window was found to be pushed in and it was unclear if the resident had over ridden the mechanism. The above was discussed with the Nursing Home Administrator and Director of Nursing on (MONTH) 10, (YEAR), at 2:00 p.m. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 07/18/18 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 07/18/18, 03/09/18, 11/30/17 28 Pa. Code 201.18(b)(1) Management Previously cited 07/18/18, 03/09/18, 11/30/17, 06/27/17 28 Pa. Code 201.18(b)(3)(e)(1) Management Previously cited 07/18/18, 03/09/18, 11/30/17 28 Pa. Code 211.5(f) Clinical records Previously cited 03/09/18, 06/27/17 28 Pa. Code 211.11(c) Resident care plan Previously cited 06/27/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 07/18/18, 03/09/18, 06/27/17 28 Pa. Code 211.12(c) Nursing services Previously cited 07/18/18, 11/30/17, 06/27/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 07/18/18, 03/09/18, 11/30/17, 06/27/17 28 Pa. Code 211.12(d)(3) Nursing services Previously cited 03/09/18, 11/30/17, 06/27/17

Based on clinical record reviews, review of documentation provided by the facility, and staff and resident interview, it was determined the facility failed to ensure one of five residents reviewed was provided adequate staff supervision and assistance to prevent accidents, resulting in actual harm to Resident R1 who sustained a fall, transfer to the hospital and [DIAGNOSES REDACTED]. (Resident R1) Findings include: Review of Resident R1's [DIAGNOSES REDACTED]. (progressive disease that destroys memory and other important mental functions). Review of Resident R1's care plan, effective (MONTH) 24, (YEAR), revealed a self-care deficit related to generalized weakness revealed an intervention of transfer with use of Hoyer lift (a mechanical lift using a sling under the resident to transfer them from one surface to another) at all times with two staff effective (MONTH) 24, (YEAR). Review of Resident R1's Quarterly Minimum Data Set assessment (MDS- periodic assessment of resident needs), dated (MONTH) 7, (YEAR), revealed the resident was cognitively intact and required extensive assistance of two persons when positioning her body in bed and transferring and ambulation did not occur during the seven day look back period. Review of Resident R1's physician's orders [REDACTED]. Review of Resident R1's clinical notes revealed a nursing entry on (MONTH) 10, (YEAR), at 4:57 p.m. stating, upon entry to shower room resident was laying on floor with feet facing grab bar on wall. Resident states, 'I'm weak from the Pneumonia, my arms gave out. Vital signs and range of motion assessed. On assessment resident complaint of 10/10 pain to right lower leg. Right lower leg appears deformed. Resident left in lying position to prevent further injury. Nursing note further stated that the physican and Emergency Medical Services (911) were called. EMS (Emergency Medical Services) in facility at 12:55, transferred via EMS onto litter. Resident was sent out to the hospital at 1:05 p.m. Further review of the of the clinical notes revealed a nursing entry on (MONTH) 10, (YEAR), at 10:05 p.m. stating resident returned from the hospital at 4:35 p.m. Right leg has an immobilizer on it. Resident is non-weight bearing. Resident stating her leg pain is 6/10. Review of the hospital emergency department documents dated (MONTH) 10, (YEAR), revealed the [DIAGNOSES REDACTED]. Review of the information submitted by the facility, dated (MONTH) 10, (YEAR), revealed the residents orders for transfers are assist of two with full body lift/Hoyer lift. It further stated that nursing staff, Employee E3 was transferring the resident without the use of a lift or assistance which resulted in the resident falling to the floor and sustaining a fracture to the right tibia and fibula. Review of nursing assistant, Employee E3's statement obtained by the facility on (MONTH) 10, (YEAR), during an investigation revealed When I went to put the resident back in her wheelchair she stood up with the enabler bars, so I could put her brief on. As soon as the resident went to sit down in her wheelchair she collapsed. She told me her arms just gave out and she let go of the bar. An interview with Resident R1 on (MONTH) 18, (YEAR), at 10:40 a.m. revealed she was standing at the rail and stated that she was holding to the rail with one hand and using her other hand to hold her dress over so Nursing Assistant, Employee E3 could fasten her incontinence brief. When she did that her other hand slipped off of the grab bar and she fell to the ground, I was weak at the time because I had pneumonia. Interview with the Director of Nursing on (MONTH) 18, (YEAR), at 11:45 p.m. confirmed that the resident fell while being transferred after a shower with the assistance of one staff member resulting in a fall and [MEDICAL CONDITION] and fibula. The facility failed to ensure Resident R1 who was diagnosed with [REDACTED]. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 03/09/18, 11/30/17 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 03/09/18, 11/30/17, 06/27/17 28 Pa. Code 201.18(b)(3) Management Previously cited 03/09/18, 11/30/17 28 Pa. Code 211.10(d) Resident care policies Previously Cited 03/09/18, 06/27/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 03/09/18, 06/27/17 28 Pa. Code 211.12(c) Nursing services Previously Cited 11/30/17, 06/27/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously Cited 03/09/18, 11/30/17, 06/27/17

Based on a review of clinical records, review of documentation provided by the facility, staff and resident interviews and facility policy, it was determined that the facility failed to ensure one of five residents reviewed (Resident R1) were free of neglect during a transfer via mechanical lift which resulted in actual harm to Resident R1 who sustained a right tibia and fibula (bones in lower leg) fracture. Findings include: Review of facility policy and procedure titled, Abuse Prevention Program, (undated) revealed the administration will protect residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of Resident R1's [DIAGNOSES REDACTED]. (progressive disease that destroys memory and other important mental functions). Review of Resident R1's care plan, effective (MONTH) 24, (YEAR), revealed a self-care deficit related to generalized weakness. The care plan revealed an intervention of transfer with use of a Hoyer lift (a mechanical lift using a sling under the resident to transfer them from one surface to another) at all times with two staff effective (MONTH) 24, (YEAR). Review of Resident R1's Quarterly Minimum Data Set assessment (MDS- periodic assessment of resident needs), dated (MONTH) 7, (YEAR), revealed the resident was cognitively intact and required extensive assistance of two persons when positioning her body in bed and transferring did not occur during the seven day look back period. Review of Resident R1's physician's orders [REDACTED]. Review of Resident R1's clinical notes revealed a nursing entry on (MONTH) 10, (YEAR), at 4:57 p.m. stating, upon entry to shower room resident was laying on floor with feet facing grab bar on wall. Resident states, 'I'm weak from the Pneumonia, my arms gave out.' Vital signs and range of motion assessed. On assessment resident complaint of 10/10 pain to right lower leg. Right lower leg appears deformed. Resident left in lying position to prevent further injury. Nursing note further stated that the physican and Emergency Medical Services (911) were called. EMS (Emergency Medical Services) in facility at 12:55, transferred via EMS onto litter. Resident was sent out to the hospital at 1:05 p.m. Further review of the of the clinical notes revealed a nursing entry on (MONTH) 10, (YEAR), at 10:05 p.m. stating resident returned from the hospital at 4:35 p.m. Right leg has an immobilizer on it. Resident is non-weight bearing. Resident stating her leg pain is 6/10. Review of the hospital emergency department documents dated (MONTH) 10, (YEAR), revealed the [DIAGNOSES REDACTED]. Review of the information submitted by the facility, dated (MONTH) 10, (YEAR), revealed the resident's orders for transfers are assist of two with full body lift/Hoyer lift. It further stated that nursing assistant, Employee E3 was transferring the resident without the use of a lift or assistance which resulted in the resident falling to the floor and sustaining a fracture to the right tibia and fibula. Review of Nursing Assistant, Employee E3's statement obtained by the facility on (MONTH) 10, (YEAR), during an investigation revealed When I went to put the resident back in her wheelchair she stood up with the enabler bars, so I could put her brief on. As soon as the resident went to sit down in her wheelchair she collapsed. She told me her arms just gave out and she let go of the bar. During an interview with Resident R1 on (MONTH) 18, (YEAR), at 10:40 a.m. it was revealed she was standing at the rail and stated that she was holding to the rail with one hand and using her other hand to hold her dress over so nursing staff, Employee E3 could fasten her incontinence brief. When she did that her other hand slipped off of the grab bar and she fell to the ground, I was weak at the time because I had pneumonia An interview with the Director of Nursing on (MONTH) 18, (YEAR), at 11:45 p.m. confirmed that the resident fell while being transferred after a shower with the assistance of one staff member resulting in a fall and [MEDICAL CONDITION] and fibula. The facility failed to ensure Resident R1 was free of neglect during a transfer which resulted in actual harm to Resident R1 sustaining a fall, transferred to the hospital and a [DIAGNOSES REDACTED]. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 03/09/18, 11/30/17 28 Pa. Code 201.18(b)(1)(e)(1) Management Previously cited 03/09/18, 11/30/17, 06/27/17 28 Pa. Code 201.18(b)(3) Management Previously cited 03/09/18, 11/30/17 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Previously cited 03/09/18, 06/27/17 28 Pa. Code 211.11(d) Resident care plan Previously cited 03/09/18, 06/27/17 28 Pa. Code 211.12(c) Nursing services Previously cited 11/30/17, 06/27/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 03/09/18, 11/30/17, 06/27/17

Based on a review of clinical records and facility policy and staff interviews, it was determined that the facility failed to monitor a resident after a significant change in condition for one of five residents reviewed (Resdient CL1), which resulted in actual harm to Resident CL1, requiring Cardio [MEDICAL CONDITION] Resuscitation and transportation to the hospital via Emergency Medical Services. Findings include: Review of facility's policy and procedure entitled, Change in a Resident's Condition or Status, date revised [DATE], indicated that, our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a (an): significant change in the resident's physician/emotional/mental condition. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of Resident CL1's hospital discharge summary dated [DATE], revealed that the resident was brought to hospital emergency department by son and daughter-in-law for a complaint of dyspnea (sudden shortness of breath) and occasional chest aches. The resident's [DIAGNOSES REDACTED]. The mitral valve is the inflow valve for the left side of the heart), [MEDICAL CONDITION] (narrowing of the arteries of heart) and [MEDICAL CONDITION] hypertension (increase of blood pressure in the [MEDICAL CONDITION] artery). Further review of the hospital discharge summary noted that it was recommended for the resident to be admitted to a skilled nursing facility for rehabilitation. Review of Resident CL1's physician's admission orders [REDACTED]. The orders recommended a daily INR beginning [DATE] until the dose is regulated; and Aspirin (medication used to prevent and to treat [MEDICAL CONDITION] and [MEDICAL CONDITION]) 81 milligram by mouth every day. Review of Resident CL1's closed record revealed a nursing progress note completed by Licensed Practical Nurse, Employee E4, dated [DATE], at 3:26 a.m. that indicated the resident, was out of bed the beginning of the shift. Had kind of a blank stare, but then talked to us. Very pale and skin pale, ashen color. Stood up and got onto bed with no difficulty. Vital signs were temperature 95.1 (temporal); Blood pressure ,[DATE]; Heart rate anywhere from ,[DATE]; Respirations 20 and 98% was her pulse ox on room air. Complained of feeling very hot yet extremities extremely cool to touch, was difficult obtaining pulse ox (oxygen) until hands warmed up a little. Faint bowel sounds noted, abdomen very tender on right side , states a lot of pain with palpation. In bed resting with no apparent distress. Color extremely pale, has been resting most of the shift. No vomiting or diarrhea noted thus far. Supervisor aware and also assessed her. No other complaints voiced. The next available nursing documentation dated [DATE], at 11:48 a.m. completed by Registered Nurse, Employee E5, revealed, Registered nurse called to room by nursing assistant, on assessment resident was found cool to touch, pale with cheyne-respirations (abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing). Unable to obtain blood pressure or pulse. Resident is a full code. CPR (Cardio [MEDICAL CONDITION] Resuscitation) started. Physician and 911 (Emergency Medical Services) contacted. 911 arrived and continued with CPR (Cardio [MEDICAL CONDITION] Resuscitation). Resident sent to hospital emergency room . Family notified by nursing supervisor. Review of Resident CL1's nursing documentation revealed that there was no documented evidence of the continued monitoring and assessment of Resident CL1's condition on [DATE], during the remainder of the ,[DATE] shift after the resident experienced symptoms at 3:26 a.m. which included a change in skin color, body temperature and pain in the lower abdomen. Interview with Nursing Supervisor Registered Nurse, Employee E3 on [DATE], at 12:50 p.m. revealed that Employee E4 did not communicate her assessment concerning Resident CL1 on [DATE], at 3:26 a.m. Employee E3 confirmed she did not complete any further assessment on Resident CL1 and had no reason to call the attending physician. Interview with Employee E4 on [DATE], at 3:10 p.m., revealed that Resident CL1 had a blank stare for a brief second and then responded. The only change was her skin was ashen in color. Her heart rate range ,[DATE] (a normal resting heart rate for adults ranges from 60 to 100 beats a minute) during her full assessment. Review of Resident CL1's hospital records dated [DATE], at 12:21 p.m. revealed the, patient arrived to the hospital emergency department by EMS (Emergency Medical Services), CPR (Cardio [MEDICAL CONDITION] Resuscitation) in progress. No respirations, no heart beat. Asystole (the absence of ventricular contractions [MEDICATION NAME] longer than the maximum time sustainable for life) on monitor. Doppler and ultrasound showed no heartbeat. MD (Medical Doctor) pronounced expired at 1208 (12:08 p.m.). Family notified. The facility failed to monitor Resident CL1 after a significant change in condition which included a change in skin color, body temperature and pain in the lower abdomen resulting in actual harm to Resident CL1 who was discovered on [DATE], during the ,[DATE] shift to be cool to touch, pale with abnormal breathing, no blood pressure or pulse requiring Cardio [MEDICAL CONDITION] Resuscitation and transportation to the hospital via Emergency Medical Services. Refer to F157. 42 CFR 483.24, 483.25(k) Provide Care/Services for Highest Well Being Previously cited [DATE], [DATE] (At 42 CFR 483.25) 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(3) Management Previously cited [DATE] 28 Pa. Code 201.18(e)(1) Management Previously cited [DATE], [DATE], [DATE] 28 Pa. Code 211.5(g)(h) Clinical records 28 Pa. Code 211.12(c) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(2) Nursing services Previously cited [DATE] 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]

Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide necessary care to prevent the development of a pressure ulcer for one of 24 residents reviewed, resulting in actual harm to Resident H15. Findings include: Review of facility policy for pressure ulcer prevention, revised June 2013, revealed that a Braden Scale (tool to determine risk for pressure ulcers) will be completed for all residents on admission and readmission times four weeks and that based on the resident's identified risk, appropriate preventive measures will be initiated. Further, on admission and weekly thereafter, the licensed nurse will complete a full body skin check and if nursing assistants note a new abnormal skin condition they will notify licensed staff. Review of admission nursing assessment for skin dated February 14, 2015, revealed that the resident did not have any wounds but did have severe dry skin peeling on both feet and the left heel was soft. Review of Braden Scale dated February 14, 2015 revealed that the resident had a score of 15 which placed him at risk for the development of pressure ulcers. Review of Resident H15's admission Minimum Data Set (MDS-assessment of resident status and care needs) dated March 4, 2015, revealed [DIAGNOSES REDACTED]. Further review revealed that the resident was an extensive assist of two for bed mobility and transfer. Review of February, 2015 physician orders [REDACTED]. Review of the February 2015 treatment administration record (TAR) revealed that the No Sting Barrier was applied from February 15 through February 28, 2015. Review of the February, 2015 TAR revealed that the order for the nurse to check feet daily was not documented for February 22, 2015, February 23, 2015, February 25, 2015 and February 27, 2015. Review of initial care plan, dated February 15, 2015, for impaired skin integrity revealed interventions as follows: [MEDICATION NAME] lotion to extremities two times per day, weekly skin checks by nurse, pressure reducing cushion to wheelchair, comfortex mattress (pressure relieving mattress), [MEDICATION NAME] cream to bilateral feet two times per day and No Sting Barrier to bilateral heels daily. There was no intervention to offload the resident's heels. Review of Wound and Skin Care Weekly Flow Sheet indicated that on February 22, 2015, eight days after admission, an unstageable 5 x 4 centimeter wound was identified with 100% eschar (dry scab in wound bed, dead tissue). An interview with the nursing home administrator on May 29, 2015 at approximately 12:00 p.m., revealed that she could not explain how the resident was identified with an unstageable 5 x 4 centimeter heel wound with 100% eschar (dry scab dead tissue in wound bed) on February 22, 2015 if the nurse had observed the heel daily while applying the No Sting Barrier as ordered. Resident H15 was admitted [DATE] with an admission note that the heel was soft. On February 22, 2015, the resident developed unstageable wound eight days after admission There was no evidence that other assessment and interventions put in place to help prevent the pressure wound from developing. The resident ' s developed an unstageable left heel wound resulting in actual harm 28 PA Code 201.18(b)(1) Management Previously cited 6/27/2014 28 PA Code 211.10(d) Resident care policies Previously cited 2/5/2015; 6/27/2014 28 PA Code 211.11(d) Resident care plan Previously cited 6/27/2014 28 PA Code 211.5(f) Clinical records Previously cited 6/27/2014 28 PA Code 211.12(d)(1)(5) Nursing services Previously cited 2/5/2015; 10/17/2014; 6/27/2014 28 PA Code 211/12(d)(3) Nursing services Previously cited 6/27/2014