Every finding on record at Maple Heights Health & Rehab Center, LLC

Based on a review of policies, clinical record review and staff interviews, it was determined that the facility failed to develop and implement a discharge planning process to align with the resident's goals and failed to provide discharge instructions, including medication times and doses for one of five residents reviewed (Resident 3). Findings include: Review of Resident 3's clinical record revealed that the facility admitted him on December 8, 2025 after falling at home and suffering a traumatic brain bleed. A comprehensive Minimum Data Set (MDS) assessment (a mandatory assessment of a residents abilities and needs) dated December 14, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and that his overall goal was to remain in the facility for long term care. The resident's care plan, dated December 10, 2025, indicated that the resident was to reside in the facility for long term care.Social services note for Resident 3, dated December 10, 2025, revealed that the resident told the social worker that he did not want to return home to his townhouse because he could not manage the stairs necessary to get in and out, he lived alone and had no one to help him and that he preferred to stay in the nursing facility for long term care.A Certified Registered Nurse Practioner's (CRNP, a higher practice nurse) note for Resident 3, dated December 11, 2025 revealed that the resident told her he had no family in the area and that he could not return home alone as he was unable to care for himself as evidenced by his recent fall with subdural hematoma (brain bleed).An Interdisciplinary Team meeting for Resident 3 on December 12, 2025, revealed that the resident did not want to return to his prior living arrangements and was willing to apply for the state insurance to stay at the nursing facility for long term care.A social services note for Resident 3, dated December 18, 2025 indicated that the resident was issued a Notice of Medicare Non-Coverage (NOMNC) letter and that he would be discharging home to his previous living arrangements on December 21.A review of Resident 3's physical therapy and occupation therapy assessments, dated December 9, 2025, revealed that the resident's goal was long term care, and not discharge to home. There was no evidence in Resident 3's clinical record that the facility followed up with the resident or the resident's family regarding the change in his plans to assure his safety upon discharge.A review of Resident 3's discharge instructions revealed that he was not provided with a list of medications with the times and dosages that he would need to take, or instructions on the medications that he should no longer take.Interview with the Social Services Director on January 21, 2026 at 12:42 p.m. revealed that the resident did want to stay long term and that he applied for the state's insurance. However, he had to spend down his $40,000 Individual Retirement Account (IRA) by paying the nursing facility for his stay before he would qualify for the state's insurance. When he learned he would have to use his IRA monies, he decided to return to his apartment. She stated that his goal in therapy was not changed in order for him to receive the training needed to return to his home.An interview with the Rehab Program Manager on January 21, 2026 at 12:57 p.m. revealed that the resident's goals while in therapy were for him to remain in the facility for long term care, therefore, the resident was to be cut from therapy. She stated that the therapy department was not notified that the resident's goal had changed from long term care to home until December 18, and that therapy should have made changes to his plan in therapy at that time. She stated that therapy had not worked with the resident on any home goals, such as housework, cooking, laundry, or stairs. She stated she was aware that he had 12 stairs to get in and out of his apartment, but that therapy had not worked with him on stairs because his goal was long term care. Interview with Casemanager on January 21, 2025 at 1:21 p.m. revealed that he did not inform the resident's insurance that the resident's goal had changed from long term care to going home and therefore the NOMNC cut letter was issued and the resident had decided to go home instead of paying for his room.Interview with the Nursing Home Administrator on January 22, 2026 at 8:39 p.m. revealed that the resident was not provided with discharge instruction which included a list of medications that he was to take and when to take them. 28 Pa. Code 201.18 (3)(e)(1) Management28 Pa. Code 211.10(a) Resident care plan

Based on a review of policies, clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of five residents reviewed (Resident 2). This deficiency was cited as past non-compliance.Findings include: The facility's policy regarding abuse, dated September 23, 2025, revealed that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriations of resident property by anyone. An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 2, dated December 7, 2025, indicated that the resident was cognitively impaired, was dependent on staff for all care needs, and had a diagnosis of Alzheimer's disease. A nurse's note for Resident 2 dated December 15, 2025, at 6:11 p.m. revealed that a nurse aide reported that another nurse aide hit the resident on the left hand while the resident was grabbing onto another resident's bed during dinner time. The alleged perpetrator was sent home. A skin check completed on the resident revealed small areas of bruising, deep purple in color, to his bilateral hands. The resident was able to move both hands without signs or symptoms of pain or discomfort and there was no swelling noted. Review of an event report dated December 15, 2025, revealed that on December 15, 2025, at 6:11 p.m. Nurse Aide 1 informed the nursing supervisor that Nurse Aide 2 was noted punching Resident 2. An interview with Nurse Aide 1 who witnessed the incident reported that the resident was attempting to self-propel out of the room when he grabbed hold of another resident's bed to help himself wheel out. When he did this, Nurse Aide 2 grabbed Resident 2's hands to get him to let go of the bed and pushed the resident away from the bed. This caused Resident 2 to become agitated, and then again grabbed onto the bed. Nurse Aide 2 intervened again and pushed the resident's hands off the bed. When he did this, the resident grabbed Nurse Aide 2 by the arm and told Nurse Aide 2 to stop it. Nurse Aide 2 removed the resident's hands from his arm and struck the resident's left wrist with his fist. Nurse Aide 2 pushed the residents out of the room. Nurse Aide 1 who witnessed the event stated it happened quickly and she was unsure of how to intervene but immediately reported it to the registered nurse supervisor. The registered nurse supervisor notified the Director of Nursing and Nurse Aide 2 was sent home immediately pending an investigation. Assessment of Resident 2 noted small bruises to both hands. A witness statement from Nurse Aide 1 dated December 15, 2025, revealed that she and Nurse Aide 2 were feeding residents in Resident 2s room. Resident 2 was attempting to wheel himself out of the room after eating supper and his wheelchair wheel got stuck on the bedside table and he was dragging it with him. Nurse Aide 2 got up and got the table off the wheel and removed the meal tray from the table and put it in the cart. Nurse aide 2 then brought Resident 2 a cup of coffee and Resident 2 stated he did not want the coffee and to dump it out. Resident 2 stated I'll dump it on your head and sat down to continue feeding another resident. Resident 2 then grabbed hold of the bed to help wheel himself out the door when Nurse Aide 2 aggressively slid his chair out and grabbed hold of the resident's hands to make him let go of the bed. Resident 2 then became agitated and grabbed back onto the bed. Nurse Aide 2 ripped the resident's hand off again and the resident grabbed Nurse Aide 2's arm and said, stop it. Nurse Aide 2 then forced the resident's hands off him and with his fist slammed down on the resident's left wrist bone area. The resident said, ouch that hurt and was holding his arm. Nurse aide 2 then pushed him out of his room and into the lounge. Interview with the regional director of clinical services on January 21, 2026, at 2:25 p.m. revealed that the allegation of abuse to Resident 2 by Nurse Aide 2 was immediately investigated upon report of it, the allegation was substantiated, and Nurse Aide 2 was terminated from employment. Following identification of the allegation of abuse, the facility's corrective actions included: Nurse Aide 2, who was involved in the allegation of abuse to Resident 2, was terminated upon completion of the facility's investigation. To identify like residents that have the potential to be affected, nursing staff/designee completed skin checks on incapable residents for signs and symptoms of abuse. To identify like residents that have the potential to be affected, nursing staff/designee completed interviews on capable residents on that unit. No capable residents were identified on that unit. Education was provided to all staff on the facility's abuse policy and abuse and de-escalation of behaviors on December 15 and 16, 2025. To monitor and maintain ongoing compliance, observations of residents were to be performed weekly four times, then monthly twice to ensure there are no issues with abuse. A review of the facility's corrective actions revealed that they were in compliance with F600 on December 16, 2025. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, manufacturer's instructions, US Consumer Product Safety Division warnings, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the environment was free from accident hazard, placing the safety of the residents in an Immediate Jeopardy situation by not adequately securing water absorbing beads from residents on the dementia unit who wander, resulting in the ingestion and ICU hospitalization for one resident (Resident 1). Findings include: The facility's policy for storage of activities items, dated September 23, 2025, revealed that items that are to be used with close supervision must be stored in locked cabinets or other designated secure storage areas. Access to these areas is limited to authorized personnel only. Staff must ensure that cabinets remain locked and secured at all times when not in active use. Manufacturer's instructions for the use of the water absorbing beads (water beads), dated 2022, revealed that ingestion of the water beads is a serious medical emergency, as the beads can expand up to 400 times their original size in the body and cause life threatening intestinal blockages or choking. Water beads are made from super- absorbent polymer that, while usually non-toxic chemically, presents a significant physical hazard as it absorbs bodily fluids and expands. This expansion can occur in the esophagus, stomach, or intestines and lead to a potentially fatal obstruction. The US Consumer Product Safety Division's safety warning for the use of water absorbing beads on January 7, 2026 revealed that dry water beads can be the size of a pinhead, making them nearly undetectable if dropped on the floor or spilled in a playroom; Ingested water beads can continue to grow inside the body. This can cause severe discomfort, vomiting, dehydration, intestinal blockages and life-threatening injuries, and surgery may be required to remove the water beads; and water beads inserted into ears can damage ear structures, causing hearing loss and require surgery. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 23, 2025, revealed that the resident was cognitively impaired, was independent with mobility, and had diagnoses that included dementia and dysphagia (impaired swallowing foods and liquids). A care plan for Resident 1, dated November 7, 2025, revealed that he exhibits wandering and is to be in a secure environment. A witness statement from Nurse Aide 1 on January 2, 2026, revealed that during 5:00 a.m. rounds she entered Resident 1's room with another nurse aide and found the resident in bed and the floor was covered in water beads. The resident was coughing and spitting the water beads out of his mouth and she went to get the licensed practical nurse. She did not see the resident get into anything. A witness stated from Nurse Aide 6, dated January 2, 2025 revealed that Resident 1 was in bed at 2:15 a.m. and nothing unusual was visualized. A witness statement from Nurse Aide 5 on January 2, 2026, revealed that she was assisting Nurse Aide 1 with nursing rounds at 5:00 a.m. and noticed that the north lounge activity room door was open and the light was on. The cabinet where the water beads are kept was open. A witness statement from Licensed Practical Nurse 2 on January 2, 2026, revealed that she was called to Resident 1's room by Nurse Aide 1 and observed him in his room. He was coughing up water beads and mucous, his vital signs were stable. His lung sounds had rattles (popping, bubbling, or clicking noises heard with a stethoscope) bilaterally and she notified the registered nurse. Investigative documents for Resident 1 dated January 2, 2026, at 4:54 a.m. revealed that Registered Nurse 3 was called to the resident's room. Upon assessment resident was awake and alert with confusion and was spitting up water beads. His respirations were even and unlabored with cough observed. Lung sounds were diminished with congestion. The physician was notified and Resident 1 was transferred to the hospital. Interview with Activity Aide 4 on January 6, 2026, at 10:43 a.m. confirmed that the water beads were kept in a closet in the north lounge activity/dining room. Interview with the Director of Nursing on January 6, 2026, at 10:13 a.m. confirmed that the water beads were unsecured in the north lounge activity/dining room on the dementia unit. She stated that it was unknown how many water beads Resident 1 had ingested. A nursing note dated January 2, 2026, at 4:25 p.m. revealed that the resident was admitted to the local hospital and was in the intensive care unit. Observations of the north lounge activity/dining room on January 6, 2026 at 10:00 a.m. revealed that it was three doors from Resident 1's room and neither room was visible from the nursing station. The storage cabinet located in the north lounge activity/dining room had two doors with a knob on each and the cabinet could be locked using a key. On January 6, 2026, at 12:14 p.m. the Nursing Home Administrator was given the Immediate Jeopardy template and informed that the health and safety of the residents were placed in Immediate Jeopardy due to the facility's failure to ensure that water beads were properly secured from residents. An immediate action plan was submitted and contained the following: The water beads were removed from the facility. Staff will identify like residents that have the potential to be affected. The Director of nursing/designee has done a house review on rooms and lounges for any like foreign objects and any other potentially noted items that would pose a like issue. Education was provided to nursing and activities staff on removing items that would pose a potential risk for residents to ingest. All activity cabinets have been locked and secured. Newly hired staff and staff on paid time-off will be educated before working the next shift. The facility will monitor and maintain ongoing compliance. The Director of Nursing or designee will complete observation audits to ensure items that have potential to be ingested are removed and activity cabinets are locked. The Immediate Jeopardy was lifted on January 6, 2026, at 1:47 p.m. when it was confirmed that water beads were removed from resident use, staff were educated on identifying potential choking hazards and storage for items used by activities. 28 Pa. Code 211.10(c)(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of employee job descriptions, as well as observations and staff interviews, it was determined that the facility's administration, Nursing Home Administrator and Director of Nursing, failed to effectively use its resources to promote resident safety and maintain the highest practicable physical well being of residents in the facility by failing to ensure that water absorbing beads were secured, placing the residents on the dementia unit at risk for serious harm which created an Immediate Jeopardy situation. Findings include: The job description for the NHA, dated September 23, 2025, indicated that the primary purpose of the job is to lead, direct, and manage the overall operations of the community in accordance with policies and procedures and current federal, state and local standards, guidelines and regulations that governs the community. As the Administrator, it is their responsibility to organize, develop, and director resources to maintain the highest degree of quality care is maintained for each resident at all times. The Administrator will also plan, implement and achieve the community's business objectives. The position description for the DON, dated September 23, 2025, indicated that the DON is responsible for organizing, developing, managing and directing the overall operations of the Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern the community. The Director of Nursing is to work directly with the Administrator and the Medical Director to ensure the highest degree of quality of care is maintained for each resident at all times. Follows all health, sanitary and infection control polices and maintains established standards of practice set forth by the community's administration and Nursing Policies and Procdures. The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F689) revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that the residents' environment remained free of accident hazards. Refer to F689. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on observations and staff interviews, it was determined that the facility failed to ensure that essential equipment was in safe operating condition in the facility's kitchen. Findings include:Observations in the facility's kitchen on November 17, 2025, at 8:56 a.m. revealed that the dishwasher was not in use and not functioning properly. There was no evidence of a confirmed plan to repair or replace the dishwasher prior to the initial tour of the kitchen.Interview with the Assistant Dietary Manager on November 17, 2025, at 11:15 a.m. confirmed that the dishwasher was not being used due to not functioning properly. He indicated that the dishwasher had not been in use since October 25, 2025 and they were serving meals on Styrofoam products since then.28 Pa. Code 201.18(b)(3) Administrator's Responsibility.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plans of corrections for an annual survey ending January 30, 2024, and a complaint survey's ending January 26; April 8; June 16; July 2; July 31; August 27, 2025, revealed that the facility developed a plan of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending November 20, 2025, identified a repeated deficiency related to right to be informed/make treatment decisions; safe, clean, comfortable homelike environment; reporting of alleged violations; accuracy of assessments; develop/implement comprehensive care plans; care plan timing and revision; quality of care; free of accident hazards/supervision/devices; and essential equipment safe operating condition. The facility's plan of correction for a deficiency regarding safe, clean, comfortable and homelike environment, cited during the survey ending April 8, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan regarding safe, clean, comfortable and homelike environment. The facility's plan of correction for a deficiency regarding reporting of alleged violations cited during the survey ending August 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F609, revealed that the facility's QAPI committee failed to successfully implement their plan regarding reporting of alleged violations. The facility's plan of correction for a deficiency regarding inaccurate MDS assessments, cited during the survey ending January 30, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan regarding completing accurate MDS assessments. The facility's plan of correction for a deficiency regarding develop/implement comprehensive care plans cited during the survey ending January 30, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan regarding develop/implement comprehensive care plans. The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending January 30, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan regarding care plan timing and revision. The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending January 30 and June 16, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan regarding quality of care. The facility's plan of correction for a deficiency regarding safety/accident hazards, cited during the surveys ending January 30, April 8, July 31, and August 27, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan regarding safety/accident hazards. The facility's plan of correction for a deficiency regarding essential equipment safe operating condition cited during the survey ending January 30, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F908, revealed that the facility's QAPI committee failed to successfully implement their plan regarding essential equipment safe operating condition Refer to F552, F584, F609, F641, F656, F657, F684, F689, F908 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at appetizing temperatures. Findings include:The facility's policy regarding food temperatures, dated September 23, 2025 indicated that hot foods should be at least 135 degrees Fahrenheit (F) when plated and should be palatable at the point of delivery. Foods were to be transported as quickly as possible to maintain temperatures for delivery and service, and appropriate hot/cold holding equipment was to be used as needed.An interview with Resident 129 on November 17, 2025, at 1:53 p.m. revealed that she believed the quality and quantity of the food served for meals was poor, and that the food was often served cold when it should have been served hot.The lunch meal on November 18, 2025, consisted of fried chicken with poultry gravy, garlic mashed potatoes, seasoned spinach, and corn bread. The recipes for the seasoned spinach only called for salt; the garlic mashed potatoes called for minced garlic, margarine and salt; and the cornbread called for water to be added to a cornbread mix.Observations in the main kitchen for the lunch meal service on November 18, 2025, at 12:09 p.m. revealed that Styrofoam containers were used instead of regular plates and bowls. A test tray left the kitchen and arrived on the third floor at 12:12 p.m. Styrofoam containers of food were passed to the residents in their rooms, and the last resident was served and eating at 12:21 p.m. The test tray on November 18, 2025, at 12:22 p.m. revealed that the temperature of the fried chicken was 127.0 degrees F and the spinach was 122.9 degrees F. The fried chicken had a hard border, and the mashed potatoes, seasoned spinach, and cornbread lacked seasoning and flavor.Interview with the Assistant Dietary Manager at that time confirmed that food should be served at correct temperatures and be palatable.28 Pa. Code 211.6(f) Dietary Services.

Based on review of state laws, facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for ten of 51 residents reviewed (Resident 3, 40, 44, 46, 52, 87, 96, 99, 115, and 158). Findings include:The Older Adult Protective Services Act of November 6, 1987, amended by Act 1997-13, Chapter 7, Section 701, requires that all administrators or employees who have reasonable cause to suspect that a resident was a victim of abuse or neglect were to make an immediate report to the Protective Services Agency, the Pennsylvania Department of Aging (PDA), and to law enforcement officials.The facility's policy regarding abuse, dated September 23, 2025, revealed that facility staff all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing and to the applicable state agency. The facility will notify the department of health when the facility receives a complaint of alleged abuse, neglect or misappropriation of resident property. The administrator or designee will provide a written report for employees, using the PB22 (a form for reporting abuse), to the department of health within five calendar days of the incident. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 28, 2025, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, had diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that causes urinary problems). Physician's order for Resident 3 dated October 30, 2024, revealed 0.4milligram (mg) of tamsulosin (a medication used to treat benign prostatic hyperplasia) was to be administered once a day between 3:00 p.m. and 5:00 p.m. A nursing note for Resident 3 dated September 29, 2025, at 1:30 a.m. and a review of the resident's Medication Administration Record (MAR) revealed that the resident was not administered 0.4mg tamsulosin on September 29, 2025. A quarterly MDS for Resident 40 dated September 11, 2025, revealed that the resident was cognitively intact, was dependent on staff for care and activities of daily living, and had diagnoses that included seizures and glaucoma (a group of eye conditions that damage the optic nerve that connects the eye to the brain). Physician's order for Resident 40 dated July 24, 2024, revealed the resident was to receive one drop of 1.4% polyvynal alcohol eye drops (artificial tears) in each eye three times a day; one drop of 0.2% brimonidine eye drops (a medication that is used to lower high pressure inside the eye caused by glaucoma) in the right eye three times a day; and 300 mg of Neurontin (a medication to prevent seizures) three times a day. A nursing note for Resident 40 dated September 29, at 9:40 p.m. and a review of the MAR revealed that the resident was not administered one dose each of the artificial tears, brimonidine eye drops, or 300mg Neurontin during the medication pass between 4:00 p.m. and 6:00 p.m. on September 29, 2025. A quarterly MDS for Resident 44 dated August 7, 2025, revealed that the resident was cognitively impaired, required maximum assistance from staff for care, and has diagnoses that included stroke, seizure disorder, dysphagia (difficulty swallowing), and gastroesophageal reflux disorder (GERD-a medical condition when stomach acid flows back up into the esophagus). Physician's orders for Resident 44 dated June 22, 2023, revealed the resident was to receive 5 mg metoclopramide (a medication used to treat gastrointestinal conditions and manage nausea and vomiting) 1 tablet twice a day. A nursing note for Resident 44 dated September 30, 2025, at 1:43 a.m. and a review of the MAR revealed that the second dose of 5 mg metoclopramide was not administered. New orders were received to administer the missed dose at bedtime on September 29, 2025. A quarterly MDS for Resident 46 dated October 1, 2025, revealed that the resident was cognitively impaired, was dependent on staff for care, and had diagnoses that included multiple sclerosis (a disease of the brain and spinal cord where the immune system mistakenly attacks the protective layer around nerve fibers, causing a disruption of communication between the brain and body), and was receiving hospice care. Physician's order for Resident 46 dated January 8, 2025, revealed the resident was to receive 650mg acetaminophen (Tylenol) every six hours. Physician's order for Resident 46 dated April 23, 2025, revealed the resident was to receive 0.5 milliliter (ml) of 5mg/ml diazepam (a medication used to treat central nervous system disorders including anxiety, seizures, and muscle spasms) twice a day and at bedtime. Physician's order for Resident 46 dated December 18, 2023, revealed the resident was to receive 25mg promethazine (a medication used to treat vomiting) every six hours. Physician's order for Resident 46 dated July 1, 2023, revealed the resident was to receive 2 tablets of 8.6-50mg Senna daily for constipation. A nursing note for Resident 46 dated September 29, 2025, at 10:08 p.m. and a review of the MAR revealed that the resident was not administered acetaminophen, diazepam, promethazine, and senna during the 4:00 p.m. medication pass on September 29, 2025. An annual MDS for Resident 52 dated August 7, 2025, revealed that the resident was cognitively intact, was independent with daily care needs, and had medical diagnoses of stroke, anxiety and depression. Physician's orders for Resident 52 dated March 22, 2025, revealed that the resident was to receive 15 mg of buspirone (a medication used to treat anxiety disorders) three times a day. A nursing note for Resident 52 dated September 29, 2025, at 10:15 p.m. and a review of the MAR revealed that the resident's afternoon dose of 15 mg of buspirone was not administered on September 29, 2025. A quarterly MDS for Resident 87 dated August 31, 2025, revealed that the resident was severely cognitively impaired, was dependent on staff for daily care needs, and had medical diagnoses of coronary artery disease, heart failure, high cholesterol, diabetes, and Parkinson's disease (a progressive neurological disorder that affects the nervous system). Physician's orders for Resident 87 dated August 25, 2025, revealed that the resident was to receive 5 mg of baclofen (a muscle relaxant) three times a day; 12.5-50-200 mg of carbidopa-levodopa-entacapone (a medication used to treat Parkinson's disease) three times a day; 200 mg of entacapone (a medication used to treat Parkinson's disease) three times a day; 12.5 mg of carvedilol (medication used to treat heart disease) twice a day with breakfast and supper; and 300 mg of tums twice a day for heartburn. A nursing note for Resident 87 dated September 29, 2025, at 9:11 p.m. and a review of the MAR revealed that the resident was not administered her afternoon doses of baclofen, carbidopa-levodopa-entacapone, entacapone, carvedilol, and tums on September 29, 2025. An admission MDS for Resident 96 dated September 24, 2025, revealed that the resident was cognitively intact, was dependent on staff for daily care, and had medical diagnoses of diabetes. Physician's orders for Resident 96 dated September 28, 2025, revealed that the resident was to receive Humalog Kwik Pen 100 units/ml depending on the sliding scale for blood glucose monitoring prior to meals. A nursing note for Resident 96 dated September 30, 2025, at 1:01 a.m. and a review of the MAR revealed that the resident did not have his blood sugar checked at 4:00 p.m. and was not administered his 4:00 p.m. dose of Humalog Kwik Pen sliding scale on September 29, 2025. A quarterly MDS for Resident 99 dated September 11, 2025, revealed that the resident was cognitively intact, was dependent on staff for care, and had medical diagnoses of osteoarthritis (a degenerative joint disease that causes pain, stiffness, swelling) and stroke. Physician's orders for Resident 99 dated October 12, 2024, revealed that the resident was to receive 25-100 mg of carbidopa-levodopa (a medication to treat Parkinsons) three times a day, and 0.5 mg of clonazepam (a medication use to treat seizure disorders) three times a day. A nursing note for Resident 99 dated September 30, 2025, at 1:50 a.m. and a review of the MAR for September 29, 2025 revealed that the resident was not administered the afternoon doses of carbidopa-levodopa and clonazepam on September 29, 2025. A quarterly MDS for Resident 115 dated September 22, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had medical diagnoses that included end stage kidney disease, diabetes, and dialysis. Physician's orders for Resident 115 dated August 12, 2025, revealed that the resident was to receive 150 mg of Lyrica for neuropathy (nerve pain) three times a day. A nursing note for Resident 115 dated September 29, 2025, at 9:57 p.m. and a review of the MAR revealed that the resident was not administered her afternoon dose of Lyrica on September 29, 2025. An annual MDS for Resident 158 dated September 22, 2025, revealed that the resident was cognitively intact, was independent with daily care needs, had medical diagnoses that included Parkinson's, and was receiving scheduled pain medications. Physician's order for Resident 158 dated December 28, 2025, revealed that the resident was to receive 5 mg oxycodone (a narcotic pain medication) three times a day. A nursing note for Resident 158 dated September 29, 2025, at 9:15 p.m. and a review of the MAR revealed that the resident was not administered her afternoon dose of oxycodone on September 29, 2025. The facility's investigation regarding the mentioned medications for the above residents determined that the medications for the residents were not administered due to omission by the nurse. Interview with the Director of Nursing on November 20, 2025, at 9:14 a.m. confirmed that the above medication errors were due to omission and were not reported to the Department of Health and should have been. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.18(e)(1) Management.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 51 residents reviewed (Resident 2, 4, 11, 16, 17, 115, 157). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the intent of Section P0100B Trunk Restraint was to record the type of restraint used by the resident during the seven days of the assessment period. A quarterly MDS for Resident 2 dated October 25, 2025, revealed that the resident was cognitively intact, was dependent on staff for daily care needs and utilized a trunk restraint. However, a review of the medical record for Resident 2 revealed no documented evidence that the resident utilized a trunk restraint during the lookback period.An interview with the Director of Nursing on November 20, 2025 at 11:05 a.m. confirmed that Resident 2's MDS was coded incorrectly for trunk restraints. The RAI manual, dated October 2025, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0415A Antipsychotic Medications (medication used for medications used for behaviors), Sections N0415I Antiplatelet Medications (medication used to prevent blood from clotting).Physician's orders for Resident 4 dated September 25, 2025, included an order for the resident to receive 81 milligrams (mg) of aspirin (antiplatelet) once a day. The resident's Medication Administration Record from October 28 through November 3, 2025, revealed that the resident received 81 mg of aspirin daily and did not receive an antipsychotic medication during the lookback period. However, a quarterly MDS assessment for Resident 4, dated November 3, 2025, revealed that Section N0415I was not coded for antiplatelet medication during the lookback period. Section N0415A was coded for antipsychotic during the lookback period.An interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m. confirmed that Resident 4's MDS was coded inaccurately and should have been coded for antiplatelet and not have been coded of antipsychotic medications. The RAI Manual, dated October, 2025, indicated that the intent of Section O0110J1 (Dialysis) was to be coded if the resident received dialysis services. Physician's orders for Resident 11 dated June 26, 2025, included orders for the resident to receive dialysis services. A quarterly MDS assessment for Resident 11 dated October 2, 2025, revealed that Section O0110J1 was not coded for dialysis during the lookback period.A interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that Resident 11's MDS assessment was coded inaccurately and should have been coded for dialysis. The RAI User's Manual, dated October 2025, revealed that if a wander/elopement alarm was used, then Section P0200E was to be coded as (0) not used, (1) used less than daily, or (2) used daily.A physician's order for Resident 16, dated August 29, 2025, included orders for the resident to use a wanderguard (device that alarms when close to exit doors), and to check the function daily and the placement every shift. The resident's Medication Administration Record for October 2025 revealed that the resident used a wanderguard from October 1-31, 2025. However, a quarterly MDS assessment for Resident 16, dated October 28, 2025, revealed that Section P0200E was coded with a (0), indicating that the resident did not use a wander/elopement alarm.Interview with the Nursing Home Administrator on November 19, 2018, at 1:48 p.m. confirmed that Section P0200E of Resident 16's MDS assessment of October 28, 2025, should have been coded (2) for daily use of a wander/elopement alarm. The RAI Manual, dated October, 2025, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. N0415F Antibiotic medications were to be coded if the resident took the medication during the seven-day look-back period. A review of Resident 17's Medication Administration Record for September 27 through October 3, 2025, revealed that the resident did not receive an antibiotic during the look back period. However, a significant change MDS for Resident 17 dated October 3, 2025, revealed that Section N0415F Antibiotic was coded that the resident received antibiotics during the lookback period.A interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that Resident 17's MDS assessment was coded inaccurately and that the resident did not receive an antibiotic during the lookback period. The RAI manual, dated October 2025, indicated that the intent of Section O0110J1 (Dialysis) was to be coded if the resident received dialysis services. Physician's orders for Resident 115 dated June 26, 2025, included orders for the resident to receive dialysis services. However, a quarterly MDS assessment for Resident 115 dated September 22, 2025, revealed that Section O0110J1 was not coded for dialysis during the lookback period.An interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that Resident 115's MDS assessment was coded inaccurately and should have been coded for dialysis. The RAI manual, dated October, 2025, indicated that the intent of Section N0300A (Insulin) was to be coded if the resident received insulin during the assessment period. There was no documented evidence in Resident 157's clinical record of the resident receiving insulin during the lookback period. However, a quarterly MDS assessment for Resident 157 dated September 22, 2025, revealed that Section N0300A was coded for insulin during the lookback period. An interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that Resident 157's MDS assessment was coded inaccurately and should not have been coded for insulin.28 Pa. Code 211.5(f) Clinical records.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 51 residents reviewed (Resident 173). Findings include: The facility's policy regarding Comprehensive Care Plans, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. An interim care plan was to be developed within 48 hours of admission to ensure that the resident's needs were met until a comprehensive care plan was completed.A nursing note dated November 13, 2025, at 7:45 p.m. revealed Resident 173 was admitted to the facility from the hospital.Physician's orders, dated November 13 and 14, 2025, included orders for the resident to receive 500 milligrams (mg) of levetiracetam (anticonvulsant medication) twice a day for seizures, 50 mg of Tramadol (narcotic pain medication) every six hours as needed for pain, and a wanderguard (device that alerts when exiting a door) bracelet to be used for safety.The Medication Administration Record (MAR) for Resident 173, dated November 2025, revealed the resident received 500 mg of Levetiracetam twice a day from November 13 through 20, 2025, received 50 mg of Tramadol as needed every six hours November 14 through 20, 2025, and used a wanderguard daily from November 14 through 20, 2025. There was no documented evidence that any individualized interventions were developed to meet Resident 173's immediate care needs for seizures/ anticonvulsant medications, pain, and the use of a wanderguard within 48 hours of admission. Interview with the Director of Nursing on November 20, 2025, at 2:56 p.m. confirmed that there were no baseline care plans developed to address the resident's seizure/anticonvulsant medications, pain, and wanderguard use, and should have been. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and homelike environment for one of 51 residents reviewed (Resident 142). Findings include:The facility's policy regarding routine environmental cleaning and disinfecting, dated September 13, 2025, indicated that proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 142, dated September 5, 2025, revealed that the resident was cognitively intact, usually understood and understands, was highly hearing impaired and had diagnoses that included a stroke with residual right sided weakness.Observations on November 17, 2025, at 12:17 p.m. and November 18, 2025, at 8:45 a.m. and 2:35 p.m. revealed that the resident was lying in her bed resting. The bilateral enablers located on her bed were noted to have a thick amount of a blackish/brown removable substance on them, especially the inside aspect of the left enabler. Interview with Licensed Practical Nurse 2 on November 18, 2025, at 2:45 p.m. indicated that the resident frequently used the enablers to assist in positioning herself. She confirmed that both enablers, especially the left one, had a large amount of removable dirt and grime on them, and they should not.Interview with Director of Nursing on November 18, 2025, at 2:45 p.m. confirmed that Resident 142's bilateral enablers should be clean, and they were not. 28 Pa. Code 201.29(j) Resident Rights.28 Pa. Code 207.2(a) Administrator's Responsibility.

Based on review of clinical records and staff interviews, it was determined that the facility failed to inform the resident representative in advance of the risks and benefits of a psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for two of 51 residents reviewed (Residents 1 and 16). Findings Include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 8, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs and had diagnosis that included chronic obstructive pulmonary disease (COPD- condition involving constriction of the airways and difficulty or discomfort in breathing).Physician's orders for Resident 1, dated October 3, 2025, included an order for the resident to receive 25 milligrams (mg) of hydroxyzine hydrochloride (psychotropic medication used to treat anxiety and tension) three times a day as needed for anxiety. Physician's orders dated October 8, 2025, included an order for the resident to receive 25 milligrams (mg) of hydroxyzine hydrochloride three times a day, every day. A nurse's note for Resident 1 dated October 3, 2025, at 3:08 p.m. indicated that the resident was reporting increased anxiety and was unable to be redirected with therapeutic distraction activities. The certified registered nurse practitioner (CRNP-registered nurse with advanced education and clinical training) was notified, and new orders were obtained to administer 25 mg of hydroxyzine hydrochloride three times a day as needed for anxiety.There was no documented evidence in the clinical record to indicate that that Resident 1 or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the dose of hydroxyzine hydrochloride.Interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m., confirmed that there was no documented evidence in the Resident 1's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating hydroxyzine hydrochloride medication. A quarterly MDS assessment for Resident 16, dated October 28, 2025, revealed that the resident could usually make his needs known, was moderately cognitively impaired, received antipsychotic medications, and had diagnoses that included schizophrenia (a serious mental health condition that affects how people think, feel and behave).Physician's orders for Resident 16, dated August 12 and September 5, 2025, included an order for the resident to receive 3.8 mg/24 hours of Secuado (antipsychotic medication) transdermal patch daily.There was no documented evidence in the resident's clinical record to indicate that Resident 16 or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Secuado.Interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m., confirmed that there was no documented evidence in Resident 16's clinical record that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Secuado. 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for three of 51 residents reviewed (Residents 12, 46, 157). Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 21, 2025, revealed that the resident was cognitively impaired, was frequently incontinent of urine, was receiving an anticoagulant, and had diagnoses that included dementia. A nursing note, dated September 17, 2025, at 8:51 a.m. revealed there was a moderate amount of bright red blood in Resident 12's toilet. The Certified Registered Nurse Practitioner (CRNP) was notified. A nursing note, dated September 19, 2025, at 1:40 a.m. revealed Resident 12 urinated in the toilet and it was blood tinged. A verbal order was received from the physician to place the resident's Xarelto on hold related to hematuria (blood in the urine) and obtain a urinalysis with a culture and sensitivity (UA C&S, test used to identify a urinary tract infection). There was no documented evidence that staff obtained Resident 12's UA C&S. Interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m. confirmed that there was no evidence that Resident 12's UA C&S was obtained. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated October 1, 2025, revealed that the resident was cognitively impaired, was dependent on staff for daily care and had diagnoses that included high blood pressure, peripheral vascular disease (a circulation disorder where blood flow is restricted due to narrow, weakened, or blocked blood vessels), and multiple sclerosis (an autoimmune disease of the central nervous system). A physician's order for Resident 46 dated October 3, 2025, revealed that the resident was to have liver function tests (blood test) completed on the 3rd day of January, April, July and October. There was no documented evidence that staff obtained Resident 46's Liver Function Tests. Interview with the Director of Nursing on November 19, 2025, at 2:48 p.m. confirmed that there was no evidence that Resident 46's Liver Function Tests. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 157, dated August 28, 2025, revealed that the resident was cognitively intact, was independent with daily care needs and had diagnoses that included high cholesterol. A physician's order for Resident 157 dated March 4, 2025, revealed that the resident was to have liver function tests (blood test) completed on the 1st Tuesday of March and September. There was no documented evidence that staff obtained Resident 157's Liver Function Tests. Interview with the Director of Nursing on November 19, 2025, at 2:47p.m. confirmed that there was no evidence that Resident 157's Liver Function Tests. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, manufacturer's instructions, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent. Findings include:The facility's medication Administration Policy, dated September 23, 2025, revealed that staff were to verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident and with the correct technique. Observations during medication administration on November 19, 2025, revealed that two medications errors were made during 27 opportunities for error, resulting in a medication administrator error rate of 7.41 percent.Current manufacturer's instructions for use of Breo ellipta (fluticasone furoate and vilanterol inhalation powder) 100 micrograms (mcg) /25 mcg (used to treat chronic obstructive pulmonary disease (COPD) and Asthma) revealed that serious side effects including thrush (a fungal infection in the mouth and throat) can occur. Directions include to rinse the mouth with water without swallowing after use to reduce the chance of getting thrush.Physician's orders for Resident 49, dated September 18, 2025, included an order for the resident to receive 100 mcg/25 mcg of Breo ellipta (fluticasone furoate and vilanterol inhalation powder with instructions to inhale 1 puff orally daily and to rinse mouth after each use. In addition, printed instructions on the Breo ellipta box stated to rinse mouth with water and spit out water after administration. Observations during medication administration on November 19, 2025, at 10:32 a.m. revealed that Licensed Practical Nurse 7 administered the Breo ellipta and did not have the resident rinse his mouth after administration. Interview with Licensed Practical 7 on November 19, 2025, at 8:55 a.m. confirmed that she should have had Resident 49 rinse his mouth after administering the Breo ellipta inhaler. Physician's orders for Resident 135, dated November 3, 2025, included orders for the resident to receive 20 milligrams (mg) of Citalopram (antidepressant medication) once a day. Observations during medication administration on November 19, 2025, at 8:59 a.m. revealed that Licensed Practical Nurse 8 administered 10 mg of Citalopram to the resident. Interview with Licensed Practical Nurse 8 on November 19, 2025, at 8:38 a.m. confirmed that she only administered 10 mg of Citalopram to Resident 135, instead of the ordered 20 mg. Interview with the Director of Nursing on November 19, 2025, at 1:10 p.m. confirmed that the nurse should have had Resident 49 rinse his mouth after administering the Breo ellipta inhaler, and Resident 135 should have been given the correct dose of Citalopram. 28 Pa Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that a dialysis emergency kit was at the resident's bedside for two of 51 residents reviewed (Residents 10 and 11). Findings include: A hemodialysis care policy dated September 23, 2025, indicated that a smooth clamp should be kept at bedside of resident with a dialysis vascular access dialysis catheter in place. An admission MDS assessment for Resident 10, dated October 24, 2025, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physician's orders, dated October 18, 2025, included an order for the resident to have dialysis. Observations of Resident 10 on November 20, 2025, at 11:40 a.m. revealed that she was sitting beside her bed in a wheel chair, and had a hemodialysis port in her left chest. There was no emergency equipment at her bedside. Interview with Licensed Practical Nurse 5 on November 20, 2025, at 11:45 a.m. indicated that if the emergency equipment was in the room, it would be taped on the wall or in the resident's top dresser drawer beside the bed. She confirmed that the equipment was not in place in Residents 10's room and should have been. A quarterly MDS assessment for Resident 11, dated October 2, 2025, indicated that the resident was cognitively impaired and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). Physician's orders, dated June 26, 2025, included an order for the resident to have hemodialysis. Observation of Resident 11 on November 20, 2025, at 12:00 p.m. revealed that she was sitting up in broda chair and had a hemodialysis port on her chest. There was no emergency equipment at her bedside. Interview with Licensed Practical Nurse 6 on November 20, 2025, at 12:00 p.m. revealed that if the emergency equipment was in the room, it would be taped on the wall or in the resident's top dresser drawer beside the bed. She confirmed that the equipment was not in place in Resident 11's room and should have been. Interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that there should have been a dialysis emergency kit at Resident 11's bedside. Interview with the Director of Nursing on November 20, 2025, at 12:53 p.m. confirmed that there should have been a dialysis emergency kit at the bedsides of Residents 10 and 11. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards by failing to ensure care-planned interventions were in place for two of 51 residents reviewed (Resident 15, 23) who were at risk for falls. Findings include:The facility's policy regarding fall prevention and management, dated September 13, 2025, indicated that the facility will identify those residents at risk for falls upon admission, readmission, and quarterly and provide appropriate interventions to modify and/or compensate for risk factors. The care plan will be updated to reflect resident-specific safety needs and interventions. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 22, 2025, revealed that the resident was severely cognitively impaired, required a mechanical lift for transfers, had a recent fall and had diagnoses that included Alzheimer's dementia. Physician's orders for Resident 15, dated October 17 and 27, 2025, included orders for staff to keep the resident's bed in the lowest position utilize bilateral floor mats, bilateral assistive handrails, a bolster overlay, and a gap filler for the mattress. The current fall risk care plan for Resident 15 indicated that the resident was at [NAME] for falls related to dementia, psychotic disturbances and anxiety. Observations of Resident 15 on November 20, 2025, at 1:15 p.m. revealed that the resident was in her bed and it was not in the lowest position, had no bilateral fall mats, no bilateral assistive handrails, no bolster overlay, and no gap filler for the mattress. Interview with Registered Nurse Supervisor 3 on November 20, 2025, at 1:24 p.m. confirmed that Resident 15 was recently moved to room [ROOM NUMBER] A from the third floor. She confirmed that the resident was in the correct bed as per documentation. She also confirmed that Resident 15's bed was not in the lowest to floor locked position, and had no bilateral fall mats, no bilateral assistive handrails, no bolster overlay, and no gap filler for the mattress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated October 24, 2025, revealed that the resident was moderately cognitively impaired, was on a bariatric bed, required assistance for bed mobility, had diagnoses that included muscle weakness and malignant melanoma of the left upper limb and shoulder. Physician's orders for Resident 23, dated October 10, 2025, included orders for staff to keep a wedge for bed positioning along her left side from her hip down, while lying in bed, and bilateral fall mats on either side of the resident's bed. A fall risk care plan dated June 23, 2025, indicated that the resident was at [NAME] for falls related to muscle wasting and atrophy. Observations of Resident 23 on November 18, 2025, at 11:00 a.m. revealed that the resident was lying in her bed and there was no wedge for bed positioning along her left side from her hip down, and no bilateral fall mats on either side of her bed.Interview with Nurse Aide 4 on November 18, 2025, at 11:35 a.m. confirmed that Resident 23 was in bed and her wedge for positioning was on the floor on the left side of her bed, instead of in her bed as ordered and that she had no bilateral fall mats in place.Interview with the Director of Nursing on November 20, 2025, at 2:47 p.m. confirmed that Residents 15 and 23 should have had all fall prevention interventions in place as ordered and care planned, and they did not. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medications and treatment administration were followed for 12 of 51 residents reviewed (Residents 3, 4, 40, 44, 46, 52, 87, 96, 99, 115, 157, and 158). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 28, 2025, indicated that the resident was cognitively intact, required assistance from staff with daily care needs, had diagnoses that included benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that causes urinary problems). Physician's order for Resident 3 dated October 30, 2024, revealed 0.4milligram (mg) of tamsulosin (a medication used to treat benign prostatic hyperplasia) was to be administered once a day between 3:00 p.m. and 5:00 p.m. A nursing note for Resident 3 dated September 29, 2025, at 1:30 a.m. and a review of the resident's Medication Administration Record (MAR) revealed that the resident was not administered 0.4mg tamsulosin on September 29, 2025. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 3, 2025, revealed that the resident was cognitively impaired, required assistance with personal care needs, and had diagnoses that included hypotension (low blood pressure). Physician's orders for Resident 4, dated October 20, 2025, included an order for the resident to receive 5 milligrams (mg) of Midodrine (used to treat low blood pressure) three times a day and to hold the medication if the resident's systolic blood pressure (SBP-the top number in a blood pressure reading) is greater than 110. Review of the Medication Administration Record (MAR) for Resident 4, dated October 2025, revealed that 5 mg of Midodrine was administered on October 22 at 6:00 a.m. when the resident's SBP was 136; on October 22 at 6:00 p.m. when the resident's SBP was 124; on October 25 at 6:00 a.m. when the resident's SBP was 114; on October 25 at 12:00 when the resident's SBP was 118; on October 29 at 4:00 p.m. when the resident's SBP was 114; on October 29, 2025 at 8:00 p.m. when the resident's SBP was 124. Review of the resident's MAR, dated November 2025, revealed that 5 mg of Midodrine was administered on November 3 at 3:00 p.m. when the resident's SBP was 125; on November 4 at 3:00 p.m. when the resident's SBP was 115; on November 11 at 7:00 p.m. when the resident's SBP was 132; on November 13 at 7:00 a.m. when the resident's SBP was 126; On November 13 at 3:00 p.m. when the resident's SBP was 126; on November 13 at 7:00 p.m. when the residents SBP was 123; on November 14, at 3:00 p.m. when the resident's SBP was 112; and on November 17, 2025 at 3:00 p.m. when the resident's SBP was 120. Interview with the Nursing Home Administrator on November 19, 2025, at 1:53 p.m. confirmed that Midodrine was administered to Resident 4 on the above-mentioned dates and times when it should have been held per physician's orders. A quarterly MDS for Resident 40 dated September 11, 2025, revealed that the resident was cognitively intact, was dependent on staff for care and activities of daily living, and had diagnoses that included seizures and glaucoma (a group of eye conditions that damage the optic nerve that connects the eye to the brain). Physician's order for Resident 40 dated July 24, 2024, revealed the resident was to receive one drop of 1.4% polyvynal alcohol eye drops (artificial tears) in each eye three times a day; one drop of 0.2% brimonidine eye drops (a medication that is used to lower high pressure inside the eye caused by glaucoma) in the right eye three times a day; and 300 mg of Neurontin (a medication to prevent seizures) three times a day. A nursing note for Resident 40 dated September 29, at 9:40 p.m. and a review of the MAR revealed that the resident was not administered one dose each of the artificial tears, brimonidine eye drops, or 300mg Neurontin during the medication pass between 4:00 p.m. and 6:00 p.m. on September 29, 2025. A quarterly MDS for Resident 44 dated August 7, 2025, revealed that the resident was cognitively impaired, required maximum assistance from staff for care, and has diagnoses that included stroke, seizure disorder, dysphagia (difficulty swallowing), and gastroesophageal reflux disorder (GERD-a medical condition when stomach acid flows back up into the esophagus). Physician's orders for Resident 44 dated June 22, 2023, revealed the resident was to receive 5 mg metoclopramide (a medication used to treat gastrointestinal conditions and manage nausea and vomiting) 1 tablet twice a day. A nursing note for Resident 44 dated September 30, 2025, at 1:43 a.m. and a review of the MAR revealed that the second dose of 5 mg metoclopramide was not administered. New orders were received to administer the missed dose at bedtime on September 29, 2025. A quarterly MDS for Resident 46 dated October 1, 2025, revealed that the resident was cognitively impaired, was dependent on staff for care, and had diagnoses that included multiple sclerosis (a disease of the brain and spinal cord where the immune system mistakenly attacks the protective layer around nerve fibers, causing a disruption of communication between the brain and body), and was receiving hospice care and was at risk for developing pressure ulcers. A care plan dated October 27, 2025 revealed that revealed that barrier cream was to be applied after each incontinent episode and as needed. Current physician's orders for Resident 46 revealed that the resident was to receive 650mg acetaminophen (Tylenol) every six hours; 0.5 milliliter (ml) of 5mg/ml diazepam (a medication used to treat central nervous system disorders including anxiety, seizures, and muscle spasms) twice a day and at bedtime; 25mg promethazine (a medication used to treat vomiting) every six hours; 2 tablets of 8.6-50mg Senna daily for constipation; and an order for the resident to receive a pressure ulcer preventative foam dressing to the lower extremity every 5 days. A nursing note for Resident 46 dated September 29, 2025, at 10:08 p.m. and a review of the MAR revealed that the resident was not administered acetaminophen, diazepam, promethazine, and senna during the 4:00 p.m. medication pass on September 29, 2025. The Treatment Administration Record (TAR) for Resident 46 revealed that the pressure ulcer preventative treatment was completed on October 21, 27, November 2, 8, and 14, 2025 and not every 5 days as ordered. Additionally, there was no documented evidence in Resident 46's clinical record to indicate that barrier cream was applied to prevent MASD. A nursing note for Resident 46 dated November 17, 2025, at 6:18 p.m. revealed that the resident developed moisture associated with skin damage (MASD). Interview with the Nursing Home Administrator on November 19, 2025, at 11:25 a.m. and 2:27 p.m. respectively, confirmed that Resident 46 did not receive medications and treatments as ordered and confirmed that there was no documented evidence of barrier cream being applied to prevent MASD.An annual MDS for Resident 52 dated August 7, 2025, revealed that the resident was cognitively intact, was independent with daily care needs, and had medical diagnoses of stroke, anxiety and depression. Physician's orders for Resident 52 dated March 22, 2025, revealed that the resident was to receive 15 mg of buspirone (a medication used to treat anxiety disorders) three times a day. A nursing note for Resident 52 dated September 29, 2025, at 10:15 p.m. and a review of the MAR revealed that the resident's afternoon dose of 15 mg of buspirone was not administered on September 29, 2025.A quarterly MDS for Resident 87 dated August 31, 2025, revealed that the resident was severely cognitively impaired, was dependent on staff for daily care needs, and had medical diagnoses of coronary artery disease, heart failure, high cholesterol, diabetes, and Parkinson's disease (a progressive neurological disorder that affects the nervous system). Physician's orders for Resident 87 dated August 25, 2025, revealed that the resident was to receive 5 mg of baclofen (a muscle relaxant) three times a day; 12.5-50-200 mg of carbidopa-levodopa-entacapone (a medication used to treat Parkinson's disease) three times a day; 200 mg of entacapone (a medication used to treat Parkinson's disease) three times a day; 12.5 mg of carvedilol (medication used to treat heart disease) twice a day with breakfast and supper; and 300 mg of tums twice a day for heartburn. A nursing note for Resident 87 dated September 29, 2025, at 9:11 p.m. and a review of the MAR revealed that the resident was not administered her afternoon doses of baclofen, carbidopa-levodopa-entacapone, entacapone, carvedilol, and tums on September 29, 2025.An admission MDS for Resident 96 dated September 24, 2025, revealed that the resident was cognitively intact, was dependent on staff for daily care, and had medical diagnoses of diabetes. Physician's orders for Resident 96 dated September 28, 2025, revealed that the resident was to receive Humalog Kwik Pen 100 units/ml depending on the sliding scale for blood glucose monitoring prior to meals. A nursing note for Resident 96 dated September 30, 2025, at 1:01 a.m. and a review of the MAR revealed that the resident did not have his blood sugar checked at 4:00 p.m. and was not administered his 4:00 p.m. dose of Humalog Kwik Pen sliding scale on September 29, 2025.A quarterly MDS for Resident 99 dated September 11, 2025, revealed that the resident was cognitively intact, was dependent on staff for care, and had medical diagnoses of osteoarthritis (a degenerative joint disease that causes pain, stiffness, swelling) and stroke. Physician's orders for Resident 99 dated October 12, 2024, revealed that the resident was to receive 25-100 mg of carbidopa-levodopa (a medication to treat Parkinsons) three times a day, and 0.5 mg of clonazepam (a medication use to treat seizure disorders) three times a day. A nursing note for Resident 99 dated September 30, 2025, at 1:50 a.m. and a review of the MAR for September 29, 2025 revealed that the resident was not administered the afternoon doses of carbidopa-levodopa and clonazepam on September 29, 2025.A quarterly MDS for Resident 115 dated September 22, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had medical diagnoses that included end stage kidney disease, diabetes, and dialysis. Physician's orders for Resident 115 dated August 12, 2025, revealed that the resident was to receive 150 mg of Lyrica for neuropathy (nerve pain) three times a day. A nursing note for Resident 115 dated September 29, 2025, at 9:57 p.m. and a review of the MAR revealed that the resident was not administered her afternoon dose of Lyrica on September 29, 2025.A Quarterly MDS for Resident 157, dated August 28, 2025, revealed that the resident was cognitively intact, was independent for daily care needs, had diagnoses that included hip fracture and received scheduled narcotics (a controlled substance used for pain). Physician's orders for Resident 157, dated July 9, 2025, included an order for the resident to receive 7.5-325 milligrams of oxycodone-acetaminophen ( a narcotic) every 4 hours.A review of Resident 157's Medication Administration Record for April 2025 revealed no documented evidence that the resident received the oxycodone-acetaminophen on September 3, 2025, at 2:00 a.m., October 7, 2025, at 8:00 a.m., and October 8, 2025, at 12:00 a.m.Interview with the Director of Nursing on November 13, at 2:36 p.m. confirmed that there was no documented evidence that Resident 157 received the oxycodone-acetaminophen on the above dates and times.An annual MDS for Resident 158 dated September 22, 2025, revealed that the resident was cognitively intact, was independent with daily care needs, had medical diagnoses that included Parkinson's, and was receiving scheduled pain medications. Physician's order for Resident 158 dated December 28, 2025, revealed that the resident was to receive 5 mg oxycodone (a narcotic pain medication) three times a day. A nursing note for Resident 158 dated September 29, 2025, at 9:15 p.m. and a review of the MAR revealed that the resident was not administered her afternoon dose of oxycodone on September 29, 2025.Interview with the Director of Nursing on November 20, 2025, at 9:14 a.m. confirmed that the medications and treatments for the 12 residents listed were not administered per the physician's orders. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for four of 51 residents reviewed (Residents 23, 28, 38, and 129).Findings include: A facility policy for Comprehensive Care Planning, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated October 24, 2025, indicated that the resident was moderately cognitively impaired, required assistance from staff for daily care tasks and, had diagnoses that included malignant melanoma of the left upper limb and shoulder. Physician's orders for Resident 23, dated September 24, 2025, included an order for the resident, while lying in bed, to have a bed positioning wedge along her left side from her hip down. Resident 23's care plan, last reviewed/revised on September 17, 2025, indicated that the resident was at risk for falls related to muscle wasting with related weakness. Interview with the Director of Nursing on November 18, 2025, at 2:45 p.m. confirmed that Resident 23's care plan was not updated to reflect that while lying in bed the resident was to have a bed positioning wedge along her left side from her hip down. An admission MDS assessment for Resident 28, dated October 20, 2025, indicated that the resident had moderate cognitive impairment, required assistance with daily care needs, used a wheelchair, had recent falls, and had diagnosis that included dementia. A facility investigation, dated March 9, 2025, at 10:00 p.m. revealed Resident 28 had an unwitnessed fall in the bathroom. The resident took herself to the bathroom to wash up and slid out of her wheelchair. She complained of knee pain and had some swelling and bruising. An x-ray was obtained and the resident was diagnosed with a left tibia (lower leg bone) fracture. To prevent further sliding from her wheelchair, dycem (anti-slip material) was added to the top of her wheelchair cushion. There was no documented evidence that the resident's current care plan included dycem to the top of her wheelchair cushion. Interview with the Director of Nursing on November 20, 2025, at 10:35 a.m. confirmed that Resident 28's care plan was not updated to include dycem, following the fall on March 9, 2025. A significant change MDS assessment for Resident 38 dated August 29, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, and had diagnosis that included dementia. A care plan for Resident 38 dated July 10, 205, indicated that the resident was receiving an antipsychotic medication. Review of the Medication Administration Record (MAR) and nurses notes for Resident 38 dated November 2025 revealed no documented evidence that the resident was receiving antipsychotic medication. An interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m. revealed that Resident 38 was not receiving antipsychotic medication and his care plan should have been revised to reflect that, however it was not. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 129 dated August 31, 2025, indicated that the resident was cognitively intact, required assistance with daily care needs, and had diagnosis that included diabetes and cancer. Care plan for Resident 129 dated April 24, 2024, indicated that the resident was receiving antianxiety and antidepressant medications. A care plan dated August 14, 2023, indicated that the resident required supplemental oxygen therapy. Review of the Medication Administration Record (MAR) and nurses notes for Resident 129 dated November 2025, revealed no documented evidence that the resident was receiving antianxiety medication, antidepressant medication or oxygen therapy. An interview with the Director of Nursing on November 20, 2025, at 10:26 a.m. revealed that Resident 129 was not receiving antianxiety medication, antidepressant medication or oxygen therapy and her care plan should have been revised to reflect that, however it was not. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on review of a policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 51 residents reviewed (Resident 18).Findings include: A review of the facility policy titled Call Light Resident Communication System, dated September 23, 2025, indicated that it is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. When the resident is in bed or confined to a chair, be sure the call light is within easy reach. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 18 dated October 30, 2025, indicated that the resident was able to make herself understood and could understand others, required assist from staff for daily care needs, and had diagnosis that included noninfective gastroenteritis and colitis (inflammations of the digestive tract that are not caused by an infection) Observation of Resident 18 on November 17, 2025, at 1:44 p.m. revealed that the resident was sitting in her chair on the left side of her bed facing the wall. She was leaning forward in her chair and across her bed attempting to reach her call bell that was on the upper right side of her bed. Upon this surveyor entering the room, Resident 18 asked if I could help her reach her call box for her because she couldn't reach it and she needed to call for a nurse. Interview with Registered Nurse 1 on November 17, 2025, at 1:48 p.m. revealed that Resident 18 could not self-propel herself in her chair and a call bell should have been within her reach for her to use. Interview with the Nursing Home Administrator on November 18, 2025, at 1:03 p.m. confirmed that Resident 18 should have had a call bell within reach while she is in her room. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 51 residents reviewed (Residents 18 and 38). Findings include: A facility policy for Comprehensive Care Planning, dated September 23, 2025, included that an interdisciplinary plan of care be established and updated as indicated for every resident in accordance with state and federal regulatory requirements. The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 18 dated October 30, 2025, indicated that the resident was able to make herself understood and could understand others, required assist from staff for daily care needs, received routine and as needed pain medication, had almost constant pain, and had diagnosis that included noninfective gastroenteritis and colitis (inflammations of the digestive tract that are not caused by an infection). Physician orders for Resident 18 dated October 24, 2025, indicated that the resident was to receive 450 micrograms (mcg) of Belbuca (a strong pain medicine used for the management of severe and persistent chronic pain) twice a day for chronic pain (pain that lasts or recurs for more than three months and can interfere with daily life) and 5-325 milligrams (mg) of hydrocodone-acetaminophen (medication used to treat moderate to severe pain ) every eight hours as needed for pain. There was no documented evidence that a care plan was developed to address Resident 18's care and treatment related to pain, and her care and treatment related to her use of pain medications. An interview with the Nursing Home Administrator on November 19, 2025, at 1:48 p.m. confirmed that there was no active care plan for Resident 18's care and treatment related to chronic pain and her care and treatment related to her use of pain medication. A significant change MDS assessment for Resident 38 dated August 29, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, and had diagnosis that included dementia. Physician's orders for Resident 38 dated October 15, 2025, indicated that the resident was to receive 100 milligrams of sertraline (antidepressant) once a day. There was no documented evidence that a care plan was developed to address Resident 38's care and treatment needs related to his use of antidepressants. An interview with the Nursing Home Administrator on November 19, 2025, at 1:53 p.m. confirmed that there was no active care plan for Resident 38's care and treatment related to his use of antidepressant medication. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors due to receiving another resident's medications for one of five residents reviewed (Resident 5) resulting in an admission to the intensive care unit. Findings include: The facility's policy for medication administration, dated December 30, 2024, indicated that medication would be administered according to physician orders. Admission diagnoses for Resident 5, dated February 7, 2025, included non-ischemic myocardial injury (damage to the heart muscle), dementia, encephalopathy (a medical condition where brain functioning is impaired), atrial fibrillation (an irregular heartbeat), and heart failure. A facility incident report for Resident 5, dated February 8, 2025, revealed that the resident received the wrong medications on February 8, 2025, at 9:02 a.m. Licensed Practical Nurse (LPN) 1 confused Resident 5 for another resident and administered 81 milligrams (mg) of aspirin; 0.4 mg of tamsulosin (a medication used to treat an enlarged prostate); 1.5 mcg of vitamin-b; 500 mg of depakote (a medication used to treat seizures); 10 mg of buspar (a medication used to treat anxiety); 75 mg of Plavix (an antiplatelet medication); 60 mg of Cymbalta (a medication used to treat depression); folic acid; docusate (a stool softener); 800 mg of gabapentin (a medication used to treat seizures); 20 mg of lisinopril (a medication used to treat high blood pressure); 5 mg of memantine (a medication used to treat depression); 40 mg of ingrezza (a medication used to treat involuntary movements also known as tardive dyskinesia); 25 mg of Seroquel (an anti-psychotic medication); and 25 mg of lopressor (a medication used to treat high blood pressure). The physician was notified and new orders were received to assess the resident's vital signs hourly for the next six hours and to report any changes to baseline. A nursing note for Resident 5, dated February 8, 2025, at 2:30 p.m., revealed that the resident's blood pressure was 78/44 mm/Hg (normal range is 120/80 mm/Hg) with a pulse of 46 beats per minute (normal range is 60-100 beats per minute). The physician was notified and new orders were received to send the resident to the emergency department for evaluation. A nursing note for Resident 5, dated February 8, 2025, at 9:01 p.m., revealed that the resident was admitted to the intensive care unit in the hospital for low blood pressure and was placed on vasopressors (medications to increase blood pressure). Interview with hospital Medical Doctor 2 on February 26, 2025, at 1:20 p.m. confirmed that Resident 5 was admitted to the intensive care unit as a result of receiving the wrong medications. Interview with the Nursing Home Administrator on February 26, 2025, at 2:57 p.m. confirmed that Resident 5 received the wrong medications as a result of LPN 1 not identifying the correct resident prior to medication administration. 28 Pa. Code 211.9(a)(1)(h) Pharmacy Services. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of policies, clinical records, and facility reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for residents residing on the secured memory impaired unit for one of 15 residents reviewed (Resident 14), placing the safety of current residents in Immediate Jeopardy. Findings include: The facility's policy regarding elopement, dated December 12, 2023, indicated that the facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated July 16, 2024, indicated that the resident was admitted to the facility on [DATE], was confused, was independent with ambulation, and she had diagnoses that included dementia. A progress note for Resident 14, dated July 11, 2024, revealed that the resident had an increase in behaviors prior to admission, including wandering outside the house in the night time, and that she had paranoia and believed that men were following her. A nursing note for Resident 14, dated July 12, 2024, revealed that the resident was wandering on the unit and that staff placed a wanderguard (device used to cause an alarm to sound when the resident attempts to exit through an area that has the wanderguard security system in place) on the resident for safety. A nursing note for Resident 14, dated July 12, 2024, revealed that the resident ripped her wanderguard off and handed it to staff, and that staff were able to place a new wanderguard later that day. A Certified Registered Nurse Practioner (CRNP - advanced practice nurse) note for Resident 14, dated July 12, 2024, revealed that staff asked the CRNP to see the resident for increased agitation and elopement attempts. The resident made multiple attempts to leave by punching in numbers to the door codes. A nursing note for Resident 14, dated July 13, 2024, revealed that while performing a check on the resident, the staff found her wanderguard in the trash can, and the resident stated that if the staff put it on her again she would take it off. A nursing note for Resident 14, dated July 21, 2024, revealed that she was agitated and going in and out of other residents' rooms stating she was hiding from staff. She was also trying to remove her wanderguard. A nursing note for Resident 14, dated July 21, 2024, revealed that staff started one-on-one observation with the resident for her safety and the safety of other residents. A nursing note for Resident 14, dated July 22, 2024, revealed that the resident had been hiding in abnormal areas like the floor between chairs or under a table and that she was on 30-minute checks by the staff. A nursing note for Resident 14, dated July 26, 2024, revealed that the resident was intrusively wandering in and out of other resident's rooms and putting their clothing on over top of her own. A nursing note for Resident 14, dated July 31, 2024, revealed that the resident was found lying under another resident's bed. A nursing note for Resident 14, dated August 1, 2024, revealed that at 12:30 a.m. the resident was not able to be located during her 30-minute check. Staff began to look for the resident and noted that she wandered out the dialysis door. The dialysis door required a code to be entered for the door to open, but the resident stated that a man let her out the door. She stated she was on her way to her hometown. She was again placed on one-to-one observations at that time. Observations on July 31, 2024, revealed that Resident 14 was not able to be found by staff and that the facility staff were searching the building inside and out for her. The search lasted approximately a half hour before the resident was located hiding under another resident's bed. Observations on August 1, 2024, at 3:18 p.m. revealed that the dialysis door is in the rear of the hall on the memory impaired unit. It had a key code pad for entry and was secured. The door enters into an alcove that houses the elevators to the other three floors. The door could not be opened to return into the nursing unit without knowing the code to return into the building. Interview with Unit Clerk/Nurse Aide 1 on August 1, 2024, revealed that he was sitting with Resident 14 for one-to-one observation. He stated that when he returned from his lunch on July 31, 2024, he was told the resident could not be located and everyone was searching for her. He said that he located her under a resident's bed when he was looking behind the curtains and saw her hand come out from under the bed. He said that she was afraid the police were searching for her as she could hear them yelling for her. Interview with Registered Nurse 2 on August 1, 2024, revealed that she was working in another resident's room around 12:30 a.m. when she heard the staff say that they could not locate Resident 14. She said that the staff were doing their 30-minute check on her and she was not in her bed where she was on the previous check. The staff began to search for her and Registered Nurse 2 called the other floors to help in the search. She said that staff found the resident behind the coded dialysis door. She said that she believed the resident was able to watch the dietary staff use the door and was able to learn the code from them. That door does not have a wanderguard system and therefore no alarm was sounding when the resident went through the door. Registered Nurse 2 stated that the resident was located when the staff heard her pounding on the glass of the door. Interview with the Director of Nursing on August 1, 2024, at 1:15 p.m. revealed that they did not consider the incident an elopement since the resident did not actually get off the floor or leave the building. She stated that the resident was behind the coded door on the fourth floor. The Immediate Jeopardy Template was provided to the Nursing Home Administrator and Director of Nursing on August 1, 2024, at 4:22 p.m. and informed that the health and safety of current residents were in Immediate Jeopardy due to the wandering residents having the ability to wander through a secured door and get trapped in that area without staff awareness. The facility submitted and implemented an immediate action plan that included ensuring that the coded door was functioning properly and that the code to the door was immediately changed. The resident was provided one-to-one observations to ensure her safety. The facility staff will complete half-hour door checks on the coded door to ensure the door is secured. The Immediate Jeopardy was lifted on August 1, 2024, at 7:29 p.m. when it was confirmed that the facility had team members monitoring the coded door and providing one-to-one observation of Resident 14. The facility provided education to 100 percent of the memory-impaired unit staff and the majority of the remainder of the staff from other units, and developed and implemented a plan for remaining staff to receive the education prior to the start of their next work shift. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(5) Nursing Services.

Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 10 residents reviewed (Resident 2) that resulted in facial bruising from being kicked repeatedly. Findings include: The facility's abuse policy, dated December 12, 2023, revealed that the facility will not tolerate abuse and that facility staff must immediately report all such allegations to the Nursing Home Administrator/Abuse Coordinator. An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 1, dated April 18, 2024, revealed that the resident was admitted to the facility on [DATE], was able to make himself understood, was sometimes able to understand others, and required supervision for personal hygiene, transfers and ambulation. An annual MDS assessment for Resident 2, dated May 17, 2024, revealed that the resident was sometimes understood, could usually understand others, required substantial or maximum assistance with personal hygiene, was independent with ambulation, and had a diagnosis of dementia with behaviors that included wandering. Physician's orders for Resident 2, dated May 13, 2024, included an order that if the resident was in his room sleeping, he was to be checked on every 15 minutes, and staff were to ensure that his door alarm was active to alert them when he began to wander. When he was awake and wandering, staff were to be present with him at all times. A nurse's note for Resident 2, dated May 27, 2024, at 7:35 a.m., revealed that the resident had purple bruising noted to both inner and outer corners of his upper eyelids. A nurse's note, dated May 27, 2024, at 1:00 p.m., revealed that upon further investigation, a housekeeper had heard residents yelling on May 26, 2024, and witnessed Resident 2 in Resident 1's room. Resident 1 was observed kicking at Resident 2 and being physically aggressive. Resident 2 did not hit back. The facility's event report, dated May 27, 2024, at 5:00 p.m., indicated that on May 26, 2024, at 1:30 p.m. the fourth-floor housekeeper heard Resident 1 yelling. She went to his room and observed Resident 2 in the room and Resident 1 was kicking at Resident 2 and being physically aggressive to get him out of his room. Staff were able to separate and redirect both residents at the time. Resident 2's door alarm did not activate to alert staff that he was out of his room and wandering, and there was no documented evidence to determine why it did not function. A witness statement from Housekeeping Aide 1, dated May 29, 2024, revealed that she heard Resident 1 yelling and witnessed Resident 2 leaving Resident 1's room. While Resident 2 was walking down the hallway, Resident 1 was kicking him. Resident 2 went and sat in a chair and Resident 1 walked over and kicked him again. A witness statement from Nurse Aide (NA) 2, dated May 28, 2024, revealed that she was told by the housekeeper that Resident 2 was in Resident 1's room and Resident 1 was kicking him. She witnessed Resident 2 sitting at the nurse's station with his eyes closed and Resident 1 walked up the hall stating, I'm going to fucking kill him, and then started to kick the resident's legs. She was able to separate the two residents and informed Registered Nurse (RN) 5 and Registered Nurse Supervisor (RNS) 6. Resident 1 continued to yell out that he was going to kill Resident 2 and RNS 6 gave Resident 1 some ice cream to redirect him. An undated witness statement from NA 3 revealed that on May 26, 2024, she had informed RN 5 at the beginning of her afternoon shift that Resident 2 had a red area to his right inner eye. RN 5 told her that she was already aware of it. An undated witness statement from NA 4 revealed that he overheard NA 2 telling RN 5 and RNS 6 that Resident 1 was following and kicking Resident 2. RNS 6 responded by giving Resident 1 ice cream and saying, There is nothing I can do, keep an eye on them. Review of Resident 2's clinical record revealed no documented evidence of the resident-to-resident altercation at the time it occurred, and no documented evidence that a RN assessment was completed until approximately eighteen hours later when bruising was noted. Interview with the Director of Nursing on May 31, 2024, at 1:30 p.m. revealed that she has no concerns related to resident safety because Resident 2's room was moved further away from Resident 1's, and Resident 2 is now on constant one-to-one observation. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.12 (d)(5) Nursing Services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's plan of care was followed for fall prevention and transfers for one of 14 residents reviewed (Resident 2) resulting in a fracture. This deficiency was cited as past non-compliance. Findings include: The facility's policy for safe patient handling and body mechanics, dated October 9, 2023, indicated that the facility promotes enhanced employee worker safety by implementing and maintaining safe patient handling processes. These processes include recognition and elimination of hazards, and engineering and administrative controls. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 24, 2023, revealed that the resident was cognitively impaired, required extensive assist with daily care needs including transfers, and had diagnoses that included heart failure and osteoarthritis. A fall care plan, dated September 21, 2023, revealed that the resident was to be transferred by two staff. A nursing note for Resident 2, dated September 18, 2023, at 6:30 p.m., revealed that the resident was being transferred from her wheelchair by a nurse aide when the resident began to yell about her leg. The resident stated that she thought she hit her leg off the bed frame. The licensed practical nurse assessed the resident and no areas of swelling were noted. A nursing note for Resident 2, dated September 19, 2023, at 1:50 a.m., revealed that the licensed practical nurse was called to the resident's room to assess a bruise on her right lower leg with slight swelling. New orders were obtained to get an x-ray in the morning. X-ray results for Resident 2, dated September 20, 2023, revealed a nondisplaced fracture of the tibia (a bone located in the lower leg). A witness statement by Nurse Aide 1, dated September 21, 2023, revealed that she put Resident 2 into bed by herself at 6:45 p.m. At that time, the resident stated that she thought her leg was broken so the nurse aide reported it to the licensed practical nurse. Interview with the Director of Nursing on October 17, 2023, at 1:19 p.m. confirmed that Resident 2 was transferred with one assist and not a two-person assist for transfers as care planned. The facility's plan of correction included: A facility audit of the transfer status for all residents was done to ensure that their transfer orders were correct. Residents were interviewed to determine if they felt safe during staff transfers. Education was provided to all staff on the abuse policy, reporting incidents, caregiver review of residents' transfer statuses, following residents' care plans, and registered nurse assessments, and was completed September 26, 2023. Facility audits were conducted on September 26, 2023, to ensure the residents were being transferred correctly. Interviews with staff throughout the facility during the on-site investigation on October 17, 2023, revealed that they were knowledgeable about the facility's policy regarding abuse, proper transfers, reporting incidents, following residents care plans, and registered nurse assessments. Attempts to interview Resident 2 during the on-site investigation were unsuccessful due to cognitive impairment. A review of the facility's corrective actions revealed that they were in compliance with F689 on September 26, 2023. Interview with the Director of Nursing on October 17, 2023, at 1:19 p.m. revealed staff education was completed, and ongoing audits are to be discussed during the monthly Quality Assurance (QA) meeting. 28 Pa. Code 211.10(a) Resident care policies. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on review of residents' clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to provide pain management for one of 54 residents reviewed (Resident 102), resulting in intolerable pain during care. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 102, dated [DATE], revealed that the resident was cognitively intact, required extensive assistance for daily care tasks, had two unstageable pressure ulcers (full thickness skin or tissue loss with unknown depth), frequent severe pain, and had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. calves to float both heels (keep the heels off the mattress), for the resident to be side lying with the wedge and bed pillows placed at all times while in bed except during meals, to alternate left and right sides frequently with the inclined wedge, and to check placement and skin integrity every shift. A skin/wound note for Resident 102, dated [DATE], at 10:30 a.m. revealed that a certified registered nurse practitioner (CRNP - an advanced practice nurse) assessed the resident at bedside and applied treatments. A new pressure area was noted on the right outer calf, and wounds were worsening to the left lateral calf, right thigh and right heel. There was improvement to the right foot and left heel, and no change to the sacral deep tissue injury. A nursing note for Resident 102, dated [DATE], at 1:09 p.m. revealed that upon changing wound dressings, the nurse observed a decline in the condition of the resident's buttocks wound, which had grown in size and had bloody drainage. Communication was sent to wounds (staff) regarding this matter, and the nurse also verbally expressed the change in condition to a wound staff member. The note indicated that comfort medications were controlling the resident's pain well. Wound care by Registered Nurses 1 and 6 on [DATE], at 10:23 a.m. was observed. Registered Nurse 1 stated that the resident was medicated with 10 milligrams (mg) of [MEDICATION NAME] (narcotic pain medication) one hour prior to the wound care. Dressings to both legs were cut off, and there was a large amount of dry drainage on the dressings. Resident 102 started to moan in pain and stated that he was already moved around earlier. Wound care was started to an area on the left lateral calf that was approximately three inches wide and extended from the top of the calf and almost down to the ankle. The resident started yelling when his leg was lifted and stated, Oh my God, my hips, my hips, please stop, please roll me over, please. The area was cleansed with wound cleanser and Santyl was applied to the wound bed, followed by an ABD pad and Kling wrap. Every time his leg was touched, the resident cried out in pain. The left heel wound, which was covered with black eschar (dead tissue) was cleansed, then the right heel wound was cleansed. The right heel wound was a large open area that extended under the heel and into the bottom of the foot approximately two inches. The resident screamed, Oh my God, oh my God, please roll me, just roll me, please, my hips, this is torture! Registered Nurse 1 stated, I'm almost done with your leg, then we can roll you to do your back side. The resident said, Oh my God, no, just leave me alone, they already did my butt earlier, please, this is too much. The resident started to cry. The surveyor walked up to resident and asked if it would help his pain if he was rolled over and he stated, What the hell do you think I've been saying? Yes, I want rolled over, but nothing will make it better at this point, please just stop, it's so bad. Wound supplies were readied for the resident's backside, and Registered Nurses 1 and 6 rolled him onto his right side to continue with wound care. The resident yelled, Owww, what the hell are you doing, just stop, oh my God, just stop, please. Registered Nurse 1 continued to wipe the area on the resident's buttocks while the resident was yelling. The area was a very large, black, butterfly shaped area that extended across the entire upper half of the resident's butt, with bright red edges. Registered Nurse 1 stated, This is much worse than the last time I looked at it. The resident was screaming, Just stop, I mean it, no more, just stop now! Registered Nurse 1 stated that she wanted to finish his wound care and the resident said, I told you no more. The surveyor asked Registered Nurse 1 to stop his care because of the pain he was experiencing. The nurse stated that the resident was pre-medicated with [MEDICATION NAME] at 9:15 a.m. The surveyor indicated that the medication was not effective. Wound care was stopped, the resident was repositioned, and was very angry at that point. Interview with Registered Nurse 1 on [DATE], at 11:18 a.m. stated that she hated to see the resident in so much pain. When asked why she did not stop the wound care when the resident repeatedly yelled out with pain and asked her to stop, Registered Nurse 1 stated that the resident has yelled out in pain before, but he never complained of the hip pain before today. She also stated that because he was pre-medicated with [MEDICATION NAME], his wound care needed to be done. Registered Nurse 1 stated that the ulcer covering the resident's buttocks was much worse today. When the surveyor indicated that despite being pre-medicated, the resident was still in a great deal of pain, Registered Nurse 1 agreed that she should have stopped his wound care and called the doctor for an increase in the dosage of his pain medication. Interview with the Nursing Home Administrator on [DATE], at 1:19 p.m. revealed that she was not aware that Resident 102's buttocks ulcer had deteriorated so much. She also indicated that the resident had an order for [REDACTED]. 28 Pa. Code 211.12(d)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's care planned interventions for safe transfers were followed for one of 22 residents reviewed (Resident R17), resulting in a hip fracture. Findings include: A significant change (a decline or improvement in a resident's status) Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R17, dated March 10, 2016, revealed that the resident was cognitively impaired and dependent for transfers. The resident's care plan, dated October 1, 2015, indicated that the resident was cognitively impaired and was to always be transferred with a full body mechanical lift (a device that uses hydraulic power to lift the resident and transfer him/her from one surface to another), and an update to the care plan, dated March 1, 2016, indicated that she had the potential for falls and injury related to impaired cognition, decreased safety awareness, and weakness, and was to use a full-body mechanical lift with a Medium sized sling (the resident is placed in the sling and the sling is attached to the lift) for transfers. Nursing notes for Resident R17, dated May 21, 2016, at 9:45 and 9:46 a.m., revealed that there was new bruising noted to the resident's left inner thigh and left hip area and an old bruise on her right hip, and the new bruising was located in areas where the mechanical lift sling would be placed when in use. An incident/accident investigation for Resident R17, dated May 21, 2016, revealed that the tentative conclusion regarding the probable cause was that the bruising may have been caused by the sling of the mechanical lift. A nursing note for Resident R17, dated May 22, 2016, revealed that the resident was observed pinching herself near the left inner thigh and groin area, and that bruising was noted to the resident's pubic region and to her left lateral leg. An incident/accident investigation, dated May 22, 2016, revealed that the tentative conclusion regarding the probable cause of the bruising was that the resident was observed pinching herself. A nursing note for Resident R17, dated May 23, 2016, at 8:31 a.m., revealed that the resident had bruising to her left leg that extended from the left hip to below her left knee, and there was also bruising to her left inner thigh, and the left hip area was swollen and painful when touched. physician's orders [REDACTED]. An investigation statement completed by Nurse Aide 10, dated May 24, 2016, revealed that she was assigned to Resident R17 on May 20, 2016, and the resident had no bruising or any complaints of pain that day. An interview note with Nurse Aide 10, dated May 25, 2016, revealed that when interviewed by the Director of Nursing, the nurse aide stated that she was pulled from her regularly assigned floor and was assigned to Resident R17 on May 20, 2016. Nurse Aide 10 asked for assistance from Nurse Aide 11 to transfer Resident R17. She indicated that she was not familiar with the resident and did not have her Activities of Daily Living (ADL) sheet (gives information regarding the resident's care, including how to transfer the resident). Nurse Aide 10 then asked Nurse Aide 11 how to transfer Resident R17, and Nurse Aide 11 stated that the resident was a two-person (manual) pivot transfer (a transfer in which the resident bears weight and pivots on at least one foot), so Nurse Aides 10 and 11 manually transferred the resident from her chair to her bed using a manual two-person pivot transfer. After completing incontinent care, the two nurse aides manually transferred the resident from her bed back to her chair using a two-person pivot transfer. An investigation statement completed by Nurse Aide 11 dated May 23, 2016, revealed that when he left work on Friday, May 20, 2016, Resident R17 was fine. Interview notes with Nurse Aide 11, dated May 23 and 25, 2016, revealed that he did not notice any bruising on Resident R17 on May 20, 2016, and that he assisted Nurse Aide 10 to pivot the resident from the chair to the bed and from the bed back to the chair. The two nurse aides also rolled the resident to provide care while she was in bed, and she did not show any signs of pain and was moving both of her legs. Nurse Aide 11 indicated that he did not see Nurse Aide 10 refer to the resident's ADL sheet and that he did not have the ADL sheet for Resident R17 because he was not assigned to her. An interview note with Nurse Aide 12, dated May 23, 2016, revealed that the aide worked until 6:30 p.m. on Friday, May 20, 2016, and did not notice any bruising or increased discomfort for Resident R17. On Saturday, May 21, 2016, when Nurse Aide 12 arrived for her shift at 6:30 a.m., she noticed a small area of bruising to Resident R17's left hip and thigh areas, which Resident R17 was grabbing at. On Sunday, May 22, 2016, the nurse aide noticed that the resident's bruising had increased, and she reported it to the licensed practical nurse. An investigation statement completed by Licensed Practical Nurse 14 (LPN 14), dated May 24, 2016, revealed that he observed bruising to Resident R17's left hip and left thigh on the morning of Saturday, May 21, 2016. On Sunday, May 22, 2016, LPN 14 noticed new bruising to the resident's pubic area and the side of the resident's left leg. Interview with the Director of Nursing on May 31, 2016, at 12:25 p.m., revealed that through further investigation on May 23, 2016, it was found that Resident R17 was manually transferred twice without using a mechanical lift per the resident's care plan. 42 CFR 483.25(h) Free of Accident Hazards/Supervision/Devices. Previously cited 4/14/16, 2/10/16, 5/7/15. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/14/16, 3/11/16, 2/10/16, 7/27/15, 5/7/15.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were given the necessary care and services to prevent the development of pressure ulcers and promote healing for one of five residents reviewed (Resident CR2). Findings include: The comprehensive resident assessment, dated 10/30/11, for Resident CR2 indicated that the resident was confused, had severely impaired decision making, required extensive assistance with bed mobility, was dependent for transfers, had a feeding tube, pressure ulcers, and [DIAGNOSES REDACTED]. The admission nursing assessment and wound assessment record, dated 10/17/11 and 10/18/11, indicated that the resident had a Stage II (partial thickness skin loss) pressure ulcer on the sacrum, and the Braden scale (tool used to assess risk of skin breakdown) assessment indicated that the resident was at moderate risk for skin breakdown. Physician orders, dated 10/17/11, and the care plan, dated 10/18/11, indicated that staff were to report any changes in the resident's skin integrity, turn and reposition the resident frequently every shift as tolerated, use a pressure redistribution mattress and cushion on the bed and wheelchair, and to request a therapy consult as needed. A physician order, dated 10/18/11, indicated that the resident was to be out of bed in a geriatric chair. A therapy progress note dated for the period of 10/18/11 to 10/31/11 indicated that the resident needed a vector cushion for effective pressure redistribution in the chair and that he needed to be repositioned in bed every two hours. There was no documented evidence that a vector cushion was obtained for the resident or that an alternate intervention was used. There was also no documented evidence that the resident was repositioned every two hours in bed. The wound assessment record, dated 11/8/11, indicated that the pressure ulcer on the sacrum worsened and became three separate Stage III pressure ulcers (full thickness of skin loss). Interview on 11/15/11 at 2:10 p.m. with the Therapy Director revealed that the vector cushion was the best cushion for the resident to obtain the most effective pressure relief, but the cushion was never issued to the resident due to unavailability. Interview on 11/15/11 at 2:36 p.m. with the Restorative Registered Nurse confirmed that there was no documented evidence that the resident was turned every two hours. 28 Pa. Code 211.12 (d)(3) Nursing services. Previously cited 8/11/11. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 11/4/11, 8/11/11.

Based on a review of Department of Health records, clinical records, and policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards from residents with wandering behaviors, for 12 of 32 residents reviewed (Residents CR1, CR2, R3, R4, R5, R6, R14, R15, R16, R18, R21, CR30). Findings include: Department of Health records, dated [DATE] at 12:26 p.m., revealed that on [DATE] at 3:35 p.m., staff were summoned to the room of Resident CR2 by Resident CR1 who was yelling "police!" Upon entering the room, Resident CR2 was lying on the floor with blood coming from the back of his head, the front of his face was bloody and swollen, he had superficial lacerations to his face, and both of his eyes were swollen shut. Resident CR1 exited the room swinging and punching out at staff. Resident CR2 was sent to the hospital and admitted to the intensive care unit. The death certificate for Resident CR2 indicated that the resident died from a closed head injury, multiple traumatic injuries, and assault. The comprehensive resident assessment dated [DATE], and a [DIAGNOSES REDACTED]. Nursing notes, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicated that the resident was verbally and physically abusive, striking out, punching staff, he was agitated, threw items at staff, tried to pull the curtains down, punched himself, tried to climb out of bed, attempted to get on the elevator, cornered and hit staff, went into other residents' rooms, bit people, broke the glass in several pictures, was combative with other residents, rummaged through his roommate's items, threw items, and charged a nurse with his wheelchair. Nursing notes dated [DATE], indicated that he was moved to the fourth floor because he got on the laundry elevator when he resided on the first floor. Nursing notes dated [DATE] to [DATE], revealed that he continued having behaviors such as agitation, cornered staff, hit staff and swore at them, went into other residents' rooms, charged at staff and rammed into them with his wheelchair, he was combative with staff and residents, tried to bite staff, lunged his wheelchair at staff and other residents, and spit at staff. A psychiatry note dated [DATE], indicated that the resident was known to this doctor, from the resident's admissions to the psychiatric unit in the past, and that he was at risk to himself by not complying with his care and at risk to others secondary to his physical violence. On [DATE], he was transferred to the hospital, due to his behaviors and admitted with cystitis and sepsis, and returned on [DATE]. Nursing notes dated [DATE], [DATE], [DATE], and [DATE], revealed that the resident showed increased aggression towards staff and other residents, wandered into other residents' rooms, attempted to hit other residents in the hallway, and hit staff. There was no documented evidence of who the other residents were that he was combative with, in order to determine any patterns of his behaviors and to ensure the safety of the other residents. The care plan dated [DATE], indicated that staff was to try three of the following interventions when the resident was having behaviors. The plan included providing diversional activities, music, reading, or religious activities, although it did not specify the type of diversional activities, exercise, music, reading materials, or religious activities that were effective. Nursing notes from [DATE] to [DATE], indicated that only food, fluid, and redirection were tried when behaviors occurred and that they were all ineffective. There was no documented evidence that the staff monitored the behaviors, identified precipitating factors causing behaviors, changed interventions when they were not effective, and developed an individualized behavior management plan in an attempt to prevent him from wandering or to prevent behaviors. An incident report dated [DATE], revealed that Resident CR2 was involved in an incident with Resident CR1 and Resident CR2 was found lying on the floor, behind the door, with his face swollen, ecchymotic (discoloration of the skin due to ruptured blood vessels in the subcutaneous layer of the skin), and he was bleeding from the top of his head and face. It indicated that Resident CR2 was bleeding from his face, nose, mouth, and head, and that his face was so swollen that it was hard to identify him. Interview on [DATE], with Nurse Aide 28 at 9:45 a.m., with Licensed Practical Nurse 29 at 10:00 a.m., and with Nurse Aide 22 at 10:05 a.m., indicated that they were not aware of any behavior problems with CR2 on the day shift. Interview on [DATE], at 11:30 a.m., with the Director of Nursing, revealed that staff was to be monitoring and recording the resident's behaviors on every shift and new interventions should be developed if others were ineffective. The facility's resident data record for Resident CR1, indicated that the resident was admitted on [DATE]. The pre-admission history record, undated, and the initial social service assessment dated [DATE], indicated that the resident was confused, had Alzheimer's dementia with behavioral disturbances, and depression, as well as a past history of a head injury. He was hospitalized from [DATE] to [DATE], and from [DATE] to [DATE], in a geropsychiatric unit. At the time of the hospitalization s, he had behaviors of resisting care, yelling out when touched, and he previously resided in another nursing home. There was no documented evidence that social service staff contacted the previous nursing home to determine why he was no longer a resident there and what precipitated his transfer from that facility. Nursing notes obtained by the Department of Health from the previous nursing home revealed that on [DATE], the resident was being walked by staff and attempted to throw his wheeled walker three times and then became combative with staff, and made several attempts to hit or punch one of the staff. On [DATE], he was found opening his roommate's drawers and removing items. When staff tried to redirect him, he stated that he was going to punch the nurse aide in the mouth, then was observed attempting to hit the nurse aide with his fist. On [DATE], he had increased behaviors and was physically hitting staff; he kicked one staff member, stomped on the feet of two others, and when asked to sit down he stated, "I'll punch you in the face, [***] ." On [DATE], he was wandering in and out of residents rooms, taking their belongings, and threatening to strike staff. When the staff attempted to redirect him, he grabbed the nurse aide's hand and squeezed and pinched it, and then swung at the nurse aide with a closed fist, striking her in the face and knocking off her glasses. Nursing notes dated [DATE], indicated that the staff from mental health evaluated the resident and determined that he was a danger to himself and other residents and would be transferred to the hospital's inpatient psychiatric unit. Interview on [DATE], at 10:01 a.m., with Social Worker 15, revealed that he did not attempt to contact the nursing home where the resident previously resided to find out what behaviors the resident had and did not develop an individualized behavior plan for the resident. The comprehensive resident assessment dated [DATE], for Resident CR1 indicated that the resident was confused, had wandering behaviors, had [DIAGNOSES REDACTED]. There was no documented evidence that an in-depth assessment was completed that assessed the possible causes or precipitating factors of the behaviors, risk factors, compounding problems, declines, lack of improvement, that he wandered, or what would work to decrease the wandering or prevent it, and information on the resident's behavioral history prior to admission. The care plan dated [DATE] and [DATE], indicated that the resident wandered on the unit, had a history of [REDACTED]. Staff were to monitor the resident when he was wandering on the unit, redirect him as needed with food and fluids, reapproach him later if he became agitated, offer books and magazines, although it did not specify the type of books or magazines to offer the resident. The plan indicated that the resident enjoyed games, but did not identify which games that he liked. The plan indicated that he liked exercise, but did not specify what type of exercise that he liked. It also indicated that he liked entertainment and music, but did not specify what type. The plan indicated that he enjoyed talking and television, but did not specify what he liked to talk about or what television shows that he liked to watch. It indicated that he liked gardening, catholic mass, and being outside. There was no documented evidence that an individualized behavior plan was developed in an attempt to prevent him from wandering or to prevent behaviors. The behavior logs dated [DATE] to [DATE], and nursing notes dated [DATE] to [DATE], indicated that the resident wandered into other residents' rooms, used their bathrooms, and was agitated and combative when staff attempted to redirect him. He punched, kicked, grabbed, and slapped staff. He was verbally abusive to staff, attempted to go out the fire doors, and threatened to punch staff. Nursing notes dated [DATE], revealed he was moved to the fourth floor, a locked nursing unit. The behavior logs dated [DATE] to [DATE], indicated that the resident did not have wandering behaviors and was not physically abusive. Social service notes dated [DATE], revealed that during the assessment period of [DATE] to [DATE], the resident was physically abusive and the care plan was reviewed and remained feasible. Interviews on [DATE] at 2:23 p.m., with Nurse Aide 9, and [DATE] at 3:29 p.m., with Nurse Aide 8, revealed that the resident wandered into other residents' rooms constantly, but they did not document the wandering behavior because they thought it was "normal behavior" for residents on that unit. Nursing notes dated [DATE], revealed that Resident CR1 was arguing with Resident R14 in the lounge and swung at this resident, causing superficial abrasions to Resident R14's nose and chin. Interview on [DATE] at 10:01 a.m., with Social Service Worker 17, revealed that he was not aware of this incident that had occurred on [DATE], and there was no documented evidence that the care plan was updated following this event. Interviews on [DATE] at 2:23 p.m., 2:25 p.m., 2:55 p.m., and 3:02 p.m., with Nurse Aide 9, Nurse Aide 10, Nurse Aide 4, and Nurse Aide 11, respectively; on [DATE] at 3:02 p.m., 3:29 p.m., 3:35 p.m., with Licensed Practical Nurse 12, Nurse Aide 8, and Nurse Aide 13, respectively; on [DATE] at 2:22 p.m., with Licensed Practical Nurse 3; and on [DATE] at 6:55 p.m., with Nurse Aide 14, revealed that the resident wandered in and out of other residents' rooms and upset some of the residents. They indicated that there was no plan in place other than for the staff to redirect the resident out of the room, but this was not always successful. They indicated that they were not aware of an individualized plan for this resident to prevent the resident from entering other residents' rooms. Staff indicated that they did not provide the resident with activities and did not document the wandering behavior because they thought it was "normal behavior" for residents on that unit. The facility's incident investigation dated [DATE], indicated that on [DATE], Resident CR1, was observed banging the door twice against Resident CR2's head and then he hit a nurse aide in the face. Interview on [DATE] at 3:02 p.m., with Licensed Practical Nurse 12, revealed that she did not receive any specialized training regarding behaviors, and she felt that mixing residents with mental illness, mental retardation, and dementia on one unit was not good since their needs were different. Interview on [DATE] at 2:45 p.m., with Registered Nurse Supervisor 16, revealed that she considered the unit an Alzheimer's, dementia, and behavior unit, but was not aware that Resident CR1 wandered into other residents' rooms, and indicated that there was no specialized training provided to staff regarding behavior management for residents with Alzheimer's disease/dementia versus mental retardation or mental illness. Interview on [DATE] at 12:20 p.m., with the Medical Director, revealed that he was aware that the criteria for admission to the fourth floor was "loose," but did not know much about the unit on the fourth floor. The comprehensive resident assessment dated [DATE], for Resident R5, revealed that the resident was confused, wandered, had physical behavioral symptoms, and significantly disrupted care or the living environment of the unit. He had [DIAGNOSES REDACTED]. The care plan dated [DATE], indicated that the resident had behaviors of refusing to speak, putting himself on the floor, attempting to jump into the nursing station over the counter, biting his lip and spitting blood on the windows, eating food from the trash, emptying trash cans onto the floor, wandering, urinating and defecating on the floor, exposing himself, locking himself in rooms, ripping the disposable glove container from the wall, and refusing to take his medications. The plan was for staff to follow the toileting program, provide encouragement and support, let the resident verbalize his fears and anger, redirect the resident, and assess him for what he may need; such as toileting, food, or fluids. Staff was to encourage him to attend activities, but it did not specify what type of activities, monitor him for pain and changes in his condition, and they were to have him wear a jump suit to prevent him from urinating or defecating on the floor. Nursing notes dated [DATE] to [DATE], revealed that he was holding another resident by the hair, threw water on residents, was eating from the garbage, wiping bowel movement from his buttocks in the lounge and leaving the paper towels on the floor, would go on the elevator, expose himself, enter other resident's rooms and agitate them and break the other residents' belongings, throw things, spit on staff, swing at other residents and staff, and urinate on the floor. The notes indicated that staff redirected the resident, but it was not always successful, and there was no documented evidence that the care plan was changed to alter his behaviors. A nursing note dated [DATE], indicated that he was transferred and admitted to the hospital psychiatric unit. A hospital record dated [DATE], indicated that the resident was sent to the hospital because the facility felt they could not control him. Nursing notes dated [DATE] to [DATE], indicated that he returned to the facility and continued to go into other residents' rooms and take their belongings, eat from the garbage, expose himself, urinate in front of residents, get on the elevator, swung and spit at staff and residents, and went into other residents' rooms and threw their belongings about the room. When these behaviors occurred, staff tried to redirect him with food and fluids, toileting, television, and activities in room. There was no documented evidence that the care plan was updated when these interventions were unsuccessful. Nursing notes dated [DATE], revealed the resident was admitted to the psychiatric unit again. On [DATE], the resident returned to the facility, and from [DATE] to [DATE], he rummaged through residents' garbage cans, dumped garbage on the floor in other residents' rooms, barricaded himself in the lounge, spit, hit, kicked, and punched staff, took food from other residents, ate food from used resident trays, got on the elevator, and urinated on the floor. The only intervention used was redirection; there was no documented evidence that the care plan was changed to prevent the behaviors. Nursing notes, dated [DATE], [DATE], [DATE], and[DATE], revealed that the resident smeared feces on the tables, television, walls, and floors of the lounge; and staff intervened by redirecting the resident, showering him, and at times documented that no interventions were used. Nursing notes dated [DATE], revealed that he was admitted to the psychiatric unit again. Nursing notes dated [DATE], revealed that he returned to the facility, and on [DATE] and [DATE], he urinated on the floor, got on the elevator, and agitated other residents. Physician orders [REDACTED]. A psychiatry note dated [DATE], indicated that he still threw temper tantrums, barricaded himself in a room, and would put himself on the floor. Nursing notes dated [DATE] to [DATE], revealed that he removed his jump suit and moved his bowels in the hallway and lounge and then attempted to eat his own bowel movement, attempted several times to go behind the nursing station, barricaded himself in the clean utility room, bit his lip and spit blood at the door and windows, walked in and out of residents' rooms and took their belongings, barricaded himself in the filing room, tried to climb on the nursing station counter, urinated on the floor in front of the nursing station, and tried to push the computers off the counter. Staff intervened by redirecting him with food, television, and an activity. The monthly behavior meeting dated [DATE], indicated the resident had behaviors of urinating, lying himself on the floor, getting on elevators, and barricading himself in rooms and lounges. The specific behavior interventions attempted were redirection, food, fluids, coloring books, and activities. There were no documented evidence of any new interventions to modify his behaviors. Interview on [DATE] at 1:25 p.m., with Nurse Aide 20, revealed that she was aware that the resident urinated on the floor, dumped water on staff, and went into other residents' rooms. She indicated that he did not exhibit behaviors if he was involved in an activity, but activity staff were only on the units until 4:00 p.m., and nursing staff did not have time to provide any activity programming. She indicated that the nurse aides just had to keep redirecting the resident when he went into other residents' rooms. Interview on [DATE], with Social Worker 17, revealed that he was aware of the resident's behaviors of wandering, putting himself on the floor, and urinating inappropriately, and indicated that the facility's policy was for the care plans to be updated following any resident behaviors, but he was not able to outline any new interventions implemented. A hospital history and physical dated [DATE], for Resident R14 revealed [DIAGNOSES REDACTED]. The comprehensive care area protocol notes dated [DATE], indicated that he self propelled in a wheelchair throughout the unit. Physician orders [REDACTED]., to alert staff that the resident was out of the bed or chair. The behavior flow records for January and February 2011, indicated that the resident had behaviors of agitation, striking out at other residents and staff, wandered throughout the unit, and was not easily re-directed. A social service assessment dated [DATE], revealed that the resident had been in the Army and served in the Korean War, had been a state trooper, graduated from a technical school, and liked to hunt. Nursing notes dated [DATE] and [DATE], indicated that the resident would become agitated, aggressive, and combative when the chair or bed alarms sounded. The only interventions used was to educate the resident to sit down and the alarm would stop. He became more agitated and combative and kicked another resident in the ribs on [DATE], and punched him on the top of the head. The only intervention was to notify the physician on [DATE], that the resident's behaviors were escalating. The plan of care updated [DATE], indicated that bed and chair alarms were to be used, but then indicated that background noise was to be reduced to decrease the resident's agitation, and he was to be redirected away from others when he was agitated. There was no documented evidence that the use of the alarms were reevaluated after it was determined that they created agitation, aggressiveness, and combativeness in the resident. Observations on [DATE] at 7:15 p.m., revealed that the resident was in his wheelchair in his room watching television, he stood up, and the alarm sounded. Two nurse aides came out of another resident's room and directed him to sit back down. The resident replied, "Turn that thing off." Staff directed the resident to sit down and then left and returned to another resident's room. The resident immediately stood up again and the alarm sounded. He walked to his closet, which was behind the door. The nurse aides entered the room again and directed him to sit back down; however, this caused him to become agitated, and he stumbled as he walked from the closet back to his wheelchair. Interview on [DATE] at 10:30 a.m., with Licensed Practical Nurse 19, revealed that the sound of the alarms agitated the resident, but staff were directed to use them. Observations on [DATE] at 8:50 p.m., revealed that the resident yelled at Licensed Practical Nurse 30 and raised his fist to him. Interview with Licensed Practical Nurse 30, on [DATE] at 9:30 p.m., indicated that the resident did not like the alarms, did not know why he needed them, and became agitated when they sounded. He indicated that he just explained to the resident why he needed to have them in place. Interview with Nurse Aide 8, on [DATE] at 9:35 p.m., indicated that she did not know why the resident had the alarms on because he was independent in walking to the bathroom and walking behind his wheelchair, but that her nurse aide instruction sheet said he was to have them on, so she put them on, and the resident did not like them. She indicated that when he wanted to walk in the hall, the staff turned the alarms off. Observations on [DATE] at 9:40 p.m., revealed that Resident R4 (a roommate of the resident) was pacing and cursing loudly in the hall. Resident R14 was wandering in the hallway. Staff did not try to direct him away from Resident R4 or get him involved in activities to keep him from wandering near Resident R4. Resident R14 started to yell at Resident R4 and raised his fist to him and both residents started towards each other until a nurse aide jumped between the two residents. There was no documented evidence of this incident in Resident R14's clinical record. Nursing notes reflected an altercation occurred between this resident and another resident who was not identified on [DATE], with this resident and Resident R5 on [DATE], and with this resident and Resident CR1, and with this resident and another resident who was not identified on [DATE]. The plan of care, updated [DATE], indicated that the resident was to be supervised when walking independently, to re-approach if agitated, and redirect him with activities of his choice when wandering. There was no documented evidence that the facility identified and monitored precipitating factors such as the effect of other resident's behaviors on this resident. Interview on [DATE] at 2:10 p.m., with Registered Nurse Unit Manager 5, revealed that the resident wandered up and down the halls. She indicated that the resident had been a state policeman and, therefore, he sometimes got into altercations with other residents when they were not behaving properly or did not answer him appropriately. She was not able to address any interventions used to prevent altercations with other residents. Observations on [DATE] at 8:20 p.m., indicated that Resident R4's wheelchair alarm sounded and when Licensed Practical Nurse 12 entered the room she began questioning him. He became very agitated with verbal outbursts. Registered Nurse Unit Manager 5 then entered the room and began to try and calm the resident, but he continued with loud outbursts and was agitated that she did not understand him. At 8:25 p.m., Registered Nurse Unit Manager 5, took him back toward his room, at which time he began loud outbursts and was agitated when a nurse aide approached him. There was no documented evidence in the clinical record of these verbal outbursts and agitated behaviors. Observations on [DATE] at 8:50 p.m., revealed that the resident yelled at staff because he wanted in his bathroom and staff told him that he could not go in because another resident was using the bathroom. The resident became very loud, yelling that he can never get into the bathroom when he wanted to use it and began pacing in the hallways and cursing loudly. He was accompanied by one nurse aide at his side and one behind him with a wheelchair. A second nurse aide approached him from the side and he became more agitated and cursed at the second nurse aide. Registered Nurse Supervisor 16 told the second nurse aide to step aside because the resident got more agitated and yelled more if there were more than one staff person beside him. Observations on [DATE] at 9:00 p.m. and 9:02 p.m., revealed that the resident was cursing loudly in the hall causing Resident R14 to yell at him and raise his first, and both residents started toward each other until a nurse aide got in between the two residents. Resident R6 was also in the hallway and became upset and stated, "He's lucky I didn't pound his mouth." There was no documented evidence of the above behaviors on the behavioral intervention records. The nursing notes did not include the details of the incident such as the precipitating factor, that the resident became more agitated when approached by more than one person, the altercation with Resident R14 which required an intervention, and Resident R6's response to the resident. The comprehensive resident assessment for Resident R4, dated [DATE], indicated that the resident had repetitive physical movements, resisted care, and was verbally and physically abusive. It indicated that the resident's mood/behavior was unstable, which inhibited his ability to interact well with others. The Omnibus Budget Reconciliation Act Target Resident Reporting Form (MA 408) dated [DATE], for Resident R4, indicated that the resident was a new admission on [DATE], from a hospital. Prior to his hospitalization he was a patient at a state mental institution since [DATE]. The form indicated that he was in and out of state mental hospitals all of his life. The physician discharge summary, dated [DATE], from the state hospital indicated that he had a [DIAGNOSES REDACTED]. It indicated that his attention span was minimal, he became very agitated and frustrated when asked more than two or three questions, he had very limited coping skills, and he had a history of [REDACTED]. The behavior detail report for [DATE], indicated that the resident had six episodes of either being verbally abusive, socially inappropriate, or wandering. The behavior detail report for February 2011, indicated that he had 17 episodes of behaviors. The behavioral intervention record indicated that agitation was the only behavior being monitored and the resident only exhibited agitation once on [DATE], on the evening shift. There was no documented evidence that staff was monitoring other behaviors such as wandering, verbal abuse, and socially inappropriate behaviors. There was no documented evidence that an individualized behavior plan was developed that incorporated his individual preferences of activities and used his known behavioral history or that included individualized interventions to assist him with the problem of not interacting well with other residents. The comprehensive resident assessment dated [DATE], for Resident R3 revealed that the resident was confused, had no wandering behaviors, and had [DIAGNOSES REDACTED]. The care plan dated [DATE], indicated that the resident had wandering behaviors and staff was to ensure her safety, redirect as needed, encourage her to watch television, offer food and drinks for redirection, encourage participation in dining group, and provide with diversional activities as needed, but the plan did not specify the measures that were effective for this resident and what her preferences were with diversional activities and food. Behavior logs dated [DATE] to [DATE], revealed that the resident wandered into other residents' rooms. The activity assessment dated [DATE], indicated that the resident liked exercise and sports but did not indicate what exercises or sports she liked. The assessment indicated that the resident liked music and television but did not specify the type of music or television shows she liked. The assessment indicated that she liked talking and conversing but did not indicate what she liked to talk about. There was no documented evidence that staff attempted to determine what time period in the persons life the resident was living in and incorporate that part of her life, into her life at the facility. Nursing notes dated [DATE] to [DATE], revealed no documentation of the resident wandering. The behavior meeting notes dated [DATE], [DATE], and [DATE], indicated that the resident was wandering in and out of other residents' rooms and taking items from other residents. The specific behavior interventions were to redirect with food and fluids and take her to the dining group. There were no new interventions added to the plan of care on [DATE] or [DATE]. A social service note dated [DATE], indicated that the resident had no mood or behavior problems. A psychiatry note dated [DATE], indicated that the staff informed him that the resident was having no problems and she was in her own little world. There was no documented evidence that staff monitored the wandering, developed an individualized behavior plan, modified interventions to prevent reoccurrence, or developed an individualized care plan in relation to her current time period she was living in and her history. Observations on [DATE] at 2:25 p.m., [DATE] at 5:30 p.m., [DATE] at 9:08 p.m., and [DATE] at 9:45 p.m., revealed that the resident wandered constantly into other residents' rooms. Interviews on [DATE] at 2:23 p.m. and 2:30 p.m., with Nurse Aide 9, confirmed that the resident wandered into other residents' rooms, but he did not document the wandering behavior because there were a lot of wanderers on this unit. Interviews on [DATE] at 2:32 p.m., with Nurse Aide 24, revealed that the resident wandered into other residents' rooms and had to be constantly redirected out of the room. The comprehensive resident assessment dated [DATE], for Resident R15 indicated that he had impaired decision making, was occasionally incontinent of bladder, and had [DIAGNOSES REDACTED]. The behavior intervention record for February 2011, indicated that the resident urinated on the floor and staff intervened by taking him to the bathroom or offering him food and fluids, which were not effective. Psychiatric progress notes dated [DATE], indic

Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that residents received the necessary care and services to prevent the development of pressure ulcers and promote healing for one of 30 residents reviewed (Resident R1). Findings include: The comprehensive resident assessment, dated 8/17/10, for Resident R1 indicated that the resident was confused, could make her needs known, required assistance with bed mobility, had limited range of motion of her legs, had pressure sores, and had [DIAGNOSES REDACTED]. The admission nursing assessment, dated 8/4/10, indicated that the resident had pressure areas on the left and right buttocks, and the Braden scale (tool used to assess risk of skin breakdown) assessment indicated that the resident was at high risk for skin breakdown. The care plan and physician orders, dated 8/4/10 and 8/6/10, indicated that staff was to report any changes in the resident's skin integrity, reposition the resident frequently as tolerated, encourage elevation of the heels as tolerated, prep wipe to heels twice a day, and apply the appropriate heel elevation boots. There was no documented evidence that the heel elevation boots were used between 8/4/10 and 8/17/10 when a wound assessment record identified a Stage II pressure ulcer on the left heel that measured 2.0 centimeters by 2.0 centimeters. Nursing notes, dated 8/8/10, revealed that the resident complained of pain in her left foot, but there was no documented evidence that the left foot was assessed for the possible cause of the pain. There was no documented evidence that a care plan was developed to address the Stage II pressure ulcer on the left heel, that the physician was notified of the new area, or that a new treatment was ordered. A nursing to therapy communication form, dated 8/19/10, indicated that the resident's left heel had a sore, red area, and the family was requesting a boot. On 8/24/10 (five days later) an order was received for Prevalon boots (boots that relieve pressure on heels) to both feet, and the boots were sent to the nursing unit. There was no indication of when the boots were to be applied. The wound assessment record, dated 8/24/10, indicated that the pressure ulcer on the left heel increased in size measuring 4.0 centimeters by 4.0 centimeters. A nursing note, dated 8/25/10, indicated that the resident would kick her Prevalon boots off, but there was no documented evidence that any new interventions were put into place to address this issue. On 9/7/10 the resident was transferred to the hospital for chest pain and was seen by the facility's medical director, and then on 9/8/10 a new treatment was ordered to the left heel. The wound assessment record, dated 9/8/10, indicated that the wound worsened and was a Stage IV pressure ulcer (a wound that is covered by eschar -dead tissue). A hospital record, dated 9/14/10, indicated that the resident had an area of eschar (dead tissue) covering the left heel pressure ulcer. Observations on 9/14/10 at 8:51 a.m. revealed that the resident was in bed without the Prevalon boots on and her left heel was in direct contact with the mattress. Interview on 8/14/10 at 8:51 a.m. with Licensed Practical Nurse 5 revealed that the Prevalon boots were to be applied when the resident was in bed. Interview on 9/14/10 at 9:02 a.m. with Nurse Aide 6 revealed that the resident attempted to get out of bed earlier, and she took the Prevalon boot off but did not put the Prevalon boot back on the resident when she was put back into bed. 42 CFR 483.25(c) Treatment/Services to Prevent/Heal Pressure Sores. Previously cited 3/26/10, 3/12/10, 12/30/09, 11/9/09, 10/22/09. 28 Pa. Code 211.12 (d)(5) Nursing services. Previously cited 8/6/10, 5/20/10, 4/6/10, 3/26/10, 3/12/10, 12/30/09, 11/9/09, 10/22/09.