Every finding on record at Markley Rehabilitation and Healthcare Center

Based on observation, interview with staff, and review of resident records and facility policy, it was determined that the facility failed to implement an infection prevention and control program in accordance with standards of professional practice for two of 23 residents reviewed (Resident R121 and R51). Review of the facility policy titled, Enhanced barrier precautions (EBPs) revised December 2024 states it is used for, Infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. Enhanced barrier precautions apply when resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and Contact precautions do not otherwise apply. Contact precautions apply when a resident is infected or colonized with any MDRO and has secretions or excretions that cannot be covered or contained; and a resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; or a resident is infected or colonized with any MDRO and there is a current investigation of a suspected or confirmed MDRO outbreak. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator. Review of the facility's policy titled, Administering Medications revised April 2019, the policy stated, Medications are administered in a safe and timely manner, and as prescribe Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. Review of Resident R121's physician orders revealed instructions for Enhanced Barrier Precautions, and orders that indicated the resident had a peripherally inserted central catheter (a PICC line is a long, thin catheter inserted into a peripheral vein and guided to a large central vein near the heart to deliver medications) that included orders for 800 mg of the antibiotic Daptomycin given intravenously one time a day for the resident's bacteremia (blood infection). During observation of medication administration on July 9, 2026, at approximately 9:00 a.m., with Licensed Practical Nurse (LPN) Employee E10, was observed administering Resident R121's IV antibiotic. Observed was a sign posted outside Resident R121's room stating, Enhanced Barrier, providing guidance that anyone providing direct care was required to wear a gown and gloves when touching Resident R121. After the IV medication was administered, it was confirmed with the LPN that he/she failed to use EBP that employ using targeted gown and glove and in addition failed to properly utilize standard precautions. LPN, Employee E10, was also observed failing to clean hands prior to donning (putting on) gloves, and failed to clean hands and reapply new gloves when the nurse was observed touching the resident's electrical outlet, IV pump machine, leaving the resident's room to check the orders, touching the medication cart and computer screen then returning to administer the IV medication to the resident. Review of clinical record revealed Resident R51 was admitted to the facility on [DATE], with diagnoses including, but not limited to, history of cerebral infarction (stroke), emphysema (chronic lung condition which makes breathing more difficult), and artificial opening of the gastrointestinal tract. During observations on July 7, 2026, at 1:20 p.m., it was noted that there was a urinal full of urine on Resident R51's over bed table. When the Nurse Aide brought in Resident R51's lunch tray, the nurse aide removed the urinal from the over bed table, emptied the urinal, and hung it on the resident's bed. After the nurse aide removed the urinal from the overbed table, he/she moved the lunch tray to the overbed table without sanitizing the surface. In an interview with Employee E1, Nursing Home Administrator, and Employee E2, Director of Nursing, on July 8, 2026, at 2:30 p.m., it was confirmed that staff is expected to sanitize surfaces after contact with urinals and other soiled items. 28 Pa. Code 211.10 (d) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of clinical records, review of facility documentation, and interview with resident and staff revealed the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of 24 resident records reviewed (Resident R10). Findings include: Review of Resident R10's admission MDS (Minimum Data Set of an assessment of resident's needs) date of April 14, 2026 revealed the resident was diagnosed with hemiparesis (one-sided weakness) following a Cerebral Infarction (stroke) affecting the resident's non-dominant side and was dependent on staff for all activities of daily living. Review of Resident R10's health status note dated April 23, 2026, stated a registered nurse and nursing assistant were in Resident R10 room assisting the resident with his admission assessment and bed change. The bed was elevated to approximately waist level to facilitate care. The resident was being repositioned side to side while soiled linens were being removed, and clean linens were being obtained. During the process, staff attention was directed toward linen management, including removal of wet blankets and obtaining a clean sheet. At that time, the resident rolled toward the edge of the bed. Staff immediately attempted to intervene; however, the movement occurred rapidly, and the resident fell from the raised bed to the floor. The resident's family was present in the room at the time of the incident and witnessed the event. Review of facility documentation revealed the Registered Nurse (RN) Employee E12 stated in the RN's witness statement that the RN and the Nursing Assistant (NA) Employee E11 were changing Resident R10's sheets. The RN indicated being on the left side of the bed, and the NA, Employee E11, was on the right. The resident was turned on the resident's left side. The RN said he/she was moving wet blankets from the bottom of the bed and as he/she looked up, saw Resident R10 roll off the bed. Nurse aide, Employee E11, stated in the witness statement that she stood on the left side of the bed and the RN, Employee 12, stood on the right. The bed was elevated to waist level. Resident R10 was turned to the NA side of the bed. The NA went to grab new sheets that were on the bedside table. The NA stated, Before I knew it family and the nurse were saying he's falling. The RN, Employee E12, and NA, Employee E11, were not available for interview. During an interview with the Director of Nursing on July 9, 2026, at 3:00 p.m. stated the nurse aide, Employee E11, moved away from the bed and at that same moment Resident R10 rolled off the bed. A telephone interview was conducted on July 10, 2026, at 10:00 a.m. with Resident R10's two family members that witnessed the fall. The family indicated that the resident was just readmitted back to the facility from the hospital after a stroke. Per the family, Resident R10 was weak and could barely move or speak. The family confirmed Resident R10's bed was elevated to waist level and that the resident was turned to the side, placed near the edge of the bed, and facing the nurse aide, Employee E11. The family stated the Registered Nurse, Employee E12, was not holding on to the resident, and the Nurse Aide, Employee E11, turned his/her back away from the resident, and at that moment the resident fell off the bed and onto the floor. Both family members agreed that as soon as the nurse aide, Employee E11, turned his/her back on Resident R10, the Registered Nurse, Employee E12, was not holding onto Resident R10 and he/she fell out of bed. Review of the facility's investigation concluded that the two staff members together were assisting Resident R10 in bed. Nurse aide, Employee E11, turned away thinking Resident R10 was secure with Registered Nurse, Employee E12, on the other side of the bed. Resident R10 propelled off the bed before anyone could intervene. An interview on July 10, 2026, at 12:30 p.m. with the Nursing Home Administrator and the Regional Director of Operations indicated the accident occurred when one staff member was not watching the resident but turned away, and the other staff member wasn't able to stop the resident from falling. 28 Pa. Code 201.18 (b)(3) Management. 28 Pa Code 211.10 (d) Resident care policies.

Based on review of facility policy, review of clinical records, and interviews with staff it was determined that the facility failed to ensure that a resident at risk for malnutrition maintained acceptable parameters of nutritional status for usual body weight or desirable body weight for one of 23 residents reviewed (Resident R11). Findings Include: Review of the facility's policy titled, Weight revised December 2022 states, It is the policy of this facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. Residents are weighed upon admission and at intervals established by the Interdisciplinary team and/or as ordered by the physician. The assigned C.N.A, under the supervision of the licensed nurse or the Registered Dietitian will obtain all resident weights. Any resident displaying a significant change in weight of greater than or equal to 5%. gain/loss in one month will be reported to the Registered Dietitian and reweighed. The Registered Dietitian will review the medical record of residents with significant weight changes (i.e. 5% loss/gain in one month, 7.5% loss/gain in 3 months, 10% loss/gain in 6 months). Dietary interventions will be recommended as needed. Review for Resident R11's admission MDS (Minimum Data Set- assessment of resident needs) dated June 16, 2026, revealed the resident was diagnosed with medically complex conditions that included cancer, and malnutrition (deficiencies or imbalances in a person's intake of energy or nutrients). The MDS assessment also indicated that Resident R11 was 65 inches in height and weighed 234 pounds. Review of Resident R11 care plan initiated on June 15, 2026, had interventions to assess meal intakes and weights per facility protocol due to malnutrition and needed hands-on assistance for eating and drinking due to the resident's Activities of Daily Living (ADL) self-care deficit. Review of facility documentation dated June 15, 2026, titled Nutrition: Initial Malnutrition/Morbid Obesity Risk Assessment, revealed Resident R11 was assessed by the facility's Registered Dietitian (RD), Employee E13, and met the criteria for malnutrition. Resident R11's initial nutritional assessment dated [DATE], assessed by the same RD, Employee E13, indicated the family made the RD aware that Resident R11 sustained a 20-pound weight loss in three weeks, and noted the resident weighed 250.8 pounds on June 4, 2026. Registered Dietitian, Employee E13, made recommendations/interventions to monitor Resident R11 weights and meal intake with a goal of 50-75% during meals. Continuing review of Resident R11 clinical record revealed no documented evidence weekly weights were obtained June 19, 2026, and June 26, 2026. The next documented weight on July 1, 2026, indicated Resident R11 was weighed at 209.6-pounds, reflecting a 24-pound weight loss in almost 3 weeks. On July 9, 2026, during an interview with RD, Employee E13, confirmed the facility failed to obtain Resident R11's weekly weights, and that once obtained, the resident was recorded with a 24-pound weight loss in three weeks. 28 PA. Code 211.10 (c) Resident care policies 28 PA. Code 211.12(d)(3)(5) Nursing services

Based on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined the facility failed to ensure residents were free from significant medication errors for three of five residents reviewed (Resident R1, R2, and R3).Findings Include:Review of undated facility policy Administering Medications revealed medications should be administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label three times to verify the right resident, right medication, and right dosage before giving the medication. The individual administering medications should verify the resident's identity before giving the resident his/her medication.Review of Resident R1's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 31, 2025, revealed the resident was admitted to the facility on [DATE], assessed as cognitively intact, and had diagnoses of atrial fibrillation (irregular heart rhythm), anxiety (definition) and depression (definition).Review of Resident R1's clinical record revealed a physician order dated September 25, 2025, to administer oxybutynin chloride table 5 milligrams (mg) two times a day for bladder spams. The medication was scheduled to be given at 8:00 a.m. and 4:00 p.m. daily. Review of Resident R2's comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], assessed as cognitively intact, and had diagnoses of heart failure, hypertension (high blood pressure), renal insufficiency (impaired kidney function), diabetes mellitus (persistently high levels of sugar in the blood), hyperkalemia (high potassium levels in the blood), anxiety, and depression. Review of Resident R2's clinical record revealed physician orders effective September 28, 2025, including, but not limited to, Coreg oral tablet 25 mg two times per day (used to treat hypertension), hydralazine 50 mg three times per day (used to treat hypertension), allopurinol oral tablet 100 mg daily (used to treat gout), and losartan potassium 100 mg daily (used to treat high blood pressure and reduce risk of stroke). Review of Resident R2's clinical record revealed a nursing note dated September 29, 2025, that the physician assistant was made aware that the resident received a one-time dose of oxybutynin. Review of facility documentation revealed on September 28, 2025, at approximately 5:00 p.m. licensed nurse, Employee E3, pre-poured medications into small cups for roommates, Resident R1 and Resident R2. Licensed nurse, Employee E3, entered the room with both cups and provided Resident R2 with the medication cup that were intended for Resident R1. After taking the medication, Resident R2 realized the name on the cup of medication was for Resident R1. The medication was identified as oxybutynin chloride 5 mg. Review of statement by licensed nurse, Employee E3, dated September 29, 2025, confirmed Resident R2 was given the medication that was prescribed/intended for Resident R1. The medication was identified as oxybutynin chloride 5 mg.Continued review of Resident R1's clinical record revealed a physician order dated September 1, 2025, for Spiriva 10 micrograms (mcg) via inhalation daily (medication that relaxes muscles in the airways and increases air flow to the lungs). Further review of Resident R1's clinical record revealed a nursing note dated November 8, 2025, that indicated he/she received Spiriva orally instead of via inhalation.Interview on November 20, 2025, at approximately 10:30 a.m. with the Director of Nursing, Employee E2, revealed Spiriva 10 mcg is a small pill that gets inserted into the cartridge of the inhaler and inhaled through the device. Review of facility documentation revealed on November 8, 2025, Resident R1 reported to his/her nurse that on November 7, 2025, the licensed nurse, identified as Employee E3, gave Resident R1 an unfamiliar pill during morning medication pass. Review of Resident R1's statement revealed he/she questioned the medication but was told by licensed nurse, Employee E3, that it was his/her Spiriva and that it was going to be given in an oral pill form versus through the inhaler. Review of statement by licensed nurse, Employee E3, confirmed on November 8, 2025, this nurse went to give Resident R1 medications for the morning medication pass. Licensed nurse, Employee E3, subsequently gave Spiriva medication by mouth and did not have Resident R1 inhale it.Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Continued review of Resident R3's clinical record revealed physician orders dated November 8, 2025, for Keppra and Lacosamide (anticonvulsant medications used to treat various types of seizures) to be given two times per day. The start date for both medications was November 9, 2025. Review of the facility's November 2025 grievance log revealed a grievance was submitted on November 12, 2025, by the family of Resident R3 related to a medication issue. The grievance alleged that Resident R3 did not receive his/her seizure medication. Review of facility documentation revealed an investigation was promptly initiated on November 12, 2025. Upon investigation, it was determined that when Registered Nurse, Employee E4, input Resident R3's physician orders into the online electronic medical record, the software defaulted the Keppra and Lacosamide to start on November 9, 2025. As a result, Resident R3 missed doses of Keppra and Lacosamide on November 8, 2025.Interview on November 20, 2025, at approximately 11:00 a.m. with the Nursing Home Administrator, Employee E1, confirmed Resident R3 missed one dose of Keppra and one dose of Lacosamide on November 8, 2025. 28 Pa. Code 211.9 (a)(1) Pharmacy services.28 Pa. Code 211.9 (c) Pharmacy services.28 Pa. Code 211.12 (d)(1) Nursing services.28 Pa. Code 211.12 (d)(5) Nursing services.

Based on review of facility policy, review of resident clinical record, observations and interviews with residents and staff, it determined that the facility did not timely update a resident's care plan to incorporate evolving clinical findings, resident preferences, and refusals of care for one of ten residents reviewed (Resident R1) Findings include: Review of the resident care plan policy titled Care Plans, Comprehensive Person Centered (Revised March 2022) revealed that a comprehensive, person-centered care plan must be developed and implemented for each resident. This care plan is required to include measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs. It must describe the services necessary to attain or maintain the resident's highest practicable level of physical, mental, and psychosocial well-being. The plan should also account for services that may not be provided due to the resident exercising their rights, including the right to refuse treatment. Additionally, it must outline any specialized services required based on past assessments or professional recommendations and identify the professionals responsible for each aspect of care. The care plan should incorporate the resident's stated goals, build on their strengths, and reflect current recognized standards of practice for managing their specific conditions and problems. Resident assessments are ongoing, and care plans must be revised promptly as new information about the resident's condition becomes available or as their needs change. Review of Resident R1's admission Minimum Data Set (MDS), a federally mandated assessment tool for all residents, revealed that Resident R1 was admitted to the facility on [DATE]. At admission, the resident had a cognitive BIMS score of 15, used a wheelchair, and was independent with most activities. The resident's diagnoses included anemia (a condition characterized by a lack of healthy red blood cells to carry adequate oxygen to body tissues), peripheral vascular disease (PVD), which affects blood vessels outside the heart and brain-typically in the legs-caused by narrowing or blockage due to fatty deposits, leading to reduced blood flow, leg pain with walking (claudication), numbness, and slow-healing wounds. Other diagnoses were diabetes, a chronic condition affecting blood sugar processing, with main types including Type 1, Type 2, and gestational diabetes; arthritis, an inflammatory joint condition causing pain, swelling, stiffness, and limited motion; cellulitis of the lower limb, a bacterial skin infection affecting deeper layers of skin and underlying tissue; narcolepsy, a chronic neurological disorder impacting sleep-wake regulation, causing excessive daytime sleepiness and sudden sleep episodes; Sjogren's syndrome, a chronic autoimmune disease where the immune system attacks moisture-producing glands; vasculitis, inflammation of blood vessels causing thickening, weakening, narrowing, or scarring that can restrict blood flow and damage organs and tissues; and a history of falls. Review of Resident R1's Wound Notes dated August 13, 2025 noted Resident evaluated in bed with staff for BLE (bilateral legs) wounds/vasculitis. New open areas noted on the left shin. BLE baseline pink discoloration. Resident reported a burning sensation from Hydrogel treatment. Toe dressings were off. Wound note dated September 10, 2025 revealed Resident examined at bedside with staff including DON (Director of Nursing), ADON (Assistant Director of Nursing), unit managers, and staff nurse. Resident reported self-ordering and applying dressings, described as ABD pads with tape and foam dressings. No treatment observed on BLE heels or great toes. Resident reported dressings frequently come off and expressed burning sensations with gauze treatment. Resident refused Dakin's cleansing, gauze, wound gel, and calcium alginate treatments citing burning sensations. Current treatment was Xeroform. Staff reported resident refusal of treatment changes, which the resident denied. Discussion with staff present revealed challenges in assessing treatment effectiveness due to resident removing prescribed dressings and self-applying unapproved dressings. Resident continues to use heels to self-propel wheelchair despite PCP (Primary Care Physician) recommendations for wheelchair leg lifts, which the resident does not use. Resident is inconsistent with compression therapy and declined heel lift boots. Review of the resident's care plan, initiated on August 25, 2025, revealed that the resident has skin breakdown and/or potential for skin breakdown related to cardiovascular disease, edema, a history of skin breakdown, impaired sensory perception, neuropathy, and vasculitis. Continued review of the resident's care plan failed to address interventions related to the resident purchasing own treatment supplies and risk and consequences of applying these treatments. 28 Pa. Code (d)(1) Nursing Services28 Pa. Code (c)(d) Resident Care Policies

Based on observations, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for two of two medication carts. (carts 3a and 3b+c)Findings include:Review of facility policy titled Medication Labeling and Storage revised February 2023, revealed that the facility stores all medications in locked compartments, only authorized personnel have access to the keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Multi-dose medications that have been opened are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Observation of medication pass on August 4, 2025, at 09:48 a.m., on the Third-floor nursing unit revealed Licensed nurse, Employee E8, preparing to administer ordered medication. Observation of the medication cart A at time of the medication administration revealed that all over the counter medication stored in the top drawer of med cart A revealed all bottled of over-the-counter medications (35 bottles of multi dose over the counter medications) were found unlabeled with date of opening. Further review of medication cart A revealed that multi dose eyedrops (21 total were not labeled with date of opening).Interview with Licensed nurse, Employee E7 at time of the observation confirmed that the multi-dose medications were supposed to be labeled with the date of opening and were not labeled. Employee E7 stated that is the responsibility of all nurses that work on the medication cart to label the medications. Observation of medication pass on August 4, 2025, at 10:10 a.m., on the Third-floor nursing unit revealed licensed nurse employee E8 completing medication pass on medication cart 3a+b, Observation of this cart revealed that all over the counter medication stored in the top drawer of med cart A+B (34 bottles of multi dose over the counter medications) were found unlabeled with date of opening. Further review of medication cart A+B revealed that multi dose eyedrops (10 total were not labeled with date of opening).Interview with Licensed nurse, Employee E8 at time of the above observation confirmed that the multi-use medications were not labeled. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12 (c) Nursing services28 Pa. Code 211.12 (d)(1) Nursing services

Based on review of facility policy, facility documentation, and staff interviews, it was determined that the facility failed to implement appropriate tracking and surveillance of infection for three of three months of infection surveillance data reviewed. ([DATE] through [DATE]) Findings include: Review of facility policy titled Surveillance for Infection dated September of 2017 revealed the infection preventionist will conduct ongoing surveillance for healthcare acquired infections and other epidemiologically significant infections that had substantial impact on potential resident outcomes that may require transmission-based precautions and other preventative interventions.For residents with infections that meet the criteria for definition of infection for surveillance, collection of the following data is appropriate:-identifying information (residents name, age, room number, unit, and attending physician)- diagnosis- admission date- date of onset of infection (may list onset of symptoms, or date of positive diagnostic test)-infection site (be specific as possible, pathogen, invasive procedure or risk factors including surgery, indwelling tubes, foley, fractured hip, malnutrition, etc.) pertinent remarks additional relevant information including temperatures other symptoms white blood cell count etcetera also recorded that the resident is admitted to admitted to the hospital or expired and treatment measures and precautions. Review of policy titled Infection Control Meeting dated February 2022, revealed that the interdisciplinary team will meet to review residents with active infections, residents with antibiotic usage, and infection prevention and control topics on a weekly basisThe interdisciplinary team will review the following areas: resident site of infection, active or resolved infection, organism, facility or community acquired, precautions, date of onset, culture results, antibiotic therapy, antibiotic stewardship efforts, root cause, and care plan interventions. Review of the document for Infection Surveillance Monthly Report date [DATE] revealed the total number of infections is twenty-eight, six community acquired, and fourteen hospitals acquired. The report is broken down further to infection category which indicates ten other, two respiratory, one skin, and nine urinary tract infections with an inaccurate total documented of twenty - eight. Actual listed of infections equal twenty-two. Continued review of the document Infection Surveillance Monthly report [DATE] revealed tracking list of infection categorized by infection type. The report exabits resident name, unit/ room, infection, signs and symptoms, status, pharmacy order and comments. There are twenty-eight infections listed on this report. No signs or symptoms, ten without identifying location(room) three antibiotic ordered with no end dates. Review of the document for Infection Surveillance Monthly Report date [DATE] revealed the total number of infections is thirty-two, thirteen community acquired, and fifteen hospital acquired. The report is broken down further to infection category which indicates six blood infections, one bone infection, thirteen other infections, three respiratory infections, two skin infections and seven urinary tract infections with an inaccurate total documented of thirty-two recorded infections. Continued review of the document Infection Surveillance Monthly report [DATE] revealed tracking list of infection categorized by infection type. The report exabits resident name, unit/ room, infection, signs and symptoms, status, pharmacy order and comments. There are thirty-two infections listed on this report. No signs or symptoms, fourteen without identifying location(room), six antibiotics ordered with no end dates. Review of the document for Infection Surveillance Monthly Report date [DATE] revealed the total number of infections is thirty-one, nine community acquired, and twenty hospital acquired. The report is broken down further to infection category which indicates four blood infections, one bone infection, one mouth and throat, one genital, seven other infections, five respiratory infections, three skin infections and nine urinary tract infections. Continued review of the document Infection Surveillance Monthly report [DATE] revealed tracking list of infections categorized by infection type. The report exabits resident name, unit/ room, infection, signs and symptoms, status, pharmacy order and comments. There are thirty-one infections listed on this report. No signs or symptoms, twelve without identifying location(room), five antibiotics ordered with no end dates. All of the above monthly infection surveillance reports failed to include pertinent information of resident diagnosis, signs and symptoms, diagnostic test results, specific infection, and any precautions. Interview with Infection Preventionist, Employee E5 on [DATE], at 1:05p.m. Employee E5 provided monthly surveillance reports and described the process of tracking the infections. When Infection Preventionist, Employee E5 was asked related the limited information provided on the report, Employee E5 stated that all the requested information can be found in the individual resident's clinical record. Employee E6 confirmed that the all the information is not currently reflected in the tracking surveillance reports. Continued interview with Infection preventionist, Employee E5on [DATE], at 10:00 am revealed that the information was able to be access from each resident clinical record and displayed the surveillance with additional information but was found to be incomplete. 28 Pa. Code 211.10(d) Resident Care Policies28 Pa Code 211.12(c)(d) Nursing services

Based on review of facility policies, review of facility documentation, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to maintain an effective antibiotic stewardship program for three of five of residents reviewed for antibiotics (Residents R53, R63, and R61).Findings include: Review of facility policy, Antibiotic Stewardship revised December 2016, revealed The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of facility policy, Review of Surveillance of Antibiotic Use and Outcomes revised December 2016, revealed, Antibiotic usage and outcome data will be collected and documented using facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. As part of the Facility Antibiotic Stewardship program all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP). The IP will review antibiotic utilization as a part of the antibiotic stewardship program and identify specific situations that are not consistent with appropriate use of antibiotics. All resident antibiotic regimes will be documented on facility approved Antibiotic Surveillance tracking form; the information gathered will include resident name, room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. Review of Resident R53's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 25, 2025, revealed that the resident was admitted to the facility on [DATE], with diagnoses including multi-drug resistant organism (MDRO), urinary tract infection, wound infection, enterococcus (bacterial) infection and fracture of the left lower leg. Continued review revealed that the resident received intravenous (IV) therapy (therapy that delivers liquid substances directly into a vein) for antibiotics upon admission to the facility. Review of Resident R53's physician orders for July and August 2025 revealed that the resident received daptomycin (antibiotic medication) from July 25, 2025, through August 4, 2025; cefepime (antibiotic medication) from July 21, 2025, through July 27, 2025; and doxycycline (antibiotic medication) from July 22, 2025, and scheduled through July 27, 2026. Further review revealed that the resident was on contact precautions for CRE from July 21, 2025, through August 4, 2025. Review of facility documentation pertaining to infection surveillance tracking logs for May, June, and July 2025, revealed that Resident R63 was prescribed an antibiotic prophylacticaly on June 4, 2025, for an indefinite amount of time. This resident was not reflected on the surveillance logs presented. Further review revealed that resident 61 also treated prophylacticaly for suspected cellulitis was not reflected on the surveillance logs. Review of Resident R63's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool, dated May 3, 2025 revealed that resident R 63 was admitted to the facility on [DATE], with diagnoses including Diabetes (chronic metabolic disorder charactered by elevated glucose levels), Hypertension( blood pressure in the arteries are persistently elevated), and dementia (decline in cognitive functions). Review of Resident R63's physician notes dated June 4, 2025, revealed that . Daughter reports she is complaining of feeling wet with urine, abdominal discomfort and hallucinations. -Resident will not allow straight cath (catheter)/she is incontinent - will treat empirically with ABT (antibiotic) Review or Resident R63's physician orders revealed an order for Cipro oral tablet 250 milligrams (mg) (ciprofloxacin HCL), give 250 mg by mouth two times a day for prophylaxis. Start Date June 4, 2025, with end date indefinite. Review of Resident R63's medication administration record revealed that the resident received the medication Cipro the entire month of July 2025. The use of this antibiotic was not reflected in the infection surveillance report. Review of Resident R61's MDS (Minimum Data Set - a mandatory periodic resident assessment tool, dated July 20, 2025, 2025, revealed that Resident R 61 was admitted to the facility on July17, 2025, with diagnoses including Asthma (condition in which a person's airways become inflamed making it difficult to breath). Review of Resident R61's physician orders revealed an order for the antibiotic ciprofloxacin 250 mg prophylactically for suspected cellulitis, there were lab no results, no specific location no, follow up notes if the antibiotic was effective, and this infection and antibiotic was not reflected in the infection surveillance. 28 PA Code 211.12(c)(d) Nursing services

Based on clinical record review, staff interview and review of facility policy, it was determined that that facility failed to provide timely assistance with activity of daily living for one of 24 residents reviewed. (Resident R9) Findings include:Review of the facility policy titled Activity of Daily Living (ADL), Supporting revised April 2025 stated, Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) . elimination (toileting).Review of Resident R9's clinical record revealed that the resident was admitted [DATE], with the diagnoses of Multiple Sclerosis (a chronic neurological disorder).Review of Resident R9's care plan dated September 2023, revealed the resident had a ADL self- care deficit due to Multiple sclerosis that assessed the resident needing the help of one assist with activities of daily living.On August 4, 2025, at approximately 11:00 a.m. the surveyor heard in the hallway, ResidentR9 hollering from the resident's room that he hadn't receive morning care to his nurse aide (NA) Employee E10. Resident yelled, sure put them first not me as it was observed the NA was in the hallway just outside the resident's room. Surveyor interviewed Resident R9 that stated, my urinal had not been emptied since last night. They don't empty my urinal so I can't use it to pee because I spill it when I went to use the urinal, it was full, and I spilled the urine on myself. If there is 3-4 inches of urine in the urinal and I am laying down trying to use it, it spills, and I get wet. I had to wait until she did lounge duty to clean me. Interview with the NA on August 4, 2025, at 1:00 p.m. confirmed the NA could not get Resident R9 ready sooner because she had to wait until she found another NA to accompany her because the resident requires two staff members for care. The NA also indicated the NA had lounge duty (residents that are safety risk require additional supervision are watched in the lounge area) between 10:30-11:00 a.m. The NA confirmed the urinal was not emptied until she was able to provide care at 11:00 a.m. Interview with the Unit Manager Employee E 11 confirmed on August 4, 2025, the resident did not receive timely incontinence care and failed to accommodate Resident R9's preferences. 28 Pa. Code 211.12(d)(1)(2) Nursing Services

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for three of five residents reviewed (Resident R39).Findings include: A Binding Arbitration Agreement is a legal process where parties in a dispute agree to have a neutral third party decide their case instead of a judge or jury. The arbitrator's decision is final, and the parties usually cannot appeal it. Review of facility policy, Binding Arbitration Agreements dated November 2023, revealed, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Continued review revealed, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement. Further review revealed, After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The President or representative must verbally acknowledge understanding and the verbal acknowledgement documented by a staff member who explains this agreement. Review of Resident R39's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), April 9, 2025, revealed that the resident was admitted to the facility April 9, 2025, and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 00, which indicated that the resident was severely cognitively impaired. Review of resident R39's clinical record revealed a psychological evaluation dated April 12, 2025, which indicated that resident R 39 has a short attention span and disoriented to date and day with impaired memory. Further review of this evaluation revealed residents thought process to be distracted and tangential. Review of nursing notes for Resident R39 revealed a nursing note, dated April 9, 2025, which indicated that the resident was oriented to person only and place only. Review of Social Service notes dated April 10, 2025, which indicated the resident has confusion. Review of a physician note dated April 14, 2025, revealed Resident R 39 was alert and oriented x 1-2(refers to a person's awareness of only one or two of four possible spheres: person, place, time, and situation, and forgetful. Review of resident's care plan revealed the resident has cognitive function with impaired though process. With intervention to include the need for supervision and assistance with decision making dated April 10, 2025. Review of Resident R39's Binding Arbitration Agreement, dated April 23, 2025, revealed that in the space designated for the signature of the resident, it was noted that Resident R39 verbally signed the agreement. In the space designated for the signature of the facility's authorized agent, the agreement was signed by Employee E7 admission Director. Interview with admission Director, Employee E7 on August 6, 2025, at 1:20 p.m. revealed that she read the Arbitration agreement to Resident R39 and the resident verbally consented to the agreement. 28 Pa Code 201.29(a) Resident rights

Based on review of facility policies, clinical record review and interviews with residents and staff, it was determined that the facility failed to provide dental services to meet the needs residents for one of 31 residents reviewed (Resident R112). Findings include: Review of facility policy, Dental Consultant dated April 2007, revealed, Dental care shall be provided through the services of a Consultant Dentist. Interview on August 4, 2025, at 12:41 p.m. Resident R112 stated that his dental problems have not been addressed by the facility. Resident R112 continued that he needs to see an oral surgeon for evaluation and x-rays. Review of Resident R112's clinical record revealed a dental examination, dated April 30, 2025, which stated that the resident has numerous broken teeth and rampant decay. Referred (below) to oral surgeon for radiographic examination and extractions of any teeth with a less than favorable overall prognosis. After extractions will re-evaluate for restorative. Please refer this patient to an oral surgeon for full radiographic examination and extractions of any teeth with less than favorable overall prognosis. Continued review of Resident R112's clinical record revealed another dental examination, dated June 3, 2025, which stated that the resident not yet seen by oral surgeon. Rewrote referral (below). After extractions, will evaluate further for restorative. Please refer this patient to an oral surgeon for full radiographic examination and extractions of any teeth with less than favorable overall prognosis. Continued review of Resident R112's clinical record revealed another dental examination, dated June 24, 2025, which stated that the resident not yet seen by oral surgeon. Rewrote referral (below). Will evaluate further for restorative after extractions are completed. Please refer this patient to an oral surgeon for full radiographic examination and extractions of any teeth with less than favorable overall prognosis. Continued review of Resident R112's clinical record revealed another dental examination, dated July 18, 2025, which stated that the resident not yet seen by oral surgeon. Rewrote referral (below). After extractions, will evaluate further for possible restorative and partials. Please refer this patient to an oral surgeon for full radiographic examination and extractions of any teeth with less than favorable overall prognosis. Further review of Resident R112's clinical record revealed no evidence that the resident was examined or scheduled for an appointment to be examined by an oral surgeon. Interview on August 6, 2025, at 11:30 a.m. Employee E3, unit manager, confirmed that Resident R112 was not seen by an oral surgeon as recommended by the dentist. 28 Pa Code 211.10(c) Resident care policies 28 Pa Code 211.12(d)(3) Nursing services

Based on interviews and review of clinical records and facility policy it was determined that the facility did not ensure a resident's care plan was developed to meet the care and assistants needed for dental services for one of 24 resident records reviewed (Resident R11).Findings include:Review of the facility's policy for Activity of Daily Living (ADL) revised April 2025 states, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygieneResident R11 was admitted to the facility on [DATE], diagnosed with anemia, major depression, anxiety, and abnormal gait and mobility.Review of Resident R11'a dental exam dated, December 13, 2024, notes moderate soft plaque buildup and inflamed swollen bleeding gums. Hygiene was noted fair and required staff to perform oral care twice daily for Resident R11 due to the resident needing help.Review of Resident R11's dental exam dated, January 14, 2025, instructed staff to perform oral hygiene twice daily due to the resident requiring help with the daily cleanings. Review of Resident R11 dental exam dated June 5, 2025, noted the resident with Extremely inflamed gingivae on margins and papillae. Staff to perform oral hygiene, suggested improved home care and to consult the physician for the resident benefiting in using Peridex (a prescript antiseptic mouth wash that helps with plaque and gingivitis).Further review of Resident R11's clinical records revealed a care plan was developed for dentures not for the oral health and care of the resident's natural teeth.The unit manager Employee E11 confirmed that Resident R11 had natural teeth and did not have dentures on August 6, 2025, at 12:00 p.m.28 PA. Code 211.12(d)(1) Nursing services

Based on review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop a baseline care plan related to antibiotics, within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, for one of 31 residents reviewed (Resident R53). Findings include: Review of facility policy, Care Plans - Baseline dated March 2022, revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Review of Resident R53's admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated July 25, 2025, revealed that the resident was admitted to the facility on [DATE], with diagnoses including multi-drug resistant organism (MDRO), urinary tract infection, wound infection, enterococcus (bacterial) infection and fracture of the left lower leg. Continued review revealed that the resident received intravenous (IV) therapy (therapy that delivers liquid substances directly into a vein) for antibiotics upon admission to the facility. Review of progress notes for Resident R53 revealed a nurses note, dated July 21, 2025, which indicated that the resident was admitted to the facility for IV cefepime (antibiotic medication) for bacterial skin infection and prosthetic joint infection. The note continued that Resident is currently on contact precautions [infection control measures used to prevent the spread of infection from one person to another] for CRE [Carbapenem-resistant Enterobacteriaceae - a type of bacteria that is difficult to treat with antibiotics] Review of Resident R53's physician orders for July and August 2025 revealed that the resident received daptomycin (antibiotic medication) from July 25, 2025, through August 4, 2025; cefepime (antibiotic medication) from July 21, 2025, through July 27, 2025; and doxycycline (antibiotic medication) from July 22, 2025, and scheduled through July 27, 2026. Further review revealed that the resident was on contact precautions for CRE from July 21, 2025, through August 4, 2025. Review of Resident R53's care plan, initiated July 21, 2025, revealed that no care plan had been developed related to the resident's infection, use of antibiotics and contact precautions. Interview on August 7, 2025, at 12:12 p.m. the Director of Nursing confirmed that no care plan had been developed for Resident R53 related to the resident's infection, use of antibiotics and contact precautions. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(5) Nursing services

Based on clinical record review and interviews with resident and staff, it was determined that the facility failed to accommodate a resident's preference for morning care for one of 24 resident records reviewed (Resident R9).Findings include:Review of Resident R9's clinical record revealed that the resident was admitted on [DATE], diagnosed with Multiple Sclerosis (a chronic neurological disorder).Review of Resident R9's, annual MDS (Minimum Data Set an assessment of residents' needs) dated June 4, 2025, revealed the resident was, alert, and oriented and indicated it was very important to the resident the time he got up and ready in the morning, and the time he went to bed. Review of Resident R9's care plan revealed the resident had an ADL (Activities of Daily Living) self- care deficit due to Multiple sclerosis that assessed the resident needing the help of one assist with dressing. On August 4, 2025, at approximately 11:00 a.m. the surveyor heard in the hallway, Resident R9 hollering from the resident's room that he hadn't receive morning care from his Nurse aide (NA) Employee E10. Surveyor immediately interviewed Resident R9 that stated, I don't like to get dressed late in the day. I like to get ready between 9-9:30 a.m. never get dressed and ready when I want. It's 11:00 a.m. and I should be ready. My urinal wasn't emptied either. If there is more than 3-4 inches already in there, I spill it on myself and I am wet. Interview with Nurse aide, Employee E10 confirmed she could not get the resident ready sooner because she needed to have another NA accompany her when giving care to Resident R9 and she could not find anyone to help her. Interview with the Unit Manager, Employee E 11 confirmed the facility failed to accommodate Resident R9's preferences. 28 Pa. Code 211.12(d)(1)(2) Nursing Services

Based on review of clinical records and interviews with staff it was determined the facility did not ensure documented communication and collaboration with one resident's hospice agency related to the resident's condition were obtained for one of 24 resident records reviewed. (Resident R2) Findings include: Review of Resident R2's clinical record revealed that the resident was admitted to the facility and placed on hospice care June 2025. Review of the communication book from the hospice service did not reveal documentation and/or evidence of the services Resident R2 received while under their care. Interview with Licensed nurse, Employee E12 on August 6, 2025, at 1:25 p.m. stated, Normally other hospice companies we use write a note telling us what type of care they provided. Things that we need to know for an example if the resident went to the bathroom, how much they ate, if they got a bath, {Resident R2} service does not document this. 28 Pa Code 211.12(d)(1)(3) Nursing services

Based on staff interviews and review of clinical records, it was determined the facility did not ensure physicians were notified of a dental recommendation for one of 24 residents reviewed (Resident R11). Findings include:Review of Resident R11's clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with anemia, major depression, anxiety, and abnormal gait and mobility.Review of Resident R11's dental exam dated June 5, 2025, noted the resident with Extremely inflamed gingivae on margins and papillae. Staff to perform oral hygiene, suggested improved home care and to consult the physician for the resident benefiting in using Peridex (a prescript antiseptic mouth wash that helps with plaque and gingivitis).Further review of Resident R11's clinical records revealed no documented evidence the physician was made aware of the dental recommendation for Peridex. Interview with Unit manager, Employee E11 confirmed there was no evidence the physician was notified of the dental recommendation on August 6, 2025, at 12:00 p.m.28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, and staff and resident interviews, it was determined that the facility failed to maintain a comfortable environment for two of six nursing units observed (3rd floor common room, and Unit C). Findings Include: A tour of the facility was conducted on July 8, 2025, at approximately 9:30 a.m. and 12:30 p.m. with Nursing Home Administrator (NHA), Employee E 1 and Regional Maintenance Director, Employee E3, to monitor the temperatures of the building and resident care areas. Temperatures taken by NHA, Employee E1, on July 8, 2025, 2025, at 12:30 p.m. in the 3rd floor multipurpose room revealed temperatures reached up to 83 degrees Fahrenheit. Temperature of the room felt hot, humid, and uncomfortable. Observations on July 8, 2025, at 12:30 p.m. in the 3rd floor multipurpose room revealed about 22 residents were gathered in the room and were being supervised by 2 nurse aides preparing for lunch. Observed was a large portable air condition unit in one corner of the room. Interviews with Resident R2 and R3 on July 8, 2025 at 12:45 p.m. reported feeling hot and uncomfortable due to the temperatures of the room located in Unit C. The air temperature in the residents' room was recorded at 82 degrees Fahrenheit. 28 Pa Code: 201.14 (a) Responsibility of licensee.

Based on review of personnel records and interviews with staff, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of in-service education per year as required for two of six nurse aide personnel files reviewed (Employee E3 and Employee E8). Findings Include: Review of facility employee record for nurse aide Employee E3 revealed the employee was hired on July 23, 2004. Review of Employee E3 record revealed the resident did not have a total of twelve hours of continued education for the year 2024 and 2025. Further review of the employees training record revealed Employee E3 had not had Abuse training completed since March 16, 2024. Review of nurse aide Employee E3's personnel file revealed that the employee was hired on on July 23, 2004. , as a nurse aide. Continued review revealed that nurse aide, Employee E3 did not have any Abuse training completed for the year of 2025. The last Abuse training complete by nurse aide Employee E3 was on March 16, 2024. The facility was asked if nurse aide Employee E3 had any additional training for the years 2024 and 2025. The facility was given additional time to provide documentation or in servicing and the facility was unable to provide. Further review of nurse aide Employee E3's training record revealed no trainings completed for mechanical lifts. The facility was asked to provide documentation that Employee E3 was trained and competent in mechincal lifts and the facility was unable to provide this documentation. Review of facility training documentation provided by the facility revealed nurse aide Employee E8's personnel file had half an hour of Abuse training on November 7, 2024.The facility was given additional time to provide documentation or in servicing and the facility was unable to provide. Interview on June 18, 2025, at 2:52 p.m. the Employee E2 Director of Nursing confirmed that the facility could not provide proof that nurse aide, Employee E3, had completed 12 hours of annual in-service education as required. Further review was made of additional employee personnel files for nurses and the investigation revealed two nurses did not have up to date abuse trainings. Review of facility training documentation provided by the facility revealed licensed nurse Employee E12 was hired on June 15, 2021. Review of facility training documentation revealed Employee E12 is still currently employed and the last had Abuse training for the employee was completed on February 16, 2024. Review of facility training documentation provided by the facility revealed licensed nurse Employee E13 was hired on July 7, 2021. Review of facility training documentation revealed Employee E13 is still currently employed and the last had Abuse training for the employee was completed on February 22, 2024. 28 Pa Code 201.19(7) Personnel policies and procedures 28 Pa Code 201.20(a) Staff development

Based on review of facility policies, clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect during a mechanical lift transfer for one of seven residents reviewed (Resident R1). Findings Include: Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 states, Policy Statement- Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation- The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff b. other residents. Review of facility policy titled, Assessment of Skin Condition and Integrity dated March 2021 states, Purpose- The purpose of this policy is to provide information regarding the routine assessment of skin integrity. Skin Assessment- 1. Conduct a comprehensive head-to-toe skin assessment upon admission, weekly, prior to discharge, and as needed. a. During the skin assessment, inspect for: i. Presence of skin impairment(s); ii. Type of skin impairment(s); and iii. Location of skin impairment(s); 2. Inspect the skin daily when performing or assisting with personal care or ADLs. Review of facility records revealed Resident R1 was admitted to the facility on [DATE] with the following diagnosis: Heart Failure (chronic condition where the heart doesn't pump blood as well as is should), Hyperlipidemia (high levels of fats in the flood), Hypothyroidism (underactive thyroid), Lymphedema (swelling), Body Mass Index 40.0-44.9, Bradycardia (slow heart rate), Anxiety Disorder (feelings of nervousness), and abnormalities of gait and mobility. Review of facility documentation dated May 2, 2025 at 11:00 a.m. revealed, Injuries- Bruise- left thigh 12 x 10 cm and rule out fracture- left elbow . Resident stated she was lowered to floor in hoyer as one of the loops got loose and began to slide down Review of facility investigation documentation revealed a witness statement dated May 2, 2025 from nurse aide Employee E3 stating, As I was lifting the resident off the bed to her chair. One of the sling loop on the left of her leg slip-off hitting her left leg first on the floor, and then the whole left side and the whole body slid off the lift slowly to the floor. The statement states, How were you lifting? By the hoyer. How far was she off the bed? About two feet. Was she still over the bed when the sling came loose? Half was to her chair. Who helped you with the hoyer? Just me. Radiology results documentation from May 2, 2025 revealed that the resident was sent out to the hospital for an x-ray of the left elbow with three views. Results showed no fractures of dislocations. Review of Witness Statement from May 3, 2025 revealed, Met with [Resident R1] in the presence of her son. Asked resident how she was doing and apologized for what had occurred. Resident said elbow hurts and son said left leg and butt bruised. Asked resident to complete a statement. Resident did not wish to do so at the time. I said I would check back with her on Monday May 5. Resident's son requested a copy of the incident report and a copy of the x-ray that was done in house. Resident handed me discharge paperwork from the hospital and I gave to the nurse. Resident was not pleased with the hospital as she was there for twenty-four hours and was given no breakfast. Resident and son very pleasant. Resident offered that aide was very good. Review of Witness Statement from May 5, 2025 revealed, Met with [Resident R1] this morning. She said that she was not in pain upon my asking. She expressed being happy to be out of bed and was planning on visiting the gym when her kids arrived. She does not wish to complete a written statement. She stated that the aide has been providing her with care since she first came here and that she has never had a problem and that he usually has someone with him when using the lift. Review of Resident R1's clinical record revealed several Weekly Skin Checks completed. Review of a Weekly Skin Check completed on May 6, 2025. Review of the Weekly Skin Check revealed Section 1a. Are there any skin impairments noted? -Yes is checked. Section 1c.-Type of Skin Impairment is left blank. Section 1d.-Body Diagram is also left blank with no description. Review of a Weekly Skin Check was completed on May 13, 2025. Review of the Weekly Skin Check revealed Section 1a. Are there any skin impairments noted? -Yes is checked. Section 1c.-Type of Skin Impairment is listed as Bruise. Section 1d.-Body Diagram listed Lower Left Extremity. Review of a Weekly Skin Check was completed on May 13, 2025. Review of the Weekly Skin Check revealed Section 1a. Are there any skin impairments noted? -Yes is checked. Section 1c.-Type of Skin Impairment is listed as Bruise. Section 1d.-Body Diagram listed Lower Left Extremity. Review of a Weekly Skin Check was completed on May 21, 2025. Review of the Weekly Skin Check revealed Section 1a. Are there any skin impairments noted? -Yes is checked. Section 1c.-Type of Skin Impairment is listed as Bruise. Section 1d.-Body Diagram listed Lower Left Extremity. Review of a Weekly Skin Check was completed on May 28, 2025. Review of the Weekly Skin Check revealed Section 1a. Are there any skin impairments noted? -Yes is checked. Section 1c.-Type of Skin Impairment is listed as Bruise. Section 1d.-Body Diagram listed Upper Extremity, Lower Extremity. An interview was held on June 18, 2025 at 12:53 p.m. with licensed nurse Employee E4 to discuss interim pain evaluation and Interim Skin Check completed by her on May 2, 2025. Employee E4 was asked about the Interim Skin Check that was completed by her for Resident R1 post fall. Employee E12 stated that she was the unit manager of the second floor that day. Employee E12 and licensed Nurse Employee E14 went into the room of Resident R1 after being called to the room by nurse aide Employee E3. When Employee E12 entered the room she stated she say the hoyer by Resident R1 and nurse aide Employee E3 also in the room. Employee E12 stated that Resident R1 had stable vital signs but that she was complaining of left hip pain and pain in her left arm area. Licensed nurse Employee E14 was called to complete an assessment also. Employee E12 stated that the physician was also at the facility and evaluated the resident right away. When asked about the Description and Body Diagram sections of the Skin Evaluations to be completed by nurses at the facility the licensed nurse, Employee E12 stated that sometimes, the numbers are used for reference or measurements, words can be noted where description is listed on the evaluation. When Employee E12 was asked where lower left extremity pain would be noted the staff pointed/indicated areas between 34 and 38 on the picture description (upper left thigh and hip area). Interview held on June 17, 2025 at 1:00 p.m. with licensed nurse Employee E14. Employee E14 was asked to discuss how she became aware of Resident R1 having a fall. Employee E13 stated that she was Resident R1's nurse on May 4, 2025 when nurse aide Employee E3 came to her with a look. Employee E14 stated, he never looks upset, and he looked upset so I asked what was wrong, and if someone fell and he shook his head yes. I went into the room, and I saw Resident R1 on the floor with the hoyer pad under her, nurse aide Employee E3 in the room, the mechanical lift was in the room, and one strap was not strapped in all the way. Nurse aide Employee E3 was called on June 17, 2025 at 12:02 p.m. but did not answer the phone. Interview on June 17, 2025 at 1:44 p.m. held with the Director of Nursing Employee E2 regarding skin assessment revealed staff at times do use to the Body Diagram and Descriptions section for the Skin Assessments. When asked where they would describe Lower Left Extremity pain, the Director of Nursing, Employee E12 pointed to the right lower leg/ankle area numbers 34 to 38 on the diagram. Interview with the Regional Nurse Employee E5 on June 17, 2025 at 10:49 a.m. confirmed that nurse aide Employee E3 did use the mechanical lift by himself in attempt to unsafely transfer the resident, when he should have had a second staff to help assist him with moving the Resident R1 from her bed to the wheelchair. 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.

Based on review of clinical records, interview with staff it was determined the facility did not maintain medical records according to professional standards for one of seven residents reviewed. (Resident R2). Findings Include: Review of facility policy Guidelines for Charting and Documentation with a revision date of April 2021 states, Purpose- The purpose of charting and documentation is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care; 2. Guidance to the physician in prescribing appropriate medications and treatments; 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; 4. Nursing service personnel with a record of the physical and mental status of the resident; 5. Assistance in the development of a Plan of Care for each resident; 6. A legal record that protects the resident, care providers, and the facility; and 7. A source of all resident charges. Further review of the policy revealed, General Rules for Charting and Documentation 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. 2. Be concise, accurate, and complete and use objective terms. Avoid brief, monotonous, and meaningless entries. 3. Document only the facts. Do not document interpretive statements or opinions, unless authorized or designated to do so. 4. Use only approved abbreviations and symbols. 5. Chart as often as necessary and as the need arises. Review of Resident R2's clinical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis (disease of the immunne system), Muscle Wasting with Atrophy (loss of musble mass), Acute Respiratory Failure with Hypoxia, Review of information submited to the State Survey Agency completed for Resident R2 when the resident alleged that sexual abuse occurred in 2024 by a nurse aide. Review of General Incident Witness Statement by licensed nurse Employee E10 dated February 4, 2025 revealed, The resident expressed to this nurse he wanted to talk about a situation that happened months ago. The resident consistently asks this nurse to come to his room for urgent matters however the resident proceeds to talk about non-urgent matters such as which aide he prefers over another or how unattractive a certain aide is, at which time this nurse tells the resident such conversation is not appropriate or urgent. Around 2:30 p.m. the resident came to the nurses station demanding to speak to this nurse, at which time he states, since your taking so long I'm calling the police. Resident states he believes he was sexually assaulted by the aide (Employee E8) around October or November. This nurse notified social worker met with resident in his room where the resident stated, the aide pulled out my penis with no gloves and began to fondle me Social worker called 911 emergency line, and protective services. This nurse notified the nurse practitioner and was given no new orders. Place resident R2 on paired care at all times. Review of General Incident Witness Statement by licensed nurse Employee E11 dated February 5, 2025 revealed, On November 18, 2025 or anytime in October and up to February 3, 2025 did Resident R2 reported being sexually assaulted by nurse aide Employee E8? No never on November 18, 2024. Employee E8 reported that he was making her uncomfortable, I spoke to Resident R2 he denied being inappropriate and he was made paired care. He never reported being sexually assaulted by her ever. Review of facility investigation revealed several General Incident Witness statements from staff containing information that was not documented in the Resident R2's clinical record. Review of General Incident Witness Statement from licensed nurse Employee E7 dated February 5, 2025 revealed, This nurse is assigned to administer medications to this resident (Resident R2) three days a week. Resident often makes inappropriate and offensive remarks. This nurse attempts to redirection with every behavior but resident becomes defensive, angry, and is non-remorseful. Resident brought me a box with a cellphone and told me that it is for me to text him when my boyfriend is not around. This nurse refused the phone and explained to the resident that his actions were inappropriate. Resident then bought this nurse flowers that were also refused and left at the facility. When administering medications to the patient he stated, If you put lotion on my butt, I will let you look at my penis. This nurse immediately told the resident that his behavior was inappropriate and not acceptable. When administering medication to the resident he often attempted to touch/grab my hand. This nurse began placing medication and water on bedside table and watching him take it. Review of General Incident Witness Statement written by licensed nurse Employee E9 on dated November 18, 2025 but signed February 2, 2025 (verbal) revealed, During my 3-11 shift nurse aide Employee E8 came up to me and told me that the resident was making inappropriate remarks to her and she felt uncomfortable, I told her to go to the charge nurse and report her experience. Review of General Incident Witness Statement by licensed nurse Employee E7 dated November 18, 2024 revealed, During my 3-11 shift, Employee E8 came to the nurses station where I was sitting and stated that the resident (resident R2) was making inappropriate remarks while she was in the room/during care and was making her feel uncomfortable. This nurse told the supervisor and resident was made paired care immediately with no other issues for the rest of the shift. Review of Resident R2's clinical record revealed from November 12, 2024 through November 19, 2025 there were no nursing notes documenting inappropriate sexual behaviors. Further review of Resident R2's notes from January 22, 2025 through January 29, 2025 there were nuring notes addressing inappropriate sexual behaviors. 28 Pa. Code 211.5 (f)(ii) Medical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of facility policy, review of resident records, review of facility documents, and interviews with staff, it was determined that the facility failed to make certain that all allegations of abuse and neglect were timely reported to the Administrator of the facility for one of six residents reviewed (Resident R1). This delay in reporting a fall incident sustained by Resident R1, resulted in actual harm to Resident R1 who experienced a delay of treatment and was diagnosed with an acute avulsion fracture of the right tibial tuberosity (separation of the kneecap from the shin bone). Findings include: Review of facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated revised September 2022, revealed, All reports of resident abuse (including injures of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Observation, on September 8, 2023, at 9:12 a.m. Resident R1 was observed resting in bed. Bruising was present along the resident's right knee and leg area. In addition, the resident was observed with contractures (permanent shortening of a muscle or joint) to both of her legs. Interview, at the time of the observation, Employee E4, unit manager, confirmed that the bruised area on Resident R1's leg was where she sustained a fracture after falling out of bed. Review of Resident R1's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated May 31, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), malnutrition (the body doesn't get the nutrients it needs) and anxiety disorder (intense, excessive, persistent worry or fear). Continued review revealed that the resident was severely cognitively impaired. Review of Resident R1's care plan, dated initiated June 15, 2023, revealed that the resident had an activities of daily living self care performance deficit related to dementia, impaired mobility and musculoskeletal impairment. Interventions included that for bed mobility, the resident required the assistance of two staff persons for turning and repositioning and that the resident was totally dependent on staff for turning and repositioning. Continued review of Resident R1's care plan, dated initiated June 25, 2023, revealed that the resident was at risk for falls related to confusion, deconditioning/weakness, history of falls and poor safety awareness. Interventions included to educate resident, family members and caregivers about safety reminders, fall prevention and what to do if a fall occurs. Review of progress notes for Resident R1 revealed a note, dated August 19, 2023, at 4:39 p.m. which indicated, Primary care nurse reported to nursing supervisor that while getting ready to provide wound care, as she was preparing her supplies, resident observed scratching herself on right knee. Skin tear measuring 2.0 cm [centimeters] x 2.0 cm observed to right knee. The next available note was dated August 21, 2023, at 3:44 p.m. which indicated, Resident noted with bruising and increased swelling to right lower extremity and skin tear to right forearm and right knee and right LE [lower extremity]. Upon investigation resident had a change in plane on 8/19/23. Nurse was dressing resident's wound and left the bed at waist level and resident rolled over and landed on floor mat. Review of Resident R1's August 2023 Medication Administration Record (MAR) revealed that the resident was ordered Acetaminophen 500 milligrams two tablets three times a day for moderate pain on August 21, 2022 with the first dose administered on August 21, 2023 at 7:00 p.m. Continued review of August 2023's MAR revealed that the resident was also ordered and administered ice to the right knee on August 21, 2023 at 10:00 p.m. which was applied at the time of the order and on August 22, 2023 at 10:00 a.m., 1:00 p.m., 4:00 p.m., 7:00 p.m. and 10:00 p.m. Review of facility documentation submitted to the Department of Health on August 22, 2023, revealed that on Saturday, August 19, 2023, a licensed nurse was performing wound care on Resident R1. The licensed nurse turned and walked to the doorway of the room to the treatment cart. Upon turning back around, Resident R1 was noted to be lying on the floor on a fall mat. The resident was placed back to bed with the assistance of a nurse aide. X-rays were obtained Monday evening August 21, 2023, identifying an acute avulsion fracture of the tibial tuberosity. Review of the facility incident investigation revealed that the administrator and director of nursing were notified on dated August 21, 2023 of the fall sustained by Resident R1. The incident investigation noted that Resident R1 was assessed for pain and the resident was noted with pain when range of motion was performed. Review of Resident R1's radiology reports, dated August 21, 2023, confirmed that the resident had a acute avulsion fracture of the right tibial tuberosity (separation of the kneecap from the shin bone). Interview on September 8, 2023, at 12:26 p.m. Employee E8, agency licensed nurse, stated that on August 19, 2023, she entered Resident R1's room at approximately 3:30 p.m. to provide wound care to the resident. Employee E8, agency licensed nurse, stated that when she went in the room, she raised the bed approximately three feet up in the air, looked at the resident and realized that she would need assistance from another staff person to help her provide care. Employee E8, agency licensed nurse, stated that she left the room with the bed still up, walked to the doorway and asked a nurse aide to assist her. Employee E8, agency licensed nurse, stated that she gathered her supplies from the treatment cart that was parked in front of the resident's door, and that when she re-entered the room, she saw Resident R1 on the floor between the bed and the door, on her back, on the floor mat. Employee E8, agency licensed nurse, stated that she performed a skin check and saw a skin tear on the resident's right knee and performed first aide. Employee E8, agency licensed nurse, stated that Employee E7, nurse supervisor, arrived on the unit and that she informed her of the fall. Employee E8, agency licensed nurse, stated that she was advised by Employee E7, nurse supervisor, to just write up an incident on the skin tear, and not the fall. Employee E8, agency licensed nurse, stated that she felt extremely uncomfortable not documenting the fall when it occurred and that Employee E7, nurse supervisor, insisted in just documenting the skin tear. Employee E8, agency licensed nurse, stated that she did not contact the Director of Nursing until August 21, 2023, when she was asked to provide a written statement. Review of Employee E8, agency licensed nurse, written statement, dated August 21, 2023, at 11:52 p.m. revealed that Employee E7, nurse supervisor, instructed me that she would do an incident report on the skin tear only. She then added the incident report into the system and instructed me to write a statement and instructed me on what to be included on the statement. I take full responsibility for not reporting the incident as it actually happened. Review of facility documentation revealed a witness statement from Employee 10, nurse aide, dated August 21, 2023, which indicated, I was at the nurse station on the 3rd floor when [Employee E8, agency licensed nurse] came to the station to inform us of the fall. [Employee E8, agency licensed nurse] said she walked away from the bed to the cart to get more wrap, she turned around [Resident R1] was on the floor. [Employee E8, agency licensed nurse] said the cart was at the door. She wasn't that far from her. [Employee E8, agency licensed nurse] informed us the bed was not in the lowest level. Review of facility documentation revealed a witness statement from Employee E12, nurse aide, dated August 21, 2023, which indicated, [Employee E8, agency licensed nurse] came to the nurse station and said [Resident R1] fell . I asked her how. She said when she was changing her wound. I went into [Resident R1's] room her bed was not to the ground and she's a fall risk. I proceeded to help [Employee E8, agency licensed nurse] pick [Resident R1] up off the floor. Then the nurse proceeded to complete wound care. I then was doing a witness statement. [Employee E8, agency licensed nurse] came to me saying don't do a 'witness statement' there's one that don't need to be done. The [nurse supervisor] said one doesn't have to be done because [Resident R1] was on the floor mat. Continued review of facility documentation revealed a witness statement from Employee 11, nurse aide, dated August 21, 2023, which indicated, On Saturday August 19th during my 3-11 shift while sitting at the nurses station [Employee E8, agency licensed nurse] came up and stated 'I was changing [Resident R1's] wound, when I turned around from the treatment cart she was on the floor face down.' [Employee E8, agency licensed nurse] walked back down the hallway and spoke to [Employee E12, nurse aide]. [Employee E7, nurse supervisor] walked off the elevator and I told her exactly what [Employee E8, agency licensed nurse] said to me. [Employee E12, nurse aide] comes back to the nurses station with a witness statement paper. [Employee E7, nurse supervisor] told [Employee E8, agency licensed nurse] that the fall 'did not need to be written up.' [Employee E8, agency licensed nurse] then walked up to [Employee E12, nurse aide] and told her that the nurse supervisor told her to discard the witness statement. [Employee E7, nurse supervisor] then applied a treatment to resident's leg and walked back into unit managers office. Interview with Employee E11, nurse aide, on September 8, 2023, at 3:10 p.m. revealed that although Resident R1's fall occurred on Saturday, August 19, 2023, she was not asked to write a witness statement until Monday, August 21, 2023. Employee E11, nurse aide, confirmed that Employee E8, agency licensed nurse, reported to other staff on duty, including the nurse supervisor, that Resident R1 fell when it occurred on August 19, 2023. Interview with Employee E9, nurse aide, on September 8, 2023, at 12:03 p.m. revealed that she was at the nurses station when Employee E8, agency licensed nurse, came down the hallway, stating that Resident R1 fell . Employee E9, nurse aide, confirmed that Resident R1 fell because Employee E8, agency licensed nurse, left the resident unattended while the bed was left up in an elevated position. Employee E9, nurse aide, also confirmed that although the Resident R1's fall occurred on Saturday, August 19, 2023, she was not asked to write a witness statement until Monday, August 21, 2023. Further review of facility documentation revealed a witness statement from Employee E7, nurse supervisor, dated August 24, 2023, which indicated, Primary care nurse reported to nursing supervisor that patient rolled onto the floor mat and sustained a right knee skin tear. It was my understanding that being as though the patient was care planned for already having [bilateral] fall mats, I needed to document the new skin issue. Interview on September 8, 2023, at 1:53 p.m. the Director of Nursing stated that during wound rounds on Monday, August 21, 2023, staff noticed that Resident R1's right lower leg looked different and that bruising was present. The physician was present, ordered x-rays and an investigation was initiated at that time. The Director of Nursing stated that the first witness statement was obtained from Employee E10, nurse aide, and that's how it was discovered that Resident R1 had a fall. The Director of Nursing confirmed that Employee E8, agency licensed nurse, is no longer allowed to work at the facility and that Employee E7, nurse supervisor, resigned from her position at the facility during the investigation. Employee E8, licensed nurse failed to timely report Resident R1's fall, and Employee E7, nurse supervisor, also failed to properly report Resident R1's fall, which resulted in neglect and the delay in treatment for Resident R1 who sustained a fall on August 19, 2023, it was not until August 21, 2023 (four days after the fall incident) that it was reported that the resident was noted with bruising and increased swelling to right lower extremity, pain during range of motion to the lower extremities. X-ray obtained on August 21, 2023 revealed that Resident R1 sustained an acute avulsion fracture of the tibial tuberosity. Refer to F600. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(e)(1) Management

Based on observations, review of facility policies, review of clinical record, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that one of six residents reviewed (Resident R1) remained free from neglect, which resulted in actual harm to Resident R1 who sustained an acute avulsion fracture of the tibial tuberosity (separation of the kneecap from the shin bone). Findings include: Review of facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated October 2022, revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Continued review revealed that the facility will, Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property. Review of facility policy, Accidents and Incidents - Investigating and Reporting dated revised July 2017, revealed, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Continued review revealed, The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of facility policy, Dressings, Dry/Clean dated revised September 2013, revealed that in preparation for the application of dry, clean dressings, that the following should be completed: 1. Verify that there is a physician's order for this procedure; 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs; 3. Check the treatment record; 4. Assemble the equipment and supplies as needed .; 5. Explain procedure to the resident and provide privacy. Observation, on September 8, 2023, at 9:12 a.m. revealed that Resident R1 was resting in bed. Bruising was present along the resident's right knee and leg area. In addition, the resident was observed with contractures (permanent shortening of a muscle or joint) to both of her legs. Interview, at the time of the observation, Employee E4, unit manager, confirmed that the bruised area on Resident R1's leg was where she sustained a fracture after falling out of bed. Review of Resident R1's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated May 31, 2023, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), malnutrition (the body doesn't get the nutrients it needs) and anxiety disorder (intense, excessive, persistent worry or fear). Continued review revealed that the resident was severely cognitively impaired. Review of Resident R1's care plan, dated initiated June 15, 2023, revealed that the resident had an activities of daily living self care performance deficit related to dementia, impaired mobility and musculoskeletal impairment. Interventions included that for bed mobility, the resident required the assistance of two staff persons for turning and repositioning and that the resident was totally dependent on staff for turning and repositioning. Continued review of Resident R1's care plan, dated initiated June 25, 2023, revealed that the resident was at risk for falls related to confusion, deconditioning/weakness, history of falls and poor safety awareness. Interventions included to educate resident, family members and caregivers about safety reminders, fall prevention and what to do if a fall occurs. Review of nursing notes for Resident R1 revealed a note, dated August 19, 2023, at 4:39 p.m. which indicated, Primary care nurse reported to nursing supervisor that while getting ready to provide wound care, as she was preparing her supplies, resident observed scratching herself on right knee. Skin tear measuring 2.0 cm [centimeters] x 2.0 cm observed to right knee. Continued review of nursing notes revealed a note, dated August 21, 2023, at 3:44 p.m. which indicated, Resident noted with bruising and increased swelling to right lower extremity and skin tear to right forearm and right knee and right LE [lower extremity]. Upon investigation resident had a change in plane on 8/19/23. Nurse was dressing resident's wound and left the bed at waist level and resident rolled over and landed on floor mat. Review of Resident R1's radiology reports, dated August 21, 2023, revealed that the resident had an acute avulsion fracture of the tibial tuberosity (separation of the kneecap from the shin bone). Review of facility documentation submitted to the Department of Health on August 22, 2023, revealed that on Saturday, August 19, 2023, a licensed nurse was performing wound care on Resident R1. The licensed nurse turned and walked to the doorway of the room to the treatment cart. Upon turning back around, Resident R1 was noted to be lying on the floor on a fall mat. The resident was placed back to bed with the assistance of a nurse aide. X-rays were obtained Monday evening August 21, 2023, identifying an acute avulsion fracture of the tibial tuberosity. Interview on September 8, 2023, at 12:26 p.m. Employee E8, agency licensed nurse, stated that on August 19, 2023, she entered Resident R1's room at approximately 3:30 p.m. to provide wound care to the resident. Employee E8, agency licensed nurse, stated that it was her first time doing wound care on the resident, that she's never had to reposition the resident before and that she did not read the resident's care plan prior to going in to provide care. Employee E8, agency licensed nurse, stated that she was not aware that Resident R1 required two person assistance for bed mobility, turning and repositioning. Employee E8, agency licensed nurse, stated that when she went in the room, she raised the bed approximately three feet up in the air, looked at the resident and realized that she would need assistance from another staff person to help her provide care. Employee E8, agency licensed nurse, stated that she left the room with the bed still up, walked to the doorway and asked a nurse aide to assist her. Employee E8, agency licensed nurse, stated that she gathered her supplies from the treatment cart that was parked in front of the resident's door, and that when she re-entered the room, she saw Resident R1 on the floor between the bed and the door, on her back, on the floor mat. Employee E8, agency licensed nurse, stated that the nurse aide entered the room and helped her put the resident back into bed. Employee E8, agency licensed nurse, stated that she performed a skin check and saw a skin tear on the resident's right knee and performed first aide. Employee E8, agency licensed nurse, stated that she went to the nurses station where several staff were sitting and asked them if they knew where the supervisor was because Resident R1 just fell . Employee E8, agency licensed nurse, continued that Employee E7, nurse supervisor, arrived on the unit and that she informed her of the fall. Employee E8, agency licensed nurse, stated that she was advised by Employee E7, nurse supervisor, to just write up an incident on the skin tear, and not the fall. Employee E8, agency licensed nurse, confirmed that she was aware that Resident R1 sustained a fracture and expressed remorse for not properly documenting the fall when it occurred. Review of facility documentation revealed a witness statement from Employee E12, nurse aide, dated August 21, 2023, which indicated, [Employee E8, agency licensed nurse] came to the nurse station and said [Resident R1] fell . I asked her how. She said when she was changing her wound. I went into [Resident R1's] room her bed was not to the ground and she's a fall risk. I proceeded to help [Employee E8, agency licensed nurse] pick [Resident R1] up off the floor. Then the nurse proceeded to complete wound care. I then was doing a witness statement. [Employee E8, agency licensed nurse] came to me saying don't do a 'witness statement' there's one that don't need to be done. The [nurse supervisor] said one doesn't have to be done because [Resident R1] was on the floor mat. Continued review of facility documentation revealed a witness statement from Employee 11, nurse aide, dated August 21, 2023, which indicated, On Saturday August 19th during my 3-11 shift while sitting at the nurses station [Employee E8, agency licensed nurse] came up and stated 'I was changing [Resident R1's] wound, when I turned around from the treatment cart she was on the floor face down.' [Employee E8, agency licensed nurse] walked back down the hallway and spoke to [Employee E12, nurse aide]. [Employee E7, nurse supervisor] walked off the elevator and I told her exactly what [Employee E8, agency licensed nurse] said to me. [Employee E12, nurse aide] comes back to the nurses station with a witness statement paper. [Employee E7, nurse supervisor] told [Employee E8, agency licensed nurse] that the fall 'did not need to be written up.' [Employee E8, agency licensed nurse] then walked up to [Employee E12, nurse aide] and told her that the nurse supervisor told her to discard the witness statement. [Employee E7, nurse supervisor] then applied a treatment to resident's leg and walked back into unit managers office. Interview with Employee E11, nurse aide, on September 8, 2023, at 3:10 p.m. revealed that although Resident R1's fall occurred on Saturday, August 19, 2023, she was not asked to write a witness statement until Monday, August 21, 2023. Employee E11, nurse aide, confirmed that Employee E8, agency licensed nurse, reported to other staff on duty, including the nurse supervisor, that Resident R1 fell when it occurred on August 19, 2023. Continued review of facility documentation revealed a witness statement from Employee 9, nurse aide, dated August 21, 2023, which indicated, I was at the nurses station doing charting when [Employee E8, agency licensed nurse] had said [Resident R1] was on the floor. [Employee E8, agency licensed nurse] said she turned around and she was on the floor. I heard [Employee E8, agency licensed nurse] say the bed was waist. Interview with Employee E9, nurse aide, on September 8, 2023, at 12:03 p.m. revealed that she was at the nurses station when Employee E8, agency licensed nurse, came down the hallway, stating that Resident R1 fell . Employee E9, nurse aide, confirmed that Resident R1 fell because Employee E8, agency licensed nurse, left the resident unattended while the bed was left up in an elevated position. Employee E9, nurse aide, also confirmed that although Resident R1's fall occurred on Saturday, August 19, 2023, she was not asked to write a witness statement until Monday, August 21, 2023. Continued review of facility documentation revealed a witness statement from Employee 10, nurse aide, dated August 21, 2023, which indicated, I was at the nurse station on the 3rd floor when [Employee E8, agency licensed nurse] came to the station to inform us of the fall. [Employee E8, agency licensed nurse] said she walked away from the bed to the cart to get more wrap, she turned around [Resident R1] was on the floor. [Employee E8, agency licensed nurse] said the cart was at the door. She wasn't that far from her. [Employee E8, agency licensed nurse] informed us the bed was not in the lowest level. Further review of facility documentation revealed a witness statement from Employee E7, nurse supervisor, dated August 24, 2023, which indicated, Primary care nurse reported to nursing supervisor that patient rolled onto the floor mat and sustained a right knee skin tear. It was my understanding that being as though the patient was care planned for already having [bilateral] fall mats, I needed to document the new skin issue. Interview on September 8, 2023, at 1:53 p.m. the Director of Nursing stated that during wound rounds on Monday, August 21, 2023, staff noticed that Resident R1's right lower leg looked different and that bruising was present. The physician was present, ordered x-rays and an investigation was initiated at that time. The Director of Nursing stated that the first witness statement was obtained from Employee E10, nurse aide, and that's how it was discovered that Resident R1 had a fall. Review of Treatment Administration Records for Resident R1 revealed a physician's order, dated to start August 19, 2023, to cleanse right knee skin tear with normal saline, apply topical antibiotic ointment and cover with border gauze. Continued review revealed that on August 20, 2023, at 6:00 p.m. the treatment was completed by Employee E14, licensed nurse. Further review of nursing notes for Resident R1 revealed that there were no notes entered for the Resident on August 20, 2023. Further review of witness statements revealed that no statement was obtained from Employee E14, licensed nurse. Interview on September 8, 2023, at 4:30 p.m. the Nursing Home Administrator confirmed that no witness statement had been obtained from Employee E14, licensed nurse, to determine if any changes or bruising were observed by this employee, and confirmed that the nurse provided direct care to Resident R1's knee on August 20, 2023, the day after the fall occurred. Review of facility documentation related to Resident R1's fall revealed that the incident occurred on August 19, 2023, at 4:00 p.m. and that the resident's family and physician were not notified until August 21, 2023. The report indicated that, Resident had a fall from bed with injury. Staff educated after performing care or feeding to have bed in lowest position before leaving room. Continued review revealed, Bed was at waist level and unattended. Nurse was dressing wound and stepped away. The facility failed to ensure that Resident R1 was free of neglect related to Employee E8, agency licensed nurse, not following Resident R1's fall prevention care plan, elevating the resident's bed and walking away to obtain treatment supplies. Resident R1 fell from the bed and sustained an acute avulsion fracture of the tibial tuberosity. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 201.18(b)(2) Management 28 Pa Code 201.18(e)(1) Management 28 Pa Code 201.29(c) Resident rights

Based on review of facility policies, review of facility documentation, review of security camera video, clinical record review and interviews with residents and staff, it was determined that the facility failed to ensure that a resident was free from physical abuse for one of three residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1 who was rough handled, slapped, poked, punched, pushed and pulled by three nurse aides (Employee E26, Employee E27 and Employee E28). This deficiency was identified as Immediate Jeopardy past non compliance. Findings include: Review of undated facility policy, Abuse, Neglect, Exploitation and Misappropriation revealed that the facility would, protect residents from abuse, neglect, exploitation and misappropriation of property by anyone, including, but not limited to, facility staff. Review of Resident R1's Quarterly Minimum Data Set (MDS- a mandatory periodic resident assessment tool) dated December 20, 2022, revealed that the resident was admitted to the facility on [DATE], and had diagnoses of dementia with behavioral disturbance (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities with behaviors that may include aggression, wandering and hoarding), ataxia following cerebrovascular disease (a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in eye movements) and visual hallucinations (you might see vivid scenes with family members, animals, or religious figures). Resident R1 was assessed with minimal difficulties with hearing. The resident required extensive assistance with transfer of one person and demonstrated no ambulatory capabilities. The resident's balance when moving from a seated to a standing was not steady. Review of Resident R1's care plan dated December 5, 2022, revealed that the resident had the potential to demonstrate verbally abusive behaviors related to dementia, mental/emotional illness. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalates the resident's behaviors and to give the resident as many choices as possible about care and activities. Review of nursing note written by the Director of Nursing (DON), dated January 6, 2023, at 11:39 a.m. indicated that she was made aware by a staff member that on January 5, 2023 while in dining room Resident R1 was physically mishandled by several caregivers including being picked up from the floor without licensed nurse assessment. The resident did not hit his head and was unable to recall details of event. Review of facility documentation, which included the information submitted to the State Survey Agency dated January 6, 2023, indicated that the receptionist, Employee E8, reported that she observed a nurse aide, Employee E26 in the dining room with Resident R1, and the aide pulled the residents shirt and pushing the resident's wheelchair into a table to keep the resident from being able to move out of his chair. The Nursing Home Administrator (NHA) further reviewed the security [NAME] video which showed Employee E26 also pinching and punching Resident R1. The [NAME] video also showed another nurse aide, Employee E27 smacking Resident R1 and pushing him in the back and a third aide, Employee E28, also on the video elbowing Resident R1 in the shoulder and poking him on the side of his head. A telephone interview on January 17, 2023, at 1:30 p.m. with the evening receptionist, Employee E8, revealed that on Thursday, January 5, 2023, she was on duty sitting at the front desk and happened to watch the security camera monitor and notice aide, Employee E26, pulling the shirt of Resident R1. She said that the Activity Director, Employee E9, was in the lobby and she called her over to watch the monitor to confirm what she was seeing. She said that the aide went on break while Employee E9 was covering the desk, and when the aide came back inside the building she asked for her name. She also said that she and Employee E9 discussed reporting the incident and that since it was after dinner and the NHA and DON had already left for the day and since she had changed her shift to 8:00 a.m. for the next day she said that Employee E9 said that she should talk to the NHA in the morning. Interview on January 17, 2023, at 1:43 p.m. with the Activity Director, Employee E9 revealed that she was behind the reception desk making copies when I heard the receptionist, Employee E8 say, Oh my god! I asked her if she was ok, and she said look at this. I looked at the monitor and saw an aide being aggressive with Resident R1. I did not know the aide's name at that point. I covered the desk while Employee E8 went to the rest room, and I saw the employee go out the front door for her break. When Employee E8 returned I told her about the aide going out the door. She said that Employee E8 said that she was going to report the incident to the NHA, and I was copied on an email that she sent to the NHA. She said that when she came in after 9:00 a.m. on Friday, January 6, 2023, the investigation had already started, so I know that Employee E8 had reported the incident. Interview on January 17, 2023, at 1:50 p.m. with NHA revealed that he had five video camera clips from the security camera on his computer which were viewed. Clip one revealed Employee E27, nurse aide, pulling Resident R1 by the back of his shirt. Clip two shows Employee E27, nurse aide, again pulling Resident R1 by his shirt while he was on the floor, unsuccessfully trying to get him back into his wheelchair, and then she grabs the resident under the arms and roughly jerks him up and struggles to drag him back into his chair. Clip three shows Employee E27, nurse aide, swatting Resident R1's hands and arms, and then she shoves him in the back. Clip four shows Employee E26, nurse aide, pulling the back of Resident R1's shirt and later pushing him in the back. Clip four also shows Employee E28, nurse aide, pushing the resident, then swatting his arms and then she pushes his shoulder roughly with her elbow and forarm like she is wiping something onto him. She then leans over the resident's left side with her face in his ear, like she was whispering something into his ear. She then walks around to the right side of the resident and roughly pushes the right side of the resident's head. Clip five shows Employee E26 coming back and getting up close to Resident R1 and putting her face next to his right ear, like she is whispering to the resident, and then she pushes his wheelchair into the table, the table moves and the resident is bracing his hands on the table to keep from being pushed into the table and the table starts to slide across the floor. Then she gets her cell phone out and sits on a chair behind the resident and plays on her phone. Employee E26 then gets up and pushes two dining room chairs away from the resident's reach and again pushes his wheelchair up against the table so he cannot get out of his chair. While trying to push the resident against the table the resident's right foot gets caught under the front wheel of the wheelchair and she continues to push the chair against the table and bending the resident's foot under the wheel. She then sits in a chair behind the resident with her feet pushing the wheelchair against the table so he cannot move. The deficiency was identified as Immediate Jeopardy past non compliance. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator on January 17, 2023, at 4:06 p.m. The facility initiated a plan of correction to address the failure of ensuring that a resident was free from physical abuse. Facility plan of correction included the following: 1. The DON completed an assessment of Resident R1, on January 6, 2023, for any signs of injury related to the allegation of physical abuse. There were no physical injuries noted. An additional skin check was completed on January 7, 2023. 2. The facility initiated an abuse investigation into the allegations on January 6, 2023. 3. The facility reviewed the Resident Abuse policy and implemented all the actionable items outlined in the policy. The facility implemented the abuse policy on January 6, 2023. 4. Nursing staff implemented assessments and documentation of the resident for signs of injury every shift for 72 hours. 5. Resident care plan was updated to reflect the incident on January 6, 2023. 6. Police were notified of the allegation on January 6, 2023, they responded to the facility and a report was filed. 7. Social Service Director assessed the resident on January 6, 2023, for signs of psychosocial harm. None were identified. 8. Social Service Director or nursing staff will continue to assess and document for affected residents for any signs of psychosocial harm for the next seven days. 9. Receptionist and three aides were in question were suspended pending the outcome of the investigation. 10. Employee files were reviewed for abuse training, background checks and reference checks. 11. Whole house audits were completed on January 6, 2023, and January 7, 2023, to ensure residents have not experienced abuse or have any physical or psychosocial signs of abuse. a. Residents who are non-interviewable received head to toe skin assessments. b. On January 7, 2023, head to toe skin assessments were completed for residents on the perpetrator's assignments for any signs of physical abuse. c. Residents who were interviewable were interviewed on January 6, 2023, by administrative staff regarding any concerns with being mistreated or violations of their rights. 12. A Resident Council meeting was held on January 9, 2023, to review and discuss abuse, neglect and resident rights. This was held by the Administrator. 13. The interdisciplinary team will review nurses progress notes during clinical meeting daily for residents with behavioral disturbances for identification of appropriate care plan interventions. Walking rounds will be conducted two times each shift by a designated staff member starting on January 6, 2023, and will be continued daily on all residents to observe for any possible abuse, neglect, or violation of resident's rights until a thorough review is conducted by the QAPI committee. Findings will be reported to the Administrator or DON daily. If any violation is observed the staff will ensure resident safety, remove alleged violator from the patient care area and report to charge nurse, Administrator, DON or abuse coordinator. Immediate staff re-education initiated by the DON and administrative staff on the following policies: 14. Education on abuse, neglect and rough handling of residents was initiated for staff members was initiated on January 6, 2023. All staff, including ancillary departments, in the facility on January 6, 2023, were in-serviced. The facility in-serviced 100% of the staff. 15. Staff not working on January 6, 2023, were required to complete abuse education prior to their next scheduled shift. Staff will receive education upon arrival to work prior to taking any assignment. The nursing supervisor will be at the time clock to provide direct education before staff report to their respective unit. An AD HOC QAPI meeting was conducted on January 11, 2023, to discuss the incident as well as all education provided, assessments of all residents, process for reporting and investigating abuse. Continued monitoring plan - The interdisciplinary team will review nurses progress notes and incident reports during clinical meeting daily for residents with behavioral disturbances for identification of appropriate care plan interventions. Walking rounds will be conducted three times per week on alternating shifts for four weeks to observe for any possible abuse, neglect or violation of resident's rights. The administrator of designee will submit findings from audits to the Quality Assurance Process Improvement Committee meetings monthly for review and additional recommendations as needed. Further audit frequency will be determined based on audit findings. Review of facility documentation revealed that the corrective action plan was immediately initiated on January 6, 2023. Audits were initiated to screen residents for abuse. Residents were interviewed by facility staff and resident council meetings were conducted. Abuse and neglect were discussed, reporting procedures were explained and residents were assured of their safety. Residents expressed no concerns and no further occurrences of abuse. Facility in-services for staff were promptly initiated and included abuse (like rough handling), neglect and resident rights and reporting requirements. Interviews were conducted on January 17, 2023, between 1:55 p.m.-3:05 p.m. with staff from various departments. All staff reported that they received the in-service training on abuse prevention and reporting within the past two weeks. It was confirmed during the interviews that they were able to recognize signs of resident abuse, that they were knowledgeable on reporting resident abuse as well as their role in the abuse investigation process. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with staff, it was determined that the facility failed to ensure that physician's orders were reconcile upon readmission to the facility, that physician's orders for insulin administration were followed and that blood glucose levels were checked as ordered by the physician. This failure resulted in actual harm to Resident R1 who developed high glucose levels for one of 13 clinical records reviewed. This failure was identified as past non-compliance. (Resident R1) Findings include: Review of the facility policy Admission Assessment and Follow Up: Role of the Nurse, undated, revealed a faciity procedure to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating, the care plan, and completing required assessment instruments. Facility policy stated that the nurse was to conduct an admission assessment (history and physical), including: a summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission .a list of active medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the policy revealed that the nurse was to reconcile the list of medications from the medication history, admitting orders, the previous MAR (Medication Administration record) (if available), and the discharge summary from the previous institution, according to established procedures. In addition, the nurse was to contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The supervisor and the physician were to be notified of immediate needs of the resident. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's orders dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's orders dated [DATE], revealed an order to check resident's blood glucose level (amount of sugar in the blood) using accucheck machine (electronic device that measures blood sugar level) four times a day, before meals and at bedtime. Continued review of Resident R1's clinical record revealed that the resident was transferred to an acute care hospital on [DATE], for vomiting coffee grounds- like substance (dark brown granular material). Resident was admitted to the hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing note dated [DATE] at 7:49 p.m. revealed that all physician's orders were verified with the certified registered nurse practitioner. Review of the discharge instructions from the acute care hospital revealed Resident R1 was to receive [MEDICATION(S)] ,d+[DATE] insulin 20 units, subcutaneously, before breakfast and before dinner. The instructions also revealed that the next dose of the insulin was to be administered at 5:00 p.m. the same day, [DATE]. Further review of the Resident R1's clinical record did not reveal that a physician's order was obtained to administer the insulin as it was included in the hospital discharge instructions. Continued review of the clinical record revealed a nursing note of [DATE], at 8:00 a.m. that indicated that resident was found on the floor next to her bed, that she had an unwitnessed fall. The same note documented that resident had full range of motion of all four extremities, and extremities were stiff. The noted also stated that Resident R1 was assessed by a registered nurse and skin was intact, and that neuro checks (assesses level of consciousness, vital signs, response to stimuli to determine abnormalities) were started. Further review of the clinical record did not reveal any documentation that resident's blood sugar level (amount of sugar in blood) was checked after the fall. Continued review of the clinical record revealed a nursing note of [DATE], at 5:42 p.m. that stated that resident ate minimal amount of food, did drink, took medications, and had no complaints of pain. It was noted that the resident's vital signs were within normal limits (WNL), and Blood Sugar was 499 (target range 70 - 160 mg. dL (milligrams per deciliter). The note stated that the physician was contacted and ordered accucheck with 6 units of NPH insulin. Review of the physician's orders for Resident R1 revealed a verbal physician's order received [DATE], at 5:06 p.m. by the nurse, Employee E17, to administer NPH Insulin Isophan & Regular (,d+[DATE]), 100 units per milliliter, 6 units, twice per day and was scheduled for 8 a.m. and 4 p.m. daily and scheduled to start [DATE]. In addition, a verbal physician's order also was received on [DATE], at 5:17 p.m., by the licensed nurse to complete an accucheck to measure the resident's blood glucose level, two times a day and was scheduled for 8 a.m. and 4 p.m and scheduled to start [DATE]. Review of Resident R1's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of the MAR for September, 2021 revealed that the NPH Insulin Isophan & Regular (,d+[DATE]) was scheduled for 8 a.m. [DATE] and there was no documentation that it was administered. Further review of the clinical record revealed a nursing note of [DATE], at 10:02 p.m. and stated that resident was sleepy most of shift, taking fluids by mouth. Also the same nursing note stated that there was no signs or symptoms of any respiratory distress noted Review of the clinical record revealed a nursing note of [DATE], at 11:30 a.m. that stated that resident was found lethargic (drowsiness, respond slowly to stimuli, questions, and commands, appears sleepy) and difficult to arouse and blood glucose level registered Hi.(indicates glucose high critical level depending on calibration, above 600 mg/dL). Note stated that no respiratory distress was noted, oxygen was administered via nasal cannula, and head of bed remained elevated. Physician was notified and gave orders to confirm resident transfer to hospital. Nursing note stated that family was notified and agreed for resident to be transferred to the hospital. Continued review of the nursing documentation revealed a note of [DATE], at 12:10 p.m. that stated that the resident was found with no apical pulse and no rise or fall of chest. Resident found expired. Review of faciity documentation revealed a death certificate (non-certified) which listed the cause of death as metastatic lung cancer. Review of facility documentation revealed that the facility initiated an investigation on [DATE], conducted staff interviews and obtained statements from staff. Review of statement from Employee E16's, supervisor ,d+[DATE] shift, [DATE], revealed that Employee E16 reviewed Resident R1's hospital discharge instructions with Certified Registered Nurse Practitioner (CRNP) and Employee E16 informed the CRNP, Employee E5, that the resident did not eat well while in the hospital. Employee E16 documented that the CRNP, Employee E5, instructed the licensed nurse to discontinue the order for insulin . Review of Resident R1's clinical record did not reveal documentation that Resident R1's hospital discharge orders were reviewed with CRNP. During an interview with the CRNP, Employee E5, on [DATE], at 2:05 p.m. revealed that Resident R1's discharge instructions were reviewed with Employee E16 and the CRNP, Employee E5, stated that she instructed Employee 16 to hold the NPH insulin for the weekend ([DATE] (Friday), [DATE] (Saturday), and [DATE] (Sunday), 2021) and that the insulin order would be review again on Monday, [DATE]. The CRNP, Employee E5, also stated during the interview that the accuchecks were to be continued. Review of the summary statement from Employee E17, licensed nurse ,d+[DATE] shift, [DATE], revealed that Employee E17 did obtain the accucheck for Resident R1 on Septmber 12, 2021, and it was 499. Also, Employee E17 did notify the Employee E19, CRNP, of the results of the accucheck level. Employee E17 did obtain a physician's order from Employee E19, CRNP, to administer 6 units of NPH insulin twice a day and complete accuchecks twice a day. Review of Resident R1's clinical record revealed that Employee E17 entered the physician's orders obtained [DATE], for the NPH insulin, at 5:07 p.m. and accuchecks, at 5:17 p.m. to be completed twice a day, and scheduled the NPH insulin and accuchecks to be started on [DATE], at 8:00 a.m. Review of the summary statement from Employee E18, licensed nurse ,d+[DATE] shift, [DATE], revealed that Employee E18 did check Resident R1's blood glucose level on [DATE] and the results were Hi. Employee E18 did contact the physician and instructed to contact family to confirm wishes to transfer resident to hospital for evaluation. Review of Resident R1's clinical record revealed that documentation on the MAR (Medication Administration Record) was initialed for 8:00 a.m. accucheck completed. During an an interview with the Director of Nursing, Employee E3, Regional Nurse, Employee E4, VP Clinical Services, and Employee E4, Regional Director of Operations, on [DATE], at 1:45 p.m. it was confirmed that the discharge instructions from the hospital for Resident R1 to receive [MEDICATION(S)] insulin before breakfast and before dinner were not followed and resident did not receive the insulin as recommended. During the same interview, it was confirmed that the physician's order of [DATE], for Resident R1 to receive NPH insulin 6 units twice a day and check of Resident R1's blood glucose level twice a day with accucheck device was not followed resulting in harm to the resident. This deficiency was identified as past non-compliance. On [DATE], the facility initiated a plan of correction to address the failure of nursing staff to reconcile physician's order for insulin, follow the physician's order to administer insulin and check blood glucose level, and identify and report a change in resident's condition (blood glucose level). Facility plan of correction included the following: 1. Interviews of nursing staff involved with care of the resident were conducted. 2. Termination of licensed nurses found to be negligent. 3. Reporting of nurses' neglect to required agencies was done. 4. Medication Error: Resident R1 expired on [DATE]; a medication error event report has been completed; the physician was notified of the medication error. An Audit was completed of all residents with insulin orders to assure compliance with physician order. Any discrepancy identified through the audit was to be reported to the physician. 5. Licensed Nurses will be educated on the appropriate insulin administration, on the process for physician notification if insulin or antidiabetic agents are unavailable, on the signs of symptoms of [CONDITION(S)] and [CONDITION(S)] and on the actions of insulin and antidiabetic agents. Licensed Nurses will not work without receiving the required education. Licensed Nurses will have a competency for insulin administration. 6. The Director of Nursing/designee will randomly audit the medication administration records of a number of residents weekly. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting will be held and results of the audits will be reviewed during the monthly QAPI Meeting. The facility alleged compliance with the QAPI Plan as of [DATE]. Review of facility doucmentation revealed that correction plan was immediately developed and initiated on [DATE]. The faciity conducted audits for all new admissions from the last 30 days prior [DATE] and physician's orders were reviewed for accuracy of transcriptions. Records of residents who received insulin were audited to confirm accuracy of physician orders and continued weekly. Nursing staff was inserviced on [CONDITION(S)], [CONDITION(S)], actions of insulin and antidiabetic agents, identification of changes in conditions of residents, and the process of medication reconciliation for admissions and readmissions. Review of facility documentation revealed competencies for insulin administration were completed for licensed nursing staff. Interviews of licensed nursing staff were conducted on [DATE], confirmed that the inservices for resident change of condition, reconciliation of admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Ps. Code 201.18(b)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(c) Nursing services

Based on review of clinical records, review of facility documentation, review of facility policies, and interviews with staff, it was determined that the facility failed to protect the rights of Resident R1 to be free from neglect, which resulted in actual harm to Resident R1 who did not receive insulin medication as ordered by the physician and developing high blood sugar levels. This failure was identified as past non-compliance (Resident R1) for one of 13 clinical records reviewed. Findings include: Continued review of the policy revealed that the nurse was to reconcile the list of medications from the medication history, admitting orders, the previous MAR (Medication Administration record) (if available), and the discharge summary from the previous institution, according to established procedures. In addition, the nurse was to contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The supervisor and the physician were to be notified of immediate needs of the resident. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident R1's clinical record revealed that the resident was transferred to an acute care hospital on [DATE] for vomiting coffee grounds- like substance (dark brown granular material). Resident was admitted to the hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing note dated [DATE] at 7:49 p.m. revealed that all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge instructions from the acute care hospital revealed Resident R1 was to receive [MEDICATION(S)] ,d+[DATE] insulin 20 units, subcutaneously, before breakfast and before dinner. The instructions also revealed that the next dose of the insulin was to be administered at 5:00 p.m. the same day, [DATE]. Further review of the Resident R1's clinical record did not reveal that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the clinical record revealed a nursing note of [DATE], at 8:00 a.m. that indicated that resident was found on the floor next to her bed, that she had an unwitnessed fall. The same note documented that resident had full range of motion of all four extremities, and extremities were stiff. The noted also stated that Resident R1 was assessed by a registered nurse and skin was intact, and that neuro checks (assesses level of consciousness, vital signs, response to stimuli to determine abnormalities) were started. Further review of the clinical record did not reveal any documentation that resident's blood sugar level (amount of sugar in blood) was checked after the fall. Continued review of the clinical record revealed a nursing note of [DATE], at 5:42 p.m. that stated that resident ate minimal amount of food, did drink, took medications, and had no complaints of pain. It was noted that the resident's vital signs were within normal limits (WNL), and Blood Sugar was 499 (target range 70 - 160 mg. dL (milligrams per deciliter). The note stated that the physician was contacted and ordered accucheck with 6 units of NPH insulin. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & Regular (,d+[DATE]), 100 units per milliliter, 6 units, twice per day and was scheduled for 8 a.m. and 4 p.m. daily and scheduled to start [DATE]. In addition, a verbal physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .m and scheduled to start [DATE]. Review of Resident R1's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of the MAR for September, 2021 revealed that the NPH Insulin Isophan & Regular (,d+[DATE]) was scheduled for 8 a.m. [DATE] and there was no documentation that it was administered. Further review of the clinical record revealed a nursing note of [DATE], at 10:02 p.m. and stated that resident was sleepy most of shift, taking fluids by mouth. Also the same nursing note stated that there was no signs or symptoms of any respiratory distress noted Review of the clinical record revealed a nursing note of [DATE], at 11:30 a.m. that stated that resident was found lethargic (drowsiness, respond slowly to stimuli, questions, and commands, appears sleepy) and difficult to arouse and blood glucose level registered Hi.(indicates glucose high critical level depending on calibration, above 600 mg/dL). Note stated that no respiratory distress was noted, oxygen was administered via nasal cannula, and head of bed remained elevated. Physician was notified and gave orders to confirm resident transfer to hospital. Nursing note stated that family was notified and agreed for resident to be transferred to the hospital. Continued review of the nursing documentation revealed a note of [DATE], at 12:10 p.m., that stated that the resident was found with no apical pulse and no rise or fall of chest. Resident found expired. Review of faciity documentation revealed a death certificate (non-certified) which listed the cause of death as metastatic lung cancer. Review of facility documentation revealed that the facility initiated an investigation on [DATE], conducted staff interviews and obtained statements from staff. Review of statement from Employee E16's, supervisor ,d+[DATE] shift, [DATE], revealed that Employee E16 reviewed Resident R1's hospital discharge instructions with CRNP and Employee E16 informed the CRNP, Employee E5, that the resident did not eat well while in the hospital. Employee E16 documented that the CRNP, Employee E5, instructed the licensed nurse to discontinue the order for insulin . Review of Resident R1's clinical record did not reveal documentation that Resident R1's hospital discharge orders were reviewed with CRNP. During an interview with the CRNP, Employee E5, on [DATE] at 2:05 p.m. revealed that Resident R1's discharge instructions were reviewed with Employee E16 and the CRNP, Employee E5, stated that she instructed Employee 16 to hold the NPH insulin for the weekend ([DATE] (Friday), [DATE] (Saturday), and [DATE] (Sunday), 2021, and that the insulin order would be review again on Monday, [DATE]. The CRNP, Employee E5, also stated during the interview that the accuchecks were to be continued. Review of the summary statement from Employee E17, licensed nurse ,d+[DATE] shift, [DATE], revealed that Employee E17 did obtain the accucheck for Resident R1 on Septmber 12, 2021 and it was 499. Also, Employee E17 did notify the Employee E19, CRNP, of the results of the accucheck level. Employee E17 did obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident R1's clinical record revealed that Employee E17 entered the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the summary statement from Employee E18, licensed nurse ,d+[DATE] shift, [DATE], revealed that Employee E18 did check Resident R1's blood glucose level on [DATE] and the results were Hi. Employee E18 did contact the physician and instructed to contact family to confirm wishes to transfer resident to hospital for evaluation. Review of Resident R1's clinical record revealed that documentation on the MAR (Medication Administration Record) was initialed for 8:00 a.m. accucheck completed. During an an interview with the Director of Nursing, Employee E3, Regional Nurse, Employee E4, VP Clinical Services, and Employee E4, Regional Director of Operations, on [DATE], at 1:45 p.m. it was confirmed that the discharge instructions from the hospital for Resident R1 to receive [MEDICATION(S)] insulin before breakfast and before dinner were not followed and resident did not receive the insulin as recommended. During the same interview, it was confirmed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency was identified as past non-compliance. On [DATE] the facility initiated a plan of correction to address the failure of nursing staff to neglect the reconciliation of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility plan of correction included the following: 1. Interviews of nursing staff involved with care of the resident were conducted. 2. Termination of licensed nurses found to be negligent. 3. Reporting of nurses' neglect to required agencies was done. 4. Medication Error: Resident R1 expired on [DATE]; a medication error event report has been completed; the physician was notified of the medication error. An audit was completed of all residents with insulin orders to assure compliance with physician order. Any discrepancy identified through the audit was to be reported to the physician. 5. Licensed Nurses will be educated on the appropriate insulin administration, on the process for physician notification if insulin or antidiabetic agents are unavailable, on the signs of symptoms of [CONDITION(S)] and [CONDITION(S)] and on the actions of insulin and antidiabetic agents. Licensed Nurses will not work without receiving the required education. Licensed Nurses will have a competency for insulin administration. 6. The Director of Nursing/designee will randomly audit the medication administration records of a number of residents weekly. 7. An Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting will be held and results of the audits will be reviewed during the monthly QAPI Meeting. The facility alleged compliance with the QAPI Plan as of [DATE]. Review of facility doucmentation revealed that correction plan was immediately developed and initiated on [DATE]. The faciity conducted audits for all new admissions from the last 30 days prior [DATE] and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Records of residents who received insulin were audited to confirm accuracy of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation revealed competencies for insulin administration were completed for licensed nursing staff. Interviews of licensed nursing staff were conducted on [DATE] confirmed that the inservices for resident change of condition, reconciliation of admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 201.14(a) Responsibility of licensee 28 Ps. Code 201.18(b)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.12(c) Nursing services

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of 43 residents reviewed, resulting in actual harm to the resident who was left unattended on the toilet, fell and sustained a fractured arm (Resident R28). Findings include: Review of the facility policy title, Fall prevention, revised September 2019, revealed that a fall risk assessment is completed by the nurse on all residents at the facility on admission/readmission, quarterly and with a significant change in condition. The facility wide fall prevention program for all residents, includes but is not limited to, orient new residents to their surroundings, use of the call bell system, instructed to summon staff for assistance to get out of bed, wear appropriate shoes with non-skid soles, color coded bracelets for resident to identify level of assistance requested for transfers/ambulation and to place personal items in easy reach of resident. Review of Resident R28's clinical record revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident R28's quarterly Minimum Data Set (MDS- periodic assessment of resident needs) dated November 5, 2019, indicated that the resident had severe cognitive impairments and required the extensive assistance of one staff person for toileting, personal hygiene and bathing. Review of Resident R28's, Fall Risk Evaluation, dated August 14, 2019, and November 5, 2019, revealed that the resident had been assessed by facility staff for her potential for falls. Continued review of Resident R28's Fall Risk Evaluation revealed that on both dates the resident was assessed as a High Risk for Potential Falls. Further review of the Fall Risk Evaluation document directed staff that, A prevention protocol should be initiated immediately and documented on the care plan. Review of Resident R28's care plan for ADL (Activities of Daily Living -refers toileting, bathing, dressing, ambulation, transfer and eating) related to impaired mobility and [DIAGNOSES REDACTED]. The interventions included to provide close supervision of resident when in wheelchair. There was no interventions developed in the resident's care plan regarding the level of assistance required during toilet use or the resident's ability to use toilet. Further review of the resident's care plan addressed the problem of frequent urinary incontinence and for the resident to be clean, dry and odor free. The interventions included to wash, pat dry and apply moisture barrier after each episode of incontinence and a scheduled toileting program. Review of Resident R28's clinical record revealed nurse's progress note dated December 27, 2019, at 6:00 p.m., which stated that, nurse was called to second floor C-Hall bathroom due to resident falling. Resident was observed sitting on the toilet, following assessment by nurse. Emergency response was called due to resident hitting her head and inability to move right upper extremity. Resident was picked up at 6:30 p.m. The nurse's progress note further stated that the resident was being admitted to the hospital for a fracture (broken bone) of right ulna and radius (two bones of the forearm near the wrist joint), right forehead hematoma (collection of blood underneath the skin), and possible syncopal ([MEDICAL CONDITION]) episode after fall. Review of facility document, Event Data Collection Worksheet, dated December 28, 2019, related to Resident R28's fall indicated that CNA (nursing assistant) had resident on toilet in C-hall shower room and went to get soap from other side of room, and resident stood up and attempted to ambulate self and fell . Was found sitting on floor by trash can in bathroom. Further review of the fall investigation dated December 27, 2019, identified the nursing assistant, as Employee, E4, under the paragraph named describe incident in full detail including events that led up to the incident. The nursing assistant, Employee E4, stated that, I put her on the toilet, went to get soap and heard her fall. Interview with Employee E4, nursing assistant, on January 16, 2020, at approximately 2:50 p.m., revealed that she was unable to provide any further details other than what she had already stated in the Event Data Collection Worksheet, dated December 28, 2019. Review of the facility provided report dated on December 28, 2019 and updated January 2, 2020, revealed that the facility instructed the nursing assistant to gather personal care items prior to toileting. The facility failed to ensure that one resident, identifed as at high risk for falling, received the appropriate supervision while on the toilet, fell and sustained a fractured right arm and a hematoma to the right forehead as a result. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1) Nursing services 28 Pa Code 211.12(d)(5) Nursing services 28 Pa Code 201.18(e)(1) Management Previously cited 2/13/2019

Based on review of the facility assessment and facility policies and procedures, it was determined that the facility failed to provide an effective employee training program for freedom of resident abuse, neglect, exploitation and misappropriation of resident property related to identification of activities or incidents that constitute abuse, neglect and exploitation; and reporting of incidents that constitute abuse, neglect, and exploitation, as determined by the Facility Assessment and staff need. This failure resulted in actual harm to four residents (Residents R29, R67, R94 and R363) and constituted Substandard Quality of Care (SQC) and an Immediate Jeopardy situation. Findings include: Review of the Facility Assessment Tool dated October/November (YEAR), revealed the facility could effectively treat [DIAGNOSES REDACTED]. The Facility Assessment Tool indicated that staff training, education and competency would be provided for abuse, neglect and exploitation in an effort to maintain an effective training program. Review of facility policy, Abuse, dated revised (MONTH) (YEAR), revealed all resident incidents/accidents/unusual occurrences/injuries of unknown origin would be documented on incident reports with all injuries of unknown origin being thoroughly investigated to determine a potential cause. The policy further clarified that incident reports would be promptly reviewd to identify events, such as suspicious bruising of residents, occurrence, patterns and trends that may constitute abuse, mistreatment of [REDACTED]. Review of the clinical record for Resident R29, revealed a quarterly MDS assessment (Minimum Data Set-periodic assessment of needs) dated (MONTH) 5, (YEAR), indicating the resident's most recent admission to the facility was (MONTH) 30, 2003, and had [DIAGNOSES REDACTED].) with impairment noted on both sides of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). The MDS indicated Resident R29 had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 13, indicating the resident was cognitively intact. Additionally, the MDS revealed that Resident R29 required extensive, two plus person physical assistance with eating and drinking. Review of the recapitulation (summary) of physician's orders [REDACTED]. Review of the plan of care, dated initiated (MONTH) 13, 2003, indicated Resident R29 had a deficit in activities of daily living (ADL's-eating, drinking, walking, toileting, bathing, etc.) and impaired mobility (inability to walk) due to cervical spine (neck) traumatic accident causing a C1-C4 (neck bones) incomplete [MEDICAL CONDITION]. Review of an Event Data Collection Worksheet, dated (MONTH) 29, (YEAR), with time of event or discovery of event at 11:00 a.m., indicated that Resident R29 accidentally dropped a cup of coffee down the front of the resident resulting in blistered areas on the abdomen and bilateral (both sides) inner thighs. The Event Data Collection Worksheet added that the lid on the resident's coffee cup was on, but the liquid poured out of the spout of the sippy cup (two-handled safety mug with secured lid). Further review of the Event Data Collection Worksheet revealed no documentation of witness statements from any staff members who were present on (MONTH) 29, (YEAR), or documentation of an interview with the resident who was assessed as being cognitively intact. Interview with Employee E5, dietary supervisor, on (MONTH) 22, (YEAR), at 12:50 p.m., revealed per the employee's recollection of the incident on (MONTH) 29, (YEAR), after Resident R29 was found [MEDICAL CONDITION] nursing staff, Employee E5 was called to the nursing unit. Employee E5 stated that the incident occurred in the resident's room at lunch time. Employee E5 indicated that Resident R29 had her own sippy cup in her room that she preferred to use and that after the lunch tray was delivered to the resident, a nursing assistant poured the resident's coffee from the one handled facility's mug into the resident's personal two handled mug. Employee E5 stated that upon the employee's assessment of the mug and lid, the employee saw that the lid did not fit properly on the resident's two handled mug and stated, The lid was too small. Review of the facility's food temperature record indicated that on (MONTH) 29, (YEAR), the documented serving temperatures for breakfast were: hot beverage 160 degrees Fahrenheit, hot cereal 180 degrees Fahrenheit; Lunch-hot beverage 165 degrees Fahrenheit. Review of a nurse's note, dated (MONTH) 29, (YEAR), at 5:30 p.m., revealed that Resident R29 accidentally dropped a cup of coffee down the resident's front resulting in blistered areas on the abdomen and bilateral inner thighs, that the lid was on the resident's coffee cup but the liquid poured out of the spout of the sippy cup, and that the resident's physician was notified of the incident and ordered treatment to the burned areas along with an order to consult with a facility contracted wound care specialist. Review of a physician's orders [REDACTED]. Review of clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed Resident R29 had the following sites and measurements of [MEDICAL CONDITION] on (MONTH) 29, (YEAR): mid abdomen measured 12.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm in depth; right upper inner thigh measured 8.0 cm long by 7.0 cm wide with no depth documented; left upper inner thigh measured 8.0 cm long by 3.5 cm wide with no depth documented; and pubic area (pelvis) measured 2.0 cm long by 1.5 cm wide with no depth documented. Review of a nurse's note, dated (MONTH) 30, (YEAR), at 6:30 a.m., revealed that Resident R29 was noted with open blistered areas to the right side of the resident's abdomen, bilateral inner thighs, and a few unopened blisters over the resident's pubic area. Review of a Certified Registered Nurse Practitioner (CRNP) wound consult report, dated (MONTH) 3, (YEAR), revealed Resident R29 was seen in follow up for wound management for FTW (full thickness wound-wound that extends below the top layer of skin and may also involve muscle and supporting areas)[MEDICAL CONDITION] by accidental coffee spill on self. The wound consult report indicated the resident was alert, ate orally (not via tube), and was quadriplegic requiring total care. The wound consult report went on to document the four burned areas as follows: full thickness ulceration of the mid abdomen measured 12.0 cm long by 9.5 cm wide by 0.1 cm in depth; full thickness ulceration of the right upper inner thigh measured 12.5 cm long by 9.3 cm wide by 0.1 cm in depth; full thickness ulceration of the left upper inner thigh measured 11.5 cm long by 12.0 cm wide by 0.1 cm in depth with some blistered areas; and full thickness ulceration of the pubic area measured 7.2 cm long by 2.5 cm wide intact clear fluid filled blister. Review of a psychology consult report dated (MONTH) 13, (YEAR), revealed Resident R29 spoke about the [MEDICAL CONDITION] the psychologist and stated, It's rough. Review of a physician's progress note dated (MONTH) 18, (YEAR), indicated that several weeks ago, hot coffee was accidentally spilled on the patient's groin and upper thighs and that Resident R29, sustained some third [MEDICAL CONDITION](injury that extends to all layers of the skin) that are under treatment. [MEDICAL CONDITION] clean and non-infected. The wound nurse is seeing (the resident) regularly. Further review of the clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed the burned area on the mid abdomen was documented as healed on (MONTH) 13, (YEAR), (approximately 20 weeks after the burn occurred); right upper inner thigh was documented as healed on (MONTH) 23, (YEAR), (approximately eight weeks after the burn occurred); left upper inner thigh was documented as healed on (MONTH) 28, (YEAR), (approximately nine weeks after the burn occurred); and pubic area was documented as healed on (MONTH) 7, (YEAR), (approximately six weeks after the burn occurred). Further interview with Employee E5, dietary supervisor, on (MONTH) 22, (YEAR), at 12:50 p.m., revealed that the coffee which was brewed by facility staff in the dietary kitchen emerges from the coffee maker at 200 degrees Fahrenheit and immediately after brewing, staff pour the coffee into one handled mugs. Employee E5 stated staff allow the poured coffee to rest for approximately 20 minutes, then plastic lids with a slit are placed on top of each mug, mugs are loaded onto the food carts, and carts are delivered to the units for distribution. Employee E5 added that hot liquids are served to residents in the main dining room on the first floor at 175 degree Fahrenheit and clarified that hot beverage temperatures do not exceed 175 degrees Fahrenheit at point of service (moment the cup is served to a resident for consumption). Further review of the facility's food temperature record on (MONTH) 22, (YEAR), at approximately 1:30 p.m., indicated that the facility's serving temperature standard for hot liquids was 170 degrees Fahrenheit (five degrees Fahrenheit less that the 175 degrees Fahrenheit as established in interview with Employee E5). Further review of the food temperature record for the week of (MONTH) 25, (YEAR), through (MONTH) 1, (YEAR), revealed the following documented food/beverage temperatures upon service to the residents: 6/25/17: Breakfast-hot cereal 186 degrees Fahrenheit; Lunch-hot beverage 178 degrees Fahrenheit; Dinner-hot beverage 172 degrees Fahrenheit. 6/26/17: Breakfast-hot cereal 180 degrees Fahrenheit; Dinner-soup 178 degrees Fahrenheit. 6/27/17: Breakfast-hot cereal 190 degrees Fahrenheit; Lunch-hot beverage 180 degrees Fahrenheit. 6/28/17: Breakfast-hot beverage 177 degrees Fahrenheit, hot cereal 186 degrees Fahrenheit; Lunch-hot beverage 178 degrees Fahrenheit; Dinner-soup 177 degrees Fahrenheit. 6/30/17: Breakfast-hot cereal 182 degrees Fahrenheit; Dinner-soup 182 degrees Fahrenheit. 7/01/17: Breakfast-hot cereal 179 degrees Fahrenheit; Dinner-soup 190 degrees Fahrenheit. Review of facility policy, Policy on Serving Hot Beverages, dated revised (MONTH) 13, 2011, revealed no documentation indicating what the facility's safe serving temperature ranges were to [MEDICAL CONDITION] accidental scalding. Interview with the Director of Nursing on (MONTH) 22, (YEAR), at approximately 1:45 p.m. confirmed that after Resident R29 sustained third [MEDICAL CONDITION] spilled coffee on (MONTH) 29, (YEAR), there was no education provided to staff on what safe hot beverage/liquid foods serving temperatures were and when staff were to monitor hot beverage/liquid foods temperatures. Review of the clinical record for Resident R54 revealed a recapitulation (recaps-summary) of physician's orders [REDACTED]. [MEDICAL CONDITION] hormone level) 150 micrograms (mcg) orally every morning at 6:00 a.m., for a [DIAGNOSES REDACTED]. physician who ordered staff to obtain blood work for [MEDICAL CONDITION] studies. Review of a nurse's note, dated (MONTH) 10, (YEAR), at 3:00 p.m. revealed the results of the blood work drawn that morning were called into Resident R54's physician who ordered staff to recheck a TSH ([MEDICAL CONDITION] stimulating hormone-pituitary hormone that stimulates the [MEDICAL CONDITION]) level again in four weeks. Review of laboratory reports for Resident R54 revealed on (MONTH) 5, (YEAR), the resident's TSH level was 5.94 mcIU/mL (microunits/milliliter - reference range 0.47-4.68 mcIU/mL), and on (MONTH) 10, (YEAR), the resident's TSH was 115.00 mcIU/mL. Review of an Employee Disciplinary Action form, dated (MONTH) 12, (YEAR), for Employee E8, licensed practical nurse, revealed that upon the facility's investigation into Resident R54's extremely elevated TSH level, administrative staff checked the medication cart and found that, No [MEDICATION NAME] was on the cart. A call was placed to pharmacy who informed us that the last date that [MEDICATION NAME] (sic) was sent was on (MONTH) 23. This possibly took us through the month of September. The resident would have had no [MEDICATION NAME] (sic) the entire month of (MONTH) up to and including (MONTH) 10, (YEAR), when the error was discovered. Review of the facility's pharmacy shipping manifest, received by the facility and reviewed on (MONTH) 1, (YEAR), revealed 14 [MEDICATION NAME] 150 mcg tablets were delivered to the facility for Resident R54 on (MONTH) 23, (YEAR), indicating the resident would finish the 14 day supply of [MEDICATION NAME] on (MONTH) 6, (YEAR). Further review of pharmacy shipping manifests revealed no documentation of any facility receipts of [MEDICATION NAME] 150 mcg for Resident R54 until discovery of the medication error on (MONTH) 10, (YEAR). Review of the Medication Administration Record (MAR) for Resident R54 from (MONTH) 6, (YEAR) through (MONTH) 10, (YEAR), revealed Employee E8 documented administering [MEDICATION NAME] 150 mcg on the following dates: (MONTH) 9, 10, 11, 13, 14, 15, 18, 19, 20, 21, 23, 24, 25, 27, 28, 29, (YEAR); and (MONTH) 2, 3, 4, 5, 7, 8, 9, 11, 12, 13, 16, 17, 18, 19, 21, 22, 23, 25, 26, 27, 30, 31, (YEAR), for a total of 38 doses documented as administered with no documented evidence that the facility had the [MEDICATION NAME] in the building to give to the resident on those dates. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 11:30 a.m., confirmed that Employee E8 documented on the MAR that the employee administered [MEDICATION NAME] 150 mcg to Resident R54 on 38 occasions when Employee E8 actually did not, and confirmed there was no documented evidence of staff education to prevent future similar incidents from occurring. Review of the clinical record for Resident R67 revealed a recapitulation (recaps-summary) of physician's orders [REDACTED]. Review of nurse's notes revealed on (MONTH) 20, (YEAR), Resident R67 was found in the facility's day room showing signs of lethargy (state of tiredness, weakness, fatigue and lack of energy), the nurse took the resident's temperature which registered at 102.5 degrees Fahrenheit tympanic (temperature taken via the ear), that the nurse administered Tylenol 650 mg at 7:00 p.m. for the elevated temperature, and rechecked the resident's temperature at 10:00 p.m. recording 99.0 degrees Fahrenheit. On (MONTH) 21, (YEAR), nursing documentation indicated at 8:30 a.m., the resident's blood pressure was 109/70 mmHg (millimeters of mercury-normal average adult blood pressure 120/70 mmHg) and temperature was 101.8 degrees Fahrenheit, that Tylenol was administered at that time, and at 11:00 a.m., Resident R67's temperature reduced to 100.7 degrees Fahrenheit with notation of the resident having one episode of soft stool. On (MONTH) 21, (YEAR), nursing documentation indicated at 1:50 p.m., the resident's certified registered nurse practitioner (CRNP) was notified of the elevated temperature who instructed staff to obtain blood work and a urinalysis (urine test). On (MONTH) 21, (YEAR), nursing documentation indicated at 10:00 p.m., Resident R67's appetite was poor for dinner and the resident's temperature was 99.0 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 6:30 a.m., Resident R67 appeared lethargic, the resident's temperature was 101.7 degrees Fahrenheit, the resident's blood pressure was 96/63 mmHg, and at 7:00 a.m. upon recheck of temperature, the resident's temperature was 100.6 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 9:30 a.m., Resident R67 was lethargic and was placed back in bed after breakfast due to lethargy, the resident's blood pressure was 82/50 mmHg, and that a message was left with the resident's physician. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:30 a.m., Resident R67 continued to be lethargic, blood pressure dropping, with blood pressure noted as 84/48 mmHg, that the resident was examined and evaluated by a CRNP who ordered staff to send the resident out to an acute care hospital for evaluation for the resident's change in mental status. Review of a CRNP progress note, dated (MONTH) 22, (YEAR), revealed the CRNP saw and examined Resident R67 to evaluate nursing staff's concern about the resident's fever greater than 101 degrees Fahrenheit over the past 24 hours and increased lethargy. The CRNP progress note stated that the resident's fever would improve with administration of Tylenol but temperature increased again as the Tylenol wore off. Resident was evaluated in bed, was described as lethargic and, ill appearing, and despite pushing fluids pt (patient-resident) has dark, malodorous (foul smell) urine. The CRNP progress note additionally indicated the resident's temperature was 101.8 degrees Fahrenheit and blood pressure was 82/50 mmHg. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:35 a.m., an outside transportation company was contacted to pick up the resident and transport Resident R67 to the hospital and that they stated 45-60 minutes. Then called 911 (emergency medical services) due to deteriorating status. On (MONTH) 22, (YEAR), at 4:15 p.m., nursing documentation indicated Resident R67 was admitted to the hospital for a [DIAGNOSES REDACTED]. Review of the personnel record for Employee E8, and clinical records for Residents R54 and R67, revealed this was the same nurse who failed to administer the [MEDICATION NAME] to Resident R54 and failed to adequately assess and monitor Resident R67 for elevated temperature during night shift on (MONTH) 21 into 22, (YEAR). Further review of the clinical record revealed no documentation that Resident R67, a resident who was identified as having an elevated temperature that began on (MONTH) 20, (YEAR), was assessed and monitored by Employee E8, the night shift LPN who was assigned to Resident R67's care on (MONTH) 22, (YEAR), and that Employee E8 and other nursing staff were educated on assessment parameters for residents experiencing a change in medical condition. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 10:00 a.m., confirmed Employee E8 was the same nurse involved in the [MEDICATION NAME] error for Resident R54. Review of the clinical record of Resident R94 revealed that the resident was admitted to the facility on (MONTH) 13, 2009, with [DIAGNOSES REDACTED]. doesn't have enough healthy red blood cells). Review of the quarterly Minimum Data Set assessment (MDS - assessment of resident care needs), dated (MONTH) 25, (YEAR), indicated that there was no BIMS (brief interview for mental status) score for resident, and noted that resident is rarely/never understood and also that resident rarely/never understands others. The Minimum Data Set also noted that Resident R94 was severely cognitively impaired. Review of the clinical nurse's notes by Employee E9, licensed registered nurse, for Resident R94 for (MONTH) 7, (YEAR), at 2:00 a.m., stated that the resident vomited dark coffee ground vomitus. The same nursing note indicated that positive bowel sounds were present and no stools were present,and the nursing note then stated will monitor. On (MONTH) 7, (YEAR), at 7:00 a.m., the nursing progress note by Employee E9, stated that the resident was hard to arouse, loose stools (bowel movements) times two, and Temperature was 98.2 degrees Fahrenheit. Swallowed meds (medications) in pudding. The note of 7:00 a.m. then stated that the resident slept through a.m. care. Will monitor. The nurse's note of (MONTH) 7, (YEAR), no time was documented, revealed that Employee E9 added an addendum to the nurse's note which stated that Resident R94's Respirations (rate of breathing) were 26 (breaths per minute) , Pulse (heart rate per minute) 82 beats per minute and Pulse Ox (measurement of blood oxygen saturation level with a pulse oximeter, a medical device that indirectly monitors the oxygen saturation of blood - normal is 95% to 100%) was 88%. Further review of Resident R94's nurse's note of (MONTH) 7, (YEAR), at 8:15 a.m. revealed that the NA (Nursing Assistant) called nurse to resident's room. The same note by the licensed registered nurse, Employee, E6, stated that Resident R94 was lethargic (sluggish, feeling sleepy, unable to do anything), responsive to tactile (to be touched)stimuli with minimal response. Also noted was that resident's skin was pale, respirations (rate of breathing, normal - 12 to 16 breaths per minute) were 28 - 32 breaths per minute, and labored (evidence of increased effort to breathe including the use of accessory muscles of respiration, stridor, grunting, or nasal flaring (nostrils widen while breathing, and may be a sign of difficulty breathing), Heart Rate (heart rate per minute - normal - 60 to 100 beats per minute) was 116 beats per minute, Temperature was 96.7 degrees Fahrenheit (normal - 98.6 degrees Fahrenheit), Blood Pressure (force of the blood pushing against the artery walls during contraction and relaxation of the heart, normal, measured in millimeters of mercury - normal -120/80 mm Hg ) was 80/60 mm Hg, and Oxygen saturation level as measured with a pulse oximeter - non-invasive medical device that measures oxygen saturation level of blood via finger/toes, normal - 95% to 100 %) was 82% on room air. Further assessment by the licensed registered nurse found that rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) were heard in resident's right upper lung. Employee E6, licensed nurse, raised the head of resident's bed to attempt to promote less strenuous breathing, initiated oxygen via nasal cannula at 2 liters per minute, as an emergency nursing measure. Resident's oxygen level increased to 91% , as measures measured with pulse oximeter. Physician was contacted and ordered resident to be transferred to the Emergency Department via 911 emergency transport, for evaluation and treatment. Review of the facility Resident Transfer Form revealed that Resident R94 was transferred from the facility at 8:50 a.m., by emergency transport - a delay of six hours and fifty minutes. There was no evidence that Employee E9 a licensed nurse, properly identified and assessed Resident R94's acute change in medical condition or that the physcian was contacted in a timely manner, and there was no evidence that the there was a correct response to the medical emergency. Resident was identified with vomiting coffee ground vomitus and abnormal vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of essential body functions) on (MONTH) 7, (YEAR), at 2:00 a.m. and adequate emergency response response by the facility was not initiated until 8:15 a.m., a delay in assessment and correct response of a change in condition, of six hours and fifty minutes. Review of hospital records revealed that resident was admitted to an acute care hospital with the [DIAGNOSES REDACTED]. The failure of Employee E9 to properly identify and assess a medical change in condition and properly respond to a medical emergency resulted in Resident R94's emergency transport and subsequent admission to an acute hospital causing actual harm. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 10:10 a.m., confirmed that there was a change in the medical condition of Resident R94, that the change in condition was not properly identified and assessed by the licensed nurse, Employee E9, resulting in a delay of a proper response of six hours and fifty minutes. During the same interview, the Director of Nursing confirmed that the facility did not have a policy for Change in Medical Condition to properly identify, assess, and correctly respond to a change in a medical condition of a resident. Review of the facility Employee Disciplinary Action form for Employee E9, dated (MONTH) 11, (YEAR), four days after the occurrence of the incident, revealed that the change in medical condition of Resident R92 was described by the Director of Nursing as an assessment which was not complete and thorough and did not reflect the condition of the resident at the time. Further review of the same facility form indicated that the disciplinary action taken for the incident involving Resident R94 was a Written Warning. Employee E9 signed that Employee Disciplinary Action form with no written comments by the employee. There was no evidence that after the medical change of condition of Resident R94 on (MONTH) 7, (YEAR), that the facility took action to prevent further abuse and neglect from occurring following the incident with Resident R94 as Employee E9, the alleged perpetrator, did not receive retraining on identifying resident change in condition and prohibition of all forms of abuse, neglect and exploitation. Review of the clinical record for Resident R363 revealed that the resident was admitted to the facility on , (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS-assessment of resident care needs), dated (MONTH) 3, (YEAR), indicated on the brief interview for mental status Resident R363 scored a 4 out of 15, indicating the resident was confused, disoriented, and forgetful, and was not able to make himself understood by other nor understood others. The same MDS indicated the resident was a fall risk related to history of falls with fractures, muscle weakness, unsteady gait, cognitive impairment with poor safety awareness, occasional incontinence, and vision impairment. In addition, the Fall Risk assessment, dated (MONTH) 3, (YEAR), revealed the resident scored a total of 22 (total score of 10 or above represents high risk for falls). Resident R363 Plan of Care, dated (MONTH) 26, (YEAR) included: A care plan for Activity of Daily Living deficit related to his Dementia, and [MEDICATION NAME] degeneration, with interventions including extensive care, and toileting assistance. A care plan for Potential for Injury related to history of falls, and impaired mobility, with interventions that included, transfer with assistance only, provide anti-skid socks at bedtime, and to check placement and function of bed alarm every shift. A care plan for Potential for bleeding related to anticoagulant (medicine that thins the blood to avoid blood clots) therapy, with interventions that included assessing for bruising, bleeding, etc. and to notify the physician. Review of the progress note, dated (MONTH) 11, (YEAR), from the facility's Medical Director, Employee E17, indicated Resident R363 had a history of [REDACTED]. It further indicated a review from a past report, revealed Resident R363 had [DIAGNOSES REDACTED] (the main artery that carries blood out of the heart to the rest of the body does not open fully, and decreases blood flow from the heart), prostatism, (inhibits urine flow), and [MEDICAL CONDITION] ( blood vessels that supply your heart with blood, oxygen and nutrients are diseased). The same progress note during the examination, Employee E17 indicated Resident R363 pulse was slightly diminished, lungs had very poor inspiratory effect (breathing in), heart tones distant, with a heart murmur (structural defects in the heart), consistent with his [DIAGNOSES REDACTED]. Employee E17 ended his examination stating Resident R363 has multiple co-morbidities and remained at high risk for complication, and the prognosis was poor. Review of the facility's Event Data Worksheet, dated (MONTH) 11, (YEAR), revealed Nursing Assistant, Employee E12 at 1:30 a.m. responded to Resident 363' s call bell. Resident R363 was found lying on the floor, on his stomach, between his bed and bathroom, the nurse on duty was then notified. Registered Nurse, Employee E9 responded to the fall. Employee assessed Resident R363 with no injury noted. Resident R363 denied hitting his head but complained of pain in his right hip area. Employee indicated that no shortening, or external rotations noted, (presuming no [MEDICAL CONDITION]). Review of the facility's Employee Disciplinary Action, dated (MONTH) 11, (YEAR) for Employee E9 from the Director of Nursing, indicated: Today, 1/11/18, Resident R363 was found on the floor at 1:30 a.m. He was laying on his stomach and complained of pain on his right side. You documented that there was no bruising noted and the resident stated that he did not hit his head. Vital signs were not documented, no mention of the resident range of motion or appearance of this right leg. There was no documentation in your nursing notes that you gave him Tylenol for pain. The Day Nurse at the start of her shift assessed the resident and noted shortening of his right leg and external rotation. She then went to you. At 8:35 a.m. you documented this as a finding. This should have been noted by you at the time of the fall and immediate action should have been taken. The physician and family were not notified for hours after the incident (7 hours). This resulted in a delay in treatment. Once the physician was notified he ordered that the resident be transferred to the hospital for possible fracture of his right hip. In each case there was no evidence that a thorough assessments were done. This c

Based on observation, review of clinical records, facility documentation, facility policies and procedures, and the American Burn Association Scald (very hot, burning) Injury Prevention Educator's Guide, and interviews with staff, it was determined that the facility failed to adequately supervise and maintain each residents' environment to ensure that the residents remained free of accident hazards created by increased temperatures of hot liquids served to residents. One of 27 residents reviewed [MEDICAL CONDITION] a hot beverage spill, resulting in actual harm to that resident (Resident R29). This failure placed the residents at a high risk for injury, and resulted in an Immediate Jeopardy situation. Findings include: Review of undated, American Burn Association Scald Injury Prevention Educator's Guide, revealed that older adults have thinner skin therefore hot liquids cause [MEDICAL CONDITION] even brief exposure, and older adults' ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too not until injury has occurred. The Guide added that the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 degrees Fahrenheit, it takes only five seconds or less for a serious burn to occur. A temperature of 148 degrees Fahrenheit takes two seconds for severe burns, and at 155 degrees Fahrenheit takes one second for a severe burn to occur. The Guide additionally stated that coffee, tea, and other hot beverages are usually served at 160 degrees to 180 degrees Fahrenheit resulting in almost instantaneous burns. Review of the clinical record for Resident R29, revealed a quarterly MDS assessment (Minimum Data Set-periodic assessment of needs) dated (MONTH) 5, (YEAR), indicating the resident's most recent admission to the facility was (MONTH) 30, 2003, and had [DIAGNOSES REDACTED].) with impairment noted on both sides of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). The MDS indicated Resident R29 had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 13, indicating the resident was cognitively intact. Additionally, the MDS revealed that Resident R29 required extensive, two plus person physical assistance with eating and drinking. Review of the recapitulation (summary) of physician's orders [REDACTED]. Review of the plan of care, dated initiated (MONTH) 13, 2003, indicated Resident R29 had a deficit in activities of daily living (ADL's-eating, drinking, walking, toileting, bathing, etc.) and impaired mobility (inability to walk) due to cervical spine (neck) traumatic accident causing a C1-C4 (neck bones) incomplete [MEDICAL CONDITION]. Review of an Event Data Collection Worksheet, dated (MONTH) 29, (YEAR), with time of event or discovery of event at 11:00 a.m., indicated that Resident R29 accidentally dropped a cup of coffee down the front of the resident resulting in blistered areas on the abdomen and bilateral (both sides) inner thighs. The Event Data Collection Worksheet added that the lid on the resident's coffee cup was on, but the liquid poured out of the spout of the sippy cup (two-handled safety mug with secured lid). Further review of the Event Data Collection Worksheet revealed no documentation of witness statements from any staff members who were present on (MONTH) 29, (YEAR), or documentation of an interview with the resident who was assessed as being cognitively intact. Interview with Employee E5, dietary supervisor, on (MONTH) 22, (YEAR), at 12:50 p.m. revealed per the employee's recollection of the incident on (MONTH) 29, (YEAR), after Resident R29 was found [MEDICAL CONDITION] nursing staff, Employee E5 was called to the nursing unit. Employee E5 stated that the incident occurred in the resident's room at lunch time. Employee E5 indicated that Resident R29 had her own sippy cup in her room that she preferred to use and that after the lunch tray was delivered to the resident, a nursing assistant poured the resident's coffee from the one handled facility's mug into the resident's personal two handled mug. Employee E5 stated that upon the employee's assessment of the mug and lid, the employee saw that the lid did not fit properly on the resident's two handled mug and stated, The lid was too small. Review of the facility's food temperature record indicated that on (MONTH) 29, (YEAR), the documented serving temperatures for breakfast were: hot beverage 160 degrees Fahrenheit, hot cereal 180 degrees Fahrenheit; Lunch-hot beverage 165 degrees Fahrenheit. Review of a nurse's note, dated (MONTH) 29, (YEAR), at 5:30 p.m., revealed that Resident R29 accidentally dropped a cup of coffee down the resident's front resulting in blistered areas on the abdomen and bilateral inner thighs, that the lid was on the resident's coffee cup but the liquid poured out of the spout of the sippy cup, and that the resident's physician was notified of the incident and ordered treatment to the burned areas along with an order to consult with a facility contracted wound care specialist. Review of a physician's orders [REDACTED]. Review of clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed Resident R29 had the following sites and measurements of [MEDICAL CONDITION] on (MONTH) 29, (YEAR): mid abdomen measured 12.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm in depth; right upper inner thigh measured 8.0 cm long by 7.0 cm wide with no depth documented; left upper inner thigh measured 8.0 cm long by 3.5 cm wide with no depth documented; and pubic area (pelvis) measured 2.0 cm long by 1.5 cm wide with no depth documented. Review of a nurse's note, dated (MONTH) 30, (YEAR), at 6:30 a.m., revealed that Resident R29 was noted with open blistered areas to the right side of the resident's abdomen, bilateral inner thighs, and a few unopened blisters over the resident's pubic area. Review of a Certified Registered Nurse Practitioner (CRNP) wound consult report, dated (MONTH) 3, (YEAR), revealed Resident R29 was seen in follow up for wound management for FTW (full thickness wound-wound that extends below the top layer of skin and may also involve muscle and supporting areas)[MEDICAL CONDITION] by accidental coffee spill on self. The wound consult report indicated the resident was alert, ate orally (not via tube), and was quadriplegic requiring total care. The wound consult report went on to document the four burned areas as follows: full thickness ulceration of the mid abdomen measured 12.0 cm long by 9.5 cm wide by 0.1 cm in depth; full thickness ulceration of the right upper inner thigh measured 12.5 cm long by 9.3 cm wide by 0.1 cm in depth; full thickness ulceration of the left upper inner thigh measured 11.5 cm long by 12.0 cm wide by 0.1 cm in depth with some blistered areas; and full thickness ulceration of the pubic area measured 7.2 cm long by 2.5 cm wide intact clear fluid filled blister. Review of a psychology consult report dated (MONTH) 13, (YEAR), revealed Resident R29 spoke about the [MEDICAL CONDITION] the psychologist and stated, It's rough. Review of a physician's progress note dated (MONTH) 18, (YEAR), indicated that several weeks ago, hot coffee was accidentally spilled on the patient's groin and upper thighs and that Resident R29, sustained some third [MEDICAL CONDITION](injury that extends to all layers of the skin) that are under treatment. [MEDICAL CONDITION] clean and non-infected. The wound nurse is seeing (the resident) regularly. Further review of the clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed the burned area on the mid abdomen was documented as healed on (MONTH) 13, (YEAR) (approximately 20 weeks after the burn occurred); right upper inner thigh was documented as healed on (MONTH) 23, (YEAR) (approximately eight weeks after the burn occurred); left upper inner thigh was documented as healed on (MONTH) 28, (YEAR) (approximately nine weeks after the burn occurred); and pubic area was documented as healed on (MONTH) 7, (YEAR) (approximately six weeks after the burn occurred). Further interview with Employee E5, dietary supervisor, on (MONTH) 22, (YEAR), at 12:50 p.m., revealed that the coffee which is brewed by facility staff in the dietary kitchen emerges from the coffee maker at 200 degrees Fahrenheit and immediately after brewing, staff pour the coffee into one handled mugs. Employee E5 stated staff allow the poured coffee to rest for approximately 20 minutes, then plastic lids with a slit are placed on top of each mug, mugs are loaded onto the food carts, and carts are delivered to the units for distribution. Employee E5 added that hot liquids are served to residents in the main dining room on the first floor at 175 degrees Fahrenheit and clarified that hot beverage temperatures do not exceed 175 degrees Fahrenheit at point of service (moment the cup is served to a resident for consumption). Further review of the facility's food temperature record on (MONTH) 22, (YEAR), at approximately 1:30 p.m., indicated that the facility's serving temperature standard for hot liquids was 170 degrees Fahrenheit (five degrees Fahrenheit less that the 175 degrees Fahrenheit as established in interview with Employee E5). Further review of the food temperature record for the week of (MONTH) 25, (YEAR) through (MONTH) 1, (YEAR), revealed the following documented food/beverage temperatures upon service to the residents: 6/25/17: Breakfast-hot cereal 186 degrees Fahrenheit; Lunch-hot beverage 178 degrees Fahrenheit; Dinner-hot beverage 172 degrees Fahrenheit. 6/26/17: Breakfast-hot cereal 180 degrees Fahrenheit; Dinner-soup 178 degrees Fahrenheit. 6/27/17: Breakfast-hot cereal 190 degrees Fahrenheit; Lunch-hot beverage 180 degrees Fahrenheit. 6/28/17: Breakfast-hot beverage 177 degrees Fahrenheit, hot cereal 186 degrees Fahrenheit; Lunch-hot beverage 178 degrees Fahrenheit; Dinner-soup 177 degrees Fahrenheit. 6/30/17: Breakfast-hot cereal 182 degrees Fahrenheit; Dinner-soup 182 degrees Fahrenheit. 7/01/17: Breakfast-hot cereal 179 degrees Fahrenheit; Dinner-soup 190 degrees Fahrenheit. Review of facility policy, Policy on Serving Hot Beverages, dated revised (MONTH) 13, 2011, revealed no documentation indicating what the facility's safe serving temperature ranges were to [MEDICAL CONDITION] accidental scalding. Interview with the Director of Nursing on (MONTH) 22, (YEAR), at approximately 1:45 p.m. revealed that there was no documentation regarding if the resident was assessed by staff for unsupervised use of a two handled mug despite the resident's [DIAGNOSES REDACTED]. Additional interview revealed that the only safety-related intervention put in to place after Resident R29 [MEDICAL CONDITION] hot coffee was that staff were to feed the resident all her meals. Observation of Resident R29 in the presence of Employee E4, Registered Nurse, on (MONTH) 22, (YEAR), at approximately 2:00 p.m., revealed healed scarred areas on the resident's right lower abdomen, bilateral inner thighs, and pubis (skin area over the pubic bone). Immediate Jeopardy to the health and safety of the residents was identified to the Nursing Home Administrator at 2:25 p.m., on (MONTH) 22, (YEAR). The facility's corrective action plan included: 1. Staff are being in-service starting on (MONTH) 22, (YEAR), at the evening meal. In-services will continue until all staff have received the in-service. 2. Food and liquid temperatures will be monitored at point of service beginning with the evening meal on (MONTH) 22, (YEAR). The temperature of hot liquids will not exceed 136 degrees Fahrenheit at point of service as recommended in the article published by the National Institute of Health in (MONTH) 2008. 3. All residents with orders for adaptive equipment for meals will be evaluated today (February 22, (YEAR)). 4. Residents that require assistance during meals will be evaluated and monitored to ensure the necessary equipment is being used and the equipment is functioning properly. 5. Residents will continue to be monitored for decline and additional assistance will be provide as needed. 6. All containers used for hot liquids will be checked for properly fitting lids. 7. All serious resident injuries will be thoroughly investigated and reported to the Pennsylvania Department of Health via the electronic reporting system as required. Following verification of the implementation of the corrective action plan and review of the temperature assessment of the hot liquids and the liquid-like foods (i.e. hot cereal, soup) served to the residents during the evening meal on (MONTH) 22, (YEAR), each meal served on (MONTH) 23, (YEAR), (MONTH) 24, (YEAR), (MONTH) 25, (YEAR), and breakfast and noon meals on (MONTH) 26, (YEAR), the Immediate Jeopardy was lifted at 1:40 p.m. on (MONTH) 26, (YEAR). The facility failed to ensure each resident received adequate supervision to prevent accidents, and failed to ensure the resident environment remained free of accident hazards related to hot beverages that caused actual harm to one resident, and placed other residents at risk for potential harm identifying an Immediate Jeopardy situation. Refer to F600, F609, and F610. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 04/03/17, 09/24/16 28 Pa. Code 201.14(c)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management Previously cited 04/03/17 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 04/03/17, 09/24/16

Based on observation, review of clinical records, facility policies and procedures and facility documentation, and interviews with residents and staff, it was determined that the facility failed to protect the rights of residents to be free from neglect by not providing the goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress related to a sustained third degree burn as a result of lack of proper supervision; a fall from bed with resultant fracture; failure to follow physician orders [REDACTED]. (Residents R17, R29, R42, R47, R51, R65, R67, R71, R73, R94, R97, R109, R362, and R363). This failure resulted in actual harm to four residents (Residents R29, R67, R94 and R363) and constituted Substandard Quality of Care (SQC). Findings include: The facility's policy Abuse dated, last revised (MONTH) (YEAR), stated that Residents must not be subjected to abuse, neglect, mistreatment, involuntary seclusion, or misappropriation of their property by anyone, including .staff. The same facility policy also defined Neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care on one or more areas (e.g. absence of frequent monitoring, or a resident known to be incontinent, resulting in being left to lie in urine or feces. The policy also stated that neglect also occurs when a number of residents receive lack of care in one or more regulatory groupings, a finding that reflects the facility's failure to have developed policies or implemented procedures to prohibit neglect .Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. The same policy stated that all facility employees are made aware of 'Resident Rights' upon employment and through annual in-services on Resident Rights and Prevention of Abuse, Neglect, Mistreatment of [REDACTED]. and stated that all staff members are accountable for the immediate reporting of any suspected, alleged or witnessed resident abuse, neglect, mistreatment, or misappropriation of property. Review of undated, American Burn Association Scald Injury Prevention Educator's Guide, revealed that older adults have thinner skin therefore hot liquids cause [MEDICAL CONDITION] even brief exposure, and older adults' ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. The Guide added that the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. When the temperature of a hot liquid is increased to 140 degrees Fahrenheit, it takes only five seconds or less for a serious burn to occur. A temperature of 148 degrees Fahrenheit takes two seconds for severe burns, and at 155 degrees Fahrenheit takes one second for a severe burn to occur. The Guide additionally stated that coffee, tea, and other hot beverages are usually served at 160 degrees to 180 degrees Fahrenheit resulting in almost instantaneous burns. Review of the clinical record for Resident R29, revealed a quarterly MDS assessment (Minimum Data Set-periodic assessment of needs) dated (MONTH) 5, (YEAR), indicating the resident's most recent admission to the facility was (MONTH) 30, 2003, and had [DIAGNOSES REDACTED].) with impairment noted on both sides of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot). The MDS indicated Resident R29 had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: ,[DATE] cognitively intact; ,[DATE] moderately impaired; ,[DATE] severe impairment) score of 13, indicating the resident was cognitively intact. Additionally, the MDS revealed that Resident R29 required extensive, two plus person physical assistance with eating and drinking. Review of the recapitulation (summary) of physician's orders [REDACTED]. Review of the plan of care, dated initiated (MONTH) 13, 2003, indicated Resident R29 had a deficit in activities of daily living (ADL's-eating, drinking, walking, toileting, bathing, etc.) and impaired mobility (inability to walk) due to cervical spine (neck) traumatic accident causing a C1-C4 (neck bones) incomplete [MEDICAL CONDITION]. Review of an Event Data Collection Worksheet, dated (MONTH) 29, (YEAR), with time of event or discovery of event at 11:00 a.m., indicated that Resident R29 accidentally dropped a cup of coffee down the front of the resident resulting in blistered areas on the abdomen and bilateral (both sides) inner thighs. The Event Data Collection Worksheet added that the lid on the resident's coffee cup was on, but the liquid poured out of the spout of the sippy cup (two-handled safety mug with secured lid). Interview with Employee E5, dietary supervisor, on (MONTH) 22, (YEAR), at 12:50 p.m., revealed per the employee's recollection of the incident on (MONTH) 29, (YEAR), after Resident R29 was found [MEDICAL CONDITION] nursing staff, Employee E5 was called to the nursing unit. Employee E5 stated that the incident occurred in the resident's room at lunch time. Employee E5 indicated that Resident R29 had her own sippy cup in her room that she preferred to use and that after the lunch tray was delivered to the resident, a nursing assistant poured the resident's coffee from the one handled facility's mug into the resident's personal two handled mug. Employee E5 stated that upon the employee's assessment of the mug and lid, the employee saw that the lid did not fit properly on the resident's two handled mug and stated, The lid was too small. Review of the facility's food temperature record indicated that on (MONTH) 29, (YEAR), the documented serving temperatures for breakfast were: hot beverage 160 degrees Fahrenheit, hot cereal 180 degrees Fahrenheit; Lunch-hot beverage 165 degrees Fahrenheit. Review of a nurse's note, dated (MONTH) 29, (YEAR), at 5:30 p.m., revealed that Resident R29 accidentally dropped a cup of coffee down the resident's front resulting in blistered areas on the abdomen and bilateral inner thighs, that the lid was on the resident's coffee cup but the liquid poured out of the spout of the sippy cup, and that the resident's physician was notified of the incident and ordered treatment to the burned areas along with an order to consult with a facility contracted wound care specialist. Review of a physician's orders [REDACTED]. Review of clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed Resident R29 had the following sites and measurements of [MEDICAL CONDITION] on (MONTH) 29, (YEAR): mid abdomen measured 12.0 centimeters (cm) long by 5.0 cm wide by 0.1 cm in depth; right upper inner thigh measured 8.0 cm long by 7.0 cm wide with no depth documented; left upper inner thigh measured 8.0 cm long by 3.5 cm wide with no depth documented; and pubic area (pelvis) measured 2.0 cm long by 1.5 cm wide with no depth documented. Review of a nurse's note, dated (MONTH) 30, (YEAR), at 6:30 a.m., revealed that Resident R29 was noted with open blistered areas to the right side of the resident's abdomen, bilateral inner thighs, and a few unopened blisters over the resident's pubic area. Review of a Certified Registered Nurse Practitioner (CRNP) wound consult report, dated (MONTH) 3, (YEAR), revealed Resident R29 was seen in follow up for wound management for FTW (full thickness wound-wound that extends below the top layer of skin and may also involve muscle and supporting areas)[MEDICAL CONDITION] by accidental coffee spill on self. The wound consult report indicated the resident was alert, ate orally (not via tube), and was quadriplegic requiring total care. The wound consult report went on to document the four burned areas as follows: full thickness ulceration of the mid abdomen measured 12.0 cm long by 9.5 cm wide by 0.1 cm in depth; full thickness ulceration of the right upper inner thigh measured 12.5 cm long by 9.3 cm wide by 0.1 cm in depth; full thickness ulceration of the left upper inner thigh measured 11.5 cm long by 12.0 cm wide by 0.1 cm in depth with some blistered areas; and full thickness ulceration of the pubic area measured 7.2 cm long by 2.5 cm wide intact clear fluid filled blister. Review of a psychology consult report dated (MONTH) 13, (YEAR), revealed Resident R29 spoke about the [MEDICAL CONDITION] the psychologist and stated, It's rough. Review of a physician's progress note dated (MONTH) 18, (YEAR), indicated that several weeks ago, hot coffee was accidentally spilled on the patient's groin and upper thighs and that Resident R29, sustained some third [MEDICAL CONDITION](injury that extends to all layers of the skin) that are under treatment. [MEDICAL CONDITION] clean and non-infected. The wound nurse is seeing (the resident) regularly. Further review of the clinical documentation titled, OTHER SKIN CONDITIONS .weekly skin grid, revealed the burned area on the mid abdomen was documented as healed on (MONTH) 13, (YEAR) (approximately 20 weeks after the burn occurred); right upper inner thigh was documented as healed on (MONTH) 23, (YEAR) (approximately eight weeks after the burn occurred); left upper inner thigh was documented as healed on (MONTH) 28, (YEAR) (approximately nine weeks after the burn occurred); and pubic area was documented as healed on (MONTH) 7, (YEAR) (approximately six weeks after the burn occurred). Interview with the Director of Nursing on (MONTH) 22, (YEAR), at approximately 1:45 p.m., revealed that the facility did not protect Resident R29's right to be free from neglect resulting in harm. Review of the clinical record for Resident R67 revealed a recapitulation (recaps-summary) of physician's orders [REDACTED]. Review of nurse's notes revealed that on (MONTH) 20, (YEAR), Resident R67 was found in the facility's day room showing signs of lethargy (state of tiredness, weakness, fatigue and lack of energy), the nurse took the resident's temperature which registered at 102.5 degrees Fahrenheit tympanic (temperature taken via the ear), that the nurse administered Tylenol 650 mg at 7:00 p.m. for the elevated temperature, and rechecked the resident's temperature at 10:00 p.m. recording 99.0 degrees Fahrenheit. On (MONTH) 21, (YEAR), nursing documentation indicated at 8:30 a.m., the resident's blood pressure was ,[DATE] mmHg (millimeters of mercury-normal average adult blood pressure ,[DATE] mmHg) and temperature was 101.8 degrees Fahrenheit, that Tylenol was administered at that time, and at 11:00 a.m., Resident R67's temperature reduced to 100.7 degrees Fahrenheit with notation of the resident having one episode of soft stool. On (MONTH) 21, (YEAR), nursing documentation indicated at 1:50 p.m., the resident's Certified Registered Nurse Practitioner (CRNP) was notified of the elevated temperature and instructed staff to obtain blood work and a urinalysis (urine test). On (MONTH) 21, (YEAR), nursing documentation indicated at 10:00 p.m., that Resident R67's appetite was poor for dinner and the resident's temperature was 99.0 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 6:30 a.m., Resident R67 appeared lethargic, the resident's temperature was 101.7 degrees Fahrenheit, the resident's blood pressure was ,[DATE] mmHg, and at 7:00 a.m. upon recheck of temperature, the resident's temperature was 100.6 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 9:30 a.m., Resident R67 was lethargic and was placed back in bed after breakfast due to lethargy, the resident's blood pressure was ,[DATE] mmHg, and that a message was left with the resident's physician. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:30 a.m., Resident R67 continued to be lethargic, blood pressure dropping, with blood pressure noted as ,[DATE] mmHg, that the resident was examined and evaluated by a CRNP who ordered staff to send the resident out to an acute care hospital for evaluation for the resident's change in mental status. Review of a CRNP progress note, dated (MONTH) 22, (YEAR), revealed the CRNP saw and examined Resident R67 to evaluate nursing staff's concern about the resident's fever greater than 101 degrees Fahrenheit over the past 24 hours and increased lethargy. The CRNP progress note stated that the resident's fever would improve with administration of Tylenol but temperature increased again as the Tylenol wore off. Resident was evaluated in bed, was described as lethargic and, ill appearing, and despite pushing fluids pt. (patient-resident) has dark, malodorous (foul smell) urine. The CRNP progress note additionally indicated the resident's temperature was 101.8 degrees Fahrenheit and blood pressure was ,[DATE] mmHg. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:35 a.m., an outside transportation company was contacted to pick up the resident and transport Resident R67 to the hospital and that, they stated ,[DATE] minutes. Then called 911 (emergency medical services) due to deteriorating status. On (MONTH) 22, (YEAR), at 4:15 p.m., nursing documentation indicated Resident R67 was admitted to the hospital for a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no documentation that Resident R67, a resident who was identified as having an elevated temperature that began on (MONTH) 20, (YEAR), was assessed and monitored by nursing staff from 10:00 p.m. on (MONTH) 21, (YEAR), until (MONTH) 22, (YEAR), at 6:30 a.m., approximately eight hours later. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 10:00 a.m., confirmed the facility did not identify this lack of assessment and monitoring as potential resident neglect and confirmed there was no documentation that Employee E8, licensed practical nurse, assessed and monitored Resident R67 in a timely manner on (MONTH) 22, (YEAR). This failure to properly and timely assess and monitor resulted in emergent transport and subsequent admission to the hospital causing actual harm to Resident R67. The facility failed to protect the right of Resident R67 to be free from neglect. Review of the clinical record of Resident R94 revealed that the resident was admitted to the facility on (MONTH) 13, 2009 with [DIAGNOSES REDACTED]. doesn't have enough healthy red blood cells). Review of the quarterly Minimum Data Set assessment dated (MONTH) 25, (YEAR), indicated that there was no BIMS score for resident, and noted that resident is rarely/never understood and that resident rarely/never understands others. The Minimum Data Set also noted that Resident R94 was severely cognitively impaired. Review of the clinical nurse's notes by Employee E9, Registered Nurse, for Resident R94 for (MONTH) 7, (YEAR), at 2:00 a.m., stated that the resident vomited dark coffee ground vomitus. The same nursing note indicated that positive bowel sounds were present and no stools were present, and the nursing note then stated, will monitor. On (MONTH) 7, (YEAR), at 7:00 a.m., the nursing progress note by Employee E9, stated that the resident was hard to arouse, loose stools (bowel movements) times two, and Temperature was 98.2 degrees Fahrenheit. Swallowed meds (medications) in pudding. The note of 7:00 a.m. then stated that the resident slept through a.m. care. Will monitor. The nurse's note of (MONTH) 7, (YEAR), no time documented, that Employee E9, added an addendum to the nurse's note which stated that Resident R94's Respirations (rate of breathing) were 26 (breaths per minute), Pulse (heart rate per minute) 82 beats per minute and Pulse Ox (measurement of blood oxygen saturation level with a pulse oximeter, a medical device that indirectly monitors the oxygen saturation of blood - normal is 95% to 100%) was 88%. Further review of Resident R94's nurse's note of (MONTH) 7, (YEAR), at 8:15 a.m. revealed that the nursing assistant called nurse to resident's room. The same note by the Registered Nurse, Employee, E6, stated that Resident R94 was lethargic (sluggish, feeling sleepy, unable to do anything), responsive to tactile (to be touched) stimuli with minimal response. Also noted was that resident's skin was pale, respirations (rate of breathing, normal - 12 to 16 breaths per minute) were 28 - 32 breaths per minute, and labored (evidence of increased effort to breathe including the use of accessory muscles of respiration, stridor, grunting, or nasal flaring (nostrils widen while breathing, and may be a sign of difficulty breathing)). Heart Rate (heart rate per minute - normal - 60 to 100 beats per minute) was 116 beats per minute, Temperature was 96.7 degrees Fahrenheit (normal - 98.6 degrees Fahrenheit), Blood Pressure (force of the blood pushing against the artery walls during contraction and relaxation of the heart, normal, measured in millimeters of mercury - normal -,[DATE] mm Hg ) was ,[DATE] mm Hg, and Oxygen saturation level as measured with a pulse oximeter - non-invasive medical device that measures oxygen saturation level of blood via finger/toes, normal - 95% to 100 %) was 82% on room air. Further assessment by the licensed nurse found that rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) were heard in the resident's right upper lung. Employee E6, Registered Nurse, raised the head of resident's bed to attempt to promote less strenuous breathing, initiated oxygen via nasal cannula at 2 liters per minute, as an emergency nursing measure. Resident's oxygen level increased to 91%, as measured with pulse oximeter. Physician was contacted and ordered the resident to be transferred to the Emergency Department via 911 emergency transport, for evaluation and treatment. Review of the facility Resident Transfer Form revealed that Resident R94 was transferred from the facility at 8:50 a.m., by emergency transport- a delay of six hours and fifty minutes, from 2:00 a.m. when the resident initially vomited what appeared to be dark coffee grounds. Resident R94 was identified with vomiting coffee ground vomitus on (MONTH) 7, (YEAR), at 2:00 a.m. and emergency response by the facility was not initiated until 8:15 a.m., a delay in assessment and of the medical change in condition, of six hours and fifty minutes. Review of hospital records revealed that resident was admitted to an acute care hospital with the [DIAGNOSES REDACTED]. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 10:10 a.m., confirmed that there was a change in the medical condition of Resident R94 and that the change in condition was not identified and assessed by Employee E9, a Registered Nurse. During the same interview the Director of Nursing confirmed that the facility did not protect the resident from neglect. The facility failed to protect the right of Resident R94 to be free from neglect resulting in harm to the resident. Review of the clinical record for Resident R363 revealed that the resident was admitted to the facility on , (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated dated (MONTH) 3, (YEAR), indicated on the brief interview for mental status Resident R363 scored a 4 out of 15, indicating the resident was confused, disoriented, and forgetful, and was not able to make himself understood by other nor understood others. The same MDS indicated the resident was a fall risk related to history of falls with fractures, muscle weakness, unsteady gait, cognitive impairment with poor safety awareness, occasional incontinence, and vision impairment. In addition, the Fall Risk assessment, dated (MONTH) 3, (YEAR), revealed the resident scored a total of 22 (total score of 10 or above represents a high risk for falls). Resident R363 Plan of Care, dated (MONTH) 26, (YEAR) included: A care plan for Activity of Daily Living deficit related to his dementia, and [MEDICATION NAME] degeneration, with interventions including extensive care, and toileting assistance. A care plan for Potential for Injury related to history of falls, and impaired mobility, with interventions that included, transfer with assistance only, provide anti-skid socks at bedtime, and to check placement and function of bed alarm every shift. A care plan for Potential for Bleeding related to anticoagulant (medicine that thins the blood to avoid blood clots) therapy, with interventions that included assessing for bruising, bleeding, etc. and to notify the physician. Review of the progress note, dated (MONTH) 11, (YEAR), from the facility's Medical Director, Employee E17, indicated Resident R363 had a history of [REDACTED]. It further indicated a review from a past report revealed that Resident R363 had [DIAGNOSES REDACTED] (the main artery that carries blood out of the heart to the rest of the body does not open fully and decreases blood flow from the heart), prostatism (inhibits urine flow), and [MEDICAL CONDITION] (blood vessels that supply your heart with blood, oxygen and nutrients are diseased). The same progress note during the examination, revealed that Employee E17 had indicated that Resident R363 pulse was slightly diminished, lungs had very poor inspiratory effect (breathing in), heart tones distant, with a heart murmur (structural defects in the heart), consistent with his [DIAGNOSES REDACTED]. Employee E17 ended his examination stating that Resident R363 had multiple co-morbidities and remained at a high risk for complication, and the prognosis was poor. Review of the facility's Event Data Worksheet, dated (MONTH) 11, (YEAR), at 1:30 a.m. revealed that Employee E12, nursing assistant responded to Resident 363's call bell. Resident R363 was found lying on the floor, on his stomach, between his bed and bathroom, the nurse on duty was then notified. Employee E9, Registered Nurse, responded to the fall. Employee E9 assessed Resident R363 with no injury noted. Resident R363 denied hitting his head but complained of pain in his right hip area. Employee E9 indicated that no shortening, or external rotations had been noted (presuming no [MEDICAL CONDITION]). Review of Resident R363's progress note, dated (MONTH) 11, (YEAR) revealed the physician was finally notified at, 8:35 a.m. (7 hours after the fall). At 10:30 a.m., via ambulance, the resident was transported to the hospital, and admitted with a [DIAGNOSES REDACTED]. Nurse's note, dated (MONTH) 13, (YEAR) indicated the facility received a call from Resident's 363 daughter, the resident has taken a turn for the worse and he was in complete kidney failure and possible [MEDICAL CONDITION]. Nurse's note, dated (MONTH) 14, (YEAR), at 10:00 a.m. indicated Resident R363 expired according to his daughter. The Director of Nursing confirmed on, (MONTH) 1, (YEAR) at approximately 2:00 p.m., the facility failed to protect Resident R363's right to be free from neglect resulting in harm. Review of Nursing Aide, Employee E13 personnel record revealed two disciplinary actions, on (MONTH) 5, (YEAR) and (MONTH) 19, (YEAR) related to incontinent care for 10 of 24 residents reviewed (Residents R17, R42, R47, R51, R65, R71, R73, R82, R109, and R362). A review of Employee E13's verbal counseling from the facility, on (MONTH) 5, (YEAR) revealed, In the a.m. when Nursing Assistant (NA) went to do their residents, many were found to be wet and some with BM (bowel movement) at 7:00 a.m. It is the employee's responsibility to check and change residents prior to leaving the shift. The residents involved were Residents R17, R51, R65, R71 and R82. In addition, a month later in the same employee's file, Employee E13, dated, (MONTH) 19, (YEAR), indicated, conditions were found when the ,[DATE] shift arrived and started their a.m. care. Resident R109's bed was soaked, wet to the point that even her blanket required laundering. Resident R47's bed was saturated, requiring a complete change of linen. There was a clean pink pad on Resident R73's bed, placed over a pad that was wet with urine. Resident R363 had on a dry brief, but was laying on a wet pink pad. Resident R47 was upset and crying. When I (the DON) asked her to tell my why she was upset, she stated that she told you (Employee E13) that she had to have a bowel movement. You (Employee E13) told her that you would not get her up and take her to the bathroom. I (DON) asked Resident 47 if you offered to place her on a bed pan. The resident stated you did not. Resident R47 is an alert and oriented resident. Refusing to provide necessary care is negligence, bordering on abuse. This care is not acceptable and cannot be tolerated. The residents involved were Residents R42, R47, R73, R109 and R362. An interview was conducted with the DON on, (MONTH) 1, (YEAR), at approximately 12:00 p.m. The DON confirmed that the facility failed to protect the rights of the residents to be free from neglect. Review of Resident R97 annual Minimum Data Set, dated dated dated , (MONTH) 22, (YEAR), had [DIAGNOSES REDACTED]. The MDS also revealed the resident had one side upper and lower extremity impairment, and was totally dependent with bathing and needed one person to physically assist her in the shower. The Care Area Assessment Summary of the MDS triggered for Cognitive loss, and Falls. Care plans for Resident R97 included, Activity of Living deficit related to impaired mobility (right [MEDICAL CONDITION]) forgetfulness, interventions were to include supervision with extensive assistance for bathing care, Potential for bleeding related to anticoagulant and to include assess for any bruising, bleeding, etc., and notify the physician. Review of the nursing note for Resident R97, dated, (MONTH) 26, (YEAR), at 3:34 p.m. indicated that while helping Resident R97 get dressed in the morning the nurse observed a large hematoma to her left arm from the axilla (under the arm where the arm connects to the shoulder) down her arm, measuring 20.5 X 18. centimeters long, and was dark purple in color. Resident stated it hurt. Resident also stated she fell in the shower room last night when she stood up. She slipped, and fell on to the shower floor. The resident further stated she hit her left arm on the railing in the shower. The resident is on [MEDICATION NAME] and aspirin (both blood thinners, which increase your risks of bruising or bleeding). Review of the facility's Event Data Collection Worksheet dated, (MONTH) 26, (YEAR), for the fall that occurred on (MONTH) 25, (YEAR) indicated it was Resident R97 that initially reported the fall in the shower room that caused the large hematoma on her arm. The investigation summary indicated the resident was in the tub room with a Nursing Aide, Employee E16. Resident R97 leaned forward to wash her genitals, lost her balance, fell and a hematoma developed. Reviewed was the counseling documentation, revealing that Employee E16, was in the tub room attending to Resident R97 as she showered. The resident lost her balance, slipped and fell . Employee E16 did not report it to the nurse because the resident got up without difficulty. The Director of Nursing (DON) further stated that any time a resident falls, the staff must report it to the nurse so an assessment can be done, and review her medications and monitor for any negative outcomes. Further review of Resident R97 record review revealed an injury of unknown origin identified on (MONTH) 3, (YEAR). It further stated that the resident was out of the facility this evening and returned after dinner. At 9:45 p.m. a nurse came in to the resident's room to administer her nighttime medication and noticed a bruise on the right lower cheek and jaw area measuring 5.0 c. m. x 3.5. c. m. and was tender to touch. In addition, the nursing assistant did not see a bruise during the resident's shower that night. Interview with the Director of Nursing on (MONTH) 1, (YEAR), approximately at 2:00 p.m. confirmed the facility did not protect the right of Resident R97 to be free from alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source. Review of the clinical record for Resident R67 revealed a quarterly Minimum Data Set (MDS-periodic assessment of needs) dated (MONTH) 1, (YEAR), indicating [DIAGNOSES REDACTED]. Review of a nurse's note, dated (MONTH) 18, (YEAR), revealed Resident R67's daughter reported a bruise on the resident's left inner thigh measuring 6.0 centimeters (cm) by 2.0 cm, and described as being light red in color. Review of the plan of care for Resident R67 dated as revised (MONTH) 18, (YEAR), revealed Resident R67 was noted with a bruise to the left inner thigh and that staff would, Assess for cause and eliminate if possible. Review of an Event Data Collection Worksheet, dated (MONTH) 18, (YEAR), with time of event or discovery of event at 7:00 p.m., indicated that Resident R67's daughter reported a bruise found on the resident's left inner thigh without knowing the cause of it. Review of an employee witness statement from Employee E14, nursing assistant, reveale

Based on observation, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to follow physician's orders [REDACTED]. for three of 27 residents reviewed (Residents R67, R94 and R363), causing actual harm to those three residents. Findings include Review of the clinical record for Resident R67 revealed a recapitulation (recaps-summary) of physician's orders [REDACTED]. Review of nurse's notes revealed on (MONTH) 20, (YEAR), Resident R67 was found in the facility's day room showing signs of lethargy (state of tiredness, weakness, fatigue and lack of energy), the nurse took the resident's temperature which registered at 102.5 degrees Fahrenheit tympanic (temperature taken via the ear), that the nurse administered Tylenol 650 mg at 7:00 p.m. for the elevated temperature, and rechecked the resident's temperature at 10:00 p.m. recording 99.0 degrees Fahrenheit. On (MONTH) 21, (YEAR), nursing documentation indicated at 8:30 a.m., the resident's blood pressure was ,[DATE] mmHg (millimeters of mercury-normal average adult blood pressure ,[DATE] mmHg) and temperature was 101.8 degrees Fahrenheit, that Tylenol was administered at that time and at 11:00 a.m., Resident R67's temperature reduced to 100.7 degrees Fahrenheit with notation of the resident having one episode of soft stool. On (MONTH) 21, (YEAR), nursing documentation indicated at 1:50 p.m. the resident's Certified Registered Nurse Practitioner (CRNP) was notified of the elevated temperature who instructed staff to obtain blood work and a urinalysis (urine test). On (MONTH) 21, (YEAR), nursing documentation indicated at 10:00 p.m. Resident R67's appetite was poor for dinner and the resident's temperature was 99.0 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 6:30 a.m. Resident R67 appeared lethargic, the resident's temperature was 101.7 degrees Fahrenheit, the resident's blood pressure was ,[DATE] mmHg, and at 7:00 a.m. upon recheck of temperature, the resident's temperature was 100.6 degrees Fahrenheit. On (MONTH) 22, (YEAR), nursing documentation indicated at 9:30 a.m. Resident R67 was lethargic and was placed back in bed after breakfast due to lethargy, the resident's blood pressure was ,[DATE] mmHg, and that a message was left with the resident's physician. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:30 a.m. Resident R67 continued to be lethargic, blood pressure dropping, with blood pressure noted as ,[DATE] mmHg, that the resident was examined and evaluated by a CRNP who ordered staff to send the resident out to an acute care hospital for evaluation for the resident's change in mental status. Review of a CRNP progress note, dated (MONTH) 22, (YEAR), revealed the CRNP saw and examined Resident R67 to evaluate nursing staff's concern about the resident's fever greater than 101 degrees Fahrenheit over the past 24 hours and increased lethargy. The CRNP progress note stated that the resident's fever would improve with administration of Tylenol but temperature increased again as the Tylenol wore off. Resident was evaluated in bed, was described as lethargic and ill appearing and despite pushing fluids pt (patient-resident) has dark, malodorous (foul smell) urine. The CRNP progress note additionally indicated the resident's temperature was 101.8 degrees Fahrenheit and blood pressure was ,[DATE] mmHg. On (MONTH) 22, (YEAR), nursing documentation indicated at 10:35 a.m., an outside transportation company was contacted to pick up the resident and transport Resident R67 to the hospital and that they stated ,[DATE] minutes. Then called 911 (emergency medical services) due to deteriorating status. On (MONTH) 22, (YEAR), at 4:15 p.m. nursing documentation indicated Resident R67 was admitted to the hospital for a [DIAGNOSES REDACTED]. Further review of the clinical record revealed no documentation that Resident R67, a resident who was identified as having an elevated temperature that began on (MONTH) 20, (YEAR), was assessed and monitored by nursing staff from 10:00 p.m. on (MONTH) 21, (YEAR), until (MONTH) 22, (YEAR), at 6:30 a.m., approximately eight hours later. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 10:00 a.m. confirmed the facility did not have any established policies, procedures or guidelines for assessment and monitoring of residents who were experiencing a change in medical condition, and confirmed there was no documentation that Employee E8, licensed practical nurse, assessed and monitored Resident R67 in a timely manner on (MONTH) 22, (YEAR). This failure to properly and timely assess and monitor resulted in emergent transport and subsequent admission to the hospital causing actual harm to Resident R67. Review of the clinical record of Resident R94 revealed that the resident was admitted to the facility on (MONTH) 13, 2009, with [DIAGNOSES REDACTED]. doesn't have enough healthy red blood cells). Review of the quarterly Minimum Data Set assessment (MDS - assessment of resident care needs), dated (MONTH) 25, (YEAR), indicated that there was no BIMS (brief interview for mental status) score for resident, and noted that the resident was rarely/never understood and that resident rarely/never understands others. The Minimum Data Set also noted that Resident R94 was severely cognitively impaired. Review of the clinical nurse's notes by Employee E9, Registered Nurse, for Resident R94 for (MONTH) 7, (YEAR), at 2:00 a.m. stated that the resident vomited dark coffee ground vomitus. The same nursing note indicated that positive bowel sounds were present and no stools were present, and the nursing note then stated, will monitor. On (MONTH) 7, (YEAR), at 7:00 a.m., the nursing progress note by Employee E9, stated that the resident was hard to arouse, loose stools (bowel movements) times two, and Temperature was 98.2 degrees Fahrenheit. Swallowed meds (medications) in pudding. The note of 7:00 a.m. then stated that the resident slept through a.m. care. Will monitor. The nurse's note of (MONTH) 7, (YEAR), no time documented, that Employee E9, added an addendum to the nurse's note which stated that Resident R94's Respirations (rate of breathing) were 26 (breaths per minute), Pulse (heart rate per minute) 82 beats per minute and Pulse Ox (measurement of blood oxygen saturation level with a pulse oximeter, a medical device that indirectly monitors the oxygen saturation of blood - normal is 95% to 100%) was 88%. Further review of Resident R94's nurse's note of (MONTH) 7, (YEAR), at 8:15 a.m. revealed that the NA (Nursing Assistant) called nurse to resident's room. The same note by the licensed nurse, Employee, E6, stated that Resident R94 was lethargic (sluggish, feeling sleepy, unable to do anything), responsive to tactile (to be touched) stimuli with minimal response. Also noted was that the resident's skin was pale, respirations (rate of breathing, normal - 12 to 16 breaths per minute) were 28 - 32 breaths per minute, and labored (evidence of increased effort to breathe including the use of accessory muscles of respiration, stridor, grunting, or nasal flaring (nostrils widen while breathing, and may be a sign of difficulty breathing), Heart Rate (heart rate per minute - normal - 60 to 100 beats per minute) was 116 beats per minute, Temperature was 96.7 degrees Fahrenheit (normal - 98.6 degrees Fahrenheit), Blood Pressure (force of the blood pushing against the artery walls during contraction and relaxation of the heart, normal, measured in millimeters of mercury - normal -,[DATE] mm Hg) was ,[DATE] mm Hg, and Oxygen saturation level as measured with a pulse oximeter - non-invasive medical device that measures oxygen saturation level of blood via finger/toes, normal - 95% to 100 %) was 82% on room air. Further assessment by the licensed nurse found that rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) were heard in resident's right upper lung. Employee E6, licensed nurse, raised the head of resident's bed to attempt to promote less strenuous breathing, initiated oxygen via nasal cannula at 2 liters per minute, as an emergency nursing measure. Resident's oxygen level increased to 91%, as measures measured with pulse oximeter. Physician was contacted and ordered resident to be transferred to the Emergency Department via 911 emergency transport, for evaluation and treatment. Review of the facility Resident Transfer Form revealed that Resident R94 was transferred from the facility at 8:50 a.m., by emergency transport - a delay of six hours and fifty minutes. There was no evidence that Employee E9 a licensed nurse, properly identified and assessed Resident R94's acute change in medical condition or that the physician was contacted in a timely manner, and there was no evidence that the there was a correct response to the medical emergency. Resident was identified with vomiting coffee ground vomitus and abnormal vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of essential body functions) on (MONTH) 7, (YEAR), at 2:00 a.m. and adequate emergency response by the facility was not initiated until (MONTH) 7, (YEAR), at 8:15 a.m., a delay in assessment and correct response of a change in condition, of six hours and fifty minutes. This failure to properly and timely assess and monitor, and respond with appropriate interventions resulted in Resident R94's emergency transport and subsequent admission to an acute hospital causing actual harm. Review of the clinical record for Resident R363 revealed that the resident was admitted to the facility on , (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS-assessment of resident care needs), dated (MONTH) 3, (YEAR), indicated on the brief interview for mental status Resident R363 scored a 4 out of 15, indicating the resident was confused, disoriented, and forgetful, and was not able to make himself understood by other nor understood others. The same MDS indicated the resident was a fall risk related to history of falls with fractures, muscle weakness, unsteady gait, cognitive impairment with poor safety awareness, occasional incontinence, and vision impairment. In addition, the Fall Risk assessment, dated (MONTH) 3, (YEAR), revealed the resident scored a total of 22 (total score of 10 or above represents a high risk for falls). Resident R363 Plan of Care, dated (MONTH) 26, (YEAR) included: A care plan for Activity of Daily Living deficit related to his dementia, and [MEDICATION NAME] degeneration, with interventions including extensive care, and toileting assistance. A care plan for Potential for Injury related to history of falls, and impaired mobility, with interventions that included, transfer with assistance only, provide anti-skid socks at bedtime, and to check placement and function of bed alarm every shift. A care plan for Potential for Bleeding related to anticoagulant (medicine that thins the blood to avoid blood clots) therapy, with interventions that included assessing for bruising, bleeding, etc. and to notify the physician. Review of the progress note, dated (MONTH) 11, (YEAR), from the facility's Medical Director, Employee E17, indicated Resident R363 had a history of [REDACTED]. It further indicated a review from a past report, revealed Resident R363 had [DIAGNOSES REDACTED] (the main artery that carries blood out of the heart to the rest of the body does not open fully, and decreases blood flow from the heart), prostatism, (inhibits urine flow), and [MEDICAL CONDITION] (blood vessels that supply your heart with blood, oxygen and nutrients are diseased). The same progress note during the examination, Employee E17 indicated Resident R363 pulse was slightly diminished, lungs had very poor inspiratory effect (breathing in), heart tones distant, with a heart murmur (structural defects in the heart), consistent with his [DIAGNOSES REDACTED]. Employee E17 ended his examination stating Resident R363 has multiple co-morbidities and remained at a high risk for complication, and the prognosis was poor. Review of the facility's Event Data Worksheet, dated (MONTH) 11, (YEAR), revealed Nursing Assistant, Employee E12 at 1:30 a.m. responded to Resident 363's call bell. Resident R363 was found lying on the floor, on his stomach, between his bed and bathroom, the nurse on duty was then notified. Registered Nurse, Employee E9 responded to the fall. Employee assessed Resident R363 with no injury noted. Resident R363 denied hitting his head but complained of pain in his right hip area. Employee indicated that no shortening, or external rotations were noted (presuming no [MEDICAL CONDITION]). Review of the facility's Employee Disciplinary Action, dated (MONTH) 11, (YEAR) for Employee E9 from the Director of Nursing, indicated: Today, [DATE], Resident R363 was found on the floor at 1:30 a.m. He was laying on his stomach and complained of pain on his right side. You documented that there was no bruising noted and the resident stated that he did not hit his head. Vital signs were not documented, no mention of the resident range of motion or appearance of this right leg. There was no documentation in your nursing notes that you gave him Tylenol for pain. The Day Nurse at the start of her shift assessed the resident and noted shortening of his right leg and external rotation. She then went to you. At 8:35 a.m. you documented this as a finding. This should have been noted by you at the time of the fall and immediate action should have been taken. The physician and family were not notified for hours after the incident (7 hours). This resulted in a delay in treatment. Once the physician was notified he ordered that the resident be transferred to the hospital for possible fracture of his right hip. In each case there was no evidence that a thorough assessments were done. This created a delay in treatment. It suggested that you did not recognizes the critical nature of each of those residents that require immediate intervention. You need to focus on your assessment, documentation, and interventions to assure the best resident outcome. Review of Resident R363's progress note, dated (MONTH) 11, (YEAR) revealed the physician was notified at, 8:35 a.m. (7 hours after the fall). At 10:30 a.m., via ambulance, the resident was transported to the hospital, and admitted with a [DIAGNOSES REDACTED]. Nurse's note, dated (MONTH) 13, (YEAR) indicated the facility received a call from Resident's 363 daughter, the resident has taken a turn for the worse and he was in complete kidney failure and possible [MEDICAL CONDITION]. Nurse's note, dated (MONTH) 14, (YEAR), at 10:00 a.m. indicated Resident R363 expired according to his daughter. The Director of Nursing confirmed on, (MONTH) 1, (YEAR), at approximately 2:00 p.m., the facility failed to assume the responsibility of ensuring the safety and well-being of Resident R363. The facility also failed to ensure the nursing staff were trained, able to react and respond in a timely manner, so the residents can receive care in accordance to professional standards of practice. Review of facility policy, Medication Administration Policy and Procedure, dated (MONTH) 12, (YEAR), revealed medications are administered in accordance with written orders of the prescriber and the individual who administers the medication dose records the administration of the resident's Medication Administration Record [REDACTED]. Review of facility policy, Missing of Unavailable Medication Policy and Procedure, dated (MONTH) 12, (YEAR), revealed that if a medication for a resident is missing, the nurse would check the emergency medication box for the unavailable medication and if the missing medication was not supplied in the emergency medication box, the nurse will contact the pharmacy and request the medication in a stat (as quickly as possible) delivery. If the medication is unavailable from the pharmacy due to shortage, the nurse will notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available. Review of the clinical record of Resident R76 revealed a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs), dated (MONTH) 17, (YEAR), indicating the resident had [DIAGNOSES REDACTED]. Review of the MAR for (MONTH) (YEAR), revealed Resident R76 was ordered [MEDICATION NAME] (blood thinner/anticoagulant) 3 milligrams (mg) to be administered orally at 9:00 p.m. every evening. Further review of the MAR for (MONTH) (YEAR), revealed [MEDICATION NAME] 3 mg was documented as not administered by the registered nurse (RN), Employee E11, on (MONTH) 3 and 4, (YEAR). Review of an Event Data Collection Worksheet, dated (MONTH) 6, (YEAR), with time of event or discovery of event at 4:00 p.m., indicated that Employee E11 did not administer [MEDICATION NAME] 3 mg to Resident R76 on (MONTH) 3, (YEAR), because the medication was not in the resident's drawer in the medication cart, and Employee E11 did not check the emergency box and did not call the pharmacy to have the medication delivered. Further review of the Event Data Collection Worksheet revealed Employee E11 did administer [MEDICATION NAME] on (MONTH) 4, (YEAR), after the medication was delivered by the pharmacy. Further review of the MAR indicated [REDACTED]. Interview with the Director of Nursing on (MONTH) 1, (YEAR), at approximately 10:30 a.m. confirmed Employee E11 did not administer [MEDICATION NAME] 3 mg, a medication to prevent blood clots, to Resident R76 per physician's orders [REDACTED].>Review of the clinical record for Resident R54 revealed a recapitulation (recaps-summary) of physician's orders [REDACTED]. [MEDICAL CONDITION] hormone level) 150 micrograms (mcg) orally every morning at 6:00 a.m., for a [DIAGNOSES REDACTED]. physician who ordered staff to obtain blood work for [MEDICAL CONDITION] studies. Review of a nurse's note, dated (MONTH) 10, (YEAR), at 3:00 p.m. revealed the results of the blood work drawn that morning were called into Resident R54's physician who ordered staff to recheck a TSH ([MEDICAL CONDITION] stimulating hormone-pituitary hormone that stimulates the [MEDICAL CONDITION]) level again in four weeks. Review of laboratory reports for Resident R54 revealed on (MONTH) 5, (YEAR), the resident's TSH level was 5.94 mcIU/mL (microunits/milliliter - reference range 0XXX,[DATE].68 mcIU/mL), and on (MONTH) 10, (YEAR), the resident's TSH was 115.00 mcIU/mL. Review of an Employee Disciplinary Action form, dated (MONTH) 12, (YEAR), for Employee E8, Licensed Practical Nurse, revealed that upon the facility's investigation into Resident R54's extremely elevated TSH level, administrative staff checked the medication cart and found that, No [MEDICATION NAME] was on the cart. A call was placed to pharmacy who informed us that the last date that [MEDICATION NAME] (sic) was sent was on (MONTH) 23. This possibly took us through the month of September. The resident would have had no [MEDICATION NAME] (sic) the entire month of (MONTH) up to and including (MONTH) 10, (YEAR), when the error was discovered. Review of the facility's pharmacy shipping manifest, received by the facility and reviewed on (MONTH) 1, (YEAR), revealed 14 [MEDICATION NAME] 150 mcg tablets were delivered to the facility for Resident R54 on (MONTH) 23, (YEAR), indicating the resident would finish the 14-day supply of [MEDICATION NAME] on (MONTH) 6, (YEAR). Further review of pharmacy shipping manifests revealed no documentation of any facility receipts of [MEDICATION NAME] 150 mcg for Resident R54 until discovery of the medication error on (MONTH) 10, (YEAR). Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing on (MONTH) 28, (YEAR), at approximately 11:30 a.m. confirmed that Employee E8 did not administer [MEDICATION NAME] 150 mcg to Resident R54 per physician's orders [REDACTED]. The facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice to achieve the highest possible level of functioning and well-being. Refer to R600 and F658. Quality of Care CFR(s): 483.25 Previously cited [DATE] 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited [DATE], [DATE] 28 Pa. Code 201.18(b)(1) Management Previously cited [DATE] 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.5(f)(g)(h) Clinical records 28 Pa. Code 211.10(c)(d) Resident care policies 29 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE]